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Cognitive Behavior Therapy for Insomnia in Those with Depression A Guide for Clinicians ( PDFDrive )

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Cognitive Behavior Therapy for
Insomnia in Those with Depression
Cognitive Behavior Therapy for Insomnia in Those with Depression is the book for
clinicians who recognize that insomnia is more often a comorbid condition that merits
separate treatment attention. These clinicians know that two thirds of those who present
for depression treatment also complain of significant insomnia and that one third of
such patients are already taking sleep medication, and they may be familiar with the
research showing that treating insomnia is often important in the management of
depression. But what strategies should clinicians use for treating insomnia? How can
motivation be enhanced? What about medications? Students and professionals alike will
find the pages of Cognitive Behavior Therapy for Insomnia in Those with Depression
replete with advanced tools to address the adherence problems often encountered
in this group, and they’ll come away from the book with a wealth of techniques for
improving both sleep and overall symptom management as well as for treating the
insomnia that occurs in comorbid disorders.
Colleen E. Carney, PhD, is an associate professor in the department of psychology at
Ryerson University and the director of the Sleep and Depression Laboratory in Toronto,
Canada. She was previously on faculty at Duke University Medical Center, where
she was awarded the prestigious National Sleep Foundation Pickwick Fellowship and
where she also established the Comorbid Insomnia Clinic. She is the president of the
Behavioral Sleep Medicine Special Interest Group of the Association for Behavioral and
Cognitive Therapies and a fellow of the Canadian Psychological Association. She is also
certified in cognitive behavior therapy by the Canadian Association for Cognitive and
Behavioral Therapies, and is an active writer, presenter, and workshop trainer.
Donn Posner, PhD, is currently working at the Palo Alto VA on clinical research in
insomnia. Before this he served as a clinical associate professor of psychiatry at the
Warren Alpert Medical School at Brown University and as director of behavioral sleep
medicine for the Sleep Disorders Center of Lifespan Hospitals. Dr. Posner is a member
of the American Academy of Sleep Medicine and is one of the first certified behavioral
sleep medicine specialists recognized by that group. He is also a founding member of
the Society of Behavioral Sleep Medicine and was recently awarded the society’s Peter
Hauri Career Distinguished Achievement Award.
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Cognitive Behavior Therapy
for Insomnia in Those with
Depression
A Guide for Clinicians
Colleen E. Carney and
Donn Posner
First published 2016
by Routledge
711 Third Avenue, New York, NY 10017
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2016 Colleen E. Carney and Donn Posner
The right of Colleen E. Carney and Donn Posner to be identified as authors
of this work has been asserted by them in accordance with sections 77 and 78 of
the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or
reproduced or utilized in any form or by any electronic, mechanical,
or other means, now known or hereafter invented, including photocopying
and recording, or in any information storage or retrieval system,
without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification
and explanation without intent to infringe.
Library of Congress Cataloging in Publication Data
Carney, Colleen.
Cognitive behavior therapy for insomnia in those with depression:
a guide for clinicians/Colleen E. Carney, PhD and Donn Posner, PhD.
pages cm
Includes bibliographical references and index.
1. Insomnia—Treatment—Popular works. 2. Depression, Mental—
Complications—Popular works. 3. Cognitive therapy—Popular works.
I. Posner, Donn. II. Title.
RC548.C363 2015
616.8′49820651—dc23
2015016125
ISBN: 978-0-415-73837-8 (hbk)
ISBN: 978-0-415-73838-5 (pbk)
ISBN: 978-1-315-81740-8 (ebk)
Typeset in Minion
by Florence Production Ltd, Stoodleigh, Devon, UK
I dedicate this book to my family, Shannon, Sydney, and Theo. Their love,
support and understanding, allows me to pursue my passion.
Colleen E. Carney, PhD
I dedicate this book to my wife Karen and son Max who definitely put
the drive into my life each and every day. Thank you for your bottomless
reservoir of support. I would also like to thank my co-author Colleen for
giving me the opportunity to be part of this thought provoking project.
Donn Posner, PhD
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Contents
Acknowledgment
1 Depression and Insomnia: An Overview
ix
1
2 Non-psychological Treatments for Those with Insomnia
and Depression
14
3 Cognitive Behavior Therapy for Insomnia (CBT-I):
Treatment Considerations
26
4 Assessment of Insomnia in Those with Depression
37
5 Behavioral Strategies for Insomnia
60
6 Cognitive Factors and Treatment
79
7 Encouraging Adherence and Troubleshooting Potential
Barriers
96
8 Rumination Strategies for Insomnia
120
9 Combining Depression and Insomnia Therapies
134
10 Case Study
157
Appendices
A Core Sleep Diary
185
B
188
Expanded Sleep Diary
C Daytime Insomnia Symptom Response Scale
194
viii Contents
D TRAP or TRAC Worksheet
195
E
Daily Activity Monitoring Form
196
F
Goal Tracking Form
197
G Blank Pro-Depression and Anti-Depressant Worksheet
198
H Blank Pro-Sleep versus Pro-Insomnia Worksheet
199
I
Blank Pro-Energy versus Pro-Fatigue Worksheet
200
J
BABIT Continuum Exercise
201
K Behavioral Experiment Monitoring
References
Index
202
203
225
Acknowledgment
We thank Dr. Rachel Manber for her intellectual contributions to this book and her
contributions to the field in the area of sleep and depression.
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1
Depression and Insomnia
An Overview
Insomnia is Important
Sleep is a significant issue for those with major depressive disorder (MDD). Up to 90
percent of those with MDD complain of insomnia (Kupfer, Reynolds, Ulrich, Shaw, &
Coble, 1982; Reynolds & Kupfer, 1987). In community samples, just under half of
people with MDD meet criteria for an insomnia diagnosis (Breslau, Roth, Rosenthal, &
Andreski, 1996; Stewart et al., 2006). In sleep clinics, the most common insomnia
patient seen is one with comorbid MDD (Buysse et al., 1994; Coleman et al., 1982;
Edinger et al., 1989; Jacobs, Reynolds, Kupfer, Lovin, & Ehrenpreis, 1988). Additionally,
there can be complaints of hypersomnia and sometimes an alternation between
hypersomnia and insomnia.
Despite the high prevalence, the importance of sleep is under-recognized and as a result
undertreated. There are several studies showing that a separate insomnia diagnosis is not
considered when MDD is suspected. For example, the best predictor of a MDD diagnosis
is the presence of an insomnia complaint (Haponik, Frye, Richards, Wymer, & Hinds,
1996). However, insomnia is not one of the two cardinal symptoms (i.e., depressed mood
and/or anhedonia) needed for a MDD diagnosis (American Psychiatric Association, 2013)
and thus should not be predictive of this diagnosis. Another potential issue in the
underdiagnosis of insomnia is being presumptuous about etiology. Some problems in
this area include the presumption that it is important to establish temporal precedence
of the insomnia—even in such cases, some presume that the insomnia is merely the first
MDD symptom to appear. There are several problems with this view. One is that
patients may not be able to remember which symptoms came first, especially given that
those with MDD have autobiographical deficits (Lyubormirsky, Caldwell, & NolenHoeksema, 1998). Second, even in sleep specialists, clinicians exhibit poor reliability in
determining whether an insomnia diagnosis is present when there are mood symptoms
present (Edinger et al., 2011). There are also assumptions that MDD is more serious and
therefore clinical attention should be exclusively focused on the MDD. Although MDD
is a very serious disorder, on some quality of life indices, chronic insomnia produces
greater impairment than MDD (Foley et al., 1995). Insomnia is associated with large
societal costs (Carney et al., 2008; Daley, Morin, LeBlanc, Gregoire, & Savard, 2009;
Ozminkowski, Wang, & Walsh, 2007). Indeed, the costs associated with MDD increase
by an additional $1K annually in those with untreated insomnia and MDD (Asche, Joish,
Camacho, & Drake, 2010). Additionally, insomnia is predictive of developing alcohol and
substance abuse (Ford & Kamerow, 1989). Lastly, chronic insomnia is associated with
2
Depression and Insomnia
increased suicidal ideation (Agargun, Kara, & Solmaz, 1997; Li, Lam, Yu, Zhang, & Wing,
2010; Woznica, Carney, Kuo, & Moss, 2014), and insomnia is an independent predictor
of suicide (Bernert, Joiner, Cukrowicz, Schmidt, & Krakow, 2005); that is, even after
controlling for depression, there is an increased risk for suicidality. In those with MDD,
suicidal ideation is increased when there is insomnia present and insomnia is a significant
predictor of suicide completion (Fawcett et al., 1990).
Inherent in the assumption that MDD is always more serious is perhaps an implicit
assumption that treatment of the MDD will likely resolve the (less serious) insomnia
problem. There are many studies to confirm that this is a faulty assumption. Across studies
using sleep items from depression inventories, the rate of residual insomnia problems
after depressive recovery following antidepressant therapy or psychotherapy is a little
less than half (Carney, Segal, Edinger, & Krystal, 2007b; Manber et al., 2003; Nierenberg
et al., 1999). It is possible that the rate exceeds 50 percent, as a study that utilized a validated
sleep questionnaire in lieu of sleep items from a depression measure found a much higher
rate (Carney, Harris, Friedman, & Segal, 2011). Additionally, in the same study, although
depression cognitions significantly decreased and were in the nonclinical range after
depressive recovery, insomniagenic beliefs did not significantly improve with depression
recovery and remained in the pathological range (Carney et al., 2011). Insomnia is also
a complicating factor for depression treatment because insomnia predicts poorer
response to evidence-based psychotherapy or pharmacotherapy depression treatments
(Buysse, 1999; Thase, 1996, 1997). Collectively, the data above confirms what was concluded at the National Institutes of Health (NIH) Consensus Conference on Insomnia:
Insomnia should be considered a comorbid condition and treated in the presence
of MDD. Moreover, after a review of the evidence, the DSM5 Sleep-Wake Disorders
Workgroup concluded that there should be no diagnostic distinction between comorbid insomnia and insomnia alone; the disorder in the fifth edition of the DSM
is simply insomnia disorder (American Psychiatric Association, 2013).
Etiological Factors in Insomnia
In considering the relationship between insomnia and depression, it may be helpful to
first consider causal factors for insomnia. There are many causes of sleep disturbance
and there may be as many precipitating or initial causes as there are clients. Although
sleep problems initially can be caused by just about anything, there are three main causes
or factors that perpetuate a chronic insomnia: problems with the homeostatic, circadian
and/or arousal systems. This idea was first presented in Spielman’s Three P Model
(Spielman, Caruso, & Glovinsky, 1987a). The model postulates that there are predisposing factors that increase vulnerability to insomnia (e.g., a tendency towards
rumination), but having a vulnerability factor does not mean that insomnia is inevitable;
it simply provides fertile ground for an insomnia disorder in the presence of a stressor.
The stressor is the precipitant in the model. As stated above, there are many precipitants,
even positive stressors such as having a baby can precipitate sleep disturbance. MDD
can be a stressor in this model. Although insomnia is often a precursor to MDD, in
some cases, MDD could lead to more protracted insomnia. Sleep disturbances that are
associated with a stressor are expected to resolve with the resolution of the precipitant.
Thus in the case of MDD precipitating sleep disruption, we would expect insomnia to
Depression and Insomnia
3
resolve when the MDD resolves. Unfortunately we know that insomnia frequently does
not remit with the resolution of the depressive episode (Carney, Edinger, Meyer,
Lindman, & Istre, 2006). Why? Sleep disturbance becomes a chronic insomnia when
there are perpetuating factors present. Perpetuating factors are those factors that often
arise from coping with the precipitating factor and initial sleep disturbance. The
consequence of these coping behaviors can create disturbances in the homeostatic,
circadian and/or arousal systems. Below we discuss each of these factors and then return
to the situation of MDD and insomnia.
Perpetuating Factor: Homeostatic System Problems
Sleep is regulated by two systems: a homeostatic and a circadian system. We will discuss
the circadian system and its role in chronic insomnia in the next section. First, the
homeostatic system is a system that balances between wakefulness and sleep. From the
moment we are awake and active, we accumulate a chemical in the basal forebrain called
adenosine. The build-up of this chemical is associated with increasing sleepiness and
pressure for deep sleep; the greater the duration of wakefulness, the greater the buildup of a drive for deep sleep. The greater the amount of time since rising, the greater is
the pressure to sleep. This system ensures that we neither sleep too much nor too little.
It compensates for sleep loss and lightens sleep if the person was attempting to produce
copious, unnecessary amounts of sleep. This means that people needn’t do anything
during periods of sleep loss except maintain their schedule, because the body will
make up for lost sleep with subsequent deep, restorative sleep. However, attempting
to make up for lost sleep by spending increased time in bed or at rest, sends a message
to the body that less deep sleep is needed; thus the compensatory mechanism is
thwarted. Below we include a sample script for CBT-I psychoeducation. Such an
explanation is included in the first treatment session of CBT-I. There are other examples
of psychoeducation delivery throughout the book, including in Chapter 5 wherein we
describe the behavioral components of CBT-I delivered in the first treatment session.
Therapist: From the moment you get up and are active, you begin to build a drive for
deep sleep. You build it all day and into the evening until so much has built up that
when you go to sleep, you produce some deep sleep and it keeps you asleep
throughout the night.
Client: Well, that never happens to me anymore.
Therapist: It may well be that you have a problem with this system. Let’s continue and
you can tell me what you think. This system determines how much deep sleep you
get and it is based on how many hours you have been awake and active. So if you
get up later, go to bed earlier, attempt to nap or rest throughout the day or you are
less active, less deep sleep drive is accumulated and the result is light, broken sleep
and maybe difficulty in falling asleep too.
Client: I definitely don’t get deep sleep anymore but it’s not like I am totally inactive
...
Therapist: Let me ask you this, when you feel tired, or you’ve had a poor night’s sleep,
or your mood is really low, how much do you feel like keeping up with your regular
activities?
4
Depression and Insomnia
Client: I’m not sure what you mean. I feel really tired so I try to do my normal
activities but I can’t always do what I want.
Therapist: Can you tell me more about that? Are you able to get right out of bed when
your alarm sounds? Are you always able to go to work? Do you keep up with all
your social engagements?
Client: Sort of. Not everything. Like I said, I feel exhausted so it’s not always possible.
Therapist: This is very common. Most people do an excellent job trying to do all the
things they used to but when the fatigue sets in, they find it more and more difficult
and they find themselves spending a little more time in bed and a little more time
inactive than before they had their sleeping problems . . .
Client: I wouldn’t say I spend more time in bed.
Therapist: Ok. I was making that assumption based on what you told me was your
routine two years ago, before all this trouble started. You had said that you went
to bed around 11 PM and got up at 6 AM each morning, you never took naps, you
had a weekly card game with friends, lunch on Fridays with coworkers, and you
worked out 4 days per week.
Client: Well it’s true that I don’t work out anymore, and guess I don’t go to lunch or
the card game. I don’t really take naps now because I often can’t sleep. I just try to
sleep. I still go to bed at 11 and get up at 6 AM.
Therapist: I see. So some of your activities have decreased and you spend more time
resting but not always napping?
Client: Right.
Therapist: Can we take a look at your sleep diary? [See Figure 10.2 in Chapter 10]
Client: Sure. See how I go to bed around 11 PM most nights? Except for Tuesday and
Wednesday.
Therapist: Yes, I see. Most nights were around 11 PM and Tuesday you went to bed
an hour earlier and Wednesday you went to bed about 2 hours earlier, around 9ish,
right?
Client: That’s right.
Therapist: And I see that your final awakening during the work week was 6:30 AM
and on the weekend it was closer to 8 AM correct?
Client: That’s right.
Therapist: The item below your final awakening is the time that you actually got out
of bed, what do you notice about the time at which you physically get out of bed?
Client: It’s later than 6:30 AM. It’s because I am tired.
Therapist: Right. Because you are tired, you have difficulty getting up at the time you
used to and it is even later on weekends. You used to spend 7 hours in bed each
night. How many hours were you in bed on Wednesday?
Client: Almost 10 hours. Wow. I never knew that. But I am not sleeping during this
time.
Therapist: Right, you are not sleeping, but you are also not building a drive for deep
sleep. You also told me that you attempted to nap for 90 minutes that afternoon.
If you spent 11.5 hours inactive in bed that day, how much time were you building
sleep drive?
Client: I don’t know [pauses] I think, 12.5 hours?
Depression and Insomnia
5
Therapist: Yes. So if there were two people and one spent 7 hours in bed so they had
17 hours of deep sleep drive build-up, and the other had 12.5 hours of build-up,
who is more likely to have deep, continuous sleep?
Client: Ok, I get it. The person who builds 17 hours has a better chance at better sleep.
Therapist: And don’t forget that the person with 17 hours of build-up also has much
more activity to add to the build-up. The person with only 12.5 hours also has a
lower amount of physical activity to contribute to the build-up.
Client: Ok, I get it.
Therapist: So we will discuss ways to work with this system to produce more deep
sleep for you. But first, I had said there is another system that works with your
homeostatic system. I think it’s important to talk about this system too.
Perpetuating Factor: Circadian System Considerations
In addition to the homeostatic system that balances sleep and wakefulness, there is a
body clock that regulates many systems in the body, including the timing of the sleep
and alerting systems. The circadian system is slightly longer than a 24 hour day and
thus is highly responsive to cues in the environment, such as the light, for entrainment
purposes. The light provides input via the eye into the brain about what time it is. When
blue spectrum light is present (i.e., in sunlight) it signals that it is day and this situation
is associated with alertness. When red spectrum light is present (i.e., following sunset)
it signals night and is associated with melatonin release; a sedative hormone. Improperly
timed cues can create sleepiness or alertness at undesirable times. Thus decreased
exposure to light can be associated with drift in the circadian system, and ill-timed light
(blue light exposure at night) can be associated with ill-timed alertness.
Although light is the most powerful cue for the clock, keeping a regular schedule of
activities including rise and bedtimes, and perhaps meal times and other activities can
help set the clock. Each of these activities is typically associated with light too, i.e., we
typically eat under lighted conditions, when we travel to work we are often exposed to
daylight etc. In those with insomnia, the regularity of daily activities is diminished relative
to good sleepers even when overall levels of activity are the same between those with
insomnia and good sleepers (Moss, Carney, Haynes, & Harris, 2014). When there is
irregular environmental input (e.g., light or activities) to the clock, the system drifts,
because it is more than 24 hours, and symptoms such as difficulty in sleeping, cognitive
difficulties, fatigue, and mood disturbance can occur. These are the symptoms experienced during jetlag. That’s because jetlag is the result of the mismatch between the
internal time and the time in the environment. Even one hour is enough to produce
these symptoms; most people can relate to this because daylight savings is only one hour
and it typically produces at least mild symptoms. The reason this is important is that
if the rise time is varied by an hour or more then the client will experience jetlag
symptoms. When people suffer from sleep or mood disturbance they often struggle at
getting up at their regular time. They may continue to set the alarm but will remain in
bed longer because they feel tired.
The circadian system regulates a variety of systems in the body including
sleep, alertness, and mood. There are regular predictable patterns for the rise and fall
of these activities across a 24 hour period but this system is also largely responsive to
6 Depression and Insomnia
Alerting signal from the clock
environmental output. One way to envisage this system is to visualize a curve that rises
in the morning, continues to rise all day, and then begins to fall in the evening and
throughout the night (see Figure 1.1). The peak is in the evening and the trough or
lowest point is in the early morning. This curve would correspond to the core body
temperature curve as this exhibits circadian periodicity. This curve would also help us
to understand alertness in a 24 hour period as the clock emits an alerting signal when
the curve is ascending; thus increasing as the day goes on and competing with the buildup of sleepiness to keep us awake. Alertness diminishes when the curve is falling (ideally
an hour or so before bed) which sets the stage for sleep. Prior to the fall in alerting
signals is the release of melatonin in the early evening, coincident with the offset of light
(i.e., sunset), which also sets the stage for sleep. Attempting to make up for lost sleep
during times at which alertness signals are being sent from the clock, or when melatonin
is not present or is present in only small amounts, makes sleep less likely. Thus, trying
to sleep during the day is ill-timed given that alertness signals will intrude. For example,
those working a night shift will have a strong sleep drive because they stayed up all night
building pressure. However, when they attempt to sleep in the morning, they are
sleeping in competition with alerting signals from the clock. This is partly why those
working night shifts also complain of less restorative sleep or shortened sleep duration.
Another consideration is maintaining a schedule that is a poor match for biology, or
chronotype. Chronotype refers to the placement of a sleep wake cycle within a 24 hour
period. Thus someone who typically becomes sleepy very early (e.g., 9 PM) and typically
starts to wake up around 4 AM exhibits morningness or an advance in phase, and
someone who typically becomes sleepy very late (e.g., 2 AM) and typically starts to wake
up later (e.g., 10 AM) exhibits eveningness or a phase delay. There is some evidence
that there is a significant genetic contribution, and there is a developmental pattern
(e.g., morningness at the early and late years of life). There is some ability to make
shifts using bright light therapy, melatonin, or maintaining a strict schedule but there
are individual differences in the ability to maintain the shift. The important consideration is whether someone is keeping a schedule discrepant from their chronotype.
Sleep
opportunity
High
Low
Morning
Afternoon
Evening
Time of day
Figure 1.1 Strength of alerting signals from the clock
Night
Morning
Depression and Insomnia
7
For example, if a client has a lifelong pattern of going to bed late and rising late, and
they are suddenly obliged to rise at 7 AM for work, they will not be able to go to bed
early just because they have to wake up early. Also important is that people can have
particular beliefs about what it means to be a morning person or a night person. Night
owls are associated with a stereotype of laziness so clients can be ambivalent about
maintaining a schedule consistent with their chronotype because there is something
“wrong” with going to bed late. Likewise, there may be a negative stereotype of being
“boring” associated with keeping an early schedule.
Below is an example of how to deliver psychoeducation about the clock in an
interactive way, using the client’s data and Socratic questioning.
Therapist: We have a clock inside our body that is not quite 24 hours in length. To keep
this clock running optimally, we have to set the clock every day with regular habits.
Client: What happens if it is not running properly?
Therapist: A variety of things can happen. The clock is responsible for mood, alertness,
sleep, in addition to other processes, so you could experience insomnia, fatigue,
and low or irritable mood and difficulty with performance, for example, it might
require more effort to concentrate.
Client: Sounds like me. What do you have to do to make it run better?
Therapist: We need to set our internal clock with regular habits such as regulating the
time at which we get out of bed.
Client: What about the time I go to bed?
Therapist: It would be ideal if we could regulate bedtime however we are not always
sufficiently sleepy at bedtime and we shouldn’t get into bed without feeling sleepy
or it will increase the likelihood of lying awake while in bed. Setting the time at
which you get out of bed at the same time every morning will regulate your clock
and make it more likely that you will begin feeling sleepy around the same time
each night. All things being equal, your bedtime would become more regular by
getting out of bed at the same time each morning.
Client: I already get up at the same time most mornings, so this probably doesn’t apply
to me.
Therapist: Have you ever taken a flight where you travelled and the time zone
changed?
Client: Yes. Recently I flew from Colorado to Boston. Why?
Therapist: What were the symptoms you had a result of the jetlag?
Client: I was tired, I had a headache and I found it hard to eat when everyone else was
and couldn’t fall asleep when everyone else was asleep.
Therapist: So you essentially had insomnia and other unpleasant related symptoms?
Client: Yes, I guess so.
Therapist: And how long did it last?
Client: Maybe two days? I think I felt tired for longer than that though.
Therapist: So there was an immediate effect and then it took a few days before things
completely improved?
Client: That’s right. What does this have to do with travel?
Therapist: Jetlag symptoms are really about this mismatch between the clock in your
body and the clock showing local time. The difference between Boston and Denver
8
Depression and Insomnia
is only 2 hours but it produced immediate negative effects that lasted a few days.
Can you take a look at your sleep log and tell me the difference between the earliest
and latest time at which you got out of bed last week? [See Chapter 10 to review
specifics of this case, including the Figure 10.2 sleep log]
Client: A little over 2 hours. Do you really think it would make that much of a
difference?
Therapist: Don’t take my word for it. What was your experience when your body
expected it to be a particular time and suddenly everything was shifted 2 hours
later? How did your body respond?
Client: Wow, ok, I get it. The problem is that I am tired so I have to make-up for lost
sleep.
Therapist: Given what you just learned about building sleep drive, do you think you
are making up for the lost sleep?
Client: I forgot. No, I guess not. And it looks like I am giving myself jetlag, which
sucks. Ok, I get it.
Therapist: There is one last consideration for the clock system and that is that there
is a window of opportunity for people, specific to them, at which time the best sleep
will be produced. Some of this relates to genetics. That is, would you consider
yourself to be a night owl or an early bird, or somewhere in between?
Client: I used to be a night owl in my early twenties but then I got insomnia and it
went away. I would say I am somewhere in between but maybe more of a morning
person than not.
Therapist: Developmentally, people tend to shift towards being night owls in their teens
and early teens and then gradually shift to somewhere in between a morning and
night person throughout adulthood. Late in life and also very early in life, older
adults and small children tend to be on the earlier side. Even though there are
developmental changes, genetics play some role so if you are born with a genetic
loading for being a night owl, it means that you will be shifted earlier as a young
child but will still be much later than all of your peers. Does that make sense?
Client: Yes. My Dad was a night owl and my Mom was an early bird or maybe
somewhere in the middle.
Therapist: What this all means is that it is important to keep a schedule that makes
sense for your body. Since you are somewhere in the middle, we wouldn’t want
you to keep a very late bedtime and rise time because that wouldn’t suit you, nor
would an extremely early bedtime and rise time. Make sense?
Client: Yes.
Perpetuating Factor: Arousal System Considerations
In sum, two regulatory systems interact to produce quality sleep: the circadian system
and the homeostatic system (Borbély, 1982). Even when these two systems are operating
optimally; that is, the sleep-wake schedule is regular and well-matched to the person’s
chronotype and there is close correspondence to the amount of sleep currently produced
and the time spent in bed, these systems can be overridden by the arousal system. This
is important, because even when homeostatic pressure is high and the timing of a sleep
opportunity is ideal, in emergency situations it is most advantageous to be able to
Depression and Insomnia
9
postpone sleep to be able to respond to the emergency. However, sometimes the body
becomes more alert in situations that are not emergencies. There is ample evidence of
hyperarousal in insomnia across multiple physiological indices (Bonnet & Arand, 1995,
1998; Nofzinger et al., 2004; Vgontzas et al., 2001). Thus, arousal is an important
consideration in insomnia and two types of arousal (e.g., conditioned arousal and
cognitive arousal) tend to figure prominently as treatment targets.
There is evidence of conditioned arousal in many people with insomnia. Conditioned
arousal refers to the repeated pairing of wakefulness with the sleep situation (e.g., bed),
such that the bed itself begins to acquire alertness-promoting properties. Many people
with insomnia report that they are able to feel sleepy and even produce sleep elsewhere
(e.g., on the couch) but when they get into bed, they become instantly alert. Such a report
is consistent with conditioned arousal. Conditioned arousal is explained to clients
during the psychoeducation component of the first treatment session and is easily
explained as the body has learned that the bed is no longer associated with sleeping;
this has occurred (unintentionally) via repeated pairings of the bed with wakefulness.
People with insomnia typically respond to wakefulness in bed by staying in the
bed, further pairing the bed with wakefulness and perhaps negative emotions such as
anxiety or frustration. Moreover, in an effort to fall asleep or to produce greater amounts
of sleep, people with insomnia do activities associated with wakefulness in the bed,
such as reading, watching television, gaming, or working on the computer. Performing
activities done while awake can create an association with the bed and wakefulness.
Thinking about sleep, worries, or anything distressing is predictive of difficulties
sleeping (Harvey, 2000; Wicklow & Espie, 2000) and cognitive arousal is seen by
insomnia patients as accounting for their insomnia (Lichstein & Rosenthal, 1980).
Worrying about sleep and fatigue is characteristic of those with insomnia (Carney &
Edinger, 2006) and when in bed and faced with wakefulness, it can perpetuate worries
about insomnia and further delay sleep onset. Thus arousal can be a major factor in
insomnia that is targeted with CBT-I. For more on how these associations are addressed
in CBT-I, see Chapters 5 and 7.
The Sleep of Those With Depression and Insomnia
There are several interesting sleep characteristics of those with MDD-I. There are many
assumptions, some true and some not, about the sleep of those with MDD. One of the
most common assumptions is that MDD-I is characterized by early morning awakenings (EMAs). Although EMAs can occur in depression, when considering all of the
insomnia complaints, including increased sleep onset latency and increased wakefulness throughout the night, EMAs have the lowest rate of occurrence (Carney et al.,
2007b). Moreover, EMAs may reflect an advancing circadian phase that occurs naturally
in aging and can be misdiagnosed as a depression in those with a circadian change only.
Because of the sleep changes seen in MDD, there have been many attempts to identify
sleep markers that could reliably identify depression. Some of the sleep-related markers
include: decreased total sleep time, decreased sleep efficiency (i.e., the proportion of
time asleep while in bed), decreased slow wave sleep (SWS), increased REM sleep, and
increased wakefulness, including increased sleep onset latency and wakefulness after
sleep onset (Benca, Obermeyer, Thisted, & Gillin, 1992).
10 Depression and Insomnia
Slow wave sleep is also called delta sleep or N3 because it is stage 3 of non-rapid eye
movement sleep (NREM). There may be abnormal proportions of SWS in those with
MDD. The number of slow waves in the first NREM period is lower than the waves
counted in other NREM periods (Kupfer, Frank, McEachran, & Grochocinski, 1990).
This is unusual because normally increased slow waves are seen in the first NREM period
and reflect a release of homeostatic pressure. It is possible that people with MDD have
decreased homeostatic pressure, given that they tend to have decreased activity and
increased time in bed in a 24 hour period, but this can also be seen in insomnia. Another
possibility is that rapid eye movement (REM) initially displaces slow waves until later
in the sleep period. A decreased slow wave count predicts MDD recurrence and also
predicts suboptimal MDD treatment outcomes (Jindal et al., 2002; Kupfer et al., 1990)
and one could expect that the consequence of this marker would be less deep sleep,
resulting in sleep continuity (e.g., difficulty staying asleep) and sleep quality complaints.
Another frequently explored biomarker is rapid eye movement sleep (REMS) related
phenomena. There are a collection of findings in MDD of REMS abnormalities
including: decreased REMS onset latency (i.e., it appears earlier in the night), as well as
increased REMS density. This has been thoroughly reviewed elsewhere (see Benca
et al., 1992; Buysse & Kupfer, 1993) so we will review only briefly. Interestingly, markers
such as REMS density appear in nondepressed first-degree probands of those with
depression and may predict vulnerability to depression (Giles, Biggs, Rush, & Roffwarg,
1988; Giles et al., 1989; Giles, Roffwarg, & Rush, 1987). Increased REMS density is also
predictive of negative depression treatment outcomes irrespective of treatment approach
(Clark et al., 2000). The fact that several (although not all) antidepressants suppress
REMS, as well as the effectiveness of sleep deprivation in the second half of the night
where REMS is most pronounced, has been taken by some to mean that REMS must
be depressogenic (e.g., Vogel, 1983). REMS deprivation produces immediate antidepressant effects although they are reversed on the subsequent recovery night (Vogel, 1975;
Vogel, Traub, Ben-Horin, & Meyers, 1968; Vogel, Vogel, McAbee, & Thurmond, 1980).
One possible explanation for these phenomena is the internal coincidence model (Wehr
& Wirz-Justice, 1980); a model that posits that sleep occurs at a time coincident with
circadian vulnerability for mood disturbance. This theory might explain the occurrence of EMAs for some as well as increased REMS. An alternative perspective for the
REMS findings, and one that accounts for the finding that insomnia is often prodromal
in depression (Baglioni et al., 2011), is the suggestion that the chronic instability of
REMS seen in insomnia (Feige et al., 2008) may eventually result in REMS rebound
(i.e., a subsequent increase in density) and resultant depression (Riemann et al., 2012).
There are also a number of other circadian-related explanations for these phenomena
including: 1) The regularity of activities erodes and provides less regular non-photic
input into the circadian system (e.g., the social zeitgeber hypothesis (Ehlers, Frank, &
Kupfer, 1988)), 2) The sleep phase of those with depression has advanced (Wehr, WirzJustice, Goodwin, Duncan, & Gillin, 1979), and 3) There is a problem with the restactivity ratio (Fulton, Armitage, & Rush, 2000). In humans, with decreasing light, total
sleep time and melatonin secretion increases, and activity decreases (Goodwin, WirzJustice, & Wehr, 1982), thus the ratio of rest to activity increases. There is some evidence
that in teens these effects are mediated by gender (Armitage et al., 2004). If a client is
unaware of a phase advance, their bedtime would not change even though sleepiness
Depression and Insomnia
11
should occur earlier, there may also be dozing during this period of sleepiness, thus
activity would both be increased in this scenario and may actually be less. Most clients
with EMAs do not respond to the awakening by getting out of bed for the day, so in
this scenario, the rest period is extended, and again, this would increase the ratio of rest
to activity. An increase in rest to activity might have a negative impact on interpersonal
contact, as people are less likely to socialize when exhausted, and they would be unlikely
to have significant social contact in the evening while dozing.
Other lines of research have focused on analyzing the EEG data of sleeping patients
with MDD with spectral analytic techniques. One line of research has focused on
coherence, or the similarity of activity in two areas (Fulton et al., 2000). There is evidence
that decreased coherence is associated with MDD and also predicts MDD recurrence
(Fulton et al., 2000). One caveat to this finding is that findings are moderated by age
and sex (Armitage, Hoffmann, Emslie, Rintelmann, & Robert, 2006). Many of these socalled markers can be characteristic of insomnia with perhaps the exception of REMS
abnormalities; thus the specificity of these indices can be somewhat poor.
There is a longstanding tradition to view psychiatric disorders as emanating from an
imbalance in neurochemicals, and there are purported chemical abnormalities (e.g.,
cholinergic hypersensitivity (Gillin, Sitaram, & Duncan, 1979) and/or serotonergic or
noradrenergic sensitivity (McCarley, 1982)) as key in the sleep disturbances in those
with MDD-I. It is unclear which of these can be considered traits versus state-like
markers (Berger, Riemann, Höchli, & Spiegel, 1989) moreover some predictions about
medications with particular properties (e.g., see Riemann, Berger, & Voderholzer, 2001;
Sitaram, 1982) do not always yield data consistent with such theories.
Of course, in each of these models, one could posit more depression-specific models
as accounting for some of the sleep problems in MDD-I. For example, interpersonal
theories could suggest that engaging in less interpersonal activity could decrease
stimulation and reinforcers and lead to decreased overall activity, thus increasing the rest
to activity ratio. With fewer people around to constrain a schedule towards conventional
regularity, there would also be less social zeitgeber input into the clock. Lastly, cognitive
etiological models focus on the importance of depressogenic thought leading to avoidance
behaviors including less social behaviors. Avoidance would have a negative impact on
the circadian system as there would be less exposure to light (perhaps increasing the rest
to activity ratio) and less exposure to regular non-photic zeitgebers that provide input
into the clock. All theories of depression and MDD-I have mixed evidence or competing
explanations; likewise, the failure to discover a universal marker with high sensitivity and
specificity is perhaps not surprising given that MDD is a polythetic disorder (for
discussion, see Carney & Moss, 2014). A polythetic disorder is a disorder in which there
are numerous variations of clinical presentations within the diagnostic criteria. Whereas
everyone with Bulimia Nervosa meets the same symptom criteria for the disorder,
someone with MDD could have insomnia, hypersomnia, or no sleep complaint at all.
Additionally, appetites can be increased, decreased, or unchanged. There may or may
not be a disturbance in mood, there may be anhedonia or this may be absent, or one could
have both anhedonia and depressed mood. Psychomotor activity may appear significantly
sped-up or remarkably slowed down and there may or may not be fatigue. The
permutations of presentations become quite large and it is difficult to imagine that all
would have the same biological substrates and sleep characteristics.
12 Depression and Insomnia
Perhaps a more parsimonious way of conceptualizing etiology in MDD-I clients who
present for treatment is to understand that it is not always possible to identify the
precipitant cause of the MDD-I so focusing on current perpetuators may be more
important.
Etiology in MDD-I
As stated previously, Spielman (Spielman et al., 1987a) suggests that there are predisposing, precipitating, and perpetuating factors for insomnia, and perpetuating factors
are key targets for chronic insomnia treatment. Applying Spielman’s ideas to MDD-I,
predisposing factors are factors that increase vulnerability but, in the absence of a
stressor, are not associated with an insomnia diagnosis. For example, particular genes,
a tendency towards rumination or a particular endogenous chemical environment,
may increase the risk for MDD-I, but without a stressor, whether endogenous or
environmental, sleep disturbance may be expected to remain at a subclinical level.
Broadly speaking, a precipitant is a stressor, which interacts with the predisposing
factors to increase sleep disturbance. A strong enough stressor (e.g., a life event) may
cause a sleep disturbance severe enough to warrant an insomnia diagnosis, however,
the expectation is that when the stressor resolves, so should the insomnia. However, in
the clinical histories of clients with MDD-I it is common to hear about the stressor
resolving and to the client’s surprise and disappointment, the insomnia does not remit.
The answer to why the insomnia does not remit, is that perpetuating factors arise that
take over as the main cause of insomnia, and the insomnia becomes chronic. This is
often explained to clients during the psychoeducation component of the first CBT-I
session because the fact that the insomnia has persisted beyond the resolution of the
initial stressor is often taken to mean that the sleep system is broken and the client
believes they are powerless to fix it. Explaining that making behavioral corrections to
perpetuating behaviors will fix the problem is empowering for clients. Perpetuating
factors often originate from coping with the sleep and/or mood symptoms first created
by the stressor. For example, when feeling fatigued, people tend to engage in fewer
activities in response. When feeling tired, whether it is related to mood or sleep
symptoms, people may spend more time at rest and in bed in the 24 hour period.
For some, this may relate to how poorly they feel, for others this may relate to a belief
that producing more sleep may help to improve their situation, and being in bed for
longer periods gives them the best chance to produce more sleep. Some may take
sleep aides, whether in the form of alcohol, marijuana, or sedating medications such
as diphenhydramine, or sleep medications. A protracted sleep problem can result in a
preoccupation about symptoms (Harvey, 2002) and why they are occurring (e.g.,
symptom-focused rumination) (Carney, Harris, Falco, & Edinger, 2013b; Carney,
Harris, Moss, & Edinger, 2010b), and rumination can become a prominent factor in
the case. A common perpetuating factor that develops is a belief about sleep effort.
Understandably, to “solve” the sleep problem, people with insomnia increase their
efforts to sleep and become cognitively inflexible in their belief that one must exert effort
to produce and compensate for sleep (Espie, Broomfield, MacMahon, Macphee, &
Taylor, 2006). In sum, although insomnia could develop from endogenous factors
described above, insomnia may also develop as an acute stress reaction to the onset of
Depression and Insomnia
13
depression—additionally, depression could arise from endogenous factors relating to
the sleep problem or other sources, or the depression could develop as a stress reaction
to chronic insomnia.
Now we turn to the three perpetuating factors of chronic insomnia and ask whether
those with MDD-I have the same factors—the answer is yes. Those with MDD-I report
comparable levels of unhelpful related thinking about sleep (Carney, Edinger, Manber,
Garson, & Segal, 2007a), including the belief that sleep requires effort (Kohn & Espie,
2005) as those with insomnia only. Similar to those with insomnia, those with MDD-I
also exhibit increased variability in the timing of the sleep period (Kohn & Espie, 2005),
as well as other zeitgebers (Szuba, Yager, Guze, Allen, & Baxter, 1992). Again, similar
to those with insomnia, those with MDD-I show decreased activity as well as increased
time-in-bed (Kohn & Espie, 2005). Lastly, those with insomnia and those with MDDI similarly show increased arousal (Kohn & Espie, 2005) and symptom-focused
rumination (Carney et al., 2013b). Given that: 1) Insomnia is such a prominent,
debilitating part of MDD-I, with implications for quality of life and depression
outcomes, and 2) MDD-I shares the same perpetuating factors effectively targeted by
CBT-I, CBT-I seems particularly well suited for the task of dissemination in this group.
Thus the remainder of this book focuses on CBT-I in this group, including, issues related
to medication (Chapter 2), treatment delivery issues (Chapter 3), assessment in nonsleep specialty settings (Chapter 4), behavioral and cognitive components of CBT-I
(Chapters 5 and 7), as well as how to troubleshoot common CBT-I delivery problems
in MDD-I (Chapter 6), rumination strategies (Chapter 8), and combined approaches
to MDD-I (Chapter 9). The last chapter follows a case through CBT-I treatment
(Chapter 10).
Summary
•
•
Insomnia is costly and important to treat in those with MDD-I.
Although there are innumerous possible precipitants for MDD-I, there are three
main causes of chronic insomnia: issues with the circadian or homeostatic systems
and/or problems with arousal.
–
–
–
•
•
Circadian system problems include schedule variability (e.g., varying rise time)
or attempting to sleep during times that conflict with the biological clock.
Homeostatic problems include too little accumulation of sleep drive to sustain
deep sleep (e.g., decreased activity or too much time at rest in a 24 hour
period).
Arousal problems include conditioned arousal and cognitive and/or physiological hyperarousal.
There are a number of sleep abnormalities in those with MDD-I (e.g., REMS
abnormalities) and theories to account for them. Such abnormalities are not
characteristic of all clients with MDD-I.
Those with MDD-I share the same perpetuating factors for their insomnia as those
with insomnia only, and are thus, good candidates for CBT-I.
2
Non-psychological Treatments
for Those with Insomnia and
Depression
Pharmacological Treatments
for Depression
There are a variety of effective pharmacological and other medical treatments for
depression; some induce sedation and improve sleep, some increase arousal and
interfere with sleep, and others are neutral with respect to sleep. In most cases the
effects on sleep are variable, with some individuals experiencing benefits and others
experiencing worsening or no effect on their sleep. The American Academy of Sleep
Medicine (AASM) has published consensus guidelines for treating insomnia (SchutteRodin, Broch, Buysse, Dorsey, & Sateia, 2008). The algorithm from the AASM (see Figure
2.1) suggests to first evaluate cost, and then preference and availability options for
Cognitive Behavior Therapy for Insomnia (CBT-I), pharmacologic, and combined
treatments. It is of note that NIH consensus guidelines (National Institutes of Health
State, 2005) and British Association of Pharmacotherapy guidelines (Wilson et al., 2010)
are that CBT-I should be the frontline treatment, and CBT-I is at the top of the AASM
algorithm. Once a decision is made to proceed with pharmacotherapy, the algorithm
presents a sequence in which the physician begins with a full dose antidepressant and
a Food and Drug Administration (FDA)-approved hypnotic such as benzodiazepine
receptor agonist (BzRA) or ramelteon. Following a poor sleep response, the second step
in the algorithm is to reconsider the diagnosis and consider switching therapy to CBTI or a combined approach. If there is non-response following this new approach, a
different BzRA or ramelteon trial begins. Following a poor response to these approaches,
a sedating antidepressant is suggested. Thus, all things considered, the suggestion of a
sedating antidepressant is one of the last recommended options because other
approaches have better efficacy and safety data available (Riemann et al., 2002; Wilson
et al., 2010).
One myth about antidepressant therapies is that they improve objective sleep, but
patients are unaware of the improvements (Clark, Smith, & Jamieson, 2011). In other
words, there are objective improvements but not subjective improvements. There are
several problems with this idea. One problem is that it may be unrealistic to expect that
clients will continue to adhere to a treatment regimen if they cannot perceive any
improvements. Although sedating antidepressants can improve some polysomnographic sleep indices, the results are mixed both in terms of the specific medication and
the specific indices of sleep fragmentation and sleep quality. There is also evidence that
some antidepressants can worsen or create sleep problems. That said, of greater interest
is that the use of objective indices as primary dependent variables in insomnia trials
Non-psychological Treatments 15
ignores the essential fact that insomnia is a subjective, not an objective disorder.
Diagnosis is based on a subjective patient complaint and there are no quantitative criteria
for the disorder, so to emphasize objective indices in insomnia is not appropriate. The
goal of therapy is to treat the insomnia complaint, and not a particular index on the
PSG. Indeed, ordering PSGs in those with insomnia is not considered within practice
parameters for the disorder (Littner et al., 2003). That is, overnight studies are not
recommended for routine use in the assessment of insomnia unless there is a suspicion
of another disorder such as apnea or periodic limb movements. Incidentally, there is
evidence that some of these occult sleep disorders can in fact be caused or made worse
by some antidepressants (Rottach et al., 2008). Objective measures of insomnia represent
a different, but not a superior construct to prospective subjective ratings. Indeed, this
is why sleep diaries are essential in the field of insomnia treatment (Buysse, AncoliIsrael, Edinger, Lichstein, & Morin, 2006). For more detail on why prospective self-report
measures (i.e., the Consensus Sleep Diary) are preferred over objective indices, see
Chapter 4.
These issues above notwithstanding, below we will briefly review the antidepressant and sleep literature. There are several pharmacologic agents with established
efficacy for depression, including monoamine oxidase inhibitors (MAOIs), tricyclics,
selective serotonin reuptake inhibitors (SSRIs), Selective Serotonin and Norepinephrine
Reuptake Inhibitors (SNRIs), and atypical antidepressant medications. MAOIs are
infrequently used because they are difficult medications to utilize given that the patient
has to follow particular strict dietary restrictions lest they risk significant and potentially
dangerous side effects. Given the uncommon use of MAOIs, we will focus on the other
four classes.
Cognitive Behavioral Insomnia Therapy (CBT-I) possible?
No.
Weigh clinical factors. All things considered,
sequencing is:
Yes.
Cognitive Behavior Therapy for
Insomnia (CBT-I)
Short-intermediate acting benzodiazepine
receptor agonist or ramelteon
nonresponse
Switch to other short-intermediate acting
benzodiazepine receptor agonist or ramelteon
nonresponse
Sedating antidepressant (e.g., TCA, doxepin)
nonresponse
• symptom pattern
• treatment goals
• past treatment responses
• patient preference
• cost
• availability of other treatments
• comorbidconditions
• contraindications
• medication interactions
• side effects
Atypical antipsychotic or anti-epilepsy
(e.g., gabapentin, olanzepine)
Figure 2.1 American Academy of Sleep Medicine pharmacotherapy treatment algorithm
16 Non-psychological Treatments
Tricyclic antidepressants: Although there is good evidence for the use of tricyclic
medications in the treatment of depression (Arroll et al., 2005), there are concerns with
safety, so the use of these medications requires a cost-benefit analysis. Although tricyclic
medications are primarily used to treat depression, they are sometimes used “off-label”
for sleep. Off-label is the term applied when a medication is used for a problem for
which there is no specific indication. There is one randomized controlled trial (RCT)
for tricyclics (i.e., trimipramine) and insomnia (Riemann et al., 2002). In the Riemann
and colleagues’ trial (2002) there was evidence for increased sleep efficiency only, as
well as some indices of improvement in subjective appraisal of sleep. Whereas some
believe that antidepressant effects may be mediated by REM suppression, trimipramine
is one of the few drugs not known to suppress REMs. Based on the one RCT, the British
Association for Psychopharmacology Consensus Guidelines on Insomnia concluded
that evidence for tricyclics for insomnia was “limited” and that there may be safety issues
and carry-over effects of concern for daytime driving and safety (Wilson et al., 2010).
An additional reason tricyclics are seldom used is the lethality potential in an overdose.
Both insomnia and depression are independent predictors of suicide (see Woznica
et al., 2014) so overdose must be a heavily weighted clinical factor.
Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs are efficacious, commonly
prescribed antidepressant medications that inhibit the reuptake of the neurotransmitter
serotonin. Commonly prescribed SSRIs for depression are: fluoxetine, citalopram,
escitalopram, and sertraline. SSRIs are widely used because of their favorable side
effect profiles relative to older medication classes. The effects of SSRIs on sleep are
variable. About one third of those treated with SSRIs experience polysomnographic
(PSG) verified worsening of sleep, including decreased slow wave sleep and reduced
efficiency of sleep (Armitage, 2000). Disruptions in sleep have been reported as long
as 30 weeks after SSRI discontinuation (Armitage, Yonkers, Cole, & Rush, 1997; Keck,
Hudson, Dorsey, & Campbell, 1991; Minot, Luthringer, & Macher, 1993; Trivedi et al.,
1999). Subjective assessment of insomnia using sleep items on depression inventories
have revealed modest improvement for some (Asnis et al., 1999; Fava et al., 2006) and
worsening in others (Zajecka et al., 1999). Although SSRIs are effective for depression,
they are generally not helpful for insomnia, as insomnia is a residual problem after
depressive recovery with SSRIs (Carney et al., 2007a; Nierenberg et al., 1999). Thus,
because insomnia is sometimes caused by and often unresolved after SSRI treatment, the use of SSRIs alone cannot be considered a sufficient strategy for those
with comorbid insomnia and depression. Instead, the independent targeting of both
depressed mood and insomnia is a more efficient, comprehensive alternative. A few
trials have examined pairing SSRIs with another medication for enhancing overall
treatment response. For example, combining a SSRI with trazodone improves insomnia
to a greater degree relative to using an SSRI alone, although there is no advantage with
respect to depression outcomes (Kaynak, Kaynak, Gözükırmızı, & Guilleminault,
2004; Nierenberg, Adler, Peselow, Zornberg, & Rosenthal, 1994). Despite improvement
in insomnia, given the lack of additional antidepressant benefit and the presence of
several safety issues (for more see atypical antidepressants below), there are reasons
to pause in considering trazodone as an adjunct medication. An alternative is to
combine SSRIs with a U.S. FDA approved sleep medication. There are two studies combining SSRIs with approved hypnotic medications with promising results for both
Non-psychological Treatments 17
depression and sleep (Asnis et al., 1999; Fava et al., 2006). Of note, combining fluoxetine
and eszopiclone improved sleep to a greater degree than fluoxetine alone, but more
importantly, the combined group had greater depression outcomes (Fava et al., 2006).
Likewise depression and sleep were improved in the Asnis et al. (1999) study, although
there was a worsening of sleep after discontinuation of the hypnotic. In both trials, there
were short treatment periods so it is unclear whether this approach is effective in the
long run. One additional note is that antidepressant medications can cause or worsen
restless leg syndrome (RLS) or periodic limb movement disorder (PLMD) (Hoque &
Chesson, 2010) as well as bruxism (Ellison & Stanziani, 1993).
Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs): SNRIs are
efficacious antidepressant medications that inhibit the reuptake of both serotonin and
norepinephrine. Like SSRIs, they are preferentially used because of their relatively safe
profile. The three most common SNRIs are: duloxetine, venlafaxine, and desvenlafaxine.
SNRIs are comparable to SSRIs with respect to depression efficacy. However, there is
some evidence that SNRIs have less of an impact than SSRIs on self-reported sleep
improvement in those with depression (Pigott et al., 2007). However, in Pigott et al.
(2007) sleep was evaluated using only single item questions from depression questionnaires, not insomnia-specific questionnaires, and the differences did not reach statistical
significance; so it is unknown as to whether SNRIs yield poorer sleep outcomes than
SSRIs. As with SSRIs, insomnia can be a side effect of SNRIs and there is no reason to
think that residual insomnia wouldn’t be a significant problem as well. Nonetheless,
SNRIs are relatively well tolerated, efficacious, and their impact may be increased by
adding an effective hypnotic medication. As with SSRIs, SNRIs can cause or exacerbate
RLS and periodic limb movements in sleep (PLMS) (Hoque & Chesson, 2010).
Atypical antidepressants: Atypical antidepressants have different pharmacokinetics
than the commonly used SSRI and SNRIs. Below we will discuss two atypical antidepressants: trazodone and mirtazapine and their use in those with MDD-I. At low doses,
trazodone will not have much of an antidepressant effect, but can have sedation as a
side effect, and thus was tested as a sleep aide for antidepressant-induced insomnia.
Indeed, pairing low dose trazodone with a SSRI improves sleep to a greater degree than
SSRI only (e.g., Kaynak et al., 2004; Nierenberg et al., 1994; Nierenberg & Keck, 1989;
Zornberg & Rosenthal, 1994). Presumably because of its effectiveness as a treatment
for the sleep-iatrogenic effects of antidepressant medications, trazodone has been used
off-label use as a hypnotic despite the paucity of effectiveness and safety data in insomnia
(e.g., Walsh & Uestuen, 1999). Mendelsohn (2005) reviewed the literature and
concluded that the risk benefit ratio for selecting trazodone was uncertain. This was
because the evidence is limited (e.g., studies available are small and with poor methodology) and there are safety issues (e.g., sedation, psychomotor changes, and cardiac
issues). These sentiments have been echoed by the leaders in sleep psychiatry in many
other reviews and in guidelines, sedating antidepressants are low on the options list
(Schutte-Rodin et al., 2008). Although there have been no new compelling trazodone
studies, this drug frequently continues to be used off-label in those without depression.
The British Association for Psychopharmacology Consensus Guidelines on Insomnia
concluded that evidence for trazodone was “limited” and there is cause for concern about
carry-over effects and safety (Wilson et al., 2010).
18
Non-psychological Treatments
Mirtazapine has good efficacy in treating depression and one of its side effects is
sedation. There are no studies of mirtazapine in insomnia without depression; therefore the somewhat common practice to treat only insomnia is considered off-label.
There are however a number of studies evaluating sleep improvements in depression
(Aslan, Isik, & Cosar, 2002; Winokur et al., 2000, 2003). Although total sleep time
and sleep efficiency appear to be improved with this medication, these studies are
limited by measurement issues (e.g., using only sleep items from depression measures
or sleep measures with dubious psychometrics in comorbid groups) (Aslan et al., 2002;
Hartmann, Carney, Lachowski, & Edinger, 2015; Winokur et al., 2000, 2003). Of greater
concern is that the sedation can be severe enough to be associated with functional and
psychomotor impairments, as well as impaired driving (Radhakishun, van den Bos, van
der Heijden, Roes, & O’Hanlon, 2000; Wingen, Bothmer, Langer, & Ramaekers, 2005).
Another concern with mirtazapine is that, as with many antipsychotic medications, there
is risk for significant weight gain, increase in body fat mass, and leptin concentration
(Laimer et al., 2006). Weight gain of this sort might be of particular concern in those
prone to or with comorbid sleep apnea. Finally as with SSRIs and SNRIs, mirtazapine
can cause or exacerbate RLS and PLMS (Hoque & Chesson, 2010).
Many antidepressants may also produce daytime sedation and this common side
effect has been linked to study participant withdrawals from sedating antidepressant
trials (e.g., Metz & Shader, 1990). An additional unfortunate consequence of this side
effect is that the increase in daytime sedation may interact with the sleepiness generated
by the sleep restriction recommendations in CBT-I, and thus, may create the potential
for a dangerous situation. In other words, delivering CBT-I to patients on sedating
antidepressants warrants extra caution because of concerns of falling asleep during
dangerous situations, such as driving. There may be other reasons (i.e., other than safety)
to be concerned with using medication solely because it produces sedation as a side
effect. The most common complaint in insomnia is daytime fatigue, and feeling fatigued
can trigger rumination in those with insomnia (Carney et al., 2006, 2010b; Carney,
Moss, Lachowski, & Atwood, 2013c). Figure 2.2 shows how medication with a side effect
of daytime sluggishness can trigger preservative thinking about their sleep problem
(i.e., symptom focused rumination). Symptom-focused rumination in insomnia, as well
as MDD-I, is characterized by thinking about how badly it feels to be exhausted as well
as thinking about the cause of the symptoms. In both insomnia and MDD-I, patients
tend to presume that the sole cause of feeling tired or sluggish is the insomnia (Harris
& Carney, 2009), so sleep worry, effort, and preoccupation become increased. Indeed,
thinking repeatedly about sleep is the best predictor of sleep onset latency problems
(Wicklow & Espie, 2000). Thinking repeatedly about exhaustion during the day further
increases the tendency towards selective monitoring for feelings of sluggishness, and
narrows attention on confirmatory examples that functioning is impaired (Harvey,
2002). Thus, daytime sedation from medication can inadvertently perpetuate insomnia
in some, even when sleep itself may look objectively better with CBT-I. In other words,
when delivering CBT-I, if daytime sedation remains (i.e., because of the sedating
antidepressant), the patient may not appreciate improvements in sleep, even when sleep
is verified with objective or self-reported indices such as the sleep diary. It can be difficult
for patients to appreciate an improvement in their sleep because the number one
complaint in insomnia is often daytime fatigue; thus, daytime sedation can be distressing
Non-psychological Treatments 19
Medication
Sluggishness
Increased
anxiety about
insomnia
Thoughts
about mental
cloudiness
Presume
cause is
insomnia
Rumination
about cause
of
sluggishness
Figure 2.2 Putative relationship between sedating medications and rumination
to insomnia sufferers (Harris & Carney, 2009). Thus, there are many reasons sedating
antidepressants are one of the last options in the sequence in the list of treatment options
presented in insomnia treatment algorithms (see Figure 2.1).
St. John’s Wort: St. John’s Wort is not an approved, regulated medication for MDD,
but is taken by many patients. The active ingredient in St. John’s Wort is hypericum
perforatum. Large, controlled studies in those with moderate to severe MDD do not
support hypericum as more effective than placebo (Hypericum Depression Trial Study
Group, 2002; Montgomery, Hübner, & Grigoleit, 2000; Shelton et al., 2001). However
some studies with mild depression report that hypericum produces comparable effects
to standard antidepressant medications, but with a more favorable side effect profile
(Linde, Berner, Egger, & Mulrow, 2005). In addition to questionable efficacy in clinically
significant depressions, an additional concern with St John’s Wort, is that it may increase
photosensitivity (Brockmöller et al., 1997; Lane-Brown, 2000). Photosensitivity may be
of concern for sleep in St. John’s Wort users because it could delay melatonin release
as well as sleep onset.
Other Non-Psychological Treatments for Depression
Electroconvulsive Therapy (ECT): ECT is an effective treatment for depression in which
electricity is transmitted through electrodes on the scalp to the brain to induce cortical
seizure activity. Effect sizes for ECT are large (The UK ECT Review Group, 2003).
Although it is more effective than pharmacotherapy, it is less frequently used because
20
Non-psychological Treatments
of the side effects (mainly memory impairments) and because of low patient preference.
There are no studies specifically investigating the effects of ECT on sleep, but there appear
to be no specific effects, disruptive or restorative, on sleep per se. Some studies on ECT
have reported outcome data for various indices of sleep. One study reported that
ECT increased core body temperature and increased circadian amplitude, which was
taken to mean that circadian rhythm functioning improved (Szuba, Guze, & Baxter,
1997); however this finding has not been replicated. Additionally, in rats ECT did not
exert an effect on the circadian pacemaker (Anglès-Pujolràs et al., 2009). There are no
studies that have looked at the combination of ECT with hypnotics or CBT-I, or whether
this has any advantage over CBT-I alone or combination therapy with medication for
MDD-I.
Transcranial Magnetic Stimulation (TMS): TMS involves placing a coil on the scalp
so that magnetic pulses (similar to those produced in MRI) can change the magnetic
field in the prefrontal cortex of the brain and stimulate activity. Meta-analyses suggest
this is an effective treatment and that effect sizes are comparable to that of antidepressant
medication (e.g., Berlim, Van den Eynde, & Daskalakis, 2013). There appear to be very
few side effects; the most common is scalp discomfort, but there are rare reports of seizure
or mania. There are no differences in sleep between TMS-treated and sham-treated
patients so there does not appear to be a TMS-mediated sleep change (improvement or
worsening) (Rosenquist, Krystal, Heart, Demitrack, & McCall, 2013).
Vagus Nerve Stimulation (VNS): VNS is a treatment for depression in which a
subcutaneous stimulation device is implanted in the chest, and the generator produces
intermittent pulses into the vagal nerve. The stimulation of the vagal nerve has mood
improving properties. Although it has Federal Drug Administration (FDA) approval
for chronic, recurrent depressions (George et al., 2005), it is a costly procedure, with all
the risks associated with surgery. Any study evaluating insomnia after VNS has been
limited by assessing an insomnia symptom with a single item on an invalidated sleep
tool (i.e., an adverse event inventory). One exception is a study of sleep architecture
after VNS (Armitage, Husain, Hoffmann, & Rush, 2003). One paper cited this study as
showing that VNS improves sleep architecture (Eitan & Lerer, 2006) however, it is
important to note that the report of decreased N1 and time awake was not statistically
significant and there was an increase in light transition stage of sleep (e.g., N2)
(Armitage et al., 2003). One important negative consequence of VNS is a worsening of
OSA (Ebben, Sethi, Conte, Pollak, & Labar, 2008); thus, an evaluation of OSA and concurrent treatment with positive airway pressure (PAP) devices is needed if considering
this treatment.
Pharmacological Treatments for Insomnia
Hypnotics
Sleep medications approved by Health Canada or the Federal Drug Administration
(FDA) are considered an effective treatment option for insomnia. A list of approved
medications is contained in Table 2.1 that follows later. Generally, approved medications
fall under benzodiazepine or non-benzodiazepine categories. Benzodiazepines are a class
of medications that facilitate gamma aminobutyric acid (GABA). GABA is thought to
Non-psychological Treatments 21
have a calming effect on the brain and therefore may be important in the onset of
sleep. Benzodiazepines work as benzodiazepine receptor agonists that target GABA alpha
receptors. Examples include the first five in Table 2.1 (e.g., estazolam, flurazepam,
temazepam, triazolam and quazepam). There are also non-benzodiazepine medications
that do not have a benzodiazepine structure but operate in similar fashion to benzodiazepines, in that they are GABA agonists that target very specific alpha receptors.
Examples include zolpidem or eszoplicone (Z-drugs). Note in Table 2.1 that the binding
for traditional benzodiazepines (the first five) is for GABA receptors generally, but this
represents nonspecific binding to a receptor. In contrast, the Z-drugs (the next four on
the list) bind to very specific GABA receptors in the brain. For example, zolpidem binds
to GABA A alpha 1 receptors only. Z-drugs were developed to have a better side effect
profile than the benzodiazepines. The thought was that a more specific binding would
lead to fewer side effects. This is generally true in that the side effects are less severe for
Z-drugs (Buscemi et al., 2007) but there are a variety of potential negative side effects
with these medications that limit their attractiveness as an optimal solution for all people
with insomnia. These include carry-over daytime sedation, tolerance, rebound insomnia
upon discontinuation, or in rare cases, the emergence of parasomnia like behaviors
during the night while asleep including sleepwalking, or sleep sex. Further, epidemiological studies show that road accidents are increased in people taking benzodiazepines
or zopiclone (Barbone et al., 1998; Neutel, 1995). In contrast, it is important to note
that there is no increased risk for auto accidents in those with unmedicated insomnia.
There are also issues with a sensation of daytime sedation and cognitive issues, e.g.,
difficulty in concentrating, remembering, etc. As a result, there are now regulations
requiring warnings on these medications about driving and the lowest recommended
doses were reduced, especially for woman (United States Food and Drug Administration, 2013, 2014). Additionally, the FDA (e.g., United States Food and Drug Administration, 2007) issued a ruling mandating manufacturers to place warnings about
parasomnias and to notify patients about the changes.
Remelteon
Perhaps because patients became wary of sleeping pills, there has been increased
research and development in the pharmaceutical industry to produce medications
different from the benzodiazepine agonists on the market. One new drug that emerged
was a melatonin agonist called ramelteon. To gain approval for the labeling as a sleep
aid, remelteon had to demonstrate efficacy. There is published evidence for this drug
for sleep onset insomnia, but not maintenance insomnia. The side effects include
sedation (when taken during the day), and slowing in performance (Mets et al., 2011).
There is also a mild increase in prolactin for women taking it for six months (Richardson
& Wang-Weigand, 2009).
Doxepin
Doxepin is a prescription medication that is a histamine (H1) receptor antagonist, or
antihistamine. There is some evidence of improvement in maintenance insomnia
although this drug doesn’t appear to be consistently effective by patients’ appraisal (Hajak
22
Non-psychological Treatments
et al., 2001) and there is evidence of rebound insomnia. Side effects of doxepin include:
sedation, nausea, upper respiratory tract infection, weight gain, constipation, urinary
retention, dry mouth, and blurred vision. Doxepin is highly toxic in an overdose
attempt (e.g., (Hawton et al., 2010)) and both MDD (Bertolote, Fleischmann, De Leo,
& Wasserman, 2004) and Insomnia Disorder confer risk independently for suicide
(Woznica et al., 2014), so this can be a dangerous drug in these populations.
Table 2.1 also lists the half-life of each of the medications. The half-life of a medication
refers to the time it takes for the concentration of the drug in the body to be metabolized
by half and therefore to lose half of its effectiveness (i.e., half of the drug is used up).
A very long half-life would be most effective for people with problems staying asleep
throughout the night (e.g., dalmane). A long half-life is also associated with increased
sedation during the day as the drug remains in the system. A short half-life is most
commonly used for those with sleep onset insomnia only. The short half-life would limit
the leftover effects of the medication the next day but would be less effective if the patient
woke up in the middle of the night.
In summary, it should be noted that the hypnotic medications specifically designed
to target insomnia have established efficacy for its treatment (Schutte-Rodin et al.,
2008), but they also confer some degree of risk with regard to side effects. Moreover,
CBT-I has demonstrated effectiveness equal to that of hypnotics in the short run, but
a greater durability of effectiveness over time, which is why it is considered the frontline
recommended treatment for a chronic insomnia (National Institutes of Health, 2005).
Off-label and Over the Counter Medications
There are a number of over-the-counter (OTC) medications designed for insomnia or
medications with sedation as a side effect, that are used off-label for insomnia. The most
common example of this is the allergy medication diphenhydramine. Diphenhydramine
is an antihistamine and histamines are important in maintaining wakefulness. Thus,
blocking histamines can produce a side effect of sleepiness or sedation, so it seems
intuitive that some people use it for insomnia. However, such medications can also
Table 2.1 FDA-approved sleep medications
Generic name
Binding
Lowest therapeutic
dose (mg)
Half-life (hours)
Estazolam
Tiazolam
Temazepam
Flurazepam
Quazepam
Eszopliclone
Zaleplon
Zolpidem
Zolpidem-ER
Ramelteon
Silenor
Nonspecific
Nonspecific
Nonspecific
Nonspecific
Nonspecific
GABA Aα1,2,3
GABA Aα1
GABA Aα1
GABA Aα1
MT1, MT2
H1
1
0.125
15
15
7.5
1
5
5
6.25
8
3
10–24
2–6
8–20
48–120
39–73
6
1
1.5–2.4
1.6–4.5
0.8–2
15–31
Source: Adapted from Walsh and Roth (2011); Krystal (2011)
Non-psychological Treatments 23
produce a paradoxical side effect of anxiety and restlessness which would clearly worsen
or even precipitate insomnia. Other side effects include dizziness, blurred vision,
constipation, and urinary retention. Ultimately antihistamines are not recommended
in the treatment of chronic insomnia due to the relative lack of efficacy and safety data
(National Institutes of Health, 2005).
Melatonin
Melatonin is a hormone excreted in the evening after the sunlight goes down that sets
the stage for sleep several hours later. Melatonin is subject to environmental input such
that exposure to evening light will delay the release of onset and this is associated with
taking a longer time to fall asleep. That said, there is no evidence to date of any
melatonin problems in insomnia. There is a report that circulating levels of melatonin
decrease with advancing age (e.g., Iguchi, Kato, & Ibayashi, 1982) but it is unclear if
these results are clinically meaningful (i.e., the significance of “decreased” melatonin is
unclear). Oral melatonin supplementation has been demonstrated to be effective in a
Circadian Rhythm disorder called Delayed Phase Syndrome. In those with a delayed
sleep phase, their entire rhythm is shifted many hours later than most (i.e., they become
sleepier many hours later than is conventional and they rise many hours later than is
conventional, for more see Chapter 3). For those with this disorder, melatonin release
occurs much later and thus, sleep onset is delayed. To correct this problem, melatonin
properly timed in the evening can help to shift or advance their cycle earlier. Despite
not suffering from a circadian rhythm disorder, some people with insomnia take
melatonin before bed as a sleep aide. There are several problems with this practice. First,
melatonin takes up to 2 hours to become effective. Second, when taken immediately
before getting into bed, endogenous melatonin would have already been present in the
brain for several hours and would therefore exert no effect. Taking melatonin before
bed does not improve sleep at night because when endogenous melatonin is already
present in the brain, there is no additive benefit of introducing exogenous melatonin
(i.e., a pill) (Wyatt, Dijk, Cecco, Ronda, & Czeisler, 2006). In contrast, consuming oral
melatonin in the early evening, results in sleepiness several hours later (because there
was no melatonin present in the brain when the pill was taken) (Wyatt et al., 2006).
Thus, it can be said that melatonin is a decent chronobiotic, but not a very good
hypnotic. In other words, it can be useful in shifting circadian phase but not so useful
in putting people to sleep. In the few supporting studies for melatonin, the effects are
so small that it is questionable that the benefits are of any real clinical utility. For example,
one meta-analysis examined positive studies and reported a mean increase of sleep
efficiency of 2 percent, an increase in total sleep time across the entire night of only 12
minutes, and a decrease in sleep onset latency of only 4 minutes (Brzezinski et al., 2005).
Although there may be some statistical significance for some of these findings, these
may not be particularly meaningful to the patient. Moreover there are studies reporting
negative findings for melatonin (i.e., that sleep worsens). In Buscemi and colleagues’
(2006) meta-analysis, melatonin’s hypnotic effects were negative when given before bed
(Buscemi et al., 2007). Therefore although the public at large may be increasingly using
melatonin to help with insomnia, there is no real supporting evidence for its efficacy
as a hypnotic.
24
Non-psychological Treatments
Valerian Root
Valerian root purportedly improves anxiety and promotes sedation. It appears to work
by facilitating adenosine and amino acids such as GABA. Valerian root has shown some
positive effects for sleep in healthy sleepers but not in those with insomnia. NIH’s
Complementary Medicine branch has concluded that there is not enough evidence from
well-designed studies to confirm efficacy and there is a lack of information about the
long-term safety of valerian (National Center for Complementary and Integrative
Health, 2012). Valerian can cause mild side effects, such as tiredness the morning
after its use, headaches, dizziness, and gastrointestinal symptoms. Additionally there
is wide variability in how valerian, and other non-regulated substances are prepared,
and the variability in the extraction process and form. This is an important consideration because whether it is dry or aqueous and whether alcohol is used in the process
affects the active ingredients. Moreover, some types of valerian involve valepotriates
which have been linked to cytotoxicity (cell death) and carcinogenic (i.e., cancer) potential (Houghton, 1999). The bottom line is that because such preparations are not
regulated, patients may not know what they are ingesting.
5-Hydroxytryptophan (5-HTP)
5-HTP is an amino acid that is the intermediate step between tryptophan and 5-HT.
Because of the role of 5-HT (serotonin) in sleep, it makes sense that one might consider
boosting serotonin to help sleep. There is a paucity of rigorous studies testing 5-HTP
thus, there is no scientific evidence for the use of 5-HTP in insomnia (Meolie et al.,
2005).
Cognitive Behavior Therapy for Insomnia (CBT-I) versus sleep
medications
CBT-I and approved sleeping medications have comparable efficacy; that is, they both
typically produce medium to large effect sizes across a variety of sleep indices (Smith
et al., 2002). There are, however, a few ways in which they diverge. For example, unlike
pharmacotherapy, the treatment gains achieved with CBT-I endure for years after the
end of active therapy (Edinger et al., 1996; Edinger, Hoelscher, Marsh, Lipper, &
IonescuPioggia, 1992; Edinger & Sampson, 2003; Edinger, Wohlgemuth, Radtke, Marsh,
& Quillian, 2001; Espie, Inglis, Tessier, & Harvey, 2001; Morin, Colecchi, Stone, Sood,
& Brink, 1999a). CBT-I is also rated as more “acceptable” to patients than hypnotic
medications (Morin, Gaulier, Barry, & Kowatch, 1992; Vincent & Lionberg, 2001).
There is also greater satisfaction with CBT-I than hypnotic medications (Morin et al.,
1999a). CBT-I also avoids issues like medication interactions or physiologic side effects.
This is why CBT-I is regarded as the frontline recommended treatment for chronic
insomnia (National Institutes of Health, 2005). For more on medication issues (i.e.,
whether hypnotic discontinuation is necessary for CBT-I), see Chapter 3.
Non-psychological Treatments 25
Summary
•
•
•
•
•
•
•
There are several efficacious pharmacological or other medical treatments for
depression, and these treatments can have positive, negative, variable or no effects
on sleep.
All antidepressant medications can have insomnia as a potential side effect.
Some antidepressants, antihistaminic agents, antipsychotics, and vagal nerve
stimulation can cause or worsen other sleep problems such as periodic limb movements, restless leg syndrome, or bruxism.
St. John’s Wort may increase photosensitivity which can create a delay in the
circadian phase and cause or worsen sleep onset problems.
CBT-I has comparable efficacy to sleep medications with several advantages over
sleep medications for chronic insomnia.
The American Academy of Sleep Medicine recommends 1) CBT-I for chronic
insomnia, however, if it is unavailable, 2) consider a short-intermediate benzodiazepine receptor agonist or remelteon, 3) when this agent is ineffective, switch
to another intermediate benzodiazepine receptor agonist or remelteon, and if these
are ineffective, consider 4) an agent with sedating side effects (e.g., a sedating
antidepressant).
Sedating agents warrant caution in combination with the Sleep Restriction portion
of CBT-I as there are pre-existing safety concerns with these medications. Sedating
agents may have a negative effect on the ability of the patient to appreciate treatment improvements, and they could potentially increase rumination.
3
Cognitive Behavior Therapy for
Insomnia (CBT-I)
Treatment Considerations
Cognitive Behavior Therapy for Insomnia is an empirically based treatment focused on
addressing research-identified maintaining factors for insomnia. It is a multicomponent
treatment made up of techniques that have been empirically validated. One advantage
of the CBT model is that it is applicable across a wide array of diagnostic categories.
This is because the model is based on the concept, that despite the variety of
precipitating events that might have initially caused the insomnia, the factors that tend
to maintain the chronicity of the disorder are similar from case to case and are
responsive to behavioral and cognitive change strategies. The idea is that in any case,
if the maladaptive perpetuating factors are present, then alterations of these factors will
lead to reductions in symptoms. Therefore, the debate about biological versus psychological etiologies determining treatment modality is somewhat of a moot point since
we know that there are many pathways to disorder and recovery. Even for biological
sleep regulatory systems such as the circadian and homeostatic systems, we know that
behavioral and environmental input can have profound corrective or disruptive
influence. The evidence for CBT-I is strong and the effect sizes are similarly large when
compared with pharmacotherapy. CBT-I is the frontline recommended treatment in
those with chronic insomnia (Howell et al., 2012; National Institutes of Health, 2005;
Wilson et al., 2010) because of the impressive short-term effects and because it is so
brief, durable, without polypharmacy risks, patient-preferred (Morin et al., 1992;
Vincent & Lionberg, 2001), and an excellent economical choice. Despite criticisms that
it is not widely available, there have been excellent gains made in the past few years
with respect to training (e.g., Manber et al., 2012), owing in part to an increase in
workshop and training opportunities, and a CBT-I training program in the Veteran’s
Affairs Administration. Moreover, there are online and telehealth treatment programs
with support (Espie et al., 2012; Ritterband et al., 2009; Vincent & Walsh, 2013). Lastly,
we have a large number of effectiveness trials demonstrating that non-sleep specialists
can effectively deliver this treatment (Buysse et al., 2011; Espie et al., 2007; Jungquist
et al., 2010). There has been discussion of utilizing stepped care modes of delivery for
CBT-I in which large numbers of patients could be introduced into early steps such as
self-help strategies and online programs, and, as needed, funnel through to steps that
might include groups run by paraprofessionals, and eventually treatment by a therapist
certified in behavioral sleep medicine for the more complex cases (Espie, 2009).
Despite the success of CBT-I there are those who do not respond to this treatment.
There is a paucity of moderator research investigating the variables that might be
Cognitive Behavior Therapy for Insomnia
27
influencing suboptimal response—a necessary step in refining the treatment. Additionally, there are currently a number of contraindications for CBT-I. For instance, sleep
disorders characterized by excessive sleepiness are a contraindication for CBT-I because
in the early stages of treatment the therapy tends to create sleepiness, which potentially
makes sleepy clients vulnerable to accidents (e.g., falls, motor vehicle, or occupational
accidents). Thus, untreated or suboptimally treated sleep-disordered breathing, narcolepsy, or periodic limb movement disorder with accompanying excessive daytime
sleepiness presents a challenge for CBT-I. Therapists should proceed with extreme
caution to plan for daytime sleepiness (i.e. disallow driving until stable) or rule out the
treatment entirely. In those with sleep apnea, it is important to determine the level of
adherence with their PAP device. Ideally, one would want clients to use their device no
greater than 75 percent of nights for a minimum of 4 hours per night at the prescribed
pressure in order to consider the apnea as treated. Such devices typically have a feature
that allows them to print out their usage, so adherence is easily verified.
Another contraindication relates to when there are more important factors worthy
of treatment. For example, when a client is in medical or psychiatric crisis, it is not
appropriate to begin a highly demanding sleep-focused therapy. Attending to and
resolving the crisis is necessary before proceeding with this treatment. For example, in
clients who present as actively suicidal, it would be essential to first assure the client’s
safety and wait for stability in mood before carrying out CBT-I. In addition to crisis,
stability of treatment for the co-occurring psychiatric or medical condition is recommended. If the client has poorly controlled diabetes or thyroid issues, it is recommended
to wait until the client is on a stable dose or treatment plan before proceeding with
CBT-I. The same could be said for clients with poorly controlled depression. It may be
sensible to hold off on CBT-I until a depression medication regimen is established that
will allow for more stable mood and a better assessment of the client’s sleep and daytime
symptoms on the medication. Similarly, active substance abuse or withdrawal are
contraindications for CBT-I. Active substances greatly impact sleep, as does withdrawal.
Once stability is established, CBT-I can be initiated, although this is one area where the
effect sizes for CBT-I may be diminished in those with extensive abuse histories. Finally,
conditions sensitive to sleep deprivation may be a contraindication or an indication to
scale back on any part of the treatment associated with sleep deprivation (e.g., sleep
restriction). Panic attacks, seizures, mania, and parasomnias can all become exacerbated
with increased sleep deprivation so a cost-benefit analysis is necessary to determine if
CBT-I is advisable or if the focus of treatment should be on stimulus control and
counter arousal rather than sleep restriction therapy. That said, it should be noted that
even in the good practice of stimulus control, there may be some sleep deprivation early
in treatment as the client remains out of bed for longer periods of time, waiting to become
sleepy and not compensating for any lost sleep by sleeping in, napping, or going to bed
early. The bottom line is that whenever practicing CBT-I, especially with the disorders
discussed above, it is always recommended to monitor for client sleepiness, take
necessary precautions, and make adjustments to therapy as needed.
In Chapter 2 we reviewed some of the costs and benefits to pharmacotherapy for
insomnia. Given these considerations, CBT-I appears to be a particularly viable treatment for MDD-I since there is no risk of polypharmacy, it is as effective as hypnotic
medication, and it produces superior, durable long-term improvements (Edinger et al.,
28 Cognitive Behavior Therapy for Insomnia
1992, 1996; Edinger & Sampson, 2003; Edinger, Wohlgemuth, Radtke, & Marsh,
2004b; Morin et al., 1999; Morin, Kowatch, Barry, & Walton, 1993; Morin, Kowatch, &
Wade, 1989; Morin, Stone, McDonald, & Jones 1994b; Perlis et al., 2000). Although there
are some variations, at the core of CBT-I treatment are Stimulus Control (Bootzin,
1972) and Sleep Restriction Therapy (Spielman, Saskin, & Thorpy, 1987b), which are
empirically validated approaches designed to eliminate conditioned bedtime arousal,
increase sleep drive and correct circadian abnormalities. CBT-I also targets the belief
that one must engage in compensatory sleep behaviors (i.e., behaviors linked to chronically poor sleep; Edinger et al., 1992, 1996, 2001, 2004b; Edinger & Sampson, 2003).
Thus far, research has suggested that CBT-I is highly safe and effective with various
insomnia patients including those with Primary Insomnia (Edinger et al., 1992, 1996,
2001, 2004b; Edinger & Sampson, 2003; Morin et al., 1994b, 1999a), MDD (Edinger
et al., 2009a; Kuo, Manber, & Loewy, 2001; Manber et al., 2008; Morawetz, 2001;
Vallieres, Bastien, Ouellet, & Morin, 2000), Periodic Limb Movement Disorder (Edinger
et al., 1996), mixed psychiatric or medical disorders (Edinger et al., 2009a; Morin et al.,
1994b), cancer (Berger et al., 2002, 2009; Fiorentino et al., 2009; Quesnel, Savard,
Simard, Ivers, & Morin 2003; Ritterband et al., 2012; Savard, Simard, Ivers, & Morin,
2005; Spiegelhalder, Espie, Nissen, & Riemann, 2008), and pain-related syndromes
(Currie, Wilson, Pontefract, & deLaplante, 2000; Edinger, Wohlgemuth, Krystal, &
Rice, 2005; Jungquist et al., 2010; Rybarczyk, Lopez, Benson, Alsten, & Stepanski, 2002;
Vitiello et al., 2013). CBT-I also appears to affect the neurophysiology implicated in
insomnia, as it results in decreased high frequency activity and increased slow wave
activity in the EEG (Cervena et al., 2004). Moreover, contrary to the above-noted
findings with hypnotic treatment, the gains achieved during CBT-I appear to endure
long after the end of active therapy.
CBT-I in Those with Depression
Those with MDD-I manifest the type of treatment targets for which CBT-I has been
specifically designed (Kohn & Espie, 2005). For example, those with MDD-I have
comparable levels of unhelpful beliefs about sleep, schedule variability, increased timein-bed, pre-sleep hyperarousal, and sleep effort behaviors to those with insomnia only
(Carney et al., 2007a, 2010; Kohn & Espie, 2005). Thus, those with MDD-I would
appear to be excellent candidates for CBT-I. Indeed, there are some promising early
findings for use of CBT-I in MDD-I patients. Morawetz (2001) found that by treating
sleep alone in MDD-I, the vast majority of patients (N = 86) treated with a self-help
form of CBT-I reported marked depression improvement in addition to the sleep
improvement (Morawetz, 2001). Morin and colleagues (2000) showed CBT-I resulted
in an improvement for sleep, and an associated mood improvement among a series of
cases with comorbid insomnia and MDD (Vallieres et al., 2000). Several studies have
documented the efficacy of CBT-I in patients with complex, multiple comorbidities
including MDD and PTSD (Edinger et al., 2009a). A randomized clinical trial combining
SSRI medication with CBT-I showed that in comparison to a SSRI alone, there were
greater insomnia symptom improvements, and greater depression symptom improvements (Carney, Edinger, Krystal, & Shapiro, 2014; Manber et al., 2008). In fact, the
addition of CBT-I to an antidepressant medication resulted in greater rates of depression
Cognitive Behavior Therapy for Insomnia
29
remission than antidepressant medication alone (Manber et al., 2008). Thus, there is
growing support for superior depression symptom outcomes by combining depression
treatments with sleep treatments, both pharmacologic and cognitive or behavioral, over
depression-only focused treatments.
Brief Delivery for Medical Settings
CBT-I is already a brief treatment but it has been adapted to very brief versions for
delivery in settings with limited patient contact, such as primary care settings. Because
there is evidence for SC and SRT as monotherapies, CBT-I is easily delivered in a session
or two. One study used abbreviated behavioral and cognitive therapy (ABCT), which
was delivered in two 25-minute sessions two weeks apart with take-home reading
materials (Edinger & Sampson, 2003). ABCT was tested using a novice therapist
supervised by a behavioral sleep medicine expert. The content of the first therapy
session focused on SC, SRT, SH, and psychoeducation. The content closely mirrors the
material presented in Chapter 5 including the patient handouts. The psychoeducation
is delivered briefly with a more in-depth explanation provided in written materials
assigned as homework. The second session is devoted to troubleshooting and making
adjustments to the schedule.
Another version, brief behavioral insomnia therapy (BBIT) (Buysse et al., 2011)
consists of one treatment session and a 30 minute booster two weeks later administered
by a nurse practitioner. This treatment has been tested with older adults (Buysse et al.,
2011; Germain, Shear, Hall, & Buysse, 2007). The content for this one session treatment
was selected rules from SC and SRT: (1) match time in bed to the current average number
of hours of sleep (minimum sleep opportunity was set at 6 hours); (2) get up at the same
time every day of the week; (3) do not go to bed unless sleepy; and (4) get out of bed
when unable to sleep. The second booster session was allocated to troubleshooting and
making adjustments, if needed, to the schedule. The results of this study indicated that
BBIT fared better than Information Control on both Sleep Diary and actigraph indices
of SOL, WASO and SE. Additionally, BBIT-treated participants continued to improve
after treatment; at the 6 month follow-up, they were sleeping about 45 minutes more
than they were at post-treatment (Buysse et al., 2011). BBIT has also been used to
successfully treat treatment-refractory insomnia after depression treatment (Watanabe
et al., 2011). A variety of CBT-I effectiveness studies have shown that common
disciplines in medical settings including nurses, primary care counselors, physicians
assistants, social work, nurse practitioners, can effectively deliver CBT-I to patients
(Espie, 2009; Espie et al., 2001, 2007). Given that both insomnia and depression, and
certainly MDD-I commonly report to primary care first, implementing CBT-I into these
settings is an important frontline priority.
Medication Issues: Is Discontinuation Necessary?
Clinicians are often faced with the apparent dilemma of what to do about medications
taken for sleep during treatment. Only treatment providers with prescription privileges
should provide advice related to medication. Some medications taken for sleep,
depending on dose, frequency of use, and duration of use, require a supervised taper and
30 Cognitive Behavior Therapy for Insomnia
stopping them abruptly could result in serious consequences. Not all clients who want
to sleep better necessarily want to stop taking their sleeping medications. It is important
to have an open conversation about the client’s treatment goals as this may or may not
include the need for cessation of sleep medication. CBT-I has been found to work with
or without sleep medications. In some trials, there are no differences between those with
CBT-I alone versus CBT-I plus sleep medications (Jacobs, Pace-Schott, Stickgold, & Otto,
2004); so sleep medications may not hamper the response except in those who are hypnotic
dependent. The best long-term benefits appear to be related to withdrawing the sleep
medication after the acute treatment phase of CBT-I, and before treatment has ended.
During the medication withdrawal period, clients should continue with extra CBT-I
sessions to manage the sleep disruptive process of withdrawal (Morin et al., 2009). It is
not uncommon in CBT-I treatment that clients often simply stop taking their medications
during treatment once they see that they can improve their sleep on their own. These
clients should always be made aware that they should make no changes on their own before
consulting with their physician. Others remain skeptical that CBT-I would work without
their medication and remain on the medications. Ultimately the pros and cons of such
a decision should be discussed between the therapist and client, and if there is a decision
to discontinue medication, a collaboration should take place between the client, therapist,
and the prescribing physician.
There is some evidence that those who are hypnotic dependent have somewhat
diminished CBT-I treatment outcomes relative to non-hypnotic dependent clients
(Verbeek, Schreuder, & Declerck, 1999). This may be due to the decreased self-efficacy
and increased unhelpful beliefs about sleep of those who are hypnotic dependent
(Carney et al., 2010a). Thus, it is not imperative that clients select hypnotic discontinuation as a goal, however when a client decides to remain on medication, the
following goals are meritorious of discussion with the client: 1) establish usage within
the recommended dose range (ideally the lowest recommended therapeutic dose) and
2) eliminate using the medication as a rescue (i.e., take the medication at the same dose
and time each night to eliminate contingent use). Most approved hypnotic medications
have tolerance properties (diminishing effectiveness over time), which often prompts
an escalation of dose. When increasing doses are used, it is often because the medication
is not as effective as the client desires, and the belief is that a higher dose will have the
same effect as the previously effective lower dose. This may be true at first, but when
the higher dose also loses effectiveness, other medications or substances such as alcohol
are often added, or another increase in dose occurs. In many cases, the client may not
share these changes with the prescribing treatment provider. This is not only a very
dangerous practice, but there is no increased efficacy, and further, it erodes the client’s
self-efficacy and increases sleep anxiety. It is important to work with the client so that
they understand both the physical dangers of such habits but also the role in
perpetuating the insomnia. It is often important to encourage the client to discuss the
issues openly with the treating physician. Many clients worry that the prescribing
treatment provider will not renew prescriptions if they are made aware of the ways in
which the client is using the medication and/or adding other substances. Collaborating
with the treating treatment provider on a plan toward safer medication use or a
medication discontinuation can help the client to feel more confident about how best
to reach their goals. In other words, it is important for the client to understand that
Cognitive Behavior Therapy for Insomnia
31
unlike possible past failed attempts to deal with medication dosing they may have
attempted on their own, this time they are not alone and that with your help they can
learn strategies that will make success much more likely.
There is good evidence for the use of CBT-I as part of the discontinuation process
(Morin et al., 2004, 2009; Morin, Colecchi, Ling, & Sood, 1995). Below is a description,
adapted from Morin’s (Baillargeon et al., 2003) discontinuation protocol, for hypnotic
discontinuation. The first step is an assessment of treatment goals. Proceeding with action
phase interventions (i.e., a taper) makes little sense if the client is in a stage of
contemplating change rather than preparedness for change (Prochaska & Velicer, 1997).
If discontinuation is a goal and the prescribing treatment provider (if applicable) has
provided a safe taper schedule, CBT-I can begin. As stated, in those with or without a
discontinuation goal, it is important for the client to set a goal of taking the same, safe
amount of medication every night at the same time. Although it is a common practice
to prescribe such medications “prn” or as needed, long-term prn use sets up medication
use as contingent on a poor (previous night’s) sleep. We would expect the body to produce
some compensatory sleep following very poor nights and if the medication is taken under
these conditions, the medication is paired with recovery sleep; however, the improved
sleep is attributed to the medication, rather than the body’s natural compensation for
poor sleep. Additionally, in those taking sleep medications long-term, there are inevitable
but unsuccessful attempts to stop the medication. The typical scenario is that the client
decides not to take the medication on a given night and they experience withdrawal from
the medication. The withdrawal symptoms include increased insomnia. Clients typically
do not know that this is a side effect and they attribute the severe insomnia symptoms
as evidence that the medication must have been working more than they thought, and
they quickly resume taking the medication either later that night or the next night,
and their confidence in their sleep system is further compromised. Moreover, if noncontingent sleep medication use is not established, the sleep improvements associated
with CBT-I will be attributed to the medication. By making the dose and timing of
medication stable every night, then any changes to the baseline sleep after that will be
attributable to the behavioral changes associated with CBT-I, which will be the only
variables that were allowed to change. Thus, clients starting CBT-I on sleep medication
need not have a discontinuation goal, but ideally, their use is kept predictable and safe
throughout treatment. Likewise if the client has just switched or begun an antidepressant
medication, it is best to wait until the drug is at steady-state so that CBT-I related
improvements are not attributed to the antidepressant medication.
Those with chronic hypnotic use have greater levels of unhelpful beliefs about sleep
than those who are not on medication or not dependent on medication (Carney et al.,
2010a); so it may be important to spend more time modifying beliefs that may get in
the way. For example, it is helpful for clients to explore the consequences of thinking
that their body can no longer produce sleep without medication. If clients attribute
improvements to the medication, the client is encouraged to look at the evidence (e.g.,
the medication was associated with poor sleep at pre-treatment and the medication
remained unchanged throughout treatment, thus the only change was in sleep habits).
These techniques are covered in Chapter 6. They are also part of the cognitive therapy
component of CBT for depression so unhelpful thoughts about medication and selfefficacy can be explicitly targeted within the context of comorbid treatment.
32 Cognitive Behavior Therapy for Insomnia
Once non-contingent sleep medication use is established, and there is only one steady
medication used (e.g., rather than a benzodiazepine one night, melatonin a second night,
and diphenhydramine on another night) at a stable dose, CBT-I can be initiated. As
CBT-I is delivered with an emphasis on increasing sleep self-efficacy and observing how
the body compensates for sleep loss naturally when sleep effort is removed, the clients
who initially felt they would not attempt medication discontinuation, may now be more
amenable to such a goal. At that point, it can be desirable for the treatment team to
proceed with the discontinuation component. The first step is to provide psychoeducation regarding rebound insomnia and psychological dependence. This was
detailed above (i.e., that contingent use of sleep medications creates a situation in which
the medication appears to be a rescue from a faulty sleep system). Instead, by providing
education regarding normal sleep regulation, the therapist can focus on the idea that
the body would be expected to compensate for poor sleep anyway (with or without the
medication) and that stopping the medication creates a worsening of insomnia
symptoms. It is important that clients understand that the worsening is a side effect of
the medication withdrawal and not indicative of an underlying insomnia that the
medication was successfully treating. This will be true even for clients that are dependent
on nightly medication. They can be made aware that, as with any withdrawal symptoms,
they are expected to fade with time, and if properly harnessed, the processes of sleep
regulation can then help them back to more normal sleep if they stay the course.
After psychoeducation, a taper schedule is constructed in consultation with the
prescribing treatment provider. In this scenario it should be noted that the client
has already been taught the techniques of CBT-I to help make sleep better while on a
steady dose of hypnotic. In some cases, the client is sleeping well with the medication
so there may be little sleep restriction in the initial CBT-I; in other cases, sleep remains
poor even on medication. Even if sleep is poor on medication, it is important to remain
cautious about safety in those taking sleep medications. The goal during a taper is to
reduce the weekly dose of medication by 25 percent per week, or whatever the prescribing
physician sees as appropriate. The therapist explains the protocol and rationale for noncontingent use and gradual reduction and solicits feedback on the plan. The client and
therapist review the relapse prevention plan for what to do after a poor night (i.e., after
rebound insomnia) as well as a coping with fatigue plan. Sometimes clients feel
confident early and want to go completely drug-free. Likewise, some physicians may
feel that a quicker taper would be suitable for their patient. For many medications at
low doses this can be an acceptable way to engage in the CBT-I + taper treatment.
However, in cases wherein withdrawal can have dangerous consequences (e.g., benzodiazepine dependence, abnormally high doses), it is important to go slowly under
medical supervision.
Group Therapy CBT-I
There is evidence that group therapy is an effective modality for CBT-I (Bastien, Morin,
Ouellet, Blasi, & Bouchard, 2004; Verbeek, Konings, Aldenkamp, Declerck, & Klip, 2006).
In some ways CBT-I is a perfect candidate for group therapy because psychoeducation,
Stimulus Control rules, sleep hygiene rules, Cognitive Therapy as well as counter arousal
strategies fit nicely with a group format. However, the sleep scheduling aspect of SRT
Cognitive Behavior Therapy for Insomnia
33
Table 3.1 Sample schedule and topics in individual versus group delivery
Week
Group
Individual
1
2
3
Psychoeducation, SC and Sleep Hygiene
Troubleshoot adherence, SRT
Troubleshoot adherence, determine if
changes necessary to schedule, add
counter arousal
Troubleshoot adherence, determine if
changes necessary to schedule, add
cognitive therapy
Troubleshoot adherence, determine if
changes necessary to schedule, continue
with cognitive therapy, introduce
termination issues, relapse prevention
homework
No meeting
Troubleshoot adherence, determine if
changes necessary to schedule, cognitive
therapy, termination issues and relapse
prevention
Psychoeducation, SC, SRT, Sleep Hygiene
4
5
6
7
Troubleshoot adherence, determine if
changes necessary to schedule, add
counter arousal and cognitive therapy
Troubleshoot adherence, determine if
changes necessary to schedule, continue
with cognitive therapy, introduce
termination issues, relapse prevention
homework
No meeting
Troubleshoot adherence, determine if
changes necessary to schedule, cognitive
therapy, termination issues and relapse
prevention
is very challenging in a group format. The idea of scheduling is very personal to clients
and linked to their particular presentation. “Scheduling” can have different meaning to
different clients; for some it equates to conformity, having a boring lifestyle, or it
activates memories of hurt experiences with an autocratic parent. Some clients hear
recommendations to change habits as an accusation that they “caused” their insomnia,
or they are in some way to blame. Additionally, deriving a schedule must take into
account current sleep time production, chronotype, individual life demands, and
relationship dynamics, so managing these issues in a group of 6 or more people, can
become challenging. One possible way to achieve this is to devote an entire group session
to deriving a schedule in which the group members exchange sleep diaries with a
partner in the group, and together they calculate the total sleep time, total time in bed
and total wake time of their partner’s diary. Together, the group calculates the time-inbed prescription of their partner’s sleep diary and then they collaborate on a schedule
in dyads. The group shares any possible difficulties encountered during the derivation
of the schedule and together they engage in trouble-shooting. The facilitator uses
questioning to help group members arrive at solutions for the other group members.
There are very few resources available for learning group delivered CBT-I, so a template
is provided below and contrasts it with an individual therapy schedule. For an example
of a schedule and topics, see Table 3.1.
Applications (apps) and Alternative Modes of Delivery
Smart Phone Applications
Smart phone applications that provide sleep estimates are very popular and widely
available. Such apps are not used clinically because of their inferior reliability and in
34 Cognitive Behavior Therapy for Insomnia
some cases dubious validity. For example, some apps purport to track and sense the
“right” time to wake up clients. The websites associated with these apps give no detail
as to how they work but the phone is placed on the bed and there is reference to the
phone tracking movement so presumably, the application is collecting data with an
accelerometer. There are no particular movements associated with optimal waking.
The best time to wakeup may be arguably during REMs but the only way to determine
the presence of REMs is to measure brain wave activity via electrodes on the scalp,
not movement. Other apps provide an “objective” estimate of total sleep time via the
accelerometer, similar to a clinical device called an actigraph. The method of placing
the accelerometer on the bed has not been tested and is presumably less reliable
than wearing an accelerometer (e.g., it can be subject to false input via pets, kids,
and other bed partners). There are, of course, wearable accelerometers, and one such
popular device was tested and compared with clinically validated actigraphs as well as
polysomnography (Montgomery-Downs, Insana, & Bond, 2012). The popular device
overestimated total sleep time by over an hour when compared with PSG and over
24 minutes compared to the actigraph. Both the actigraph and the device were particularly poor (i.e., showed greater error) in those with poor sleep; arguably the people most
drawn to such devices.
Some apps are treatment specific, such as CBT-I COACH. This app accompanies CBTI treatment and was developed from the CBT-I materials for the VA training rollout.
Such apps typically provide sleep diaries, help with calculating sleep prescriptions,
psychoeducation materials, and capability for reminder messages with tips, motivation,
and alarms to change sleep habits. These are essentially the same as the materials
provided with treatment but the delivery mode is different and there may be some
advantages to using an app on a Smartphone. For example, it is more readily accessible
and discreet to complete forms such as a thought record using a phone than carrying
a paper form and completing it in public. Additionally, calculating sleep diary indices
can be daunting for some clients, so these apps can make it far easier.
Self-Help Books
Self-help books (i.e., bibliotherapy) are a popular mode of delivery for people. Therapy
is expensive and many people cannot take time off from work or family each week to
attend sessions, while others, particularly in rural areas, may not have ready access to
live therapists. Some also may feel uncomfortable talking to a professional about their
problems. Bibliotherapy has the potential to increase access to empirically supported
treatments in written format. The main drawback to this approach is that for the most
part these products are not significantly vetted and so anyone can publish a self-help
book and there is no guarantee about the strength of the material presented. In other
words, all bibliotherapies are not equal and may not be empirically supported. However,
there are books written by experts and voted on by other experts to recommend,
e.g., the VA CBT-I training rollout selected a self-help book (Carney & Manber, 2009)
available commercially for their training. In addition, there may be no opportunity
to receive individual advice when there are issues not covered in the book and the
client runs into problems. This has been shown to be important because in tests of
bibliotherapy, there is evidence that it is effective (Mimeault, 1999), however the effect
Cognitive Behavior Therapy for Insomnia
35
was enhanced when telephone consultation was added. Other studies have similarly
reported that bibliotherapy with telephone consultation was equally effective as
individual, traditional psychotherapy (Bastien et al., 2004; Currie, Clark, Hodgins, &
El-Guebaly, 2004). Thus, although there is support for bibliotherapy, the best support
is when there is individual follow-up as well. For those with MDD-I there are few books
available, with one exception (Carney & Manber, 2009), written with clients with
complex comorbidities like depression, pain, or anxiety in mind.
Internet Delivered CBT
There is evidence for successful CBT-I treatment using sophisticated interactive software
programs at home or delivered over the internet (Espie et al., 2012; Ritterband et al.,
2009; Strom, Pettersson, & Andersson, 2004; Vincent & Lewycky, 2009). This may be
a particularly helpful mode for those with poor access to CBT-I or those in remote areas.
Such interactive programs may be an important way to increase access to CBT-I
although there is some concern about high attrition (24–33 percent) (Strom et al., 2004;
Vincent & Lewycky, 2009) so it is important to conduct moderator studies to understand
who benefits most from this modality. Perhaps they may be best utilized as an initial
step in a stepped-care model of delivery. As such, those that do not do well nor drop
out might be encouraged to move on to the next step in care. To avoid “inoculation”
against more intense levels of treatment, it may be important to alert clients to the
concept of stepped care from the start so that there is understanding and buy in that if
earlier steps do not succeed that other levels of treatment are available. In this way clients
may be less likely to simply give up if the initial steps do not work.
Resources
The Anxiety and Depression Association of America is a resource for those with
depression and/or anxiety. There is information and resources for finding therapists,
self-help materials, and applications. Website: www.adaa.org/
The Mood Disorders Society of Canada is an organization devoted to support and
advocacy for those with Mood Disorders, including MDD. Website: www.mooddis
orderscanada.ca
The Canadian Association for Cognitive and Behavioral Therapies (CACBT) has a list
of Canadian practitioners who have been certified in Cognitive Behavior Therapy.
Website: www.cacbt.ca
The Association for Behavioral and Cognitive Therapy (ABCT) has a find-a-therapist
listing as well as a listing of self-help resources, and information about disorders.
Website: www.abct.org/home/
The National Sleep Foundation is a site devoted to providing information and advocacy
about sleep. Website: www.sleepfoundation.org
The American Academy of Sleep Medicine (website: www.aasm.net): There is an accreditation process in the United States for medical sleep specialties. More information,
36 Cognitive Behavior Therapy for Insomnia
including a list of providers and sleep centers accredited by the American Academy of
Sleep Medicine can be found on at www.aasmnet.org/accreditation.aspx
The Depression and Bipolar Support Alliance provides support for those with depression. Website: www.dbsalliance.org
Summary
•
•
•
•
•
•
CBT-I is a highly efficacious and effective treatment, shown to be effective in those
with depression, and to enhance the treatment of depression.
Contraindications for CBT-I include: untreated or suboptimally treated sleepdisordered breathing, narcolepsy, or periodic limb movement disorder with accompanying excessive daytime sleepiness, unstable condition, substance abuse. CBT-I
should be used with caution in those sensitive to sleep deprivation such as those
with bipolar disorder, panic disorder, epilepsy, and parasomnias.
CBT-I has been shown to be effective in very brief formats (one to two sessions)
and as delivered by non-sleep and non-mental health treatment providers.
There is evidence for other modalities of delivery including group therapy, some
internet delivery, telephone delivery and bibliotherapy. It would be useful to have
moderator data on alternative modes so that we could determine for whom these
modes work best.
It is unnecessary to discontinue sleep medications before starting CBT-I but it is
important to establish non contingent use at a stable dose and time each night before
proceeding with CBT-I.
Although there are many dubious sources of information on the internet, there are
also reputable internet sites available to locate treatment providers certified in
CBT-I, and to learn more about sleep or depression, and/or for clients to obtain
support.
4
Assessment of Insomnia in
Those with Depression
Assessment should be regarded as an ongoing activity throughout CBT-I, rather than
a single event at the beginning of treatment. It is essential to continuously assess for
changes in sleep patterns, varying levels of sleepiness, and client adherence, and remain
open to emerging evidence. Consider the following example: at the sleep assessment
session, you meet a 41 year old female with average body habitus, no knowledge of
whether she snores, no hypertension, and a normal, albeit elevated score on sleepiness
scale. Such findings are not particularly suggestive of sleep apnea. If, however, over the
course of treatment, there is high adherence to treatment, a very quick sleep onset latency,
even when the time spent in bed has been lengthened, there are complaints of subjective
sleepiness and a report of many very brief wake-ups in the second half of the night, one
should reconsider whether there may be an occult sleep disorder, such as sleep apnea.
The goals of the initial assessment session are to establish a diagnosis of insomnia
and initial conceptualization of the case, rule out other sleep disorders or conditions
contraindicated for CBT-I, assess for comorbidities, substances and medications,
establish treatment goals, and obtain family, medical, sleep, and previous treatment
histories. That said, new information about any of these factors may emerge throughout
treatment and should be revisited.
History of the Insomnia
All assessments begin with a discussion of consent and limits to confidentiality followed
by a history of the sleep problem. Of course, it is important in psychotherapy to get a
history of other issues, including current and past interpersonal, occupational, and health
details, but since these remain the same for all problems, we will not go into these general
psychotherapy issues here. Instead, we will remain focused on sleep and mood related
details. Later we provide a general guide for assessment that we find helpful clinically.
The first order of business is typically a question such as, “What brings you here?” or
“Please tell me about your sleep problem.” The goal of this question is manifold. What
is the nature of the current problem? Is the primary complaint about nighttime or
daytime difficulties? When did it start? Is it a lifelong problem, i.e., are there family
stories about difficulties as a baby, through childhood, teenage years right up until the
present? In some cases, there will be a report of a lifelong insomnia but after beginning
work together, it will become apparent that this is not the case. Such is the case with
Kelly, a case example presented in Chapter 10 and throughout the book. In such cases,
38
Assessment of Insomnia
this can reflect an all or none way of viewing oneself as a “bad sleeper.” Such beliefs
likely will be targeted for modification at some point in therapy. How did the problem
start (i.e., is the client aware of a contiguous stressor or did it occur unexpectedly)? What
is the client’s explanation for what is going on (i.e., to what do they attribute the
insomnia)? When providing psychoeducation (see Chapter 5), it will be important to
emphasize a case-specific explanation. For example,
I recall that you had said that initially the insomnia began in the weeks before your
wedding, and you were puzzled by the fact that it continued even after the stress
of the wedding subsided. I would like to talk about some possibilities for why the
insomnia persisted even after the wedding . . .
Continue querying about whether the problem changed over time, how long the
problem has persisted and the reason for seeking treatment now. It is important to
understand how they have tried to fix the situation (i.e., what has been tried with respect
to medication or a change in habits), as this is the information the therapist needs to
assess sleep effort and to help debunk other possible failed attempts. For example, if the
client ceased caffeine in an attempt to fix the situation, it is important to address why
this did not work and what other measures are necessary to manage the insomnia.
Otherwise, any mention of caffeine will be met with skepticism because it was already
tried. In addition, such debunking should help to raise hope for the client that this time
their efforts may be more likely to succeed. Lastly, it is important to have agreement on
the goals for treatment. Unrealistic goals (e.g., “I want to sleep like I did as a teenager,”)
are helpful to uncover because it permits cognitive modification of unrealistic beliefs
about sleep. It also serves to demonstrate that the way clients view sleep can have an
important effect on both how well they sleep and how they feel during the day. The
treatment goals discussion at the end of the assessment session is often the start of the
intervention. That is, once realistic expectations are stated (i.e., “I would like to spend
less time awake during the night,”), the therapist and client can easily agree on such
goals and the therapist can discuss a conceptualization and treatment plan for moving
forward with the client.
Diagnosis of Insomnia
The diagnostic criteria for an Insomnia Disorder require a complaint of difficulty
initiating or maintaining sleep or non-restorative sleep for a minimum of three months
(American Psychiatric Association, 2013). There is no guidance as to what numeric value
would constitute difficulty initiating or maintaining sleep for a number of reasons. First,
it is important to note that insomnia is a subjective disorder. Certainly, “non-restorative
sleep” is a subjective term that would be difficult to quantify except perhaps on an EEG.
Whereas a cutoff of sleep disruption greater than or equal to 31 minutes is a reasonable
proposal (Lichstein, Durrence, Taylor, Bush, & Riedel, 2003), this proposal lacks evidence
for optimal sensitivity and specificity (Lineberger, Carney, Edinger, & Means, 2006).
Another important factor in this diagnosis is the presence of one or more of the daytime
symptoms of insomnia listed in the Research Diagnostic Criteria for Insomnia (Edinger
et al., 2004), including fatigue or malaise, attention or concentration problems, negative
Assessment of Insomnia
39
mood, social or vocational dysfunction, or poor school performance, somatic symptoms
such as tension headaches and gastrointestinal symptoms in response to sleep loss,
motivation or energy or initiative reduction, daytime sleepiness, and worry about sleep.
Without the presence of these daytime sequelae, the disruption in sleep alone would
have to be seen as a consequence of different problems such as short sleep (i.e., someone
who requires less sleep than the average) or perhaps mania. However, with both the sleep
disruption and daytime sequelae present, it is no longer relevant to consider if the disorder
is “related” to another Axis I disorder, as there is poor evidence of validity for the
distinctness of these types of insomnia (i.e., secondary insomnia) (Edinger et al., 2011).
Diagnostic and Measurement Pitfalls
The most recent DSM update (DSM5) (American Psychiatric Association, 2013) was
characterized by significant changes, including a renaming of the Sleep Disorders
section to Sleep-Wake Disorders. The renaming of the section denotes an acknowledgment that insomnia and other sleep disorders are a 24-hour phenomenon; that is, they
have both nighttime and daytime sequelae. In a chart review study, the best predictor
of whether a patient was diagnosed with depression was whether they complained of
insomnia (Krupinski & Tiller, 2001). The best predictor of a depression diagnosis should
be the presence of one of the MDD criteria in section A (i.e., depressed mood or
anhedonia). Indeed, these are the discriminating symptoms for differentiating those with
insomnia only from those with MDD-I; insomnia and fatigue are not discriminating
items (Carney, Ulmer, Edinger, Krystal, & Knauss, 2009). When the patients in the chart
review study diagnosed with MDD were followed-up with diagnostic interviews, just
over one quarter actually met diagnostic criteria for MDD; the 72 percent incorrectly
diagnosed with MDD had undiagnosed insomnia (Krupinski & Tiller, 2001). As noted
above, the DSM5 eliminated the distinction between an insomnia related to a mental
disorder versus an insomnia that was considered primary, mainly because this distinction lacks reliability and validity (Edinger et al., 2011). In addition, when patients suffer
from a comorbid mental disorder, studies suggest that treatment providers are less likely
to consider conditioning, beliefs or poor sleep habits as treatment targets or maintaining factors (Nowell et al., 1997), even when the evidence suggests that these are primary
factors for such patients (Carney et al., 2010a; Kohn & Espie, 2005). Historically,
insomnia has been under diagnosed and consequentially, undertreated, and the changes
to the DSM will hopefully improve this problem.
With regard to depression and insomnia, perhaps part of the issue relates to the degree
of overlap between the two conditions. Daytime symptoms for insomnia include:
fatigue, cognitive complaints, mood disturbance (including dysphoria), and impaired
functioning (American Psychiatric Association, 2013; Edinger et al., 2004). Indeed,
there are very few discriminating items for these disorders (Carney et al., 2009). In a
comparison of those with MDD and those with ID only, the only items that discriminated the two groups were: depressed mood, anhedonia, guilt, pessimism, thinking about
past failures, self-dislike, crying, agitation, hypersomnia, and decreased appetite. Clinical
cutoffs for mild and moderate depression on the second edition of the Beck Depression
Inventory (BDI-II) (Beck, Steer, & Brown, 1996) have slightly less support when
insomnia is present (i.e., specificity is decreased). Thus, the concern is that some
40 Assessment of Insomnia
depression measures, and perhaps the diagnostic criteria for MDD itself, may subsume
ID within the items. The overlap also becomes a problem in studies in which those with
insomnia are included. One way that researchers have dealt with this issue is to remove
the sleep items from depression measures. This is an unacceptable remedy because
sleep is only one of many overlapping symptoms (e.g., fatigue, cognitive complaints).
There is no greater empirical reason to take away the sleep item over any other nondiscriminating ID daytime symptom (e.g., fatigue). Another remedy for this conundrum
is to covary depressed mood on a depression measure in those with insomnia or to covary
sleep on an insomnia measure in those with depression. The use of analysis of covariance
in such situations is fraught with statistical problems reviewed elsewhere (Miller &
Chapman, 2001). Essentially, when two variables naturally covary, removal of the
variance of the other covarying variable results in a third variable that does not exist.
Thus, investigating the properties of the nosological categories of sleep and depression
and finding measures with improved specificity, but with acceptable sensitivity is still
needed.
Assessment and Intervention Strategies
Insomnia is assessed with several methods. The clinical interview is a critical piece of
the assessment and can be supplemented with a semi-structured interview, such as the
Insomnia Interview Schedule (IIS) (Morin, 1993) or the Duke Structured Interview for
Sleep Disorders (DSISD) (Edinger et al., 2009b). These instruments can be used to help
evaluate diagnostic criteria for insomnia as well as other sleep disorders. Structured
interviews may be particularly helpful for the novice therapist in sleep disorder treatment. Such interviews help by providing critical questions regarding sleep and medical
histories (e.g., the history, nature, and severity of the current complaint, current habits,
medical history, treatment history, substance use, and environmental factors such as
noise), as well as questions to assess signs and symptoms of other intrinsic sleep
disorders. The DSISD is particularly helpful because diagnostic criteria are mapped across
DSM, International Classification of Sleep Disorders (ICSD-3; American Academy
of Sleep Medicine, 2014), as well as Research Diagnostic Criteria (RDC) (Edinger et al.,
2004a) nosologies. In other words, the questions in the DSISD follow directly from
the specific diagnostic criteria in these manuals. For example, the following questions
are used to query the presence of ID: “Do you have a problem such as difficulty getting to sleep, OR difficulty staying asleep, OR waking up too early?” If the client reports
yes to any of the insomnia symptoms, there is a follow-up question that queries whether
there are any daytime symptoms:
Does this sleep difficulty cause you any problems in the daytime such as: fatigue
or malaise? Impaired concentration, attention or memory? Impaired social or
vocational functioning or poor school performance? Mood problems or irritability?
Daytime sleepiness? Decreased motivation, energy, or initiative? Increased errors
or accidents at work or while driving? Tension, headaches, or stomach upset in
response to sleep loss? OR excessive sleep concerns or worries?
In cases in which the client does not endorse a daytime symptom, the DSISD queries,
“How would things be better if your sleep problem were eliminated?” If the response
Assessment of Insomnia
41
refers to a daytime problem, the criteria are met. The remaining DSISD questions query
if the insomnia occurs at least three times per week for at least three months and whether
the sleep problem occurs in the context of an adequate opportunity for sleep, e.g., “Do
you have this sleep difficulty even if you give yourself enough time to sleep?” Lastly, the
DSISD queries whether the insomnia is related to an inadequate or unsafe sleep
environment, a substance or medical condition. Asking these questions ensures the
therapist covers all of the criteria relevant to making the diagnosis of insomnia disorder.
An essential component of insomnia assessment is the daily sleep diary. Sleep diaries
are the gold-standard in assessing insomnia because insomnia is a subjective disorder
and the prospective reporting method increases accuracy of the subjective ratings
(Buysse et al., 2006). For further discussion of the merits of using subjective sleep diary
data in the assessment of insomnia, see Chapter 7. Sleep diaries provide details about
the severity of sleep onset and maintenance difficulties, habits that disrupt the circadian
system (e.g., variability of bedtimes and rise times), or the homeostatic drive for deep
sleep (e.g., napping, extended time in bed), as well as calculated indices such as total
sleep time or sleep efficiency. There are many versions of sleep diaries that measure
various aspects of the insomnia problem, but the variability among diaries limits that
ability to make comparisons across studies. To resolve this issue, a consensus diary
was derived. This diary was constructed by soliciting a large sample of diaries used
by experts working the field of behavioral sleep medicine and then a panel of insomnia
experts extracted key items to form a diary draft that was subjected to a larger pool
of experts for rating. After that revision, the tool was subjected to lexical analyses and
tested with focus groups. The result was the Consensus Sleep Diary (CSD) (Carney
et al., 2012) which is the recommended tool for the prospective monitoring of sleep.
Copies of a brief, core version and an expanded version with optional items are provided
in the Appendix (Appendices A and B). Permission is granted for clinical use only
(contact the first author of this book, C. E. Carney, for research related permission).
Table 4.1 provides instructions about using the CSD (i.e., how to score indices for both
assessment and use throughout treatment). Items that do not require scoring and are
self-explanatory are not included in the table (for example, item 12, 13, and 14 query
alcohol, caffeine, and medication use, respectively and are simply inspected to determine
what substances are consumed and the timing or proximity to bedtime).
Sleep diaries are extremely important for assessing the client’s baseline sleep, but are
also essential for tracking outcomes throughout treatment. Treatment tracking is readily
accomplished with sleep diaries but a retrospective global rating of insomnia symptoms
is useful as well. The most validated measure for this purpose is the Insomnia Severity
Index (ISI) (Morin, 1993). Another commonly used measure for this purpose is the
Pittsburgh Sleep Quality Index (PSQI) (Buysse, Reynolds, Monk, Berman, & Kupfer,
1989) however, the PSQI has dubious psychometric properties in those with comorbid
Axis I disorders (Hartmann et al., 2015). The ISI is a very brief measure that allows
clients to retrospectively rate the severity of their insomnia symptoms (Bastien,Vallieres,
& Morin, 2001; Morin, Belleville, Belanger, & Ivers, 2011). One reason for supplementing
a gold standard tool (i.e., the sleep diary) is that it can reveal the client’s perception of
their sleep problem. For example, a client may present for an assessment with an ISI
score and clinical interview results (e.g., “I barely sleep at all”) suggestive of a severe
insomnia, while the sleep diary may reveal indices in the mild insomnia to normal range.
Item 5: In total,
how long did
these awakenings
last?
Item 6d: How
much earlier
[than planned]?
Wakefulness
after sleep
onset
(WASO)
Early
morning
awakening
(EMA)
If 6c is ‘No,’ set 6d to zero. An average
EMA is calculated by adding the EMA
values for each morning (including the
zero values from the previous step)
and dividing the sum by the number
An average WASO is calculated by adding
the WASO values for each night (after
converting to the same metric, minutes
OR hours) and dividing the sum by the
number of nights with available data
in the recording period.
An average NWAK is calculated by adding
the NWAK value for each night and dividing
the sum by the number of nights with
available data in the recording period.
Item 4: How
many times did
you wake up,
not counting
your final
awakening?
Number of
awakenings
(NWAK)
Computations
An average SOL is calculated by adding the
SOL values for each night (after converting
to the same metric, minutes OR hours) and
dividing the sum by the number of nights
with available data in the recording period.
Item #
Sleep onset
Item 3: How
latency (SOL) long did it
take you to
fall asleep?
Essential
clinical
index
Table 4.1 How to Use a Sleep Diary
An average EMA greater than 30 minutes is considered an
indication of clinically meaningful problem with early
morning awakening, as is presence of EMA values greater than
30 minutes on three or more nights a week.
An average WASO greater than 30 minutes is conventionally
considered an indication of clinically meaningful problem
with sleep maintenance, as is presence of WASO values greater
than 30 minutes on three or more nights a week. Although
there are no quantitative criteria for insomnia.
Multiple brief awakenings may suggest the presence of sleep
apnea or other occult sleep problems.
Three or more awakenings is considered an indication of
clinically meaningful problem with sleep fragmentation.
If the client’s chronotype is delayed and SOL problems occur
exclusively with an early bedtime (item 1), it may suggest a
Circadian Rhythm Disorder rather than ID.
A low average SOL (<10 minutes) suggests sleep duration
might be too short for optimal wellbeing.
An average SOL greater than 30 minutes is conventionally
considered an indication of clinically meaningful problem
with sleep initiation, as is presence of SOL values greater than
30 minutes on three or more nights a week. Although there are
no quantitative criteria for insomnia.
Interpretations/Significance
Computed
from items 6a
(What time
was your final
awakening?)
and 7 (What
time did you
get out of bed
for the day?).
Computed
from SOL,
WASO and
Item 6c
Computed
from item 1
(What time
did you get
into bed?)
and item 7
(What time
did you get
out of bed
for the day?).
Lingering
in the
morning
Total Wake
Time (TWT)
Time-inbed (TIB)
An average TIB is calculated by adding the
TIB values for each night and dividing the
sum by the number of nights with available
data in the recording period.
The difference between item 1 and item 7.
If any one of SOL, WASO, or EMA is
missing then TWT is considered missing.
Nightly TWT=SOL + WASO + EMA,
making sure they all are in the same
metric (hours or minutes). An average
TWT is calculated by adding the nightly
TWT values and dividing the sum by the
number of nights with available data in
the recording period.
The daily value is the difference between
item 6a and item 7. An average index of
lingering is calculated by adding the
lingering value for each day and dividing
the sum by the number of nights with
available data in the recording period.
of nights with available data in the
recording period.
continued . . .
When TIB is far greater than TST, query why. Some
considerations include: 1) high sleep effort (i.e., trying to sleep
by spending more time in bed), 2) using the bed for escape,
3) sedentary life style (i.e., low levels of activity), and 4) feeling
sedated due to medications with long sedative half-life.
This is an index of overall unwanted wakefulness. For people
without insomnia TWT is usually less than 45-60 minutes.
Although there is not a set cutoff of which we are aware,
however it is typical in clinical trials to set TWT>60 minutes
as suggestive of moderately severe insomnia.
Some of the time spent in lingering in the morning may be
spent trying to get more sleep (Item 6b) and some of the time
may be staying in bed without necessarily trying to sleep.
Query about how the time lingering in the morning is spent.
The longer the time spent lingering, the more of an
opportunity for conditioned arousal. This may reflect sleep
effort or avoidance or beliefs about what time is reasonable
to rise.
Clinical judgment is needed when a client does not have a
planned wake up time. In such cases the client can be asked
to rate how much earlier than acceptable, or desired did they
wake up.
Item #
Computed
from Item 2
(What time
did you try
to go to sleep?)
and Item 7
(What time
did you get
out of bed
for the day?)
Computed
from ISP
and TWT
Computed
from TST
and TIB
Essential
clinical
index
Intended
sleep period
(ISP)
Computed
Total Sleep
Time (TST)
Sleep
Efficiency
(SE)
Table 4.1 Continued
An average SE is calculated by adding the
SE values for each night and dividing the
sum by the number of nights with available
data in the recording period.
SE = TST/TIB
Alternatively, average TST can also be
determined by subtracting average
TWT from average ISP.
Average TST is calculated by adding the
TST values for each night and dividing
the sum by the number of nights with
available data in the recording period.
TST= ISP – TWT
An average ISP is calculated by adding the
ISP values for each night and dividing the
sum by the number of nights with available
data in the recording period.
The difference between item 2 and item 7.
Computations
SE values range between 0 and 1, wherein 1 means that the
client slept 100% of the time spent in bed and 0 means the
client has not slept at all. The average SE in population studies
is around 85%. A SE above 95% suggests the possibility of
insufficient sleep, possibly because the sleep opportunity
window might be too short.
The computed TST does not always agree with the client’s
estimated sleep duration (i.e., response to Item 8: In total,
how long did you sleep?). Discrepancies between computed
TST and the client estimated sleep duration (Item 8) could be
due to a variety of factors that should be explored. Examples
include: 1) reporting bias (e.g., the client might have not
included light sleep as sleep); 2) a systematic error in one or
more diary entries (e.g., considering including EMA in
response to Item 5, in which case the computed TST
underestimates actual TST).
Some clinician and sleep researchers compute SE as the ratio
between TST and ISP. This alternative is a better
approximation of how SE is computed when sleep is
measured objectively by actigraphy or polysomnography.
The ISP is the time allotted for sleep. Its duration is shorter
than TIB when a client spends time engaged in wake activities
in bed, such as reading and watching television.
Interpretations/Significance
Item 11b
(In total, how
long did you
nap or doze?)
Computed
from TST
and item 11b
(In total, how
long did you
nap or doze?)
Computed
from item 1
(What time
did you get
into bed?)
and item 2
(What time
did you try
to go to sleep?)
Derived
from item 2.
Nap duration
Total sleep
time in
24 hours
(TST24)
Lingering
in bed in
the evening
Bedtime
variability
(BEDVAR)
Identify the earliest and latest bedtimes
(item 2) for the reporting period (typically
a two-week period). One index of variability
is the difference between the earliest and
latest bedtimes. For example, if the latest
bedtime over two weeks was 1AM and the
earliest bedtime was 9 PM, the variability
is 4 hours.
An average daily lingering in the evening
is calculated by adding the values for each
evening and dividing the sum by the
number of days with available data in the
recording period.
The difference between item 1 and item 2.
Equivalently, this is also the difference
between TIB and ISP.
An average TST24 is calculated by adding
the TST24 values for each 24 hour period
and dividing the sum by the number of
24 hour periods with available data in the
recording period.
TST + Nap duration (item 11b)
If 11a is ‘No,’ set 11b to zero. An average
daily nap duration is calculated by adding
the nap durations for each day (including
the zero values from the previous step) and
dividing the sum by the number of days
with available data in the recording period.
continued . . .
This provides an estimate of poor input into the clock. In the
absence of low activity or other habits that would reduce sleep
drive, regular bed and rise times create a strong drive to
become sleepy around the same time each night and wake up
naturally around the same time each morning. In the adjacent
example, 4 hours of variability is the biological equivalent to
taking a trip from Manhattan to Los Angeles.
Query about average values greater than half an hour. This
could be due to boredom, anhedonia, habit, spending time
with a bed partner, or it could imply sleep effort, that is, an
attempt to produce sleepiness in the bed in order to fall asleep.
In most individuals with insomnia TST24 is almost identical
to TST because most are not able to nap. A difference that is
more than half an hour might indicate circadian rhythm
abnormality or the presence of a comorbid disorder associated
with daytime sleepiness. In the latter case, it is possible that
daytime sleep interferes with nocturnal sleep.
Provides a total amount of nap duration for the day. In clients
reporting dozing (i.e., unintentional naps), it is useful to
encourage them to capture dozing with this item too.
Take the prescribed TIB (e.g., 7 hours)
and subtract the average TIB value for
the recording period (e.g., 8.25 hours).
TIB
prescription
variation
(TIBVAR)
Computations
Take the latest rise time (item 7) for the
reporting period (typically a two-week
period) and subtract the earliest rise time
(item 7). For example, if the latest rise
time over two weeks was 11 AM and the
earliest rise time was 5 AM, the variability
is 6 hours.
Item #
Rise time
variability
(RISEVAR)
Essential
clinical
index
Table 4.1 Continued
Negative values reflect non-adherence to the TIB prescription,
i.e., increased TIB. In the adjacent example, the TIB
prescription variation is -1.25, in other words, there is an extra
hour and 15 minutes spent in bed. Explore non-adherence
issues using suggestions in Chapter 7. Zero or positive values
are reflective of adherence to the prescription.
This provides an index of poor input into the clock. Regular
bed and rise times create a strong drive to become sleepy
around the same time each night and wake up naturally
around the same time each morning. In the adjacent example,
6 hours of variability is the biological equivalent to taking a
trip from Manhattan to Europe. Most people have a fixed rise
time several times per week because of work or family
obligations, so this is often used as a point at which rise time is
fixed for the week. Rise times that vary an hour or more may
have circadian consequences that mimic jetlag (e.g., fatigue,
concentration and mood problems etc.) For an explanation of
jetlag symptoms in insomnia and fixing a standard rise time,
see chapter 5.
Therapists should be curious about reasons for values greater
than one hour. For example, is the difference due to having an
environmental constraint? Is it due to a belief that one has to
“make-up” sleep on the weekends? Is it due to the person’s
chronotype?
Interpretations/Significance
Assessment of Insomnia
47
In such cases, the discrepancy between the diary and the client’s self-rating and report
should be the focus of further inquiry and assessment. It will be useful to discover the
reason for the discrepancy since one’s perception of being a poor sleeper or a perfectionistic style or all-or-none thinking, may reflect unhelpful thinking worthy of
further discussion in therapy. Similarly, objective (e.g., actigraph) and subjective (e.g.,
sleep diary) improvements with treatment without corresponding improvements on
global ratings scales (e.g., ISI) warrant exploration with the client. It is important to
understand what the client is capturing in a high rating of sleep disturbance on the ISI,
in the presence of little corroborating evidence on other measures. In some cases, this
may be a misattribution about daytime symptoms, for example, the fatigue may relate
to inactivity, anxiety, or depression, rather than poor sleep. Maintaining the belief that
the fatigue is solely the product of poor sleep can lead to more discouragement and
sleep effort on the part of the client, which in turn can ultimately undermine treatment
gains. In this case, remediating sedentary habits or revisiting whether the client’s mood
or anxiety is adequately treated, may improve sleep ratings. The ISI is typically responsive to changes in self-reported sleep problems across treatment and is thus useful
for tracking treatment progress (Bastien et al., 2001). A summed score of 14 or greater
(10 or greater in community samples) is suggestive of clinically significant insomnia;
scores less than 8 are suggestive of a healthy sleeper (Bastien et al., 2001).
Objective Measurement of Insomnia
Polysomnograms (PSG)
So-called “objective” measures of sleep are not commonplace in the clinical assessment
of insomnia. PSGs are scored using consensus (i.e., arbitrary) criteria and there are many
reasons to question the validity or utility of these criteria for insomnia. For example,
some individuals with insomnia have subjective complaints that may not be supported
by the standard “objective” sleep indices of PSG. By relying solely on visual scoring of
the sleep record we might miss more subtle features of the record that standard scoring
does not detect and therefore dismiss the subjective complaints of the client. In lieu of
the visually scored approach used in objective analysis, if we analyze the PSG data
through spectral analysis; a more sophisticated and less arbitrary approach, the brain
wave activity of these insomnia clients tends to show increased high frequency activity
(i.e., a frequency associated with light sleep or wakefulness). Moreover, the amount of
high frequency activity correlates with their subjective complaint (Krystal, Edinger,
Wohlgemuth, & Marsh, 2002). Thus there are serious limits to using visually scored
criteria for assessing insomnia. Another problem with PSG for insomnia is the issue of
the environment itself. That is, when people with insomnia sleep in an unfamiliar
environment, it is not uncommon on the first night for them to experience worse sleep
than usual. Conversely some individuals with insomnia will have a very good first night.
This may be because there is conditioned arousal associated with their specific bed, or
perhaps because some will hope that poor sleep is seen by the clinician on the PSG record
and thus the client completely let’s go of sleep effort and therefore paradoxically sleeps
much better than usual. In either case, it is difficult to make too much of an inference
about the sleep continuity data found on a first night of PSG.
48
Assessment of Insomnia
Actigraphy
Actigraphy is another possible “objective” measure of sleep. An actigraph is a wearable
device, most commonly worn on the wrist that measures movement with an
accelerometer. Movements are sampled at a sampling rate that is set by the user and
stored for future downloads with the accompanying software. The downloaded data is
subject to automated scoring via an algorithm that estimates whether a pattern of
movement is most typical of sleep or wakefulness. Such units are generally only as good
as the scoring algorithm so it is important to purchase one that has many validation
studies associated with it. Actiwatches most often provide estimates of sleep onset
latency, wakefulness during the night, total sleep time, and sleep efficiency (Lichstein
et al., 2006). Depending on the device, actigraphs have acceptable psychometric
properties, albeit somewhat reduced in those with insomnia (Blood, Sack, Percy, & Pen,
1997; Chambers, 1994; Hauri & Wisbey, 1992). That is, when actigraphs are used in
insomnia there tends to be an overestimation of sleep. Depending on the algorithm being
used, actigraphs may at times mistake lying awake as sleep. That said, those who wish
to see sleep disordered clients on a regular basis may opt to purchase a few actigraph
units for specific purposes. These devices are more frequently used during Circadian
Rhythm Disorder assessment in sleep disorder centers because the assessor can view
pattern across the 24-hour period more readily. Additionally, they can be useful in
behavioral experiments in those clients with gross underestimation of sleep, that is, those
clients who report little to no sleep consistently. For example, allowing clients to
examine their actigraph estimates of sleep in comparison to their sleep diary estimates,
reduces the degree of misperception and also decreases sleep-related anxiety (Tang
& Harvey, 2004). Thus, although there is some utility to actigraphs, they are not a
routine tool in the assessment of insomnia unless there is suspicion of a Circadian
Rhythm Disorder or gross underestimation of sleep (Buysse et al., 2006; Lichstein et al.,
2006; Littner et al., 2003; Standards of Practice Committee of the American Academy
of Sleep Medicine, 2003). For a discussion of commercially available apps utilizing
accelerometers versus validated actigraphs, see Chapter 7.
Fatigue
Fatigue is important to assess in insomnia. It is often the chief complaint (Bishop et al.,
2004) when the client is presenting for treatment; that is, many will complain more
about the impact of their insomnia on how they feel during the day than the distress
of being awake during the night. Fatigue is a common issue among those with a variety
of other health conditions. Fatigue is also often the trigger for rumination in those
with insomnia (Carney et al., 2006, 2010b, 2013b). There are a number of valid fatigue
measures available but two of the most researched and frequently used self-report
questionnaires are the Fatigue Severity Scale (FSS) (Krupp, LaRocca, Muir-Nash, &
Sternberg, 1989) and the Multidimensional Fatigue Inventory (MFI) (Smets, Garssen,
Bonke, & De Haes, 1995). These two measures are recommended as standard scales in
the assessment of fatigue in insomnia (see Buysse et al., 2006). The FSS has only nine
items (as compared to 20 items in the MFI), thus it is very brief and easy to use. The
construct measured is the degree of self-reported severity (Likert scale rating) of fatigue
Assessment of Insomnia
49
symptoms over the past week. The MFI is also a rating of fatigue in the past week but
focuses on the impact of fatigue across five dimensions, including general fatigue,
physical fatigue, mental fatigue, reduced motivation, and reduced activity. Of interest
is that fatigue reporting appears to relate to cognitive factors in those with MDD-I
(Carney et al., 2013). In other words, the best predictors of physical or mental fatigue
in those with both ID and MDD are: a tendency to ruminate in response to feeling tired,
believing that one cannot function without a specific amount of sleep, and believing
that one needs to avoid activities after a poor night’s sleep. Thus, in addition to targeting
sleep, specific fatigue interventions such as activation and cognitive techniques to test
maladaptive beliefs about sleep may be needed in those reporting high fatigue. It is
noteworthy that behavioral activation (BA) may be a key intervention in both those
with depression and insomnia. With regard to mood, increased activation is essential
in that it expands a person’s contact with reinforcers, and with regard to insomnia
increased activity helps to build a healthier drive for deep sleep as well as helping the
client to debunk catastrophic fears about the consequences of poor sleep.
Cognitive Factors
There are a variety of cognitive scales available. In this book we have highlighted two.
The Daytime Insomnia Symptom Rumination Scale (DISRS) (Carney et al., 2013b) is
a 20-item scale that assesses the tendency to ruminate in response to daytime insomnia
symptoms. This measure discriminates good sleepers from poor sleepers and has good
reliability (Cronbach’s alpha = 0.93) (Harris, Carney, & Moss, 2010). The DISRS is
included in Appendix C and permission is granted for clinical use only.
The Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) (Morin, Vallières,
& Ivers, 2007) is a questionnaire to assess the level of dysfunctional beliefs theorized to
contribute to the maintenance (and possibly, the development) of insomnia. The
DBAS16 is the most widely used measure of dysfunctional sleep beliefs; scores above
3.7 discriminate those with insomnia and those without (Carney & Edinger, 2006). The
DBAS16 is sensitive to clinical change and is correlated with several indices of clinical
improvement (Carney & Edinger, 2006).
Sleepiness
In addition to fatigue, it is important to assess for sleepiness. Clients commonly use the
terms sleepiness and fatigue interchangeably but they differ in important ways. Unlike
fatigue, sleepiness is a relatively uncommon symptom in insomnia because sleepiness
is the propensity to sleep; that is, when sleepy, if given the opportunity to sleep, one
would fall asleep (and quickly). Excessive daytime sleepiness, that is a tendency to fall
asleep involuntarily during the day without efforts to prevent it, is a characteristic of
many sleep disorders, but not insomnia. Unfortunately many people are not always aware
of the extent of their sleepiness, which puts them at risk for mishaps, including motor
vehicle accidents (Ward et al., 2013). For example, sleepiness is associated with extended
blinks and slow eye rolling movements and these eye movements are associated with
accidents in driving simulators (Åkerstedt, Folkard, & Portin, 2004). It is important to
understand that in the early phases, CBT-I will likely increase sleepiness, even in those
50 Assessment of Insomnia
who do not initially report this symptom, and this can pose a potential safety risk if not
addressed. Moreover, in the clients with insomnia who do report sleepiness at base line,
the potential for significantly increased excessive somnolence is high and the risks are
multiplied. Therefore it should be a high priority to assess for sleepiness both at the
beginning and throughout the treatment. To this end, the first step is to make sure that
the client understands the definition of fatigue and sleepiness and the distinction
between them. Whereas fatigue is the subjective feeling of weariness or tiredness and
the desire to rest or sleep; sleep is the propensity to sleep. For instance, many clients
with insomnia will report lying in bed awake, utterly exhausted but unable to sleep. This
is a good example of fatigue. The same client may also report that there are times when
they are sitting on the sofa watching TV, and find themselves unable to keep their eyes
open. This is a good example of sleepiness. Understanding and monitoring for this
difference is not only a safety issue but becomes an important piece of the treatment
especially in Stimulus Control instructions that ask the client not to go to bed until sleepy.
Once the client seems to understand and can differentiate between the two, the therapist
can then assess for sleepiness independent of fatigue.
During the initial interview and throughout treatment, the therapist should discover
the situations in which the client is most likely to doze. The therapist can ask about
missing plots while watching TV, needing to re-read pages of a book, having to rewind
a movie, others telling the client they had dozed off, or especially near misses of falling
asleep at the wheel. There are instruments that can help to assess for sleepiness and also
help novice therapists to frame the questions. The DSISD contains the following query
regarding hypersomnia: “Do you often fall asleep or do you have to struggle to stay
awake when you are in any of the following situations: Talking with others, driving,
talking on the phone, standing, performing your work, or any other situations?” The
Epworth Sleepiness Scale (Johns, 1994) is an 8-item scale in which clients rate the
likelihood of dozing on a 4-point Likert scale across a variety of circumstances (e.g.,
watching TV). Scores above 10 are suggestive of clinically significant sleepiness (Johns,
1994). The scale can be found at www.epworthsleepinessscale.com.
Other Sleep Disorders
There are a variety of sleep problems that can present like insomnia (e.g., sleep
disordered breathing) (Cuellar, Strumpf, & Ratcliffe, 2007) but are actually not insomnia
at all. However, these problems can also be co-occurring disorders that complicate or
undermine treatment, so assessment in MDD-I must be comprehensive. Any properly
trained therapist can screen for the signs and symptoms of most of these sleep disorders
in the context of a good assessment interview; but often, establishing the actual sleep
disorder diagnosis requires referral to a sleep center for PSG. Therefore the job of the
therapist working with MDD-I clients is to know when to refer their client to the sleep
center and when referral is unnecessary.
Sleep Disordered Breathing
There are a variety of breathing-related conditions during sleep; the most common of
which in MDD-I is obstructive sleep apnea (OSA) (Harris, Glozier, Ratnavadivel, &
Assessment of Insomnia
51
Grunstein, 2009b). OSA is a disorder in which there are repeated breathing pauses
or reduced oxygen flow due to obstruction or narrowing of the airway during sleep.
OSA is associated with significant morbidity including excessive daytime sleepiness,
cognitive impairments, and worsened mood (Borak, Cieślicki, Koziej, Matuszewski, &
Zieliński, 1996; Cheshire, Engleman, Deary, Shapiro, & Douglas, 1992; Sivertsen et al.,
2008). The presence of OSA may convey risk for the development of insomnia as well
(Vandeputte & de Weerd, 2003; Wahner-Roedler et al., 2007). The links between OSA
and MDD include: 1) fragmented sleep (Schroder & O’Hara, 2005; Sforza, de Saint
Hilaire, Pelissolo, Rochat, & Ibanez, 2002; Sharafkhaneh, Giray, Richardson, Young, &
Hirshkowitz, 2005), 2) hypoxemia (Kamba et al., 2001; McGown et al., 2003; Pizza,
Biallas, Wolf, Werth, & Bassetti, 2010), 3) serotoninergic system abnormalities (Adrien,
2002), and 4) shared common risk factors (e.g., obesity, cardiovascular disease, diabetes,
etc.) (Schroder & O’Hara, 2005).
The most important consideration for CBT-I treatment in those with comorbid OSA
and MDD-I is to ensure there is adequate treatment of the OSA. CBT-I generates sleep
deprivation to harness greater drive for deep sleep (see Chapter 5), and as stated, those
with pre-existing daytime sleepiness may be at risk for accidents or falls if their
sleepiness related to OSA (or PLMD or whatever other disorders they have) remains
undertreated. The gold standard treatment for OSA is a PAP device in which air is
delivered via a hose and facemask at a pressure strong enough to keep the airway open.
For those adherent with PAP treatment, it is highly effective for addressing excessive
daytime sleepiness and improving the overall quality of life (Giles et al., 2006). For those
having difficulty with adherence, there are effective behavioral protocols for helping with
adherence related PAP issues (Carney & Edinger, 2010). As a safety precaution in
delivering CBT-I, it may be advisable to require a minimum of 4 nights per week with
usage 75 percent or greater each night to safely proceed with CBT-I. One quick
assessment tool for screening OSA in non-sleep specialty settings is to assess for eight
factors. These eight factors are part of the STOPBANG instrument (Chung et al., 2012).
The first feature, the “S” of the STOPBANG is the presence of loud, persistent (i.e., not
occasional) snoring. The “T” is for tiredness, although in this context it actually refers
to sleepiness; that is, is there a propensity to fall asleep. It is this propensity and not
fatigue that the therapist should be looking for. One of the best ways to assess sleepiness
is by administering an Epworth Sleepiness Scale, which can help in this assessment. The
“O” of the STOPBANG is whether there are any observed apneas, that is, whether anyone
has ever seen the client exhibit breathing pauses while asleep. The “P” is for elevated
blood pressure, which can be obtained in the medical history. The “B” refers to whether
the body mass index [weight in kilograms/(height in meters)2] of the client is greater
than 35. The “A” refers to whether the client’s age is 50 years or more. The “N” refers
to whether the neck size or circumference of the client is larger than 40 centimeters or
15 inches. Finally, “G” refers to gender, that is, whether the client is a man, since men
are more likely to suffer from sleep apnea than women. For every answer in the
affirmative, the item is scored as a 1, and a summed score of 3 or greater warrants at
least a strong consideration of referral to a sleep disorders center for further assessment.
That said, not all of these signs should be considered as equivalent and so it should be
said that elevated excessive daytime sleepiness even in isolation, whether by self-report
or by an elevated Epworth Sleepiness Scale (ESS) score (ESS>10), should be a strong
52 Assessment of Insomnia
indication to instigate the referral process to a sleep center. Additionally, do not be fooled
that the absence of any one of these factors, for example, being female, very young, or
small in stature, should be taken as a sign to bypass an apnea assessment. All clients
should be assessed for co-occurring sleep disorders, especially OSA.
Restless Leg Syndrome (RLS)
RLS is a neurological disorder characterized by a compelling urge to move the legs
especially during rest or inactivity; thus, symptoms most often appear in the evening
and especially when getting into bed. The urge is often accompanied by unpleasant
tingling sensations in the legs and the sensations are typically at least partially alleviated
by moving the legs and walking. RLS can range from a mild nuisance to a disorder that
significantly delays the onset of sleep and adversely impacts quality of life (Allen et al.,
2005; Happe et al., 2009). The cause of RLS is not fully understood—the most commonly
implicated etiologies involve dopamine dysfunction (Hornyak, 2010; Trenkwalder &
Paulus, 2010), genetics (Schormair et al., 2008; Stefansson et al., 2007; Winkelmann
et al., 2007) and poorly controlled anemia (Allen, Auerbach, Bahrain, Auerbach, &
Earley, 2013). It is particularly important to assess for RLS in those with MDD-I because
those with RLS typically report symptoms with substantial overlap with MDD, such as
fatigue, disturbed sleep, poor concentration, and psychomotor agitation (Allen et al.,
2003; Sevim et al., 2004). Indeed, there is a relationship between RLS and MDD (Cuellar
et al., 2007; Sevim et al., 2004; Winkelman, Finn, & Young, 2006). The treatment of RLS
may, in some cases, simply involve treating iron deficiencies. However, in most cases,
if such deficiencies are not present or iron supplementation fails, treatment involves
the prescription of a dopamine receptor agonist (Trenkwalder, Högl, Benes, & Kohnen,
2008). The following questions (contained in the DSISD) are useful in determining
whether someone should be referred for evaluation and treatment of RLS:
Do you ever have a very strong urge to move your legs? Is this urge accompanied
by an unpleasant sensation in your legs such as crawling, tingling, drawing,
restlessness, or ‘electric’ sensations? Does the urge to move and/or unpleasant
sensations begin or worsen during periods of rest or inactivity? Are these sensations
temporarily relieved by moving your legs or walking? At what time of day do these
symptoms occur?
The last question is assessing whether the symptoms occur or worsen in the evening or
at night. Those with RLS experience creepy crawly sensations in their legs and typically
have a strong urge to move their legs in the evening, particularly when at rest. The
sensations are lessened when permitted to move the legs. Lastly, in assessing for RLS,
it is important to pay careful attention to the medical history. Query if there has ever
been a problem with iron levels, the date of the last physical examination and whether
blood work assessed iron levels. As well, determine if the timing of the RLS symptoms
were contiguous with the start of a new medication. Some antidepressants, including
antihistaminergic agents and antipsychotics, can cause or worsen RLS (Allen, Lesage,
& Earley, 2005a; Kim et al., 2008), and thus, medication use is part of a thorough
assessment.
Assessment of Insomnia
53
Periodic Limb Movement Disorder
Periodic Limb Movement Disorder is a neurological disorder in which there are multiple
brief (0.5 to 5.0 second) lower extremity twitches during sleep (Aurora et al., 2012).
This is not merely moving frequently during sleep, tossing and turning, or restlessness,
but rather these are stereotyped, sometimes subtle twitches which happen at such a high
rate as to potentially cause brief arousals that will fragment sleep, much like OSA can
do. It should be noted, that most clients with PLMD are unaware of the movements or
the arousals because of their brevity. There is a very high comorbidity between RLS and
PLMD, such many with PLMD also have RLS (Allen et al., 2003). That said, one can
have PLMD and not have any symptoms of RLS. As with RLS, PLMD is linked to
dopaminergic dysfunction (Picchietti & Winkelman, 2005) and treatment involves
dopaminergic agonist medications (Boeve et al., 2007). There are also increased rates
of MDD in those with PLMD (Picchietti & Winkelman, 2005). In addition, there are
reports of increased PLMs with antidepressant medications such as clomipramine,
imipramine (Hornyak, 2010), and some SSRIs (Dorsey, Lukas, & Cunningham, 1996)
which underscores the importance of a complete medical and medication history. In
the DSISD, the PLMD section queries whether a bedpartner has noticed the client’s leg
jerking or twitching repeatedly during sleep and prompts the assessor to ensure the
client’s description sounds like PLMs. That is, the movements should be described as
repetitive, stereotyped extensions of the big toe in combination with partial flexion of
the ankle, knee, and in some cases, the hip. Clinically relevant PLMD is often associated
with excessive daytime sleepiness, and as noted above, EDS of unknown etiology should
result in a sleep disorder center referral for an overnight study to rule-out PLMD and
other occult sleep disorders.
Narcolepsy
Narcolepsy is a neurological sleep disorder which can be associated with hallucinations
upon waking up or falling asleep, sleep disturbance, daytime sleepiness, and/or muscle
weakness during waking hours. The presence of excessive daytime sleepiness necessitates a follow-up query about narcolepsy; a significant sleep disorder that can also be
associated with increased rates of MDD (Ohayon, 2013). The DSISD contains the
following query:
Have you had any of the following symptoms: 1) inability to move while in bed
(i.e., temporary sleep paralysis), 2) seeing frightening images or visions while in
bed, 3) carrying out some activity without being fully aware of what you are doing;
or 4) a broken or disrupted sleep pattern at night?
Any of these symptoms along with excessive daytime sleepiness and/or unintentional
sleep during the day warrant a referral to a sleep center to assess for narcolepsy.
Additionally, a report of cataplexy (i.e., sudden but brief, bilateral muscle weakness or
paralysis associated with the experience of emotion) is suggestive of narcolepsy and
warrants referral. Narcolepsy is treated with pharmacotherapy for the specific symptoms
of the disorder (e.g., stimulants for daytime sleepiness, SSRIs for cataplexy etc.)
(Morgenthaler et al., 2007).
54
Assessment of Insomnia
Circadian Rhythm Disorders
Circadian Rhythm Disorders are disorders in which there are abnormalities in the
timing of the client’s preferred sleep-wake schedule. In other words, the client’s
preferred circadian phase is out of sync with the demands of their social and work
schedules. Depending on the relation of intrinsic phase to the client’s preferred schedule,
a person can experience a variety of problems with sleep initiation and maintenance,
but this should not be confused with insomnia and should be assessed and ruled out
before beginning CBT-I. In the DSISD, this is queried with the following lead question:
“Have you ever had a sleep schedule that was unusual or undesirable to you, OR
different from the sleep-wake patterns of most other people you know (for example,
working at night and sleeping in the daytime)?” An affirmative response to this question
is followed-up with questions about eveningness (e.g., Delayed Sleep Phase Type) and
morningness (e.g., Advanced Sleep Phase Type), shift work (e.g., Shift Work Type), cross
time zone travel (e.g., Jet Lag Type), multiple short sleeps or naps totaling an approximately normal total sleep time in 24 hours (e.g., Irregular Sleep-Wake Type), or a
circadian system longer than conventional, such that sleep-wake times are delayed each
night or day, resulting in sleep-wake times that are not entrained to the environment
(e.g., Free-Running or Non-Entrained Type). Again, Circadian Rhythm Disorders are
not the same as Insomnia Disorder even though many individuals with a circadian
dysrhythmia will present to a sleep therapist thinking they have insomnia. Making this
differential diagnosis is important because Circadian Rhythm Disorders are not treated
with CBT-I, but rather they are best assessed and treated in Sleep Disorder Centers using
light therapy, medications, or chronotherapy.
Despite the fact that full Circadian Rhythm Disorders are not amenable to change
from CBT-I, it should be noted that, delayed sleep phase and advanced sleep phase are
part of a continuum of eveningness and morningness respectively, and milder forms
can occur in ID and normal sleepers. That is, there are night owls and larks in the normal
population and in those with ID, and who differ from those with full Circadian Rhythm
Disorders both in the severity of the delay or advance as well as the amount of
interference or distress the pattern causes. Such individuals can and should be treated
using CBT-I. In those who have a night owl tendency with comorbid insomnia (e.g.,
see Client #1 in Table 4.2a), late nights do not produce a consistent sleep improvement.
For example, the latest bedtime on Saturday is associated with taking an hour to fall
asleep but one of the earliest bedtimes (i.e., 11 PM on Thursday) is associated with taking
the shortest amount of time to fall asleep (i.e., less than 35 minutes). Additionally,
although there are later rise times on the weekend, the client can wake up conventionally
early, but this does not consistently resolve their sleep onset problem. For such clients
with insomnia and phase delays or phase advances in the absence of a full Circadian
Rhythm Disorder, CBT-I can be used but there are a variety of adjustments that may
be needed (see Chapter 7).
On the other hand, for those who have full Delayed Sleep Phase Type and Advanced
Sleep Phase Type, following their ideal schedule resolves any problems (i.e., going to
bed late and waking late or going to bed early or waking early). That is, if the individual
follows their preferred internal clock, they will have no trouble either initiating or
maintaining sleep. As an example, client #2 (see Table 4.2b) consistently falls asleep
120 min
10 min
6 AM
7:50 AM
Time to fall
asleep
Time awake
during night
Wake time
Rise time
8:30 AM
6:15 AM
15 min
90 min
1:30 AM
Tuesday
12:00 AM
180 min
10 min
8 AM
8:30 AM
Bedtime
Time to fall
asleep
Time awake
during night
Wake time
Rise time
Monday
8:45 AM
8 AM
15 min
90 min
1:30 AM
Tuesday
Table 4.2b Sleep Diary for Client #2
11:00 PM
Bedtime
Monday
Table 4.2a Sleep Diary for Client #1
8:30 AM
8 AM
5 min
150 min
12:30 AM
Wednesday
7:45 AM
6:10 AM
5 min
50 min
12:30 AM
Wednesday
9 AM
8 AM
10 min
170 min
12:00 AM
Thursday
6:15 AM
6 AM
15 min
35 min
11:00 PM
Thursday
8:45 AM
8 AM
5 min
35 min
2:30 AM
Friday
7:45 AM
6:05 AM
5 min
60 min
1:00 AM
Friday
2:15 PM
2 PM
5 min
5 min
3:00 AM
Saturday
10:45 AM
8:00 AM
5 min
60 min
2:00 AM
Saturday
2:40 PM
2:30 PM
15 min
120 min
12:30 AM
Sunday
10:30 AM
7:50 AM
15 min
120 min
11:15 PM
Sunday
56 Assessment of Insomnia
around 3 AM (falling asleep very quickly at 3 AM) with a late wake-up time on the
weekend followed by an almost immediate rising. This client will require phase shifting
which is beyond the scope of this book and will require a referral to a sleep center.
Psychiatric Comorbidities
It is important to assess for psychiatric comorbidities as these will be an important part
of the case formulation and depending on their severity and nature may affect the
tailoring of treatment. There are some disorders that may make participation in a
structured therapy such as CBT-I challenging, for example, psychotic disorders. There
are no randomized controlled trials of which we are aware in which CBT-I was tested
in those with psychotic disorders. However, one pilot study in those with persistent
persecutory delusions found that CBT-I produced sleep improvements associated with
large effect sizes as well as reductions in persecutory delusions (Myers et al., 2011). The
presence of mania or perhaps even hypomania warrants caution in using techniques
such as Sleep Restriction, as sleep deprivation can trigger mania or hypomania. Likewise,
the presence of Panic Disorder or Seizure Disorders may warrant the same degree of
caution as both panic attacks and seizures can be precipitated by sleep deprivation. On
the other hand, insomnia is a very common problem in Post-Traumatic Stress Disorder
(PTSD), and CBT-I is highly effective for those with comorbid insomnia, MDD and
PTSD (Edinger et al., 2009a; Lichstein, Wilson, & Johnson, 2000). Nightmares are a
frequent problem in PTSD and it is important to assess the frequency and intensity
of nightmares, and whether the nightmares play a key role in the insomnia. When
nightmares are a problem, one could consider additional medication such as prazosin
(Raskind et al., 2003, 2007) or adjunctive therapies such as Imagery Rehearsal Training
(Krakow et al., 2001). If there is a comorbid Obsessive Compulsive Disorder, it is helpful
to know if there are any pre-sleep rituals that account for the delayed sleep onset. In
other words, if the client is complaining about feeling tired and it taking a long time to
fall asleep, but it is discovered that the sleep initiation attempts are delayed by the client’s
need to engage in rituals, the compulsions become an important treatment target.
For all comorbid conditions, it is important to ascertain whether the client views that
there is a relationship between the condition and the insomnia. That is, did the sleeping
problem start, change, or worsen with the onset of the other condition, or did the sleeping problem precede the comorbid condition? Even if the client is not an accurate
historian with the timeline, such questions provide insight to how the client views the
relation between sleep and other existing conditions. Ultimately, for but a few of the
contraindicated comorbidities listed above, insomnia can and should be targeted for
treatment within the context of the comorbidity; this is particularly true for MDD.
Finally, there are several semi-structured interviews available that can be used to assess
for psychiatric disorders including the Structured Clinical Interview for DSM5 Axis I
Disorders (First, Williams, & Spitzer, 2015).
Medications or Substances
It is important to assess for past and present over-the-counter, prescription, and herbal
medications as well as illicit substances and alcohol. The medication list should include
Assessment of Insomnia
57
sleep-related medications or medications taken to affect sleep, in addition to medications not taken for sleep. The list of medications that affect sleep is too large to reproduce
in a book. Suffice it to say that almost any substance can potentially affect sleep. The
following medications are only a partial list that can exert negative effects on sleep: central
nervous system stimulants, antihypertensives, respiratory medications (e.g., steroid
inhalers), chemotherapy, decongestants, and some antidepressants. It is important to
take note of all medications, timing, dose, and duration of use. For all medications or
substances it is important to ascertain if there is any relationship between the substances
and sleep. That is, did the sleeping problem start, change, or worsen with the start of
the medication or substance? It is also important to assess for common substances such
as caffeine, alcohol, marijuana, and nicotine. It is important to know the timing,
frequency and dose of the active ingredients in these substances. At the time of this
printing, The Mayo Clinic website has a useful guide to estimating caffeine content:
www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/caffeine/art20049372.
Active substance abuse or dependence may be a contraindication or a limiting factor
for CBT-I because there will be sleep disturbance related to the active properties of the
substance as well as the withdrawal that can produce increased alertness or increased
sleepiness at undesirable times. In general, it is not advisable for clients who are not
stable medically or psychologically to engage in a rigorous treatment such as CBT-I.
Instability of sleep is an expected reaction to extreme stress and CBT-I will not override
the physical symptoms associated with an acute emergency so it is advisable to wait for
medication, medical and psychological stability before embarking on this treatment. For
any medications and substances, it is important to consider how the substance may be
affecting sleep.
Many people presenting for CBT-I treatment will be taking sleeping medications so
it is important to assess for hypnotic dependence. The first thing to establish for
dependence is nightly use of the medication, and the second thing to establish is their
anxiety or willingness to discontinue the medications. Nightly users who are unwilling
to discontinue medications and/or those who respond to these queries with extreme
anxiety may have hypnotic dependence. Hypnotic dependence is not a contraindication
for CBT-I but it is useful to know, as treatment will have to improve sleep self-efficacy,
and because many clients who are dependent on such medications have beliefs that
interfere with adherence to CBT-I. That is, if the belief is that their sleep system is broken,
then attempts to correct the problem with a shift in behavior may be met with low
confidence and resistance. See Chapter 3 for an in-depth discussion of hypnotic
medications, treatment decision making regarding such medications, and tapering
schedules.
Past Treatment History or Experiences
It is important to query what treatments, both pharmacological and non-pharmacological, the client has tried in the past and what were the end results. Such information
provides detail about what has worked, what has failed, and beliefs about treatments
and medications. With regard to past behavioral treatments, sleep hygiene information
is the most readily available online and it is the most frequently used treatment
58
Assessment of Insomnia
component for insomnia (Moss, Lachowski, & Carney, 2013), therefore most clients
have been exposed to and tried some form of this sleep education. Given that sleep
hygiene is an insufficient treatment for insomnia when used as a monotherapy (Morin
et al., 1999, 2006) most clients will not report success with this treatment. However,
many may have confused sleep hygiene with a full course of multi-component cognitive
behavioral therapy and thus may have some tempered expectations for CBT-I. Openly
exploring the client’s experience of what has been helpful and not helpful is important
for building rapport and gaining insight into their struggle with sleep effort and their
beliefs about your work together. It is important to assess the client’s memory and
understanding of the rationale for the strategies they used. Additionally, it is important
to assess the specific detailed behaviors the client implemented in the past that did not
work, as many will say that they have tried CBT-I when in actuality they may have only
set their alarm during weekdays and decreased caffeine use. Such changes in isolation
would not be expected to be effective, but pointing out the reasons for previous failure
and the treatment components, that can be added, can debunk the previous experiences
and generate new hope for the client. Lastly, it is important to query what substances
or medications they have tried. Be sure to ask about timing, dose, course, and if there
are any contingencies, e.g., “I only take trazodone following a really bad previous night.”
Assess for both positive and negative beliefs about medication. Some clients believe
medication is “bad” and refrain from taking prescribed medications for their depression,
pain, or other conditions. Sometimes clients substitute other substances that are
ineffective or unsafe to avoid prescribed, effective sleep medications.
Treatment Targets
Perhaps the biggest goal for assessment is to collect data for determining treatment
targets. For example, poor sleep drive habits (e.g., naps, increased time-in-bed, or high
caffeine consumption on a sleep diary), circadian rhythm dysregulatory habits (e.g.,
irregular rise times on a sleep diary or a schedule that is a poor match for the client’s
chronotype, such as early bedtimes and rise times in a night owl), sleep effort behaviors
(e.g., going to bed early without any ability to sleep early on the sleep diary), and poor
sleep hygiene (e.g., smoking, alcohol and/or marijuana before bed). Understanding these
factors is ultimately what helps the therapist to adequately conceptualize the client’s
insomnia and set up techniques and protocols that can address these problems and help
the client achieve much better sleep. See Table 4.1 for a list of treatment targets and
how to calculate them from a sleep diary. Treatment targets are described in Chapters
5, 6, and 8.
Summary
•
•
Essential tools for assessment of insomnia include a clinical interview as well as
sleep diaries.
It is important to help the client differentiate fatigue for sleepiness and to assess
for excessive daytime sleepiness and refer to a sleep clinic for assessment of
disorders that require further follow-up such as OSA, PLMD, Circadian Rhythm
Disorders, and narcolepsy.
Assessment of Insomnia
•
•
59
Assess medical and psychiatric conditions, as well as a substance or medication
history and past treatment history.
Data from the initial assessment is used to formulate the case, but assessment should
continue throughout treatment.
Notes
1. Permission for the DSISD can be obtained by contacting the first author (J.D. Edinger).
2. Research permission can be obtained by contacting the first author (C.E. Carney).
5
Behavioral Strategies for
Insomnia
The evidence for CBT-I is strong (Morin et al., 1999, 2006). Cognitive behavioral
therapies are empirically driven therapies so they are developed and refined using data
derived from research. The sleep index improvements with CBT-I are associated with
large effect sizes in sleep continuity similar to the effect sizes for treatment with hypnotic medication in the short term (Morin, Culbert, & Schwartz, 1994a; Murtagh &
Greenwood, 1995; Smith et al., 2002). Unlike hypnotic treatment, with CBT-I once
therapy is discontinued, treatment gains are maintained into follow up periods for as
long as two years post-therapy (Edinger et al., 1992, 1996, 2001; Edinger & Sampson,
2003; Morin et al., 1999a). Although CBT-I is a multicomponent therapy that can vary
with regard to the components used, there are some common core elements (i.e.,
Stimulus Control and Sleep Restriction) that tend to be incorporated across all the
treatment versions. These behavioral strategies form the backbone of the treatment.
There is even evidence (see Morin et al., 1999b, 2006) for Stimulus Control and Sleep
Restriction to be used successfully as monotherapies but in clinical practice, and in
clinical trials, it is most common to combine these highly effective approaches into a
multicomponent treatment package. Therefore the clinician has a menu of techniques
from which to choose and can decide the appropriate sequence, emphasis, and
combination of elements to use depending on the conceptualization of the relevant
factors impacting the client’s sleep. The most frequently utilized components of CBTI (Edinger & Carney, 2014) include:
1.
2.
3.
4.
5.
Stimulus Control (Bootzin, 1972): a set of sleep rules to address conditioned arousal.
Sleep Restriction (Spielman et al., 1987b): a technique to increase sleep drive by
matching the time spent in bed with current sleep production time.
Cognitive Therapy: a set of techniques to modify catastrophizing beliefs about
sleep and fatigue that cause or exacerbate insomnia (discussed in Chapter 7).
Counter arousal strategies: a set of techniques to address hyper arousal, including
establishing a wind-down period before bed, pre-sleep structured information
processing, and relaxation therapy.
Sleep Hygiene: a set of rules designed to address sleep-interfering habits, substances,
or environmental factors.
The goal of the assessment session is to diagnose the nature of the sleep disruption,
discover the factors that are maintaining the problem, assess for any complicating
Behavioral Strategies for Insomnia
61
comorbid disorders, and determine whether there are any issues that would contraindicate the use of CBT-I (see Chapter 4). Once it is established that there is a diagnosis
of insomnia and that CBT-I is an indicated treatment, the process of deriving goals
for treatment can ensue and the first treatment session can be set (i.e., Treatment
Session 1).
Essential to the cognitive behavioral treatment of insomnia is that from the outset
and throughout treatment, the client will need to fill out sleep diaries to monitor sleep
continuity variables. Ideally, it can be helpful to have already supplied the client with
diaries and written diary instructions along with other clinic materials (e.g., directions
to the clinic etc.) in the mail and have the client bring the diaries to the assessment
session, so that some sleep continuity information is already available to the clinician.
In any event the clinician should allow some time at the end of the assessment session
to either review the accuracy of diaries that have already been filled out, or to teach the
client for the first time how to monitor their sleep. What follows is an example of a
diary review dialogue (see Chapter 10 for more on this case):
Therapist: First of all I want to thank you for filling out the sleep diaries that we sent
to you. These diaries are going to be a very important part of assessing how you
are sleeping now but also throughout therapy it will help us to track your progress
as we make changes to improve your sleep. I do see that there are some spaces that
you left blank and others where you put question marks. Can you tell me what is
happening there?
Client: Well it said in the instructions that I wasn’t supposed to look at the clock, but
that was making me nervous because sometimes I’m not sure how long I have been
lying awake.
Therapist: That is a very common concern but one that you really do not need to worry
about. The truth is that I am much more interested in what it felt like to you, instead
of the exact number of minutes that you were awake. So what I really need is your
“guesstimate.” Anyway it turns out that people are consistent in the way they report
their sleep. If you are off by a few minutes here and there, any so-called errors will
be consistent throughout the treatment. Meaning if you tend to under- or overestimate how much sleep you produce, you will do this consistently, so it will be
ok for our purposes. Does that make sense?
Client: I guess so, but what if I really am off by a lot?
Therapist: How about if we do a night together and see how it goes?
Client: Okay.
Therapist: First of all, let’s do last night because it’s much more likely that you will
make a better guesstimate from the most recent night of sleep as opposed to any
night earlier this week. So tell me how long did it take you to fall asleep last night?
Client: It’s really hard to say and hard to put a number on it.
Therapist: Just give it a shot. Give me the first number that comes to mind.
Client: I think about 30 minutes.
Therapist: Great! It’s just that simple. You say 30 minutes and we both know that that
is probably not right to the minute but nevertheless it is close. That is, you know
that it probably wasn’t anything like five minutes and you also know it wasn’t 2
hours. Am I correct?
62
Behavioral Strategies for Insomnia
Client: Yes I guess that’s right.
Therapist: So although it might have been 25 minutes or 35 minutes or even 40
minutes we know we are in the ballpark, which is what we need. All the other
columns in the diary can be filled out in the same way. That is, by giving your best
ballpark guesstimate. Now, is that something that you think you can do?
Client: Yes I think so. If that’s all you need, I can do that.
Therapist: Great! From here on that is how I want you to fill out your diaries.
It is important to emphasize that the diaries are essential because they will give a
sense of the fluctuations in the client’s sleep and the treatment decisions will be based
on them. Therapists should explain that at the beginning of each session the therapist
will review and analyze the diary alongside the client so that in the future, the client
will be able to analyze it without the help of the therapist and make needed adjustments
on their own. As can be seen from the dialogue, it is important to emphasize that clients
need not worry about the accuracy of their estimates. It is also important to note that
the best time for filling out diaries is first thing in the morning when the memory of
how the night proceeded is fresh in the client’s mind. Once the client is clear on how
to fill out the diary, they can be provided with two weeks of diaries to assess their baseline
sleep. Two weeks is ideal because it does not require too long a period of time between
the end of assessment and the first treatment session and yet gives enough data to account
for the variability of the clients sleep.
Treatment Session 1
As in all cognitive behavior therapy treatments, the client is oriented towards what to
expect. For those clients who have participated in insight or support-oriented therapies
in the past, the didactic nature of the sessions as well as the intense between-session
work can be surprising, and may not suit all clients. As early as the assessment session
the client may need to be oriented to the nature of a more focused cognitive behavioral
therapy so that they are prepared for what is to follow. This message will then continue
to be reinforced in treatment Session 1 as psychoeducation begins and homework
assignments are developed. Once expectations are set, the client is free to choose whether
this is a therapy in which they would like to engage. Of course the degree to which the
client is ready to make the needed changes to their behavior will play out in the coming
sessions and resistance will become part of the focus of the therapy.
There are two main approaches to setting up CBT-I treatments: one is a set sessionby-session manual driven approach seen most commonly in clinical trials (see Edinger
& Carney, 2014) and in training settings. In Chapters 5, 6, 7, 8, and 10, we have used a
set approach. The second approach is a more flexible, client-derived case formulation
approach (see Manber & Carney, 2015). Across both approaches, the most important
techniques will target the most salient problems, but in fixed session approaches there
may be extra, potentially superfluous techniques as well. A case formulation approach
is more advanced, so we refer the reader to Manber and Carney (2015) for more details.
An example of this approach the BA and Behavioral Insomnia Therapy (BIT) treatment
is described in Chapter 9 in which elements of BA and BIT are flexibly combined across
Behavioral Strategies for Insomnia
63
three modules. For the purposes of this book, we will use the more basic fixed approach
(e.g., Carney, Edinger, Krystal, & Shapiro, 2014) with adaptations relevant to depression
described in (Carney & Manber, 2009; Manber & Carney, 2015). For most versions of
fixed CBT-I, there is an attempt to present Stimulus Control, Sleep Restriction, and to
some extent, Sleep Hygiene, in the first session. As a result, it is important to practice
a succinct delivery of the rationale (i.e., psychoeducation) to be able to deliver it with
efficiency. If at all possible, it is preferable to practice with a peer rather than alone,
because psychoeducation is best delivered interactively using Socratic questioning (see
Chapter 7 for more on Socratic questioning). One may want to anticipate a number of
possible client reactions and questions that will arise while delivering the psychoeducation and practice how to respond to each in turn. Such Socratic delivery may be
particularly important in those with comorbid depression because the cognitive impairments in depression make it difficult to remember the rationale between sessions and
clients may not follow the treatment prescriptions without buy-in. An interactive
delivery will be demonstrated below under Stimulus Control.
Stimulus Control
Stimulus Control is a treatment for insomnia that can be delivered with good results
on its own (Morin et al., 1999b, 2006); however it is most commonly delivered in the
context of a cognitive-behavioral package. One common problem that arises in chronic
insomnia is the development of conditioned arousal. Conditioned arousal is a situation
in which a client has inadvertently learned to associate the bed or sleep situation with
alertness or wakefulness. This occurs with the repeated pairing of the bed and sleep
situation with being awake, thinking, ruminating, emotional arousal, and/or a variety
of sleep incompatible behaviors (e.g. watching TV, reading, etc.). That conditioned
arousal if present reveals itself in the assessment as a story in which the client readily
is able to sleep under particular circumstances, for example, when on the couch reading, however, when getting into their own bed, sleepiness dissipates, and alertness
increases—such is a prime example of conditioned arousal. Fortunately, clients can
unlearn this association by being in bed only when sleepy, or very close to it. To
counteract conditioned arousal there are five rules for re-establishing the stimulus value
of the bed for sleep, they are:
1.
2.
3.
4.
5.
Go to bed only when sleepy.
Get out of bed when unable to sleep and only go back to bed when sleepiness returns.
Get out of bed at a consistent time each morning regardless of the amount of
obtained sleep.
Use the bed and bedroom only for sleep.
Do not take daytime naps.
Sample Delivery for Stimulus Control Rationale
Therapist: You said that you are often feeling very sleepy in the evening?
Client: Yes, in fact sometimes I even fall asleep while watching TV.
64 Behavioral Strategies for Insomnia
Therapist: So you go to bed and what happens?
Client: That’s the odd thing, Nothing happens except that I wake right up. I can’t sleep.
I’m not sleepy once I get into bed.
Therapist: I see. Do you become alert then?
Client: Yes, very alert.
Therapist: I would say that this is one of the most common problems people with
insomnia experience. Any theories as to why this happens?
Client: No. It doesn’t make sense to me. Sometimes I think maybe I moved too fast
to the bed so I walk slower, but this doesn’t work either.
Therapist: People with insomnia have one common experience: they have repeated
experiences of being awake in bed. When we repeatedly pair experiences like feeling
wide awake, with an object (like a bed), this creates an association in our brain even
though we are not aware of it. The association is that the bed is the place in which
I am wide awake . . .
Client: Wide awake and frustrated.
Therapist: Yes, wide awake and frustrated, or worried, or experiencing racing
thoughts. Good point because it is one thing to be awake but it becomes even more
intense when there is a negative emotion such as frustration that becomes paired
with the bed. Does this make sense to you?
Client: My bed is the place where I am wide awake? Yes, I definitely think that’s true.
Therapist: It’s as if your bed has now become a trigger for waking up rather than
sleeping. The good news is that our brain can “unlearn” this pattern. We can create
a new association of sleep with the bed by following some rules throughout this
treatment. The rules are essentially to be out of bed when you are awake and in
bed during a particular time at night and only when you are sleepy. If you are only
in bed when you are sleepy, it increases the chances that you will fall asleep. If
something changes and you are suddenly awake again, you are no longer sleepy so
you need to get out of bed again.
Client: That doesn’t make sense. My problem is that I become awake every time I get
into bed. So this means I will always be getting out of bed and I will never sleep
again.
Therapist: So your theory is that you will never sleep again, ever?
Client: Yeah, EVERY time I get into bed I am awake so if I have to get out of bed each
time, I will never be able to sleep.
Therapist: You don’t think that some sleep deprivation will build-up and eventually
put you to sleep?
Client: Maybe for normal people, not for me.
Therapist: Let me tell you about an experiment with people with insomnia and then
let’s revisit this issue, ok?
Client: Ok.
Therapist: In one study, they had someone with insomnia sleep in the laboratory and
they of course had poor sleep that night. The next day they asked them to nap. Do
you think they were able to fall asleep after having such a poor night of sleep?
Client: I don’t know. I know that I wouldn’t be able to fall asleep during a nap even
though I am absolutely exhausted.
Behavioral Strategies for Insomnia
65
Therapist: And neither could the people in the study. People with insomnia develop
something called hyper arousal. All of their bodily systems become hyperactive to
help them function, so although they are tired, they are also “wired.” Ultimately
this is how people with insomnia still manage to function but it also makes sleeping
very difficult because you cannot sleep when alert. In the same research study, they
had people with no sleeping difficulties stay in the laboratory bedroom next to the
person with insomnia and every time the person with insomnia was awake, they
woke up the healthy sleeper. By the morning, both the person with insomnia and
the healthy sleeper were awake the same amount and slept the same amount. They
asked the healthy sleeper, whose sleep they disrupted, to try to nap. What do you
think happened?
Client: They probably fell asleep right away and slept the whole time.
Therapist: But why? They both had the exact same sleep.
Client: There is something different about insomnia.
Therapist: That’s correct. There is something different about insomnia—hyper
arousal. Now to the third part of our study. In a third bedroom in the sleep
laboratory they had another person with insomnia, and every time our first person
with insomnia was awake, they woke up the other person with insomnia. So, some
of the time, that person was awake because they have insomnia but other times
they were awake because they were awoken to match the other person with
insomnia’s sleep disruption. The next morning, every 2 hours, they asked the
person with insomnia, whose sleep they disrupted, to try to nap. What do you think
happened?
Client: I don’t know.
Therapist: The person with insomnia who was woken up when the other person with
insomnia was awake became systematically sleep deprived, and suddenly, they were
able to nap. The hyper arousal was over-ridden by the systematic sleep deprivation
that was created by keeping them awake an amount more than they were already
used to. If you were to stay out of bed when you were not sleepy and really wait
until you were sleepy again as opposed to just tired or frustrated with being awake,
and as a result sleep deprivation was building, what do you think would happen?
Client: I’m worried I would stay awake forever but I guess that’s pretty unlikely. You
think that I would eventually become sleepy?
Therapist: It’s not about what I think, it’s about how the body works. There have been
many people throughout history who have invested billions of dollars to try and
discover a way for people like soldiers or astronauts to be able to resist sleep and
stay awake for long periods of time—no one has been able to do it, because the
body always finds a way to override it.
Client: That makes sense. So I just stay out of bed permanently until I am sleepy?
Therapist: (Smiles) What I can say is that such relearning will not happen in just one
night. It may take some time for the new message to sink in. The new message
being your bed is a place for sleep. So how about I give you a set of less extreme
guidelines that use what we know about the body that can help us re-associate your
bed with sleep, and get rid of the feeling that an awake switch goes off when you
get into bed?
Client: Ok.
66 Behavioral Strategies for Insomnia
Below are the specific Stimulus Control Rules and rationale for their use:
1.
2.
3.
4.
Go to bed only when sleepy: Sleepiness, unlike fatigue, is a sensation experienced
just before the transition into sleep. Sleep naturally unfolds when a person is sleepy
and when given an opportunity for sleep such as a comfortable bed somewhere free
from noise and light. Getting into bed because it is a particular time (e.g., “I have
always gone to bed at 11 PM” or “I want to sleep,” or “. . . my spouse goes to bed
at 11 PM so I go to sleep then too”) rather than because of sleepiness, can result in
increased wakefulness, and consequent frustration while in bed. The bed should
become associated with sleepiness, and therefore, rapid sleep onset. Therefore,
clients are instructed to get into bed in the presence of this cue exclusively.
Get out of bed when unable to sleep (and only go back to bed when sleepiness
returns): Conditioned arousal occurs because there are repeated pairings of the bed
and wakefulness. It is a common experience for people with insomnia to lie in bed
for long periods of time, frustrated with their inability to sleep. Most people do not
leave the bed because they are exhausted and believe that staying in bed gives them
their best odds for eventually falling asleep. However, conditioned arousal prolongs
the time that it takes to fall asleep and further pairs the bed with worry and
frustration so this strategy tends to backfire. Getting out of bed when unable to
sleep prevents the pairing of wakefulness and the bed. Moreover, giving up the effort
to sleep makes it more likely that arousal will decrease and that the client will be
more likely to be ready to return to the bed. Once out of bed the client should engage
in quiet relaxing activities and again return to bed only when sleepy as opposed to
out of a feeling of need or desperation. If still unable to sleep the client should repeat
this step as much as necessary.
Get out of bed at a consistent time each morning (regardless of the amount of
obtained sleep): Ideally bedtime would be set every night but because of the first
rule (i.e., only go to bed when sleepy) the bedtime cannot be fixed. However, clients
can control when they rise by setting an alarm. Setting an alarm sets a window of
opportunity so that the body can learn that this window is the only chance it has
to sleep. Stimulus control is a technique in which the stimulus value of the bed at
night for sleep is increased. However, this rule has other benefits including setting
of the biological clock and therefore limiting the possibility of social jetlag
symptoms. Further by not allowing oneself to attempt to sleep in longer in the
morning, there is no dissipation of the extra sleep drive that was built from being
awake longer that night. This starts an earlier build of pressure for deep sleep the
following night, whereas lingering in bed reduces the amount of drive for the
subsequent night.
Use the bed and bedroom only for sleep: If the goal is to increase the stimulus
value of the bed for sleep only, then clients should avoid doing anything in the
bed that they do when awake. Wakeful activities, when done in bed, can train
the body to be awake in the bed. A careful assessment can uncover whether clients
eat, read, watch TV, do work or homework, use the computer, phone or other
devices in the bed. Then the client can be instructed to move these activities to
someplace other than bed and preferably outside the bedroom entirely. Sex may
be an exception to this rule under particular circumstances. For some people, sex
Behavioral Strategies for Insomnia
5.
67
is relaxing and so may be conducive to good sleep. For those individuals for which
sex is alerting and possibly disruptive to sleep they may need to make a choice about
when this is worth it to them. In our experience, good sleep can usually be restored
by eliminating all the other waking activities and by especially eliminating sleep
effort in bed.
Do not take daytime naps: If the goal is to strengthen the stimulus value of the
bed to be associated with sleep only, during a particular window at night, then
sleeping outside of this opportunity will undermine the process. This is one of the
reasons why naps are prohibited. There are other reasons to object to naps. For
example:
(a) Naps reduce the drive for deep sleep at night by reducing Process S. Naps,
especially long naps, produce a small amount of sleep and an exponential
amount of stage 3 sleep (N3) is lost the subsequent night (Feinberg et al., 1985).
(b) Naps are sleep effort and sleep should be effortless. Naps reinforce the idea
that because one cannot sleep well during the night, one must engage in effort
to compensate, even if it is during the day.
(c) Naps reinforce beliefs about low sleep self-efficacy. In other words, napping
reinforces the idea that one cannot cope with fatigue. By napping the client
misses an opportunity to see how they would do trying to make it through the
day without the nap, thus allowing them to maintain catastrophic beliefs about
their ability to function without good sleep.
(d) Naps decrease daytime activity in a group (i.e., MDD-I) known for decreased
activity.
(e) Naps disengage people from goal pursuits during the day and decrease
exposure to positive reinforcers.
(f) Naps are often a prime example of following a feeling rather than a plan.
Napping is a depressogenic and insomniagenic behavior; that is it makes both
conditions worse rather than better. However, many people with depression
and insomnia feel “compelled” to take naps because of the fatigue. When
people feel compelled to act in a way that inadvertently maintains the negative
state (i.e., fatigue) behavioral conceptualizations would target this behavior for
change. Please see Chapter 9 for a description of integrated BA plus Behavioral
Insomnia Therapy (BABIT).
(g) Naps may be an avoidant behavior—a way to escape emotional stress and/or
the experience of fatigue. Avoidance reinforces negative mood and negative
beliefs about one’s self efficacy to cope.
(h) Naps decrease exposure to social and photic zeitgebers (stimuli that provide
circadian cues for entrainment of our clock) that can help mood and sleep.
From a circadian entrainment point of view when one naps they are also
training their brains that there are times in the middle of the day that are sleep
times, thus in essence training themselves to need the nap.
By following all the stimulus control rules, the paired association of the bed with
wakefulness is undone or unlearned, and a new association of the bed with sleep is
produced. Eliminating conditioned arousal and sleep effort in bed is a key target for
addressing insomnia.
68
Behavioral Strategies for Insomnia
Sleep Restriction
Just like Stimulus Control, Sleep Restriction is a treatment for insomnia that has been
shown effective as a monotherapy (e.g., Morin et al., 2006) but it is most commonly
delivered in the context of CBT-I as part of a treatment package. The main target for
sleep restriction is to increase sleep drive so that sleep at night becomes more
consolidated. As such, sleep restriction is often thought of as targeting mostly sleep
maintenance problems, but it has been shown to work with problems of sleep onset and
mixed insomnias as well. Many clinicians do not use the term sleep restriction with
clients because it increases anxiety. Sleep restriction is an inaccurate description as sleep
is often not restricted; only the time spent in bed is restricted. Alternatives for this term
are time-in-bed restriction, sleep efficiency training, or sleep quality training. Below is
a sample delivery of the Sleep Restriction or Time-in-bed Restriction rationale (for more
on this case, see Chapter 10).
Therapist: You told me that your main problem is that you cannot stay asleep
throughout the night and the sleep you produce seems light?
Client: Yes, I can’t take it anymore.
Therapist: Any thoughts as to why this is happening?
Client: Hormones?
Therapist: I wonder if there may be a simpler answer, especially since you have had
insomnia throughout your life so although hormonal changes are co-occurring now,
they were likely not a factor earlier in your life.
Client: I guess that’s true.
Therapist: Let’s talk about a different possibility. We have a system in our body that
regulates how much deep sleep we get, so if we understand this system, we can use
it to give us more deep sleep. Does that sound like this may be worth exploring for
you?
Client: Of course. I feel like I get no deep sleep at all.
Therapist: We call the system that determines how much deep sleep we get Process
S. It operates by accumulating a drive for deep sleep for every moment that we are
awake. It is actually the result of building up a chemical associated with our cells
working. So what builds the drive for sleep is being awake, but being out of bed
and active builds an even stronger healthier sleep drive. This is because if we have
been out of bed and active, our cells have been working hard and we have built up
a store of the chemical needed for deep sleep. When we go to sleep, we eliminate
this built-up chemical and the result is deep sleep. Producing deep sleep is good
because, we are less prone to waking up and our bodies feel more restored and
refreshed when we wake. In essence getting deep sleep and a more continuous sleep
is equivalent to saying that you are getting a better quality sleep. Make sense so far?
Client: I think so. You need a chemical to build-up by being active? If you are awake
but not active, does it still build?
Therapist: To some degree, but there is an association between low levels of activity
and light sleep, so being active, rather than lying in bed, is probably an important
part of building the strongest sleep drive that you can.
Client: But the reason why I am not that active is that I am exhausted. I’m not lying
down on the couch for any reason other than the fact that I am so tired.
Behavioral Strategies for Insomnia
69
Therapist: That makes sense. Fatigue is one of the more debilitating symptoms of both
depression and insomnia. However, one cause of the fatigue may relate to
fragmented, light sleep, so in truth one way to help with the fatigue in the long run
may be to increase the drive for deep sleep. Do you think it’s worth trying to test
that idea?
Client: Maybe. I think it’s possible that I wouldn’t feel as tired if I could stay asleep
or get some deep sleep.
Therapist: That may be true. If deep sleep is determined by staying out of bed and
being active an adequate number of hours each day, what do you think happens
when you try to nap?
Client: Well, I’m not building up the deep sleep chemical?
Therapist: True. Also you are spending some of the sleep drive that has been built up
for the day so that it is not available to you at night. So by napping you suspend
build-up of sleep drive and will have less drive for deep sleep that night. In addition,
even during very brief naps, you can produce some deep sleep and even the loss of
only a little deep sleep during the day can result in an exponential loss of deep sleep
that night. It also means that you have to start building the sleep drive from
whatever time you wake up from your nap, but then you won’t have enough time
to rebuild sufficient sleep drive by the time you go to bed. What happens if you
sleep-in in the morning?
Client: I don’t actually “sleep”-in, I am just lying there exhausted.
Therapist: I see. But if you are lying there, what does that mean for the build-up of
deep sleep drive?
Client: Not much I guess. I’m awake but not physically active. I guess I wouldn’t build
it up.
Therapist: That’s right. Even if you are really awake all of that time you are lying in
bed, since you are not active if you do build any drive it is likely to be weak. There
is another problem. Remember I said that when we go to sleep we release the
chemical that was built-up and this is associated with deep sleep production? The
release happens rather quickly so there is very little deep sleep in the second half
of the night and essentially no deep sleep in the morning hours. So by staying in
bed in the morning you prevent the build-up of healthy strong deep sleep for the
next night and even if you were to drift off and get a little bit of sleep that morning
it will not be deep sleep but more likely fragmented shallow sleep, whether you
experience it this way or not. In this way you are doing what many people with
insomnia do; that is, you are trying for as much quantity of sleep as you can get
but in the process you are sacrificing good quality sleep. Does that sound like a
good trade?
Client: No, not really. I am always trying to get any little scrap of sleep that I can but
now that I think of it, it never really feels like very good sleep.
Therapist: OK. So at least in the short run, does it seem reasonable to go for a better
quality sleep rather than quantity?
Client: I think that makes a lot of sense.
Therapist: Good. Let’s talk about some strategies you can try to get your quality sleep
back on track?
70
Behavioral Strategies for Insomnia
In sum, spending an increased time in bed relative to current sleep production
ultimately will result in a decreased amount of sleep drive that is likely to result in a
continued cycle of difficulty sleeping. Thus reduced sleep drive can result in a variety
of clinical presentations including: an increased time to fall asleep (i.e., delayed sleep
onset latency), waking up more frequently during the night, greater difficulty returning
to sleep, a sense of lightened sleep, and every combination of these complaints. In other
words, all the problems that constitute insomnia.
To address these impairments in sleep drive we use Sleep Restriction; a straightforward
technique with two steps:
Step One: Set the time-in-bed to equal the client’s baseline average total sleep time.
Step Two: Gradually increase time-in-bed once quality sleep is achieved and sleepiness
is evident.
To increase sleep drive, we create systematic sleep deprivation by restricting the time
spent in bed to match the amount of average sleep produced as measured by baseline
sleep diaries. Some variants in the application of sleep restriction allow for a normal
amount of wakefulness in bed (i.e., 30 minutes); thus the time-in-bed prescription
could be the average total sleep time plus an added 30 minutes. Then, once sleep
deprivation increases and we see sleepiness and improved sleep, clients can start to spend
more time in bed. This may seem counterintuitive. Many people think that people with
insomnia are already sleep deprived; however there are a few things to consider. One
is that often people with insomnia have great variability in their sleep pattern over the
course of several days. That is, they can have very horrible nights but then they typically
have a few recovery nights; thus their overall average total sleep time may be close to
or within normal adult limits (i.e., at least 6 hours). Second, people with insomnia report
increased levels of fatigue but not significantly increased levels of sleepiness, suggesting
that they are “tired but wired.” Also when they have a bad night they typically respond
by increasing their time in bed and/or cutting back on activity, thus weakening or
reducing their sleep drive. However the fact that they cannot actually sleep well even
during the day suggests that their level of hyper arousal often overcomes their level
of sleep deprivation. They need to find a way to send a message to the homeostatic
system to produce more pressure for deep sleep, to overcome hyper arousal. Lastly, the
explanation provided to our case example Kelly (see also Chapter 10) above (in the
Stimulus Control section) about the study in which the person with insomnia was sleep
deprived to match the sleep of another person with insomnia is based on a series of
studies by Bonnet and Arand (Bonnet & Arand, 1997). In these studies, introducing
systematic sleep deprivation overrode hyper arousal and allowed the sleep deprived
person to sleep during the day—something they were previously unable to do. These
studies demonstrate that people with insomnia are not as sleep deprived as it may seem,
or at least not sleep deprived enough to overcome their hyper arousal. Thus introducing
sleep deprivation in the short run may be just what is needed to cause therapeutic changes
to the insomnia that allows for easier sleep.
When someone has a stomach virus that causes vomiting, as soon as they stop
vomiting and start to feel hungry, the natural tendency is to eat. There is nothing
pathological about eating when hungry, but while ill, this behavior will likely have a
Behavioral Strategies for Insomnia
71
negative effect, namely, more vomiting. A different approach to this illness is what is
called for to produce a different response—“stomach-rest.” Stomach-rest is a fasting
period to allow the stomach to recuperate. When hungry this approach seems as
counterintuitive as the idea to restrict the time spent in bed, but both time-limited
remedies are highly effective in the long-term. When sleeping poorly, resting or
increasing sleep attempts with increased time in bed seems to make good sense, while
limiting time in bed further does not make intuitive sense. However, since this is a
homeostatic system that automatically recovers deep sleep, the system needs less time
in bed to trigger compensation; that is, more deep sleep.
It is important to note that good application of sleep restriction requires sleep diary
monitoring. Most often, problems with this very effective treatment relate to a novice
therapist attempting to sleep restrict using a client’s retrospective report of their sleep
in order to make the prescription. This is a notoriously much poorer estimate than can
be obtained by the prospective estimates on sleep diaries. It is imperative to assign two
weeks of prospective sleep diaries directly before the prescription is made in order to
derive an accurate “dose” of sleep restriction.
The first step for sleep restriction is to calculate the client’s average total sleep time,
which is best accomplished by working backwards. To more easily fit on a page, in the
example provided in Chapter 10 (Figure 10.2), we present seven days of data only.
To begin, calculate the time-in-bed each night. The time in bed is the difference
between getting into bed and getting out of the bed in the morning. Examine item 1
and item 7. On the first day (1/15/14), the intervening time between 11:15 PM and 7:10
AM is almost 8 hours. If you do this for each day and add all of these time-in-bed values
together and divide them by the number of days (7), you will get approximately 9 hours
and 25 minutes. Next, calculate the total time spent awake while in bed. To do this, add
item 3 and 5 together, as well as calculate the amount of time the client was awake from
the time they woke up (item 6) and the time they got out of bed for the day (item 7).
For example, on the first day (1/15/14), the time to fall asleep is 40 minutes, the time
awake during the night is 80 minutes, and the time between the final awakening (i.e.,
6:30 AM) and the rise time (i.e., 7:10 AM) is 40 minutes; thus, 40 + 80 + 40 = 160 minutes.
Calculate the rest of the days the same way. The result is the following for total wake
time: 160, 170, 220, 190, 290, 180, and 290 minutes = 60 + 65 + 55 + 120 + 70 + 190 +
390. Subtract the total time awake during the night from the time spent in bed to calculate
the average total sleep time. For example, the first night (1/15/14) is 475 – 160 = 315
minutes of total wake time, or approximately 5.25 hours. To calculate the average total
sleep time, add all of the total sleep time up and divide by the number of days monitored:
(5.25 + 6.33 + 6.25 + 5.33 + 3.33 + 7.25 + 6)/7 = 5.6 hours. The next step is to use this
amount (i.e., average total sleep time is about 5.6 hours) to match with the client’s
prescribed time in bed. However, keep in mind that, although not essential, 30 minutes
can be added to allow for a normal amount of time to fall asleep. The decision to add
time or not is at the discretion of the therapist and can depend on a number of different
factors such as age of the client, level of sleepiness the client is experiencing at baseline,
and assessed impact of other comorbid disorders. In other words, the decision to add
30 minutes to average total sleep time may depend on how much the therapist judges
the client’s overall functioning and resources to be compromised by other factors. For
the purpose of this book, since clients with depression generally could be considered to
72 Behavioral Strategies for Insomnia
already be compromised by their mood disorder we will assume that 30 minutes will
be added. Therefore, this client will be asked to spend a maximum of about 6 hours in
bed during the initial restriction phase.
The next step is to determine WHEN the client should get into and out of bed for
their time-in-bed prescription. This is done collaboratively. The window must be the
same every night in order to optimize the circadian system (that is, the biological clock).
Remember that one way to entrain the clock is to get up and get light exposure at the
same time each morning. In the example above, the prescription is to spend no more
than 6 hours in bed, and currently, it appears from the diary as though they have to be
awake around 6:30 AM 5 days a week. Thus, the client may want to set 6:30 AM as their
standard rise time, but this should be confirmed with the client. Keeping the rise time
at 6:30 AM every morning, that is, 7 days per week, will optimize the clock’s functioning as well as being consistent with Stimulus Control’s rule of setting a standard rise
time. Counting back 7 hours, the earliest bedtime would be 12:30 AM. This is called
the “earliest possible bedtime” because remember that Stimulus Control has a rule that
stipulates to refrain from getting into bed until sleepy; so 12:30 AM would be the
earliest bedtime. If the client finds themselves not feeling sleepy at 12:30 AM, then they
stay up until they become sleepy. This minimizes the amount of time they spend awake
while in bed and simultaneously increases the drive for deep sleep.
It should be noted that as the client carries out this plan then it can be anticipated
that in the first few days the client may become more sleepy than usual. Therefore, session
time needs to spend discussing strategies that can be used to help the client stay awake
during the day. In addition, there is a safety issue to be considered. The client should
be alerted to the possibility of becoming significantly sleepier during the day and as
such could be at more risk for such things as falling asleep while driving. Although
it has been emphasized that it is not ideal for the client to nap, in the case of safety the
client can be instructed that they may need to nap for a short time before engaging
in driving or other dangerous activities or they should refrain from such activities
altogether during the first days of treatment.
Finally, once the client’s sleep is improved and they show signs of sleepiness, the time
in bed is increased by 15 minutes per week until the sleepiness resolves or their sleep
worsens. Alternatively, the time spent in bed can be increased by 30 minutes every two
weeks. This decision is again at the discretion of the therapist and should be discussed
with the client. Generally the more sleepiness the client complains of, the more likely
it is that they would be able to tolerate a 30 minute increase to time in bed without it
disrupting their sleep.
Again the process of sleep restriction sends a message to the homeostatic system to
increase the depth of sleep in response to systematic nightly deprivation. If the client
does not immediately increase their time-in-bed following a poor night’s sleep, there
will be an increased pressure to sleep deeply the next night or subsequent nights, and
this system can naturally compensate for lost sleep over time.
Sleep Hygiene
Sleep Hygiene is the treatment that most treatment providers outside of sleep know
about and use (Moss et al., 2013) but it is not an effective treatment as a monotherapy
Behavioral Strategies for Insomnia
73
(Morin et al., 1999b). In one study, 106 non-sleep specialty healthcare providers were
surveyed about how they treat insomnia. Of all of the interventions listed for insomnia
(including Stimulus Control, Sleep Restriction, sleep medications), the most commonly used
intervention for insomnia was Sleep Hygiene (88 percent reported using sleep hygiene as
a tool in their practice). A similarly high number believed that it was an effective treatment
for insomnia (80 percent). When quizzed about efficacious treatments such as stimulus
control, they mistakenly thought that SC included: caffeine, alcohol, bedtime snack and
temperature or light recommendations even though these recommendations are actually
sleep hygiene. In the same study, sleep hygiene was the most common technique provided
in a google search of insomnia treatment on the internet, so clients are able to access this
information for themselves as well. Sleep hygiene is categorized as NOT empirically
supported according to American Psychological Association criteria (Morin et al., 1999b,
2006). It is not that these practices are unimportant for sleep health; however the data shows
that making changes in sleep hygiene behaviors will not by itself eliminate insomnia. In
other words, they are necessary, but rarely sufficient to treat insomnia.
One can assume that many clients with insomnia have already been exposed to some
form of sleep hygiene instruction, either on the Internet, on TV, or through their
primary care physician. It is also safe to assume that most of these clients have not experienced much benefit from making changes to these behaviors especially considering that
they are in your office still seeking help for a chronic insomnia. Therefore, before
discussing sleep hygiene with the client, it may be useful to have a brief discussion about
why these changes may have not been successful in the past but how they may be able
to have a greater impact in the context of the multicomponent therapy that is being
provided. For example, it may be useful to question the client about how these behaviors
were put in place in the past and for how long. Many clients may only change one or
two behaviors at a time which might not have been enough to fix their insomnia
especially in the context of hyper arousal, conditioned arousal, and poor circadian
entrainment. Likewise if a client only changes caffeine or alcohol consumption for a
few days, it may not have been enough to draw any real conclusions about the effect
that these substances have on their insomnia. In this way the therapist may be able to
generate greater motivation on the part of the client to engage in more consistent and
thorough sleep hygiene changes.
Another concept that can be discussed is that although sleep hygiene by itself may
not have caused or will fix the client’s problem, it may be said that poor sleep hygiene
creates at least a vulnerability to having worse sleep. For example, drinking too much
liquid in the evening may produce at least a semi-full bladder which may lead to a greater
propensity to wake up during the course of the night. In a client who is prone to waking
with frustration and worry, decreasing liquid in the evening may help but not enough
to fix the problem. That said, during sleep restriction, one of the steps is to gradually
extend time in bed to help the client achieve optimal sleep. If the client continues to
have a full bladder this may affect how much the client can extend their total time in
bed. In other words with a full bladder at night the client might only be able to extend
to a total of 6.5 hours in bed while a client with an empty bladder might be able to
extend to seven hours. Discussion of all of these issues can serve as good motivation
for clients to reengage in healthy sleep practices again even though this has not led to
success in the past.
74 Behavioral Strategies for Insomnia
Once this debunking of past experience and provision of rationale for reengagement
of good sleep practices has taken place, you are now ready to present the actual rules
to the client.
Sleep Hygiene Rules (In No Particular Order):
1.
2.
3.
4.
5.
6.
Caffeine: Reduce the intake of caffeine, preferably to one cup (200 mg) per day,
early in the day. If more is consumed, consumption should be discontinued at least
in the afternoon so that it is not too close to bedtime. Caffeine blocks adenosine
build-up so theoretically it could limit the drive for deep sleep. Further it is a
stimulant that can increase arousal. Caffeine also produces an increase in fatigue
during the withdrawal phase which can be misattributed to the sleeping problem,
tempt the client into napping or decreasing activity, and produce increased distress
or anxiety about the sleep problem. There are likely individual differences in the
sensitivity to caffeine and the efficiency with which one eliminates caffeine for the
body, so more specific recommendations for timing and consumption are very
difficult. Thus, there are likely multiple reasons to manage caffeine use.
Nicotine: Eliminate or reduce consumption of tobacco products. Tobacco has
stimulant properties and thus interferes with the depth of sleep. Moreover, once
nicotine is eliminated, withdrawal symptoms are produced and clients can wake
up with a craving for a cigarette. One note to the therapist is that in the addicted
client, giving up nicotine entirely is clearly a very difficult process and may not be
advisable simultaneous with the already difficult protocol of CBT-I. For those
clients that are on nicotine it may be advisable simply to educate the client about
the insomnogenic properties of nicotine and to perhaps shift the timing of nicotine
consumption so that it does not occur shortly before bedtime.
Prescribed exercise: Be sure to be active and exercise if possible. Exercise and
increased activity should have a positive impact on building healthy sleep drive.
Some recommendations suggest refraining from exercise that is too close to
bedtime for fear that it can be too alerting.
Consume a light bedtime snack, preferably one that contains tryptophan (e.g.,
milk, peanut butter). Tryptophan is a building block for producing serotonin
(a neurotransmitter implicated in sleep) so the thought is that tryptophan-rich foods
would improve sleep. There is no real evidence for this recommendation in those
with insomnia. That said, it can be said that having some light food in your stomach
during the night might decrease the possibility of arousal at night due to hunger.
Also, consistently having a snack at the same time can begin to serve as a circadian
cue for the coming of bedtime.
Avoid middle of the night eating: There are a few reasons for avoiding eating in
the middle of the night. First, gastrointestinal upset is associated with sleep problems (Shaheen et al., 2008). Second, eating upon awakening can create conditioned
arousals to eat at the same time each night.
Avoid heavy liquid consumption in the evening: As stated, having a full bladder in
the middle of the night can lead to increased arousal and number of awakenings.
Cutting down overall liquid consumption over the last 4–6 hours of the evening
before bedtime can be helpful.
Behavioral Strategies for Insomnia
7.
8.
75
Reduce alcohol and other substances: Alcohol and substances such as marijuana
lighten sleep. Both substances can decrease arousal initially and may even help with
sleep onset; however the body must then work to break them down and eliminate
them. While the body works to eliminate these toxins, REM sleep is suppressed.
Once most of the substance (e.g., marijuana or alcohol) is broken down, REM sleep
rebounds and lightens sleep in the latter part of the night. Therefore, while it can
be said that consuming alcohol or marijuana may help one to get to sleep, it is also
certainly true that it will disrupt sleep maintenance. Thus the net result from a sleep
perspective is negative. One other note is that, as stated, in the early phases of CBTI there is a tendency for an increase in sleep deprivation and consequent daytime
sleepiness. This can be especially problematic in the evening when the client is
having trouble staying awake until their prescribed later bedtime. It may be helpful
to point out to such clients that consuming substances that can be hypnotic may
only serve to exacerbate their struggle. As such it may be advisable to cut down or
eliminate these products as much as possible to aid in the early stages of treatment.
Optimize environment to minimize light, noise, or extremes in temperature. It is
difficult to sleep when too hot or too cold but it should be noted that it is generally
easier to get warm in a cool environment than it is to get cool in a warm environment. Therefore, it is generally better to keep bedrooms at cool temperatures.
Likewise, minimizing noise is conducive to better sleep. Finally, a lit bedroom (e.g.,
leaving lights on or the television) can be alerting and interfere with restorative
sleep.
Counter Arousal Techniques
Counter arousal is an umbrella term that incorporates techniques aimed at general
arousal reduction. There are several different techniques for counter arousal, but
included below are the most frequently used. The first of these is creating the buffer
zone. The buffer zone is simply a one hour wind-down period before bed. During this
period, it is preferable to cease goal-directed activities. That is, it should be a period of
time devoted to leisure and relaxation (e.g., baths, listening to music, watching movies,
hobbies, yoga), and/or a release from responsibilities and stress (e.g., refraining from
checking e-mails or engaging in work catch-up, doing housework). The body needs to
de-activate in order to allow sleep to unfold. Goal-directed activities require a certain
degree of physical and mental arousal, which is counter to good sleep.
Another counter arousal strategy is to engage in pre-sleep structured information
processing. If clients don’t have a chance to process information during the day, they
will tend to do it once they get into bed or by waking in the middle of the night. Thus
shifting the timing of this needed information processing may be useful. There are several
different versions of these strategies none of which have been compared head-to-head.
So it is difficult to say which will have the best result for your client but may require
some experimentation during the course of therapy. The first of these approaches is
early evening problem-solving (Carney, Edinger, & Segal, 2005; Espie & Lindsay, 1987).
The instructions are very simple: clients set aside some time in the early evening, when
at their problem-solving best, to work through a problem constructively. To do this,
ask the client to divide a page in half and label the first column concerns and the second
76 Behavioral Strategies for Insomnia
column solutions. In the evening, typically just after dinner, they write down a concern
that is on their mind, and then generate the “next” step in solving the problem. Writing
down the ultimate end-solution can be overwhelming because there may be many steps
before the solution is effective. For example, if the concern is holiday shopping for the
child’s daycare, the ultimate solution is to buy the gift, but the next step may be to set
a budget for the gift. The client then puts away the form at the end of the problem solving
session, reminding themselves that they worked on this problem when at their problemsolving best and that they can return to this task again tomorrow at the appointed time.
For this to work best it is useful to have the client commit to regular practice each evening
so that it can become a habit. There is no set amount of time to set aside for this task,
most often it takes about 20–30 minutes. It may be especially effective to have the client
select not only a time but also a special place. In this way, with repeated practice, this
time and place may take on a stimulus function and operate as the “worry time and
space” such that once the client leaves there it is as if they can pin their concerns there
and leave them behind. Another processing strategy is done in the pre-sleep period:
the Pennebaker technique (Harvey & Farrell, 2003; Smyth & Pennebaker, 2008). In a
Pennebaker exercise, clients write about their experiences, concerns, and emotions in
an attempt to process them before bed. The rationale is that if clients have something
on their minds, when there is no stimulation (i.e., in the dark, without sound), clients
will naturally start to process the material, and it is better to do this outside of the bed.
These techniques are most helpful for decreasing pre-sleep arousal rather than
improving sleep per se (Carney et al., 2005; Mooney, Espie, & Broomfield, 2009) so they
should be incorporated as part of a package with Stimulus Control and/or Sleep
Restriction Therapy. Again, setting up a special place and time for this emotional
processing can work well in conjunction with the behavioral techniques in that the client
is both conditioning themselves to have designated sleep space and time distinct from
the worry or processing space and time.
Finally the most widely studied counter arousal approaches are relaxation therapies.
Relaxation therapy has evidence for use as a monotherapy; however, the effect sizes are
more modest than the other two monotherapies SC and SRT (Morin et al., 1999b, 2006).
There are no reasons to favor one relaxation strategy over another (e.g., progressive
muscle relaxation versus autogenic versus diaphragmatic breathing) so it may be helpful
to ask clients whether they found any particular relaxation strategy to be useful or not
useful in the past and proceed from there. This way, if a client has had a negative
experience in the past, they can try a different one from the list. The therapist may also
decide to choose one strategy over another if it is felt that it particularly targets a specific
problem. For example, all things being equal, if a client is assessed to be particularly
physically tense, the therapist might choose to start with progressive muscle relaxation,
etc. It is important to advise the client not to use relaxation strategies as sleep effort. In
other words, if the client uses the relaxation strategy like a sleeping pill by applying it
upon getting into bed and trying at that point to relax as a way of making themselves
sleep, such effort is only likely to lead to more arousal and frustration and is therefore
doomed to backfire and fail. Rather relaxation strategies should be approached as a
method for reducing basal levels of arousal overall throughout the 24 hour period. Clients
need to be taught that it takes consistent practice to be able to “relax” on command.
With sufficient practice, eventually, people will be able to access those skills in the
Behavioral Strategies for Insomnia
77
pre-sleep period so that they can be generally relaxed as they get into bed. However,
attempting to use these strategies while in a highly tense situation like getting into bed
while anxious will likely have poor results, and the client may terminate the use of this
strategy prematurely.
Implementation
If possible, Stimulus Control, Sleep Restriction, and Sleep Hygiene are most commonly
presented in the first treatment session. That said, there may be circumstances when
there is not enough time for all three and some of the content will have to wait until
treatment Session 2. SC and SRT are still considered among the most potent elements
of CBT-I and so all efforts should be made to cover at least those techniques in Session
1 in order to get the client started on the right foot. Regardless, there is always a lot of
information for the client to consume and remember. Given that those with insomnia
and depression may suffer from increased concentration difficulties, it is advisable to
always provide a take-home summary of the recommendations that have been made in
the session. An example of such a handout is provided in Figure 5.1. There are reminders
My plan for better sleep
Over the next two weeks, I will do the following:
1. I will use a standard get-up-out-of-bed time, seven days per week, regardless of the
sleep I obtain on any particular night. My latest time out of bed is: _________________.
2. I will go to bed only when I am sleepy, but never before my earliest possible bedtime. My
earliest bedtime is: __________________.
3. I will get up out of bed when I can’t sleep. I will give up the effort to sleep, and go to
another room until I feel sleepy enough to fall asleep quickly before returning to bed.
4. If I still cannot fall asleep when I return to bed, repeat step 3.
5. I will avoid doing wakeful things while in bed. In other words, I will use the bed for
sleeping only. If sexual activity is not alerting, this can be an exception to the rule.
6. If I find myself worrying, problem-solving, ruminating, planning in bed, or engaging in
sleep effort, I will get up and stay out of bed until this thinking dissipates and I feel sleepy
enough to return to bed.
7. I will avoid daytime napping or spending time lying down throughout the day except in
the case of safety.
8. I will fill out my sleep diary each morning, preferably within an hour of rising, so that I can
track the impact of this plan on my sleep.
9. I will set aside the hour before bed as a wind-down period.
Other helpful hints: I will limit caffeine to one drink as far away from bedtime as possible. I will
attempt to exercise, although not right before bed.
Figure 5.1 Client summary of sleep rules
78
Behavioral Strategies for Insomnia
of the elements that have been discussed and what is expected as “homework” in
between sessions. There is also space for the client to write down the earliest possible
bedtime and latest possible rise time. One could also provide space to write down
strategies that have been discussed to help the client stay awake before their prescribed
bedtime. Although counter arousal strategies may become part of the treatment package,
other than the buffer zone, which is almost always discussed in Session 1, formal
relaxation therapy is not likely to be covered until the second or third treatment
session and can be added at that time. Aside from covering any additional information
that was not covered in Session 1, much of the time in the other sessions is spent on
troubleshooting any possible nonadherence to the sleep schedule or stimulus control
instructions and using cognitive strategies to help restructure over valued ideation
(for troubleshooting see Chapter 6). Finally, the last session should be devoted to going
over what treatment gains have been attained and how to manage any recurring acute
insomnia so that relapse is prevented in the future.
Summary
•
•
CBT-I is a highly efficacious treatment for insomnia with durable effects.
CBT-I is comprised of: Stimulus Control, Sleep Restriction, Sleep Hygiene, Counter
arousal strategies and Cognitive Therapy (Chapter 7).
–
–
–
–
–
Stimulus Control helps to disassociate the bed with wakefulness (i.e., conditioned arousal)
Sleep restriction increases the drive for deep sleep
Cognitive therapy modifies sleep-interfering beliefs
Sleep hygiene is sometimes necessary but rarely sufficient to address insomnia
Counter arousal strategies encourage pre-sleep processing or problem-solving
to decrease the likelihood of processing while in bed
6
Cognitive Factors and Treatment
The Cognitive Model
Cognitive-behavioral models share one main idea, which is that mood, behavior, and
thoughts are linked in such a way as to be mutually influential on one another. Thus
making positive changes in cognition can have a positive impact on behavior and mood.
Cognitive treatments that target the negative thinking implicated in maintaining health
issues are expected to spur positive behavior and mood change. Practically speaking,
cognitive therapy (CT) also may be an important tool to be used in behavior therapy
in cases in which over valued beliefs get in the way of following behavioral recommendations (Carney & Edinger, 2006). For example, if one believes that 8 hours of
sleep is necessary to function well during the day, the recommendation to limit the time
spent in bed to less than 8 hours may be met with poor adherence because it is in
opposition to the client’s beliefs. Modifying sleep need beliefs to favor sleep quality
over quantity is more likely to yield adherence with an instruction to limit time in bed.
We would expect less anxiety and arousal and therefore less resistance in someone whose
beliefs were modified to value quality over quantity, relative to someone who valued
sleep duration exclusively. Thus, although the goal of CT is to modify negative thinking linked to disorder, CT also may have an added positive impact on adherence to
behavioral or even pharmaceutical adjuncts to treatment.
Depression-Specific Versus Sleep-Specific Cognitions
and Overlapping Processes
Depression-Specific Cognitive Factors
The neuropsychological literature suggests that cognitive impairments in MDD appear
most reliably across the following domains: processing speed, selective and sustained
attention, autobiographical and explicit memory, inhibition of goal-irrelevant stimuli,
and effortful processing. To elaborate, those with MDD do more poorly on timed tasks
(e.g., Knott, Lapierre, Griffiths, De Lugt, & Bakish, 1991) while those who recover from
MDD show post-treatment improvements in processing speed (Seppälä, Linnoila,
& Mattila, 1978). Those with MDD also show sustained attention deficits (Hart, Wade,
Calabrese, & Colenda, 1998; Zakzanis, Leach, & Kaplan, 1998) perhaps owing to
preferential allocation of attention resources to negative, self-referent material (Gotlib
& McCabe, 1992). These attention issues appear to resolve with treatment, as responders
80
Cognitive Factors and Treatment
to CBT show less interference for negative self-relevant material on the primed
emotional Stroop task but non-responders continue to experience interference on the
Stroop (Segal & Gemar, 1997). Further, depressed individuals have difficulties on tasks
that involve explicit memory (Bazin, Perruchet, De Bonis, & Feline, 1994), but they
remember negatively valenced material preferentially (Dalgleish & Watts, 1990). They
also exhibit autobiographical memory deficits; that is, those with MDD preferentially
remember negatively valenced and vague personal memories (Williams et al., 1996a;
Williams, Mathews, & MacLeod, 1996b). Similarly, those with depression have issues
with inhibition; that is, they have trouble ignoring goal-irrelevant stimuli (e.g., negative,
self-referent stimuli) in favor of goal-relevant stimuli (Hasher & Zacks, 1988; Lau,
Christensen, Gemar, Segal, & Hawley, 1999). Lastly, those with MDD show the greatest
deficits on effortful, not automatic tasks (Hartlage, Alloy, Vázquez, & Dykman, 1993),
in other words performance is worse for tasks requiring volitional effort.
These neuropsychological findings are largely in support of prevailing Cognitive
Theories of Depression (e.g., Beck, 1967). A shared component across cognitive theories
of depression is an information processing bias. More specifically, depressed individuals
specifically monitor for and attend to negative, self-referent stimuli (e.g., Gotlib &
McCabe, 1992; Segal, Gemar, Truchon, Guirguis, & Horowitz, 1995; Williams et al.,
1996b). These findings are consistent with Beck’s schema activation hypothesis (Beck,
1967), a theory that posits increased activation for negative, self-referent schemas when
dysphoric mood is present. This may account for autobiographical memory deficit
findings (Dalgleish & Watts, 1990; Williams et al., 1996a, 1996b.), in that recollection
of personal memories during an MDD episode is biased towards negative moodcongruent content (Teasdale & Barnard, 1995). Beck has also argued that negative
thinking is automatic and reflexive, rather than effortful and deliberate (also argued in
Hartlage et al., 1993).
This may account for the consistent finding that those with MDD show deficits on
effortful processing tasks but not automatic tasks, and perhaps why information
processing is slow (e.g., Knott et al., 1991). Deficits in effortful processing are also
consistent with Response Style Theory (RST) (Nolen-Hoeksema, 1991), which posits
that rumination is defined by both a negative processing bias and the automaticity of
this process. Whereas effortful processing is difficult, rumination is automatic. Possibly
because those with depression have a preferential bias for depression-related and selfreferent material, rumination appears to be something that occurs quite naturally. When
those high in depression symptoms are instructed to ruminate on their feelings, they
show problem solving deficits, but those who are instructed to distract themselves from
such content show problem solving capabilities comparable to those of their nondysphoric cohorts (Lyubomirsky & Nolen-Hoeksema, 1995). When asked to think
repetitively on concrete aspects of the problem (the “what”), problem solving is more
effective than when one is instructed to think repetitively about the “why” and the
consequences of the situation (Watkins, Moberly, & Moulds, 2008). For a clinical
demonstration, see Chapter 8. Thus, the experimental, theoretical and psychopathology
literatures converge on several themes of cognitive deficits in those with MDD; namely,
1) a negative information processing bias, that is (2) experienced as an automatic
process, and (3) is activated in the presence of depressed mood.
Cognitive Factors and Treatment 81
Sleep-Specific Cognitive Factors
The neuropsychological literature suggests some equivocal results in insomnia,
particularly when sleep duration is in the normal range. There is evidence to suggest
some shared neuropsychological deficits between insomnia and MDD, namely, 1) an
information bias which in insomnia is sleep-related and 2) some slowing in effortful
(Orff, Drummond, Nowakowski, & Perlis, 2007), sustained processing (Edinger, Means,
Carney, & Krystal, 2008b). Although the evidence is somewhat mixed, the findings
become more consistent with respect to these deficits when the mean total sleep time
is below normative values (< 6 hours). At these levels of total sleep time the neuropsychological deficits are more reliably produced, and pronounced (FernandezMendoza et al., 2010). Studies with positive findings, suggest those with insomnia have
slower processing speed (Orff et al., 2007), difficulties with selective and sustained
attention (Edinger et al., 2008), and difficulties inhibiting goal-irrelevant stimuli (i.e.,
effortful processing) (Jones, Macphee, Broomfield, Jones, & Espie, 2005; MacMahon,
Broomfield, MacPhee, & Espie, 2006). These studies of neuropsychological deficits
provide some support for cognitive theories of insomnia.
The first Cognitive Model of insomnia was articulated by Charles Morin (1993), as
he applied the Cognitive Model of Depression (Beck, 1967) to sleep continuity
disturbance. The idea is that people with insomnia have dysfunctional beliefs about their
sleep that can perpetuate insomnia. These beliefs about sleep include unrealistic
expectations about sleep need, catastrophic thoughts about the negative consequences
of insomnia on functioning and health, fears of losing control of sleep ability, and the
conviction that sleep is unpredictable (Morin, 1993). There has since been considerable
evidence to support Morin’s earlier (1993) theories (e.g., Carney & Edinger, 2006;
Carney et al., 2006, 2010a). There are also several other cognitive models that draw from
and expand on Morin’s work (Espie, Broomfield, MacMahon, Macphee, & Taylor,
2006; Lundh & Broman, 2000; Perlis, Giles, Mendelson, Bootzin, & Wyatt, 1997)
including Allison Harvey’s (2002) Cognitive Model. Harvey’s model is heavily influenced by existing models of anxiety. The central idea is that overvalued beliefs (about
sleep and daytime functioning) lead to negative thoughts when in a triggering situation.
The trigger may be lying awake at night or it may be feeling low energy during the day;
in either scenario, negative thoughts that are driven by dysfunctional beliefs about sleep
and/or fatigue lead to states like anxiety, depression, and distress. When a negative state
and negative thoughts about sleep or functioning are triggered, this instigates increased
monitoring of the internal or external environment for confirmation that the situation
is in fact threatening. For example, noticing fatigue while at work and thinking, “I am
never going to get my work done if I can’t perk up,” leads to a focusing of attention on
further signs of fatigue or evidence that one cannot properly concentrate on work. This
can set up a vicious cycle of focusing on symptoms of impairment and a belief that the
impairment will result in negative outcomes can yield greater perceived impairments
despite no evidence of any objective impairments on tests (Semler & Harvey, 2006).
When such selective attention is directed away from disconfirmatory evidence, it
increases the likelihood of discovering confirmatory, albeit weak, evidence, and results
in a worsening perception of the feared symptoms such as fatigue. This further
reinforces the original belief (e.g., that one cannot cope with the consequences of sleep
82 Cognitive Factors and Treatment
loss) and increases the likelihood that the clients will engage in what Harvey calls “safety
behaviors” (e.g., caffeination) to avoid the undesirable experience (e.g., in this case,
fatigue).
The problem is that when one engages in safety behaviors (i.e., to avoid an anticipated
undesired outcome such as nocturnal wakefulness or daytime fatigue), this can result
in the unintended perpetuation of insomnia as a consequence. Some examples of safety
behaviors related to fatigue may include consuming a stimulant like coffee, cancelling
social engagements, avoidance of difficult mental work, decreasing or eliminating
exercise, and/or napping. Some examples of safety behaviors related to nocturnal
wakefulness may include using a sedating medication, going to bed early or sleeping in,
or attempts at thought suppression while in bed. All of these behaviors can be said to
be perpetuating factors of insomnia. Perhaps of greatest concern is that all of these
behaviors could be considered evidence of sleep effort. (Espie et al., 2006). Sleep effort
refers to behavior aimed at fixing the problem of insomnia, albeit in a way that is more
likely to exacerbate rather than relieve the situation. It stands to reason that if one is
engaged in any kind of behavioral or mental effort this should result in increased
arousal. Therefore, by definition sleep effort runs in opposition to and undermines the
body’s natural compensatory mechanism for sleep loss. In addition, the inevitable failure
of sleep effort to produce good sleep also reinforces low sleep self-efficacy. That is that
the person will quickly lose any sense that they have control over their sleep, and there
are few things as anxiety provoking as believing that one has lost the ability to sleep
despite all their best efforts.
Overlapping Cognitive Factors for Insomnia and Depression
There are some obvious information processing characteristics shared across depression
and insomnia. The classic Beckian model of mood-thought-activation (which emanate
from latent beliefs) is at the core of both of these disorders. We know that those with
depression and insomnia (MDD-I) have the similar types of unhelpful beliefs about sleep
as those with insomnia but without depression (Carney et al., 2010a). General negative
thinking is not characteristic of people with insomnia alone, but we see such negative thinking in those with MDD-I. We see attentional biases in both disorders; that is
we see increased attention to sleep threatening information (Broomfield, Gumley, &
Espie, 2005; Semler & Harvey, 2004) in those with insomnia and we see increased
attention to general threats to the self in those with depression (Hasher & Zacks, 1988;
Lau et al., 1999). Further, rumination or repetitive thought are evident in both disorders.
In those with depression we see that ruminative content tends to be negative and selffocused while there can also be repetitive thinking about symptoms (Bagby & Parker,
2001). In those with insomnia, the content is not self-focused; rather, the content tends
to be focused on symptoms such as fatigue (Carney et al., 2006, 2010b). Moreover, in
those with MDD-I, insomnia symptom rumination is associated with poor sleep even
after controlling for depression, while general depression-related rumination does not
predict insomnia (Carney et al., 2013b). Similarly, although depressive thinking resolves
and becomes subclinical with depressive recovery, insomnia beliefs, and therefore
insomnia, do not tend to remit without insomnia-focused treatment (Carney et al., 2011)
Finally, in depressed individuals with insomnia, even after controlling for depressive
Cognitive Factors and Treatment 83
mood, unhelpful beliefs about sleep remain at the same level of those with insomnia
only (Carney et al., 2010a). Thus, while there are some interesting overlaps in the
cognitive styles and types of thinking of both individuals with depression and
individuals with insomnia, it seems that there are beliefs that are particular to insomnia,
which do not have their roots in depressive cognition and which require specific and
directed treatment in order for them to change. We will focus on rumination and
strategies to address rumination in Chapter 8. Now that we have reviewed the highlights
of cognitive features of insomnia, depression, and the combined condition of MDD-I,
we turn our attention to cognitive treatment strategies.
Cognitive-Focused Treatment for Insomnia
Despite evidence for cognitive factors in the etiology of insomnia, unlike CT for
depression, the evidence for CT for insomnia is not well-established. Core behavioral
strategies in CBT-I such as Stimulus Control or Sleep Restriction, are so effective that
they enjoy guideline status as monotherapies, but the evidence for CT as a monotherapy
does not currently meet American Psychological Association (APA) criteria for an
effective therapy (Morin et al., 2006). In a recent randomized clinical trial comparing
BT, CBT-I, and CT, it found that CT was similar to BT and CBT-I, although CBT-I
produced more rapid response than CT (Harvey et al., 2014). Nonetheless, a change in
the way one thinks about sleep and fatigue is predictive of treatment response and belief
change is linked to adherence (Edinger, Carney, & Wohlgemuth, 2008a). Thus, even if
CT lacks evidence as a monotherapy, it is included in CBT-I for a variety of reasons,
not the least of which is to enhance adherence to follow the behavioral instructions. For
those familiar with cognitive therapy for depression, you will find that the specific
cognitive techniques therein translate very nicely into CBT for insomnia.
Cognitive therapy is a therapy based on the idea that solutions to difficult behavioral
problems can be found by changing the way one thinks. In this model how people think
will affect what they do and how they feel, so making changes in thinking can affect
powerful change. There are a number of counterproductive and overvalued beliefs that
are associated with insomnia. One example is that people with insomnia often believe
that there is a particular amount of sleep needed in order to “function” adequately. In
particular, most people believe that 8 hours of sleep is needed in order to have energy,
perform well, and stay healthy. In truth, there is no magic number. Sleep is highly variable
from night to night and person to person, and overall functioning is not tied to the
absolute amount of sleep one obtains (Harris, 2014). Sleep need for any given person
is sometimes difficult to determine, but in general one can be thought to be getting the
“right amount” if they feel well rested and alert for most of their day. It is only when
one is consistently obtaining less than what they specifically need that a condition of
sleep deprivation exists, but people with insomnia generally tend to obtain what is
considered low-normal amounts of sleep on average. The consequence of maintaining
the belief that one must obtain 8 hours is that when sleep is less than that magic number
it increases anxiety about the ability to cope, and it can become a self-fulfilling prophesy
in the maintenance of insomnia chronically. There are numerous maladaptive beliefs
that crop up in insomnia and serve to perpetuate the condition indefinitely. In CT the
therapist encourages the client to examine whether such beliefs might be unhelpful, and
84 Cognitive Factors and Treatment
encourages them to explore other alternative beliefs that may be less anxiety provoking.
Belief change can be approached using several techniques. The most widely used of these
techniques are as follows:
•
•
•
•
•
Cognitive Restructuring using Thought Records
Cognitive Restructuring Using Socratic Questioning
Cognitive Restructuring Using Behavioral Experiments
Coping Cards: Encouraging Negative Thought-Incongruent Behavior
Shifting Information Processing Using Stimulus Control
The remainder of this Chapter will describe each of these approaches.
Cognitive Restructuring Using Thought Records
One of the most common techniques in CT to change beliefs is the use of a worksheet
known as a Thought Record (TR). The TR is a monitoring tool for negative thoughts
that teaches clients how to examine the evidence for their thoughts associated with
distress and to use this examination to generate possible alternative and more balanced
thoughts and to consider if this helps to improve mood. Most TRs start with a column
to record the situation in which the client experiences an activating thought. Just
recording the situation may be helpful in and of itself because if the client records the
same circumstance across multiple TRs, this can help them to recognize common
triggers for negative thinking. For example, in insomnia, a common trigger might be
trying to engage in focused performance at work. Situations such as these that are high
in perceived resource demand could trigger thoughts about the sleep problem and
worries about how lack of sleep may hinder performance and result in negative
outcomes. The second column in TRs typically records mood, and often the client is
asked to give a mood intensity rating, (i.e., if the mood is “anxious,” anxiety intensity
is rated from 0–100). The third column is generally where clients are asked to record
their specific thoughts. Clients are encouraged to record any thoughts occurring in the
situation. The therapist encourages the client to explore any and all the related thoughts
that occur to the client in the situation as a way to identify the thought that is most
connected to the negative mood state recorded in the second column. Thoughts that
are strongly connected to the negative emotion are labeled “hot thoughts” and are circled
so that the client can focus attention on examining the evidence for and against this
particular thought in columns four and five.
It should be noted at this point that when the client is first learning how to complete
the TR, it is advisable that the therapist helps the client to practice this in session. Before
moving to columns four and five, a good deal of work can go into just having the client
get good at filling out the first three columns of the TR (i.e. situation, mood, and
thoughts). At first they are not always going to be readily able to generate their automatic
and catastrophic thoughts. For example, a client can write thoughts descriptive of how
they feel such as, “I am so tired,” but it may take some Socratic questioning to get the
client to discover hot thoughts that are related to the most intense emotion, such as,
“I won’t be able to function today.” It is essential that cognitive work eventually identify
core beliefs since these may be the drivers of anxiety, sleep effort, and ultimately chronic
Cognitive Factors and Treatment 85
insomnia. In addition, to practice in session, for some clients it may be advisable to
have them work on only the first three columns for homework until they have the task
fairly well in hand.
Once the therapist is satisfied that that client can identify “hot thoughts,” the client
can move on to practicing columns four and five and examining the evidence. Whereas
some versions of the TR focus solely on amassing evidence against the thought, we prefer
versions that encourage the client also to write down the evidence that supports the
thought. This is because the intention in this work is not to suggest that the client’s
thinking is necessarily erroneous. All thoughts will be based on some degree of truth.
That is, there might very well be some evidence supporting the fact that when the client
is tired, they won’t be performing as well as they might if they were feeling completely
well rested. To ignore such evidence will eventually seem ingenuous and invalidating.
By looking at both the positive and negative evidence we can validate the client’s
concerns while still showing that things are not as severe and catastrophic as they may
seem, and calling into question whether the thought is helpful. This is really the key to
cognitive restructuring; that is, it is not to have the client wholly discard their thought,
but rather to have them temper the thought to something more reasonable and
workable.
As with uncovering core catastrophic beliefs, recording information against the
thought can be difficult for some clients. This is because some clients will have a
cognitive style of automatic thinking and a well-developed mechanism for ignoring
disconfirming information. For example, if the thought is related to a concern that sleep
will never happen again, the client may not be able to acknowledge the fallacy in this,
because of the strength of the emotion accompanying that thought. In other words, it
“feels” as though it is true so disconfirming information is ignored. This type of thinking
is called emotional reasoning. In CT for depression, emotional reasoning is highlighted
as a cognitive error that should be challenged directly (Beck, Rush, Shaw, & Emery,
1979). It is somewhat common for clients to record examples of emotional reasoning
in the evidence column. Through careful questioning, the therapist can help the client
to discover how feeling as though something is true, is not the same as it actually being
true; moreover this cognitive style is unhelpful for their sleep and daytime functioning.
In this same way, the therapist will have opportunities to also explain other overvalued or unhelpful beliefs and how they can create problems. For example, a selffulfilling prophesy is a belief in which the client assumes that something negative will
happen, and the strength of this belief and the resulting behavioral accommodations
makes it more likely that something bad will indeed happen. For instance, waking up
and believing that feeling groggy upon awakening is evidence that one had a poor night’s
sleep and that it will therefore be a bad day, may result in increased monitoring for
signs of fatigue throughout the day and a greater likelihood of feeling more tired.
Likewise, such a person might decide to engage in less challenging activity which can
lead to boredom and poor mood. Thus the belief and resulting adjustments to
perception and behavior in order to accommodate the belief make the “bad day”
prediction more likely. Upon seeing this kind of situation detailed in the TR a therapist
can begin to have the client see the inherent problems in this type of thinking. The
therapist can ask clients to imagine that there are two people and one woke up thinking,
“Ugh what a horrible night, I am never going to be able to do my work today,” and the
86
Cognitive Factors and Treatment
other thought, “Ugh, what a horrible night, but I have had other nights like this and I
know it will turn out ok,” Then the therapist can ask the client to predict which one is
more likely to have a better day. Most clients can begin to see the vicious cycle when
it is presented to them in this way. In one experiment, people with sleep problems
were randomly assigned to a positive feedback condition upon awakening (i.e., they
were told in the morning that their sleep was of good quality) or negative feedback
condition (i.e., they were told that their sleep was of poor quality) (Harvey, Schmidt,
Scarna, Semler, & Goodwin, 2005). Even though objective sleep was no different across
the groups, the negative feedback group reported more negative thoughts, more daytime
fatigue, and more sleep-interfering behaviors during the day. Such studies make clear
that the way sleep is appraised can have a powerful impact on daytime experiences.
Once evidence against and in support of the thought are listed in the appropriate
columns, clients are encouraged to derive alternative thoughts that are more balanced
with respect to evidence (column six). In other words, clients learn to write more
adaptive, helpful thoughts such as, “even though I am tired, I usually am able to get my
work done if I take a walk in the afternoon.” Once more balanced thoughts are generated
and recorded, clients are asked to reflect on their mood again and re-rate the intensity
(column seven). If mood ratings do not improve, the TR is re-reviewed. Common TR
problems include that the circled thought is not truly the hot thought, in which case
the therapist can probe with further questions to uncover the relevant core negative
thought that is most highly emotionally charged. Once the new information is added,
the mood can be re-rated. Another problem is that the more balanced, adaptive thought
may not be particularly believable or compelling at first, in which case the session can
focus on what evidence the client holds against the thought, and care can be taken to
provide psychoeducation about cognitive errors. In addition, if the client is somewhat
dubious about the newly generated alternative, this can provide an opportunity for a
behavioral experiment (see below) to test the validity of the new thought. It is hoped
that eventually the client will begin to consider alternative, more helpful thoughts,
which in turn should have positive impact on mood and behavior. In Figure 6.1 we
provide a sample completed TR.
Cognitive Restructuring Using Socratic Questioning
Socratic questioning is a process intended to help the client uncover for themselves more
adaptive viewpoints and to challenge their own unhelpful thinking. This technique is
not mutually exclusive of other techniques and, in fact, Socratic questioning is also often
used when completing a TR. This line of questioning can be used to uncover key
thoughts as well as encouraging the client to identify evidence against the thought. Below
is an example of Socratic questioning to help the client discover unhelpful thinking in
their thinking and how unhelpful this type of thinking is in implementing behavior
change. The example is meant to depict the depressive-specific issues that can arise in
delivering sleep treatment in someone who is depressed. In the example below, the
therapist is trying to troubleshoot difficulty the client is having with following a
prescribed rise time. In doing so, the Socratic questioning brings up issues about selfefficacy and self-confidence. The therapist and client discover a pattern of dichotomous
thinking in which things need to be done perfectly or the client is defective in some
Cognitive Factors and Treatment 87
Situation
Mood
(rating
0–100)
Thoughts
Evidence
for the
thought
Watching
television in
the evening
Exhausted
80%
What if I
can’t sleep
again
tonight?
I have had
I eventually
this problem sleep, just
for a while.
not well.
Anxious
90%
I can’t
believe how
tense I feel.
I am never
going to be
able to
sleep
without a
pill.
This is
ridiculous.
Evidence
Balanced
against the thought
thought
Thinking
about how
tense I am
may make it
I feel tense
Sometimes I more likely
right now so am tense an to fall
I am
hour before asleep.
probably
bed but
going to
somehow
I may or
have some manage to
may not
trouble
fall asleep.
have trouble
falling
falling
asleep.
I was out of asleep
town and
later—
forgot my
thinking
pill and still
about it may
fell asleep.
make it
worse.
The pill
doesn’t
Even if I
work that
have trouble
great all the falling
time.
asleep, it
doesn’t
mean I will
never fall
asleep
without a
pill—I have
slept
without a
pill before
Re-rate
mood
(0–100)
Exhausted
60%
Anxious
45%
Figure 6.1 Thought Record example
way. The client in the interchange below is Kelly, described fully in Chapter 10. In the
example that follows, the questioning exploring negative self-talk is similar to that seen
in CBT-D, but the therapist is also able to bring the discussion back to the topic of sleep.
Client: You are going to be angry at me. I didn’t get up at the time we set.
Therapist: I’m going to be mad at you?
Client: Yah, I’ve always had trouble following through with things. I screw up
opportunities like this all the time.
Therapist: Can you tell me a little more about this?
88 Cognitive Factors and Treatment
Client: Well, I never finished medical school . . .
Therapist: You never finished medical school, so this means. . . . ?
Client: Well that I’m a screw-up.
Therapist: I see. What was the reason you switched out of medical school?
Client: Well, I switched out of that track because I had always wanted to teach kids.
But my Mom was disappointed . . .
Therapist: Does this mean that once you start a program you should finish it even if
you discover it is not your passion?
Client: Well, yes.
Therapist: I wonder if this is 100 percent true? You told me about your daughter Barb
switching programs one month ago and how proud you were that she “had the guts
to pursue what she really wanted.” Can you help me reconcile this?
Client: I don’t know. But she definitely made the right choice.
Therapist: Yes, it certainly sounds like she did. But did you make the right choice?
Don’t you love teaching?
Client: Yes, I do. Very much so.
Therapist: Then are you saying that following a passion is OK for your daughter, but
not for you?
Client: Yes. I guess it just felt like I screwed up but I’m probably not being fair with
myself now that I think about it that way.
Therapist: I wonder how it makes you feel when you have thoughts such as, “I screw
things up?”
Client: Crappy. I feel bad about myself and wonder why I can’t do anything right.
Therapist: And what happens when you are having thoughts like, “I screw things up,”
and you are feeling badly?
Client: It’s hard to turn it off then. I don’t feel like doing anything and I feel horrible,
sometimes for days.
Therapist: So, having the thought, “I’m a screw up,” makes you feel badly and you
think about this over and over again, and then you lose motivation to do anything
at all?
Client: Yah.
Therapist: Sounds like having that thought makes you stuck even more?
Client: I guess so. But I am not intentionally telling myself that I am a screw-up.
Therapist: Of course, but when you do have that thought, you feel so horrible that
you cannot move forward with a plan?
Client: I guess so, yes.
Therapist: If you were able to interrupt this type of negative thinking, like we just did
by talking about your daughter, could this have a different outcome?
Client: Maybe.
Therapist: OK so let’s look at what got in the way of getting up the prescribed time
in the morning?
Client: Well, I got out of bed at the right time during the week but not on the weekends
...
Therapist: So 5 out of 7 times you got out of bed at the prescribed time, but you told
me that you didn’t get out of bed at the right time?
Client: Well, not all the time.
Cognitive Factors and Treatment 89
Therapist: Do you see a possible problem with seeing things as all or none? In other
words, you either do it 100 percent of the time or you have “screwed up” completely
in some way?
Client: I’m not sure I know what you mean?
Therapist: If you got up at the agreed upon time 5 of 7 nights, does that mean you
would say that you “screwed up” completely?
Client: No, I guess not.
Therapist: Is there a consequence for you to be seeing things as all correct or all terrible?
Client: I guess it’s sort of negative, is that what you mean?
Therapist: If you can never take credit for something you accomplish unless it is 100
percent perfect, seems like there might be very few opportunities to feel good about
what you have done. Seems like a recipe for feeling bad about yourself no matter
what happens, which probably doesn’t do much for your confidence. What do you
think this type of thinking does for the belief that you are a screw-up?
Client: I see what you mean. I’m not really a screw-up but it frustrates me when I can’t
follow through on something.
Therapist: You already did it over 70 percent of the time, we just need to think about
what got in the way the other two days. What was different about the two days you
struggled to get out of bed?
Client: It seemed weird to set an alarm on a weekend day and thought I might just
get up naturally around the time.
Therapist: That makes sense. Can you think of a way we can solve this problem?
Client: This week I can just make sure to set the alarm.
Therapist: Sounds reasonable. Can you think of anything that could get in the way?
Client: No, I think I can do this.
Cognitive Restructuring Using Behavioral Experiments
Whereas TRs have been the most traditionally used tool, in recent years, contemporary
CT has focused more heavily on behavioral experiments (BE). That said, none of the
strategies laid out thus far need to be thought of as mutually exclusive. A therapist can
use TR’s and Socratic questioning to unearth catastrophic thinking and then use a BE
to assess the validity of the belief. A BE is a test the client designs with the therapist
to gather data about their beliefs. In essence, many of the techniques that are used in
CBT-I can be considered as forms of BE. Clients are often leery about recommendations
to get out of bed at the same time every morning irrespective of their previous night’s
sleep, but some are willing to suspend their disbelief and test it out for two weeks. It is
often helpful to frame all of the behavioral recommendations as experiments that are
short term in nature.
Following SC rules serves as a behavioral experiment that can modify many sleeprelated beliefs that are unhelpful. For example, if a client is fixated on needing a
particular number of hours for a sleep opportunity each night, following stimulus
control instructions will typically vary the amount of sleep one obtains. By accepting
that sleep duration will vary a bit initially, it helps the client face their fears about needing
a particular magical number of hours of sleep. Challenging these fears, as well as
discovering that better sleep quality even without the desired quantity yields better than
90
Cognitive Factors and Treatment
expected functioning, will reduce anxiety about sleep. Also implicit in SC instructions
is the idea of acceptance when sleep is not forthcoming. In other words, clients who
practice good SC learn to behave, and eventually think like a person who is not
preoccupied with sleep. Clients who practice this rule increase the drive for deep sleep
and unlearn conditioned arousal but they also covertly challenge the idea that one MUST
sleep simply because one wants to or because it is a particular time. In essence, clients
are learning not to engage in sleep effort. Many clients are unaware that they are
challenging these beliefs, but if a client is adhering to this rule, they are inadvertently
building their confidence as someone who can cope with sleep loss, and someone who
need not exert effort to sleep because they trust their body to produce sleep when it is
truly needed. The following is a sample dialogue with Kelly, a case example from
Chapter 10, for setting up standard wake times as a behavioral experiment:
Therapist: Given all you just learned about how your sleep system works, I wonder if
you are willing to try a few strategies to get your sleep system back on track.
Client: I can give it a try.
Therapist: If we know that getting up at the same time every morning helps to set the
clock and also ensures that you start building enough sleep drive for deep sleep the
next night, then can we experiment over the next two weeks with a set time to get
out of bed and keep track of the results?
Client: [Smiles]. I might be able to do it for two weeks. I’m not sure if it will work for
me. I already get up at the same time five times a week.
Therapist: [Picks up sleep diary for them to look at together]. I see that your alarm is
set for the same time five times a week, but are the rise times and final awakening
times the same on this diary?
Client: Well no, sometimes I just keep hitting the snooze button and stay in bed longer,
but it’s because I am really tired.
Therapist: Yes, of course. And what about the weekend?
Client: Again, I am really tired so that’s why I stay in bed.
Therapist: Understandable. But we know that the habits reported on this sleep diary,
however good they feel in the moment, are the habits associated with recurring
insomnia week after week—this is why you are here. So I wonder what happens if
you test out a standard get out of bed time and we compare the two diaries in two
weeks’ time.
Client: You think my sleep could get better in two weeks?
Therapist: We won’t know unless we try. We can keep track of the experiment with
your sleep diaries. This way, you don’t have to take my word for it. You will be able
to see your sleep system in action and how this simple change will help it to
improve your sleep. Are you willing to do this over the next two weeks?
Client: I’m skeptical, but willing to try it out.
As stated, it is often helpful for clients to see these recommendations as time limited
so framing the steps of various protocols as BEs encourages willingness. For example,
see Figure 6.2. This client is testing out the belief: “I’m tired and need to save my energy
so that I have enough resources to deal with things.” This belief is very common in
people with insomnia. Fatigue is a key feature of both insomnia and depression and BA
Cognitive Factors and Treatment 91
is an effective strategy for improving mood but beliefs about needing to rest in order
to manage fatigue, often get in the way of activation. Resting is a common sense strategy
for improving fatigue so by the therapist merely saying that resting increases fatigue is
often not particularly compelling. It may be more effective for clients to achieve belief
change through an experiential learning process. While resting when tired can truly feel
good in the short run, excessive rest can have a negative effect on motivation. The adage
that an object at rest, stays at rest, is particularly poignant in this circumstance. Spending
long periods on the couch watching television or on the computer tends to lead to further
time on the computer or television. In addition, it tends to produce boredom and
lethargy. Conversely, engaging in goal directed activities can have positive effects on
motivation and energy, as there is momentum in such a strategy. Further, moving around
increases blood flow and oxygenation, whereas staying at rest can create deconditioning
and muscle shortening which can lead to aches and pains. Lying down activates the
parasympathetic nervous system, but being upright activates the sympathetic branch.
Excessive rest can also have a negative effect on sleep because it may lead to dozing or
napping, and mitigate the build-up of drive for deep sleep. Excessive rest can have
negative mood consequences as well because people can become anxious or feel badly
about themselves if they have a low rate of goal-directed activity. For example, if a client
has a to-do list of 5 items for the week and at the end of the week, little on the list was
accomplished, it can inspire self-focused rumination about what is wrong with them
that they are unable to meet goals or worry about the consequences of not getting the
needed tasks completed. Worry and rumination can lead to increased sleep effort and
further worry (e.g., the person may go to bed with the thought, “I had better get some
sleep tonight or else I will not be able to get the items on my list accomplished”). Lastly,
rest can have negative effects on mood because without movement and leaving the house,
the possibilities for positive reinforcement are diminished. Rest is often done in solitude
or with little active social engagement, which leads to a less rewarding life, and fewer
exposures to situations that could provide regulatory input into the circadian system.
Thus, when a client is encouraged to engage in a BE like the one presented in Figure
6.2, generally, contrary to their beliefs, they will notice an improvement in either fatigue,
mood and/or sleep with activation, and/or a worsening of fatigue, mood and/or sleep
with conservation.
In addition to the standard protocol instructions of CBT-I, there are other behavioral
experiments that specifically target belief changes. Given that each client can present
with their own unique set of beliefs and concerns, theoretically there can be as many
different types of experiments as there are clients. That said, there are several common
experiments we test in those with insomnia and depression fairly consistently.
Another common belief is that: “I need to scan my body to figure out if I have enough
energy and resources to [do a task].” Such body scanning is what Harvey (2002) refers
to as monitoring. The belief that body monitoring is helpful can be tested with an
instruction to focus intensely (for 15 minutes) on fatigue symptoms followed by 15
minutes of focus on the present environment, e.g., sounds, smells, sights, and tactile
information in the environment. In each case the client can rate mood and fatigue and
compare the differences. Generally, solely to be searching for signs of fatigue will most
certainly yield evidence of fatigue and perception of greater intensity. Conversely, when
one is focused outward on the here and now they will tend to feel better.
92 Cognitive Factors and Treatment
Belief to test:
I’m tired and need to save my energy so that I have enough resources to deal with things.
Week One Experiment:
Spend one week conserving energy as much as possible. Track sleep efficiency (SE) on sleep
diary, mood and fatigue.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Felt nice to
do nothing
☺ achy
Bored and
depressed
8/10
Achy and
bored;
depressed
8/10
Too boring
in house
(went
shopping)
Ruminating
Depressed
9/10
SE was
64%--sleep
was crappy
SE = 62%
Fatigue
9/10
Fatigue
6/10
Aches and
very tired
9/10
Depressed
6/10
Couldn’t
take it-shower and
go for a
walk
SE = 64%
SE = 69%
Fatigue
8/10
Overall
fatigue =
9/10
Depressed
9/10
Fatigue
9/10
SE = 62%
SE = 65%
SE = 64%
Depression
6/10
Fatigue =
6/10
Week Two Experiment:
Plan activities to expend energy. Track sleep efficiency (SE) on sleep diary, mood and fatigue.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Laundry,
showered,
walk and
dinner with
friend
Showered,
read, walk,
cleaned
closet
Depressed
6/10
Showered,
paid bills,
walk, made
dinner
Depressed
2/10 (felt
good today)
Out with a
friend
Visited
Mom, went
to store to
switch out
phone
Depressed
5/10
Fatigue
4/10
Depression
2/10
SE was
81%
SE = 82%
Fatigue
5/10
Fatigue
5/10
Fatigue
2/10
SE = 69%
Depressed
3/10
Fatigue
5/10
SE = 84%
Depressed
5/10
SE = 84%
Sunday
Brunch,
skating,
grocery
Showered,
shopping,
walk, out for clean house
coffee,
bought gifts Depressed
3/10
SE = 85%
Fatigue
Fatigue =
3/10
6/10
SE = 82%
Figure 6.2 Behavioral experiment tracking example
Another testable belief is, “I need to fix my depression and feel more motivated before
I can do [any task, including the behavioral recommendations in CBT].” A belief that
motivation needs to come first to perform tasks can be tested by asking the client to do
one task without the sensation of motivation and monitor the results. The essential point
is that behaving and experiencing the outcome is often superior to verbal delivery of
information, and is less vulnerable to resistance and often self-perpetuating in a positive
Cognitive Factors and Treatment 93
direction, thus less prone to relapse. Readers are encouraged to read Ree & Harvey (2004)
for more on insomnia-focused behavioral experiments.
Coping Cards: Encouraging Negative Thought-Incongruent Behavior
Often, in-session, the client can begin to see a range of alternative possibilities and is
able to process the information that disconfirms their long held negative beliefs about
sleep. Clients may feel ready to make a behavior change in session, but then when they
get home, they may find themselves overcome by old automatic thinking and emotions
and therefore unable to implement new strategies. Coping Cards are “notes to the self”
to be read at times when information processing may undermine the commitment to
the behavioral goals. Once a particular type of information processing is activated,
information that is congruous with the negative mood and thoughts is over attended
to at the expense of disconfirming information. If the client writes a message to themselves at a time when information processing is more open to a range of information,
and then reads this alternative when they feel more stuck, it may prompt them to engage
in a more adaptive behavior. A note to the self on a smart phone, cue card, note pad,
or post-it note can be an effective lifeline that encourages behavior change and increases
self-efficacy.
In the example below, we see the therapist establishing the mood-thought-behavior
connection in order to encourage the client to make a behavioral change. Rather than
buying into the client’s formulation that particular circumstances or moods (e.g., feeling
horribly in the morning) determine behavior (e.g., whether or not to set an alarm clock
for the morning), the therapist suggests an alternative coping behavior (e.g., setting and
turning on the alarm clock at a different time, when mood is less negative). While the
therapist is making the thought-mood-behavior connection, the client spontaneously
suggests a method akin to the Coping Card. In most circumstances, the therapist will
introduce the idea.
Therapist: How did things go last night? Were you able to set the alarm?
Client: No.
Therapist: What got in the way?
Client: I don’t know.
Therapist: Did you have the thought, “I should set my alarm” last night?
Client: Yes, but I felt so horribly last night because I’m so tired that I knew I wasn’t
going to be able to do it. The idea of setting the alarm was not at all appealing.
Therapist: I get it. And how did you feel the next morning?
Client: Well, horrible—even worse. I was exhausted.
Therapist: You responded to feeling horribly by doing something that made you feel
even more horrible. Sounds a bit like a trap. Maybe the way to get out of this trap
is to respond to this situation in a different way. If not setting an alarm makes you
feel horrible the next morning, could we experiment with setting the alarm and
gathering information on whether your mornings could be less horrible?
Client: Well, that was my plan.
Therapist: Right, but you followed your feeling rather than your plan. This resulted
in feeling more horrible and you started to criticize yourself for not following the
94 Cognitive Factors and Treatment
plan, which also worsened your mood. Instead of tying the “on” button of your
alarm clock to how you feel—what if your alarm was turned on during the day
when you feel better? Your alarm clock can be turned on at any time, right?
Client: I never thought about this. I could turn it on when I got home—take the decision
out of it.
Therapist: Can you think of anything that could get in the way?
Client: I wonder if I would turn it off before bed if I was feeling really bad.
Therapist: Well, we could wait and see if this is a problem or we could try something
to minimize the likelihood of this happening.
Client: I could put a post-it note on the clock like: “DO NOT TURN OFF, NO
MATTER WHAT!”
Therapist: Do you think this would help?
Client: I do. The idea of the note kind of makes me laugh. I think if I saw the note it
would change my mood a little. I think this may work. I am going to start turning
on my clock when I get back from work, before my mood plummets, and I will
stick a funny note on it to remind me not to turn it off.
It is often most helpful to have the client write the coping card in session. We keep
a small stack of post-it notes and index cards for this purpose. It is often helpful to have
several reminders on the card including a reminder of the desired behavior. Some choose
to put reminders on their smart phones.
Shifting Information Processing Using Stimulus Control
The Stimulus Control instruction to get out of bed when unable to sleep is important
for giving up sleep effort and addressing conditioned arousal but there may be other
benefits as well. When people are lying in bed attempting to sleep, they unknowingly
go in and out of a very light stage of sleep but are often unaware of any sleep at all. The
reason why they misperceive or underestimate sleep has many possible explanations
Stay up until 11 PM
If you fall asleep, you will be awake
later.
This will fix your sleep problem.
Turn on the lights.
Don’t lay down.
Invite a friend over.
I would rather sleep than nap.
Go out and visit Louie.
Figure 6.3 Coping card example
Cognitive Factors and Treatment 95
(Harvey, 2002; Lundh & Broman, 2000; Perlis et al., 1997). Most theories suggest a role
for arousal (Bonnet & Arand, 1996, 1997; Perlis et al., 1997, 2000; Tang & Harvey, 2004).
For example, high frequency brain activity intrudes into the onset of sleep and is
perceived as wakefulness rather than sleep. The consequence is that staying in bed trying
to sleep could result in a confusional state between wakefulness and sleep. In addition,
information processing, problem solving and emotion regulation are less than optimal
while in this transitional stage between wake and sleep. Ever heard of the saying, “things
will look better in the morning?” That may well be true in part because looking at things
when half asleep is not likely to feel positive. Getting out of bed creates a shift into full
wakefulness, ends the light stage of sleep, and as a result, increases lucidity. While lucid,
information processing, problem solving and emotion regulation is more optimal so
that the client has a better chance to become calm and ready to return to bed.
Summary
•
•
•
•
A cognitive model for insomnia (Harvey, 2002; Morin, 1993) emphasizes the role
of beliefs about sleep self-efficacy and fatigue in activating negative thoughts about
sleep or fatigue. These thoughts lead to increased monitoring in the environment
for sleep or fatigue threats as well as increased safety and avoidance behaviors that
interfere with sleep. There are similarities across cognitive theories of sleep and
depression; namely attentional bias towards negative information (depression) and
sleep or fatigue threats (insomnia).
Cognitive therapy attempts to address cognitive causal factors and may also act by
addressing cognitive barriers to adherence.
Cognitive Therapy does not have APA level evidence as a monotherapy but
nonetheless is a common element in CBT packages for insomnia.
There are a variety of cognitive techniques used in insomnia treatment including
Thought Records, Socratic Questioning, Behavioral Experiments, and Coping
Cards. These can all be used simultaneously to discover alternative thoughts and
enhance outcomes.
7
Encouraging Adherence and
Troubleshooting Potential
Barriers
There are many successful trials of CBT-I in those with MDD-I (Edinger et al., 2009b;
Kuo et al., 2001; Lichstein et al., 2000; Manber et al., 2008; Morawetz, 2001; Watanabe
et al., 2011). In each of these trials CBT-I was delivered unaltered. Nonetheless, CBT-I
is a demanding treatment and MDD-I clients can present with specific barriers that can
interfere with tolerating the rigors of the protocols, and make following the treatment
more challenging. In this chapter, we provide some troubleshooting strategies for the
more common problems. Cognitive therapy, as stated in Chapter 6, is an important tool
for increasing adherence. We have included in this chapter some cognitive strategies
that can be utilized for troubleshooting resistance, but the reader is directed to Chapter
6 to understand the theoretical underpinnings of such techniques.
Most problems of non-response or suboptimal response to CBT-I in those with or
without a comorbid condition, amount to difficulties following all of the strategies. It
is important to check in every session with the client’s experience with following the
recommendations. The first step in addressing non-adherence is a troubleshooting
assessment. Throughout this assessment, it is important to gather as much information
as possible about the factors that may be interfering with adherence. In addition, the
assessment affords an opportunity to intervene as well. It is important not to assume
the reason behind nonadherence. Query for the antecedents, the presumed barrier to
adherence and the consequences. There are many reasons why someone has difficulty
following an instruction such as getting out of bed at a same time. These rules are not
easy to follow, especially when one is experiencing fatigue and low mood, so it is always
important to validate these experiences and acknowledge that it is difficult but not
impossible to focus on behavior change to improve sleep. Approach the situation
empathetically and openly, and foster a spirit of curiosity. What follows is a series of
common troubleshooting scenarios with Kelly, a case study from Chapter 10.
Troubleshooting Difficulties with the Morning
Discomfort
Therapist: So, the last time we met, we discussed quite a long list of recommended
changes to your sleep routine and I wanted to check in with how things went over
the last two weeks.
Adherence and Troubleshooting Barriers
97
Client: It was ok but I really couldn’t get up at 5:30 AM—I just couldn’t.
Therapist: I see. I would like to get some more information so that we can understand
what got in the way if that’s ok? [Client nods yes]. There was so much to remember
from last week, can we start by checking in with what you remember about why
we are setting a rise time each morning?
Client: To build sleep drive?
Therapist: Excellent. That’s right, to build enough drive for deep sleep the next night
and the nights to come. Can you remember any other reasons?
Client: I’m not sure. . . .
Therapist: There was another reason that related to the clock, does this sound familiar?
Client: Sort of . . . I need to set my clock each morning around the same time?
Therapist: That’s true. You sound like you are referring to your alarm clock. I was
alluding to your biological clock. Getting up at the same time every morning can
help to set your biological clock so that over time your brain learns when to go to
sleep and when to wake. But you are correct that setting the alarm clock can help
you to wake at the same time each morning. So, can you tell me more about what
happened in the morning? Were you able to set the alarm and get out of bed at
5:30 on any morning?
Client: The first morning, but then no.
Therapist: [looking at the sleep diaries] I love that you started off right away with the
recommendation, what happened this first morning that you were able to do it?
Client: I think I was pretty eager for the treatment to work, but I didn’t notice sleeping
any better the next night so I may have lost my drive?
Therapist: So by the second morning you felt unmotivated or perhaps discouraged?
Client: Maybe. I don’t know. I was so tired. I just couldn’t get up. I would think I’ll
just lie here for a few minutes but then an hour would go by . . . I don’t know.
Therapist: Were you sleeping during this time?
Client: No.
Therapist: So you would notice that you felt tired and you would have the thought,
“I can’t get up.”
Client: I guess.
Therapist: Did you have any other thoughts?
Client: I’m not sure. . . . that it was too cold to get up?
Therapist: You mean you noticed that you were cold?
Client: Not that I was cold, but that if I get up I will be cold. I’m so comfortable and
warm in the morning and I can’t imagine getting up. I hate the feeling of getting
up and feeling cold. In fact, it’s not so much I’m too tired to get up—I’m used to
feeling tired when I get up. I just can’t face the idea of the shock of feeling cold. It
feels so awful to suddenly be cold. It makes me feel achy and it seems like it takes
an hour before I feel comfortable.
Therapist: I can see why this would be unpleasant and make it more difficult to stick
to your plan. If we were to find a solution to this problem, would you be able to
get out of bed at 5:30 AM, or do you think there is something else?
Client: No. I think that would help.
Therapist: I notice that after three days the final awakening is past 5:30 AM. Did you
continue to set an alarm?
98 Adherence and Troubleshooting Barriers
Client: No. I knew I couldn’t do it so I figured what is the point?
Therapist: So on one hand, getting out of bed at the same time would probably fix
your sleep problem, which is important to you, but on the other hand, getting out
of bed and feeling cold would feel unpleasant. If this is an issue of physical
discomfort, can you think of a way to help with the discomfort of transitioning
from a warm bed to a cold room?
Client: I tried programming the thermostat to warm up the room in the morning but
it didn’t work because I felt even toastier in the morning and I didn’t want to get
up [smiles].
Therapist: I guess that’s off the list, even though it sounded like a good idea. Any other
ideas?
Client: No. If I could just get my bed to hover downstairs maybe that would work
[smiles].
Therapist: [laughs] maybe that’s a good idea . . . I don’t know of a way to get your bed
to hover, but what if you were to wrap yourself in your blanket and leave the room?
Client: So that I stay warm?
Therapist: What do you think? Is it worth a try?
Client: That might work. I’ll try it. I could sit on the couch for a bit.
Therapist: Anything else that would make it easier?
Client: I could have some nice warm socks next to the bed to put on before my feet
hit that cold floor.
Therapist: That’s brilliant! And you could still combine this with the blanket idea?
Client: Ok. I can do all of that.
Therapist: What about the alarm? This was a secondary problem with sticking to the
plan. Are you willing to set it now that you have this strategy for physical comfort
in place?
Client: Yes, I think so.
Therapist: Any other possible problems?
Client: No I actually think this might work.
Therapist: Great. Let’s write down the blanket, warm socks, and alarm ideas on the
bottom of your recommendations sheet.
In this case, the nonadherence was related to thoughts about how uncomfortable and
cold it is out of the bed in the morning. Devising a plan in which one transitions with
some warmth to a seated position in another room, can be a helpful way to make
following the rule of getting out of bed at the same time every morning less aversive.
Sleep Inertia
For some, the feeling of grogginess in the morning is aversive and is taken as a sign to
stay in bed. There are many ways to help with this issue. First, attributing sluggishness
exclusively to a poor night’s sleep is unhelpful and most often inaccurate. It is not unusual
to experience temporary sleepiness upon waking up. This state is called sleep inertia; a
transitional state which often relates to the stage of sleep out of which the person is
roused (e.g., Tassi & Muzet, 2000). Waking from deep sleep will produce more sleep
inertia than waking from N1 sleep. Although sleep inertia can also result from sleep
Adherence and Troubleshooting Barriers
99
deprivation, this is not typically the case in insomnia and assuming that how one feels
in the morning relates only to poor sleep will increase sleep anxiety and likely sleep
effort as well. Similarly, assuming that sleep inertia is predictive of a poor day of
functioning can lead to behavior that would confirm this belief (i.e., it can become a
self-fulfilling prophesy for a bad day). The therapist can begin to shift these attributions
by providing psychoeducation that sleep inertia is experienced universally by good
sleepers and those with insomnia alike, most often lasts less than 30 minutes, and is
simply a product of the stage of sleep occurring just prior to waking-up. Therefore, sleep
inertia is not thought to have much bearing on how one will feel the rest of the day.
Such challenging of unhelpful thinking about the significance of this state is one way
to address problematic outcomes that result from more negative attributions. Another
way to help with this problem is to encourage the client to devise a behavioral
experiment. If the belief is, “Sleep inertia is related to how poorly I slept, so it means I
will feel badly all day,” this can be tested by an experiment wherein the client uses
techniques that can minimize the time spent in sleep inertia and then monitor what
happens during the rest of the day. This can be compared to a week in which the client
applies no coping strategies. Some coping techniques to enhance alertness and diminish
sleep inertia are to encourage movement (physical activity such as taking the dog for a
walk, showering, and turning on lights or going outside to enhance exposure to bright
light). Another possible experiment would be to have the client rate the severity and
duration of the sleep inertia each morning and then perhaps have a phone alarm set
for several time points in the day to cue the client to rate their level of fatigue at each
time point. Most clients will discover that morning sleep inertia does not correlate well
with their daytime fatigue and function. This will tend to diminish the significance of
the inertia for the client.
Eveningness or Night Owl Tendencies
There are many other reasons people have for having difficulty adhering to a set wake
time. One important reason relates to being a night owl, or an eveningness chronotype.
Those who have a delayed sleep phase sometimes are faced with waking close to the
nadir of their circadian rhythm, so melatonin has not switched off and the alerting signals
from the clock have not yet begun. Getting up at such a time can be challenging. There
are many possible solutions to this problem. One way is to set-up the environment to
encourage a slight shift away from eveningness, towards an earlier bed and rise time.
Setting an earlier rise time and sticking to it every single day will expose the client to
light earlier in the day and should result in at least a slight advance of their natural
tendency. That is, the nadir of their rhythm will move to an earlier hour. This should
eventually allow the client to wake more easily at these times. Emphasizing that such a
shift can take place and that difficulty rising will only be temporary may be helpful in
increasing adherence. Nevertheless, for some the night owl tendencies may feel too
overwhelming to adhere to this recommendation, and so more help is needed. Solutions
to difficulties rising at a standard time tend to focus on implementing strategies either
in the morning, evening, or both.
Morning strategies target ways to get out of bed and to increase alertness. The first
goal in trying to shift someone earlier is to get them out of bed. In most cases this will
100 Adherence and Troubleshooting Barriers
be accomplished with an alarm clock. Setting an alarm does not guarantee that someone
will hear the alarm or get out of bed, but without the alarm there is almost no chance
that the person will wake spontaneously. So it is an essential first step in solving the
problem. The therapist should attempt to determine what the client’s history has been
when the alarm sounds. If the client reports being unaware of the alarm sounding, he
will need a louder alarm. There are a variety of very loud alarms available including
ones with very high decibels, ones that vibrate in addition to sounding, and ones that
employ flashing strobe lights. Most clients use a more conventional clock and these may
be inadequate. Some clients will report that they are in the habit of pressing the snooze
button, often unaware that they have done so. One solution for this may be multiple
staggered alarms across the room that may be just annoying enough to force the sleepiest
individuals to get out of bed to shut the alarm off. Additionally, some find it helpful to
use the alarm as a cue to at least slide their legs over the side of the bed. When legs
dangle over the edge of the bed, it creates discomfort in the lower back and can increase
arousal until the person can get out of bed entirely. When someone else lives with the
client, another solution may be to ask this person to be the backup plan to the alarm.
Whatever the method(s), once awake, it may be helpful to use some of the sleep inertia
strategies discussed above, including movement or physical activity, and/or light (either
going outside, turning on bright lights, or using a bright light box). For some clients,
scheduling enjoyable morning activities such as going out for a coffee and/or meeting
a friend, can be helpful in looking forward to the morning and motivating to getting
out of bed on time.
Another possibility for helping night owls to begin to rise earlier is to focus on
interventions in the evening. There are a few possibilities for evening management,
including decreasing the level of light exposure in the evening and/or limiting the
amount of late evening activity. It may be particularly important to decrease evening
light exposure in clients taking St. John’s Wort as there is some evidence that this
compound increases light sensitivity (Schey et al., 2000). Curtailing light exposure can
be achieved by minimizing the overall number of lights in the room and using soft
lighting, or lighting high in red or amber wavelengths (i.e., the part of the light spectrum
associated with melatonin release) and low in alerting (blue wavelength) light. Use of
blue spectrum blocking sunglasses if outside or free downloadable programs for computer screens, (e.g., f.luxTM) can minimize the degree of blue light absorption (i.e., light
in the 440–460 nm wavelength range). With regard to activity level, those who are night
owls often become most alert in the evening hours so it may take longer for them to
disengage from tasks in the evening. Activity begets more arousal and more activity, so
clients should be encouraged to create a buffer zone of quiet relaxing activities about
1–2 hours before bed time, which may be a helpful way to start winding down.
Early Morning Awakenings
Early morning awakenings (EMAs), or waking up an hour or so earlier than desired,
may be an indication of “morningness,” or a side effect of depression, or both.
Differentiating these conditions can be accomplished during the assessment by asking
the client if the EMAs were present prior to depression onset. A positive response
suggests an advanced chronotype which means that the nadir of the circadian rhythm
Adherence and Troubleshooting Barriers
101
comes earlier than average, implying that melatonin has switched off earlier and the
alerting signals from the clock are already fairly high well before the client’s desired
wake time. Such an individual may also feel sleepy long before their desired bed time.
Such a tendency may need to be taken into consideration when determining the bed
time and rise time for SRT and SC. In other words, for such morning-types, learning
to sleep beyond their habitual rise time may prove too difficult and it may turn out to
be easier to align the prescribed schedule with their inherent tendency. Depressed
individuals with a more neutral chronotype may eventually be able to be trained to sleep
later, but for morning-types who may not know that they are more of an early bird the
rise time may need to be earlier than initially desired. It should be noted that some
clients may express ambivalence about morningness. There are those that see an
advanced chronotype as negative. Common stereotypes exist that early birds are boring
and cannot have an active social life because they go to bed early. Many clients are
unaware that chronotype is largely genetic so some psychoeducation is important.
Additionally, it is helpful to use cognitive techniques such as TRs, Socratic questioning
or BEs to modify beliefs about an earlier chronotype. In truth, early birds are not
prohibited from having an active, satisfying social life. They can certainly stay up later
for special events especially if they are physically active during the event. In addition,
after their insomnia abates, they can take a brief nap prior to going out to manage their
level of sleepiness. They may find some friends in their circle who enjoy morning
activities. Clients can make a list of the possible benefits of getting up early in the
morning, such as having increased time for goals such as exercise, alone time, or a chance
to beat the traffic on a morning commute. On that same list, they can make another
column in which they list the things they worry they will lose by shifting their schedule
earlier. In a final column, clients can troubleshoot ways they could continue doing the
activities listed in the second column (i.e., moving some activities to different times or
use time gained by waking early). Once the list is complete, BE’s can test the belief that
“life is unsatisfactory with an earlier schedule.” In most cases the results of the BEs
demonstrate that the clients sleep better, feel better during the day, and are more
productive, by implementing some of the strategies on the final column of their list.
Another strategy to foster greater acceptance of shifting one’s schedule earlier is to
use analogies. This is a technique most commonly associated with Acceptance and
Commitment Therapy (ACT) (Hayes, Strosahl, & Wilson, 1999), discussed in Chapter
8. One analogy is a story in which a child always wanted to be a center in basketball.
Center is the position in basketball generally held by one of the tallest members of the
team. The child dreamed of being a star center but grew-up to be a short young man.
Despite being short he continued to try out for center and every year he did not make
it to the team. Finally a coach said he could join the team but only if he was willing to
try the guard position [this is typically reserved for the shortest members on the team].
The boy steadfastly insisted that he was a center and would not like to be a guard. The
coach told him that it was his choice but reminded him he was playing outside of his
strengths, and encouraged him to try something new. The young man relented and
became a star guard for his team. He found that he had skills that suited being a guard
and he found that he quite enjoyed playing the position. He also knew the center
position so well that he had a talent for getting the ball to the center to score. By shifting
his perspective and playing within his game, he was able to combine the best of both
102 Adherence and Troubleshooting Barriers
worlds, with amazing results. The purpose of the analogy is to present scenarios that
clients can relate to as a way of helping them to understand the general concept and
more easily shift their perspective. The key, of course, is to find the right analogies that
fit the client’s experience and help them to easily relate it to the behaviors that they are
trying to change.
Troubleshooting Difficulties with Bedtime
Staying Awake Until the Prescribed Bedtime
A ubiquitous problem in the practice of CBT-I is when clients return to subsequent
treatment sessions and explain, “I can’t stay up until my earliest bedtime. I’m way too
sleepy.” If nothing else, if the client is truly sleepy and not just tired, this is ironic since
when they first presented they complained of an inability to get sleepy and fall asleep.
It can therefore be suggested that this shift is good news and confirms that the client
is on the right track and building a healthier sleep drive. That is, if the treatment is
working the client should start experiencing increased sleepiness. In essence, in CBT-I
we are attempting to shift the client’s focus away from sleep, over which they have
little control, to strategies to stay awake, over which they can have much better control.
The client should be warned from the outset of therapy that increased sleepiness in
the first few weeks is likely and can make it more difficult to continue staying up until
the prescribed bedtime. When sleepiness is a problem, if the client is getting close to
their prescribed bedtime and sleep is going well, the best solution to the problem is
to begin extending time in bed according to SRT protocol. That is, add 15 or 30 minutes
depending on how robust the sleep and how sleepy the client. However, there will be
numerous occasions in the early going of treatment when the client gives over to
sleepiness at variable hours, resulting in dozing or going to bed much earlier than
prescribed. There are several things to consider. First, it is always important to help
clients understand the distinction between what is meant by sleepy versus fatigued. Those
with insomnia have high levels of fatigue but rarely have pre-treatment sleepiness.
The following dialogue demonstrates how the therapist can help the client make this
distinction and uses this to encourage the client to stay awake longer:
Therapist: I wonder if we are using the word sleepiness to mean the same thing.
Although people tend to use the word fatigue and sleepy interchangeably, they
actually represent different things. When I say “sleepy,” I mean it as a description
of the state right before falling asleep. It is the propensity to fall asleep, or the struggle
to stay awake. This means that if given an opportunity to sleep while feeling sleepy,
you would fall asleep and fairly quickly. Fatigue on the other hand is exhaustion,
whether it is physical, mental, or emotional, and it is associated with a strong desire
to sleep, but if given an opportunity, sleep would not necessarily occur (or at least
not quickly). Fatigue is the same as feeling tired or run down. So sleepiness is
associated with falling asleep, fatigue is not. Therefore, one can be fatigued without
necessarily being sleepy. Does this make sense?
Client: I think so. Well then I almost never feel sleepy. But I feel fatigued almost every
waking minute.
Adherence and Troubleshooting Barriers
103
Therapist: That is actually fairly common for people with insomnia. So you felt “too
tired,” meaning too fatigued, to follow the recommendations?
Client: Yes I felt so tired that I had to go to bed before the time we said.
Therapist: I see. So you didn’t feel sleepy but because you felt tired you went to bed.
Do I have this right?
Client: Yes.
Therapist: But it seems from your diaries that when you go to bed tired but not sleepy,
you often do not go to sleep or seem unable to stay asleep. Does that seem right?
Client: Yes, I guess that’s true.
Therapist: Well since you don’t often experience sleepiness currently, we need to
create a situation in which you will experience it because when you feel sleepy, sleep
will happen more naturally. Going to bed when you are fatigued, doesn’t allow
sleepiness to occur. You say that you feel fatigued every waking minute, so what
made you go to bed at the time that you did?
Client: I just get so tired of feeling tired. There’s nothing to do and I am so desperate
to sleep.
Therapist: That makes sense. But what if we could find something for you to do until
sleepiness sets in and then you could actually fall asleep rather than tossing and
turning in bed for hours?
Client: I can’t imagine there could be something I could do because I am so tired.
Therapist: Fair enough, but is it worth discussing, given that the only way you can get
a break from this pattern is to set up a situation wherein you start to experience
sleepiness?
Client: Sure.
Fatigue and dozing in the evening often can be helped by having the client engage
in evening activation. Evening activation simply refers to scheduling activities that are
likely to succeed in keeping the client awake. Some examples would be scheduling joint
activity with other people, engaging in activities that require one to stay in motion (i.e.
folding laundry, sorting photos, baking cookies, etc. or doing more activities to maintain
alertness). One thing to note is that eye strain is relatively common in those with fatigue,
so briefly holding a cool cloth over the eyes while seated, can help with the temptation
to close the eyes for prolonged periods.
Particularly in people with depression, there is inadequate build-up of a drive
for deep sleep, increased fatigue, greatly reduced activity, especially goal-directed
activity in the 24 hour period, and decreased availability of potential reinforcers in the
environment. As a result, it’s as if their entire day serves as a wind-down in preparation for bed. This may prematurely stunt deep sleep drive build-up and may reflect a
preoccupation with sleep or an avoidance strategy; both of which are potentially sleepand mood-interfering. For people with MDD-I the therapist will do well to consider
BA throughout the day as a way to not only bring the client into contact with positive
reinforcers but also to help build healthier sleep drive for the night. That said, it is
especially important in such cases, to work on evening scheduling of activities whether
inside or outside of the home, with a termination of the activities and a demarcated
drop into wind down activities one hour before bed. Another strategy is to make sure
that people with MDD-I refrain from putting on nightclothes like pajamas until just
104 Adherence and Troubleshooting Barriers
before their prescribed bedtime. For some clients with MDD-I, putting on nightclothes
occurs right after work or directly after dinner; some may remain in pajamas all day.
This is a change-worthy habit because it increases sleep preoccupation. It is always
important to identify instances of over-focusing on sleep during the day or night because
it will almost always lead to increased anxiety about sleep and sleep effort.
Delaying Bedtime
While some people struggle to stay awake or out of bed before the prescribed bedtime,
others have the opposite problem in that they remain engaged in activities well into the
morning hours, delaying bedtime significantly. This might be a positive thing for
building sleep drive but for some, the delay in bedtime often results in a delay in rise
time as well. As a result, their schedule becomes more and more delayed. From the outset
it is important for a thorough assessment of the cause of delaying bedtime. For those
who are night owls, mood and energy may be best in the evening, and this may be the
first time in the day when they feel good. It is thus understandable that a client would
feel compelled to take advantage of a time in which they start to feel awake and alert,
and avoid going to bed. In such cases it can be helpful to engage the client in a discussion
of the consequences of not following their schedule goals, e.g., they will become shifted
later, they will have greater difficulty adhering to the scheduled rise time, they are likely
to experience increased fatigue, they may wind up missing appointments in the morning, and they may engage in negative self-talk about not following goals. Solutions include
starting the wind-down period (i.e., the buffer zone) an hour earlier to encourage greater
disengagement, and largely troubleshooting adherence to a standard rise time discussed
earlier in this Chapter (i.e., increasing morning activity, manipulating light exposure in
the morning and before bed, and use of alarm clocks, etc.). Ultimately, adhering to an
earlier standard rise time should have some impact on shifting the person’s circadian
clock earlier, which in turn should allow them to get sleepy and disengage earlier.
Troubleshooting Common Problems in Depression
Anhedonia
Waiting for the feeling of motivation to do something is a common strategy that we
may all use from time to time. However, waiting for motivation in a disorder characterized by motivation deficits, often interferes with goal pursuit. It is a faulty assumption
that the feeling of motivation must always precede behavior. To demonstrate this truth,
ask your client to think about examples of things they do despite not feeling like it.
There are many things that people do for which they feel little to no internal motivation.
For example, many people will admit that there are days that they may not feel like
getting up and going to work, and yet they swing their legs around off the bed, get up,
shower, eat breakfast, and go to work; all without feeling like it. Likewise, imagine if
you always waited first for motivation. If one were to listen to the thought “I don’t feel
like going into work today,” it is easy to see how quickly life might become that much
more difficult and unworkable. It is precisely this kind of difficulty that people with
depression find themselves in when they wait for motivation to come before action.
Waiting for motivation often results in inaction, decreased positive reward, social
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isolation, and continual depressed mood and anhedonia. The alternative is to set up a
plan for how one would like their day to go and then to follow this to determine if life
works better or worse. Such strategies are used in BA (Dimidjian et al., 2006; Lejuez,
Hopko, & Hopko, 2001; Martell, Dimidjian, & Herman-Dunn, 2013). Even if not
engaged in a full BA protocol, it is helpful to use tenets from BA to help with motivation
issues. For more detail, see Chapter 9. Briefly, instead of using an internal state to guide
behavior (i.e., behaving from the Inside-Out), clients can use a plan that can eventually
lead to different contingencies and thereby change their internal state. In other words,
they can follow a plan, not a feeling (i.e., behaving from the Outside-In). By setting up
an “Outside-in” instead of an “Inside-out” strategy and by collaborating on a plan with
a chain of positive contingencies, the client is more likely to achieve their desired goal.
Clients may not at first be able to articulate a full plan to get out of bed that is highly
likely to succeed, but they may be able to identify a strategy for: setting an alarm, devising
a backup to the alarm, keeping their eyes open, sitting upright in bed, getting out of
bed, staying out of bed, and a reward system for being out of bed. It is important to
break down all the components of getting up and the identified barriers as well as discuss
morning contingences that will increase the likelihood of getting out of bed shortly after
the alarm rings. Setting-up the strategy to make behaviors more likely and easier is a
prominent focus in BA. There are as many contingency plans and strategies as there
are clients for getting out of bed in the morning. Some possibilities include: keeping
blinds or curtains open in the bedroom, using a timer for the lights in the morning,
using the alarm as a cue to stand up or sit up, setting an alarm clock to loudly broadcast
a news channel to provide a transition, using the sound of the alarm as a cue for the
feet-on-the-floor technique (i.e., swinging legs over the edge of the bed), setting the coffee
on a timer the night before, keeping a coping card with positive thoughts next to the
bed, walking directly to the bathroom to take a shower, using multiple and staggered
alarm clocks throughout the bedroom, eliciting help from others to help with getting
out of bed, taking a blanket and going to a different room to sit until more fully awake
as a transition, scheduling morning activities (maybe with other people), and setting up
a reward system for mornings in which the goal is met. The key is to explore the idea
that behaviors can and do occur in the absence of motivation. Further, it is important
to help the client discover that their life often goes better when they set it up in this
way. For depressed clients who do not have enough of these examples already in their
lives or who can’t remember what that is like, behavioral experiments can again be useful
to help the client begin to discover the value of outside-in strategies.
Using Sleep or the Bed as an Escape
In those with MDD-I, there are some who use the bed as an escape. Such avoidance is
a common perpetuating factor in depression (Martell et al., 2013). Avoidance maintains
low mood because it limits access to positive reinforcement, i.e., there are few
opportunities for positive reinforcement in the bedroom especially if one cannot sleep
and lays awake tossing and turning. Moreover, although avoidance initially alleviates
tension, the net result is that protracted escape becomes confining, and the world of
the client shrinks. Such tendencies can be addressed in a variety of ways. Socratic
questioning and/or Thought Records can challenge unhelpful thinking about the role
of avoidance. Once a client has had psychoeducation about sleep regulation Socratic
106 Adherence and Troubleshooting Barriers
questioning about the consequences of using the bed for escape can serve as a check to
see how much the client has retained or understood of the sleep regulation rationale.
Clients should be able to explain that increased time in bed decreases drive for deep
sleep, decreases regular input into the body clock, increases fatigue, increases conditioned arousal, decreases positive reinforcement, thwarts goal pursuit, and maintains
negative mood.
Another strategy is to create ambivalence as a way of enhancing motivation. The
therapist can create such ambivalence by presenting two contradictory arguments sideby-side. The following dialogue demonstrates how exploring the pros and cons (both short
term and long term) of self-imposed isolation can create the desired client ambivalence:
Therapist: From what I understand, life seems overwhelming so you believe it is better
to remain in your room when you’re home. Have I got that right?
Client: Yes. It just feels better to stay tucked away in my room.
Therapist: But at the same time you are also tired of feeling tired, you want better
sleep and you have said repeatedly that you are lonely. Sounds like you are at an
impasse?
Reflecting the two sides of the problem, or “sharing the dilemma” allows the therapist
to refrain from arguing for adherence (which can only encourage resistance) and
encourages the client to take responsibility for a shift. If the client argues for maintaining
avoidance, the choice and consequences are highlighted.
Therapist: So it sounds like at this point, you would prefer not to explore ways to increase
your time out of your bed because it is too hard. Would it be a better use of our time
to shift our goals away from improving sleep and fatigue, and towards acceptance?
Clarifying how the behavior is contrary to their goals often causes clients to shift and
consider behavior change. However, in cases in which the client agrees that sleep should
no longer be a treatment target—this becomes their choice and it may be a reasonable
decision for that moment in time. Smoking is never a healthy choice and is always changeworthy but people may not be ready to make a change. Likewise, knowing that we can
successfully improve someone’s sleep does not mean that they are ready to make the considerable effort needed to make this happen. Clients sometimes come to the conclusion
that their sleep isn’t bad enough for them to keep a schedule 7 days per week and get out
of bed when unable to sleep. This decision reflects some degree of increased confidence
in the ability to cope with the consequences of sleep and might actually bode well for
decreases in sleep anxiety and arousal. Treatment can shift towards other therapy goals
and/or acceptance when clients no longer consent to sleep-focused treatment.
Troubleshooting Fatigue
The Belief that Fatigue Precludes Following Behavioral Recommendations
Some clients will explain, “I am too exhausted to follow any recommendations.” This
makes sense because central fatigue is generated when there is a mismatch between
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107
the estimated resources needed to complete a task and the perceived personal resources
one has to allocate to the task (Chaudhuri & Behan, 2004). In the case of CBT-I, clients
will often estimate the resources needed to complete the task of following sleep schedule
recommendations as impossibly high, given that they estimate their personal resources
as too low to meet the demands of this task. This is why it is necessary to collaboratively
build contingencies to lighten the resource demand of the sleep schedule. The task of
rising 2 hours earlier than desired has higher resource demand than being awoken
2 hours earlier by a loved one who has filled the apartment with the smell of coffee,
slipping into a warm robe and slippers, and getting into a nice, hot shower. The second
part of the equation for central fatigue is an estimation that personal resources are
deficient to meet the needs of the task. In those with insomnia, there are beliefs of low
self-efficacy (Edinger et al., 2008), a sense one cannot cope with the consequences of
fatigue (Morin, 1993), a tendency to selectively scan and focus on evidence that one is
fatigued (Harvey, 2002), and a tendency to think repetitively about fatigue (Carney
et al., 2010b). Thus, especially those with MDD-I are highly likely to perceive themselves as deficient of resources. Again therefore, it is helpful to break down the task
so that it has less of a resource demand (as above), however it is also important to explore
the deficiency beliefs. In truth, most people with insomnia, including those who are
depressed, are often amazing in their ability to cope long-term with sleep disruption. Insomnia is chronic and often lasts for years and years and despite this, people
with insomnia have a disproportionately low level of disability. In many ways they are
expert copers. In a ten-year insomnia history, there may be some difficult experiences,
but there will be over 3700 days of coping as well. The therapist can use Socratic
questioning to help clients discover their own amazing strengths.
The Belief that Fatigue is Dangerous and/or Rest is Essential
Some clients believe, “I NEED to rest, I am exhausted.” Behind this belief is the idea
that there is a need to compensate for poor sleep and to resist compensating is hazardous
to one’s safety or health. It is important to reinforce with the client the rationale for
being out of bed when unable to sleep (i.e., to reverse conditioned arousal). They also
can be educated that the body has a natural mechanism to compensate for sleep loss
(i.e., sleep drive), and with insomnia, the lost sleep creates too great an opportunity for
sleep, rather than too little an opportunity. Thus the sleep of those with insomnia tends
to be quite variable rather than consistently poor and with the compensatory behaviors
in which they tend to engage, their overall total sleep average is usually not much less
than normal (i.e., 6 hours). The therapist can use Socratic questioning to uncover the
depth of understanding of these very important facts about the sleep system.
In addition to difficulties with the rationale, it is important to query catastrophizing
about the consequences of fatigue. Outside of the context of insomnia, resting when
tired can be an adaptive strategy in moderation, but the sleep system is a homeostatic
system (Chaudhuri & Behan, 2004) and while too little resting causes exhaustion, the
excessive resting seen in both people with depression and insomnia also maintains fatigue
(Kohn & Espie, 2005). Often, clients have heard news stories about links between sleep
loss and early deaths, cancer, cardiovascular disease, dementia, diabetes, etc. It is natural
to assume that such research applies to insomnia as well, but in actuality these studies
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are less likely to apply to people with insomnia with the exception of those with
chronically low average total sleep times (less than 4–6 hours per night on average)
(Fernandez-Mendoza et al., 2010). Such research often employs epidemiologic methods
that assess sleep disruption with one or two broad sleep-related questions. Querying
sleep in this way includes people with all kinds of sleep disruption and excessive daytime sleepiness such as those with sleep apnea, periodic limb movement disorder, shift
work sleep disorders, circadian rhythm disorders, and/or those with chronic voluntary
sleep restriction. The links between sleep and early mortality, cardiovascular disorder,
and diabetes have been established in these disorders (e.g., Folkard & Tucker, 2003;
Irwin et al., 2008; Spiegel, Tasali, Leproult, & Van Cauter, 2009), but not in insomnia.
In cases of catastrophizing, it may be helpful to use either psychoeducation, or Socratic
questioning, or a Thought Record to challenge unhelpful thinking that equates the
consequences of general sleep disruption with those of insomnia. As has been stated
before, most clients with insomnia have had their problem for years rather than days
or months by the time they are in your office. It does not take much prompting on a
TR or with Socratic questioning to demonstrate that despite hundreds and often
thousands of nights of insomnia, the client remains in otherwise reasonable health.
Finally, behavioral experiments can also be set up to test the hypothesis that fatigue
is dangerous (see Chapter 6 for the energy conservation versus energy expenditure
experiment). It is ultimately counterproductive to stay in bed when tired because it
reinforces a belief that fatigue can be dangerous, it delays the build-up of sleep drive,
it associates the bed with wakefulness, and the consequence of lying in bed for long
periods is typically more fatigue and lethargy, not less. Experiments that explore the
link between moderate activity and fatigue versus inactivity and fatigue can be helpful.
For those combining CBT-I with CBT-D or BA, activity monitoring (see Figure 9.2 in
Chapter 9) is an excellent way for a client to make the links between wakeful inactivity and increased fatigue experientially. Explore what contributes to feeling fatigued
during the day and create ambivalence about fatigue-producing habits such as inactivity,
poor food choices, substances, etc. Many people with insomnia will tend to attribute
all negative daytime effects to poor sleep and tend to ignore the variety of factors that
can produce fatigue (i.e. boredom, tension, depression, dehydration, extended time on
computers, etc.)
The following dialogue demonstrates how the therapist can help the client discover
new reasons for their fatigue. The dialogue takes place within the context of a concurrent BA protocol, such as BABIT (see Chapter 9), however one can assign activity
monitoring and schedule activities within the context of CBT-I for clients with decreased
activities.
Therapist: So you said you cannot do anything about your sleep because you are too
fatigued. Do you think there is anything you could do to help your fatigue?
Client: Well, no, because I’m tired because of my sleep.
Therapist: What else might account for your fatigue?
Client: Nothing. I’m tired because of my sleep.
Therapist: I wonder if it is possible that other things cause fatigue too? We talked about
jetlag like symptoms occurring with irregular bed and wake times when the body
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clock has difficulty adjusting to the variability of the sleep and activity schedule.
What are some of the symptoms that occur with this schedule variability?
Client: Feeling grouchy, irritable, fuzzy-headed . . . and I guess fatigued.
Therapist: That’s right. So could this have a small role in the fatigue you are feeling?
Client: Maybe but I can’t keep a schedule because I’m so tired I can’t change it.
Therapist: Ok. If we look at your activity log, do you notice any patterns between your
highest fatigue ratings and what you are doing?
Client: The highest is 8, and it happened 3 times—watching TV on the couch.
Therapist: What about the lowest rating?
Client: The lowest was 4, which happened once when I went out to see my friend Jake
downtown.
Therapist: What’s the difference between these two types of activities?
Client: I guess sitting on the couch is not really an activity, or may be low activity.
Therapist: Do you see a connection between low activity and fatigue and greater
activity and feeling less fatigued?
Client: Maybe . . .
Therapist: I want you to stand up right now and stretch in whatever way feels
comfortable to you. [after client stops stretching] How do you feel now?
Client: A little better. Feels good to stretch.
Therapist: Moving muscles, getting greater circulation and oxygen has a positive effect.
Constricting flow and staying in the same position for a long time increases fatigue.
Do you think dehydration or nutrition have any impact on fatigue?
Client: I guess so. In fact, now that I think of it I feel weak and tired if I haven’t eaten
or had anything to drink for long hours. Junk food can also backfire on me.
Therapist: Ok. So you have had these experiences. What about coffee—have you ever
experienced an energy crash a few hours after you have a coffee?
Client: Yes, definitely. I am so tired I usually have another coffee.
Therapist: This suggests caffeine withdrawal. As it is eliminated from our system, we
get withdrawal symptoms of fatigue. Having another coffee will get rid of the
symptoms but then you will face them again later. How about your medication?
Do you think this contributes to your level of alertness or fatigue?
Client: Unfortunately my sleeping pill makes me feel groggy the day after I take it. So,
I guess so yes. Well, I guess the answer is that there are a bunch of things that make
me tired.
Therapist: And we have many tips to help with fatigue, including being active, eating well,
staying hydrated, limiting caffeine, increasing bright light exposure, or taking a shower.
When we blame fatigue on sleep exclusively and believe there is nothing we can do to
manage it, suddenly there is a lot riding on fixing the sleep problem. Can you see how
this belief might get in the way from making changes to improve the situation?
Client: Yes, definitely.
Comorbid Pain and Mobility Issues
There may be circumstances (e.g., pain, mobility, frailty) in which there are concerns
about a client getting out of bed in the middle of the night. When providing SC
instructions about getting out of bed it is important to remind all clients, and especially
110 Adherence and Troubleshooting Barriers
ones with mobility concerns, about turning on enough light to provide for a safe path
to where they are going. Some clients may be reluctant to do so out of fears it will make
them more alert and/or concerns about waking up other family members. Given that
most light sources in the house will not have high concentrations of blue spectrum light,
the chances of the light activating the person is negligible. This may be particularly true
as we age (Herljevic, Middleton, Thapan, & Skene, 2005; Verriest & Uvijls, 1977).
Research studies on light and alertness often recruit young healthy sleepers rather than
people with insomnia across the age spectrum, so it is not known how such factors affect
those with insomnia. Giving up the effort to sleep should create enhanced sleepiness
while out of bed and do much more to ease arousal than any amount of standard room
light can do to boost arousal. Concerns about disturbing family members by turning
on a light is understandable but the client can often trouble-shoot including using low
level night lights along the floor, or closing bedroom doors so the light from other rooms
will not shine into the bedroom. Moreover, it is always helpful to remind clients that
the recommendation to get out of bed is only temporary until reconditioning takes place,
so most family members are tolerant of these measures knowing they are short term,
and especially if they typically sleep through it anyway.
These issues aside, there may be valid reasons for safety concerns in some clients.
For those who are frail, in pain, and/or have significant mobility issues getting out of
bed may be risky or even ill-advised. In such cases, a technique called counter control
may be a useful alternative to the standard SC instruction (Hoelscher & Edinger, 1988).
Counter control is a technique in which the client still gives up the effort to sleep but
does not leave the bedroom or bed (Davies, Lacks, Storandt, & Bertelson, 1986). The
instructions are to sit up in bed and engage in an enjoyable restful activity until sleepy.
Once the client is sleepy, they can turn off the light, stop the activity, and once again
see if they are able to sleep. The crucial element to counter control is that the client does
not engage in any sleep effort nor allow themselves to remain in bed feeling frustrated
or upset about sleep. Traditional stimulus control is still preferable because with counter
control, the client is doing wakeful activities while in bed so there still could be concerns
about conditioned arousal, however, given the hope that they are not in bed engaged
in sleep effort, it is a reasonable compromise for those who may be unable to get out
of bed. The support for counter control suggests that it is best for issues with waking
up in the middle of the night (Hoelscher & Edinger, 1988) so the other SC rule about
not going to bed until sleepy still applies.
One other consideration in those with pain and mobility issues is resting. Rest may
be necessary for certain physical conditions; however, excessive resting is associated with
increased pain and fatigue as well as lightened sleep. Using the bed or bedroom for rest
rather than only for sleep may strengthen the bed as a cue for pain and suffering and
weaken the bed as a cue for sleep. Thus for those with physical conditions that necessitate resting, it is advised that if possible clients rest in positions other than supine and
not in the bed or bedroom. Finding ways to safely and gradually increase activity and
provide resting guidelines is an important intervention strategy for such clients.
Relationship Issues
Sexual activity is often an exception to the Stimulus Control recommendation to avoid
doing wakeful activities in bed. Many individuals may find that following sexual activity,
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they are actually more relaxed and prone to sleepiness. However, when sex is alerting
for the client we encourage them to consider moving sex to another place and/or time
at least during treatment to re-establish the bed as a place solely for sleep. In such cases,
it is important to ask clients whether they foresee any difficulties in raising this issue
with their partner. Some clients may be uncomfortable discussing with their partner
the possibility of moving sex to a place other than their bed or a time other than bedtime
during treatment. There are a variety of possible issues that require follow-up inquiry.
Especially for clients with depression they may be prone to engaging in “mind-reading”
and assuming their partner will say no. In truth, partners of people with insomnia often
are quite willing to support treatment recommendations because in addition to wanting
to help their partner, their partner’s insomnia often impacts them negatively. If clients
are making assumptions about their partners, it is important to work with them about
their belief and see if they are willing to test their negative assumption. Some clients
may need assertiveness or other communication skills training before tackling sensitive,
intimate communication with their partners. Sometimes this assessment reveals
significant relationship issues—a common problem for people with insomnia, and this
may require additional work. Lastly, both people with insomnia (Carney et al., n.d.) and
people with depression report libido problems (Cyranowski, Frank, Cherry, Houck, &
Kupfer, 2004; Johnson, Phelps, & Cottler, 2004). This is further complicated by the fact
that those with depression may experience sexual dysfunction as a result of their
pharmacologic treatment for depression (see Lane, 1997). Thus, this simple assessment
of whether there are any barriers to moving sexual activity out of the nocturnal bed
and/or to a different time can reveal a range of issues and potential treatment targets,
which do not relate to sleep directly but could nonetheless have an impact on well-being
and thus, indirectly—sleep.
Another common problem in relationships is the fact that many partners do not
necessarily share the same circadian tendencies. That is, sometimes owls live with larks
or vice versa. Part of the insomnia problem may be due to, for example, an “owl” client
who is consistently going to bed with their “lark” partner earlier than when they
themselves are sleepy. In the first weeks of treatment, it is not uncommon that clients
will complain that their bed partner will be unhappy that they are going to bed later
and not coming to bed with the partner. Again, one way to handle this is to remind the
client that the initial schedule for time in bed is temporary and may eventually be shaped
to work out closer to that of their partner. However, if the client and/or their bed partner
are still not persuaded, some troubleshooting discussions will be needed. One possible
solution is to have the client go to bed at the earlier hour with their bed partner to cuddle
and spend some quality time, but then to leave the bedroom once their bed partner has
fallen asleep. Then the client can return to bed but not before their prescribed bedtime
at the earliest. In this way the client is spending some time with their partner in their
bed, albeit awake, but again is not engaging in any sleep effort at that time. Similar
problem solving can be accomplished for “lark” clients who wake earlier in the morning
than their “owl” partners.
In the best of all possible worlds the therapist might consider bringing bed partners
into CBT-I sessions. From the very first assessment to the last session, including bed
partners can help enrich the assessment (especially of intrinsic sleep problems such as
apnea, periodic limb movements or parasomnias), help with adherence to protocols, and
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provide support and optimize treatment response (for more see Rogojanski, Carney, &
Monson, 2013). Further, it should be noted that the instructions for stimulus control and
sleep restriction protocols are not necessarily intuitive at first blush. When that client
goes home to describe these protocols to a bed partner, without sufficient provision of
the rationales, it is possible that bed partners could unwittingly sabotage the clients efforts
by encouraging them to do things like gain more rest, go to bed earlier, or sleep in later
when they haven’t slept well. Having the bed partner in the office from the first session
can eliminate this problem in that the bed partner is instructed in the rationale along
with the client. This usually allows for better collaboration between client and partner.
Cognitive Issues
People with insomnia and depression can suffer from cognitive issues and the amount
of material covered, especially in session 1, can be a lot to retain. One novice mistake
is to deliver the psychoeducation material (contained in Chapter 1) like a general lecture.
There should be ample information from the assessment that should permit tailoring
of the educational material to the specific client presentation. More importantly, psychoeducation should be collaborative and emerge as a two-way conversation. Although the
therapist is the expert on sleep, the client is an expert on their own sleep experience.
The therapist should use questioning to elicit examples of each sleep regulation concept
as well as have the client pick out examples from their sleep logs that could be acting
as maintaining factors in their insomnia. Such active two-way engagement is an
important therapy technique to enhance retention of the materials. It is important to
check in and ask questions about how much the client heard and understood, while
normalizing any memory issues the client is having as part of the their disorder. Use
repetition and begin every session with a bridge from the last session. This is done by
asking the client to recall what they remember from last week and use questions to try
and elicit any information missing from their bridging attempt. In clients with memory
issues, providing handouts and writing down homework so that they can bring the
information home, is a helpful way to ensure that clients follow treatment recommendations. Some clients like to make a note on their phone or on a coping card if
they have concerns about remembering the material. In clients with traumatic brain
injury (TBI) we use a sleep diary with a larger font and only the following key variables:
Day; Into Bed; Time to Fall Asleep; Total Time Awake During the Night; Time you
Woke Up; and Time Out of Bed. With TBI it is crucial to use handouts for retention.
Also it may be necessary to break the information normally covered in session one
into two sessions: Stimulus Control during the first week and Sleep Restriction and
Sleep Hygiene the following week. The rest of the sessions will tend to look the same
as CBT-I in those without TBI. In sum, for some clients, retention, understanding, and
accommodation of the material may take longer and require a few more sessions to
bring to fruition.
Troubleshooting: Assessing or Modifying Therapist Beliefs
Therapists need to be mindful that they bring a set of personal beliefs to the therapeutic
relationship. As always, being aware of and ensuring that these beliefs do not intrude
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113
into therapy is essential to good practice. In addition to therapists’ personal beliefs about
psychotherapy, therapists also have their own beliefs about sleep. If a therapist believes
that people need 8 hours to function or they don’t believe sleep need is controlled by a
homeostatic system that produces an adequate amount for health if given an adequate
opportunity, they may have greater difficulty implementing CBT-I. Below we discuss
common therapist beliefs that can interfere with competent delivery.
Beliefs that Underestimate Clients’ Abilities to Make Change
If a client does not adhere to a schedule prescription, it is important to avoid making
assumptions about the cause. For example, if the therapist concludes “Of course my
client cannot follow a prescription—they have anhedonia, so they can’t follow recommendations,” then logically, little can be done until the anhedonia is resolved. This is
evidence of the same kind of inside-out thinking that creates a barrier for clients and
was tackled earlier in the chapter as problematic. There are many reasons why people
have difficulty following prescriptions and spending time discovering the reasons
behind this resistance is the key to increasing the likelihood of adherence. A key core
belief in depression is hopelessness (Beck, 2008) and it is important not to collude with
the client in this unhelpful assumption. An important therapist activity is to use Socratic
questioning to help the client to discover instances that disconfirm hopelessness and to
help the client design experiments to test the belief of hopelessness. Numerous studies
have demonstrated conclusively that CBT-I can be effectively delivered without any
modifications in people with insomnia with various comorbid problems including
depression, pain, hopelessness, and anhedonia (Kuo et al., 2001; Lichstein et al., 2000;
Manber et al., 2008; Morawetz, 2001), so this belief is worthy of testing.
For therapists who are just now learning CBT-I for the first time, remember that, as
with our clients, when learning anything new there is a tendency at the first sign of
discomfort to resist and to return to old, more comfortable patterns of behavior. Hence,
when meeting resistance from clients who say that they cannot engage in some instruction because they are too depressed, anxious, worried, etc. there may be a tendency for
the therapist to quickly abandon CBT-I in favor of therapies with which they have more
familiarity, facility, and history. It is important for therapists to monitor for their own
beliefs about insomnia and their clients. Depression symptoms may pose barriers to
insomnia treatment implementation but barriers can be assessed and problem-solved
within the context of CBT-I and improving sleep is as important for improving
depression as is improving depression for sleep (Manber et al., 2008).
Beliefs that Sleep Diaries are Unnecessary
It is not uncommon for novice CBT-I therapists to have unhelpful beliefs about sleep
diaries. Such unhelpful beliefs include: “Sleep diaries are not accurate, we should use
objective measures instead,” “I can’t ask my client to do this, it is too much work,” or
“Tracking sleep will worsen my client’s sleep problem.” The belief that “objective”
measures of sleep are preferable is unhelpful and inaccurate in a variety of ways. First,
it is a myth that objective measures of sleep are somehow “truer” measures of sleep.
114 Adherence and Troubleshooting Barriers
Sleep is a construct, defined and measured in a variety of ways. One objective measure
of sleep is overnight polysomnography (PSG). During a PSG study, sleep is defined by
particular patterns of electrical activity in the brain. This definition of sleep using this
method is somewhat arbitrary. The first consensus system was derived by visually
examining 30 second periods (because this is what fit on a PSG page) and labeling
whether it is sleep or not sleep. Sleep is coded when the brain wave activity is slower
than alpha with low voltage amplitude for greater than 50 percent of the 30 second period
(Rechtschaffen & Kales, 1968). However, there are many problems with this way of
defining sleep. In the example provided above, 14 of the 30 seconds could be
characteristic of wakefulness, but we may categorize it as sleep. This may or may not
match with the perception of the sleeper, because they are aware that there was
substantial wakefulness (i.e., 14 of the 30 seconds) in this period. For example, in some
with insomnia, their sleep looks fairly normal using this criteria, but they have large
subjective complaints and measuring the degree of high frequency brain wave intrusion
(via spectral analysis) reveals poor sleep depth that correlates with the subjective
complaint (Krystal et al., 2002). Consensus clinical assessment guidelines do not support
the use of the PSG as routine practice in those with insomnia and depression (Kushida
et al., 2005). Other problems with relying on PSG include the fact that the sleep lab can
either create so much anxiety that the degree of sleeplessness is exaggerated or the sleep
lab is such a novel environment that conditioned arousal is reversed and the degree of
sleeplessness is under-represented. So PSG is not at all preferable to prospective sleep
diaries.
Another way to conceptualize sleep is the relative absence of or gross reduction of
motor movement. This is the way it is defined in actigraphy. Actigraphs are often worn
on the wrist and use accelerometers to sample movement and store the data. The
sampled data are analyzed using algorithms for what movement patterns are most
typical of rest versus activity. Many apps use accelerometers and profess to measure
sleep. There are multiple problems with valuing this particular definition or measurement of sleep. Accelorometers that are used clinically are often subject to many
validation tests of the algorithm. Even with these many validation studies, we know that
this form of measurement can be dubious in insomnia, owing to the fact that sleepless
people can lay awake with minimal movement (Blood et al., 1997; Chambers, 1994; Hauri
& Wisbey, 1992). Algorithms associated with smart phone apps or wearable devices such
as the Fitbit TM are not subjected to the same rigorous validation and have been shown
to be even less accurate than clinical actigraphs (Montgomery-Downs et al., 2012).
In contrast, sleep diaries reflect a subjective perception of sleep, and Insomnia
Disorder is a subjective disorder. The diagnosis is based on the client’s complaint of
sleeplessness. Despite some reasonable suggestions (Lichstein et al., 2003) there are no
consensus quantitative criteria for insomnia because morbidity cutoffs are not reliable.
That is, occasional severe sleep loss can be similar to mild, chronic loss (Lineberger
et al., 2006). Although subjective perception is most important in insomnia disorder,
not all subjective measures are the same. The best evidence suggests that prospective
measurement of subjective data is superior to retrospective measurement (Coates et al.,
1982), and sleep diaries are a prospective measure. Subjective retrospective measures
such as the PSQI or the ISI have appeal because they are brief and have good
psychometric properties. Unfortunately, the psychometric properties of the PSQI may
Adherence and Troubleshooting Barriers
115
be somewhat questionable when used in those with comorbid psychiatric disorders
because of the confound of the PSQI with anxiety (Hartmann et al., 2015). The question
of whether the ISI may be preferable in those with MDD-I has not been investigated to
date. Nevertheless only sleep diaries capture the variability of sleep (Wohlgemuth,
Edinger, Fins, & Sullivan, 1999) as well as the sleep indices needed for sleep scheduling
(Buysse et al., 2006). That is, it is near impossible to carry out effective sleep restriction
therapy without sleep diaries. It is true that people with insomnia most often
underestimate sleep diary total sleep time, and overestimate sleep onset latency and
wakefulness after sleep onset relative to absolute PSG estimates of the same values (Coates
et al., 1982; Spielman, 1986). However, the evidence for sleep diary reliability is strong,
e.g., the agreement between PSG and diaries is high (kappa = .9), as well the sensitivity
(92.3 percent) and specificity (95.7 percent) (Rogers, Caruso, & Aldrich, 1993). Because
of the importance of subjective complaints and the reliability of the measure of longer
periods (i.e., 2 weeks), and problems with retrospective subjective measures, PSG and
actigraphy, the sleep diary is the gold standard measure in the field of insomnia (Carney
et al., 2012).
Sleep Diaries with Improbable Values
In a small proportion of cases of people with insomnia, there is a phenomena called
paradoxical insomnia, or sleep state misperception (SSM). SSM occurs when there are
consistently improbably low sleep total values in conjunction with intact functioning.
It is not possible to go without any sleep for more than a few days without considerable
efforts in place to do so. Moreover, even in cases of low total sleep time, sleep is variable
so any consistent report (i.e., every single night) of little to no sleep is likely inaccurate.
For example, clients with SSM might report getting 0–2 hours of sleep a night for months
or years and yet report surprisingly reasonable daytime functioning. Although sleep
diaries have validity as evidence, ultimately the construct they measure is sleep perception so the perception of the client’s sleep may not match what their bed partners report,
or what the PSG or actigraphy suggests. The degree of that discrepancy determines
the degree to which the perception represents typical or paradoxical insomnia. In the
case when the therapist suspects that the diary data may reflect SSM, it is important
to consider how, when, or if to raise this issue with a client. There needs to be a strong
working alliance before raising this issue or it can be interpreted as evidence that the
therapist does not believe that the sleep problem is “serious” or that the therapist
believes the client is fabricating the data. Either interpretation can cause a rift in the
therapeutic alliance. If raising these issues is not possible given the current relationship,
it is important to take time to develop this relationship before raising it. Luckily, the
discrepancy fades with time-in-bed restriction; so one possibility is simply to arbitrarily
select 5 or 6 hours for the TIB prescription. Below are some possibilities for troubleshooting this problem in those with an established therapeutic relationship.
There are many possible reasons for SSM, including hyperarousal. Hyperarousal
often occurs in chronic insomnia and one result of hyperarousal is increased fast
wave activity intruding into sleep which can interfere with the amnestic effects that
should result during sleep (Perlis et al.). This phenomenon seems particularly severe in
SSM. Even good sleepers will have brief arousals during the course of every night, and
116 Adherence and Troubleshooting Barriers
during these arousals the person might process information like a sound in the room,
the feel of the sheets, or the sight of the clock. These arousals are extremely brief and
in normal sleepers there seems to be no memory trace for the experience. So, for the
good sleepers it is as if the arousal never occurred. In insomnia, and particularly in SSM,
the intrusion of fast brain wave activity is severe enough that it appears to inhibit the
amnesia for these small arousals so that the individual with SSM remembers every little
sound, sight and sensation. Therefore, although they might be sleeping most of the time,
they encode the time passed, as “awake” time. The problem with doing CBT-I in
someone with SSM, is that compared to people with more typical insomnia, sleep and
wake estimates from those with SSM will be so far off that to match a sleep restriction
prescription to the clients total sleep time estimate, would exceed the lower limits of
time-in-bed that are safe. In other words, in SRT we recommend that the restriction
of TIB match the client’s estimate of TST plus 30 minutes but never drop below
5 hours. In clients with SSM their estimates average total sleep time per day might be
anywhere from zero to 4 hours. The problem therefore, is that to do SRT with these
clients the TIB prescription will have to be somewhat arbitrary. Although someone
reports 0 minutes of total sleep time, we cannot restrict TIB to 0 + 30 minutes. In this
case the therapist might simply have to choose 5 hours as the starting point for
restriction. A word of caution here is that for clients with SSM there is the possibility
that the arbitrary prescription for SRT might be much lower than the client is actually
sleeping even though they do not perceive it. This sets up the possibility of creating
more extreme sleep deprivation in these clients than is typical early in the treatment.
That is, if the client estimates that they are sleeping 15 minutes per night but is actually
sleep 7 hours per night, and the therapist restricts this client to 5 hours, this is more
sleep deprivation than usually occurs in more typical insomnia where the deprivation
set up by SRT is mild. These clients will complain of very little sleep but often will be
surprised how well they are functioning. This is because they are actually getting much
more sleep than they think. One sign that the dose of restriction is too high is that in
the early going of restriction the client may perceive more sleep at night but paradoxically
may report much worse sleepiness and fatigue during the day because now they are
getting significantly fewer hours than when they started. This may force the therapist
to reconsider the SRT dose. At the very least these clients should be carefully monitored
for sleepiness and warned that they should not engage in any activities where sleepiness
would become a danger. The good news is that eventually the misperception tends to
minimize when drive for deep sleep builds and overrides hyperarousal as the treatment
progresses. In the meantime there are consequences to SSM that can interfere with
treatment. Those reporting little to no sleep tend to be quite anxious. They use dichotomous language such as “I don’t sleep at all” and understandably, they have extremely
low sleep self-efficacy. In one study, participants wore actigraphs and then reviewed
the actigraph data with the experimenter and compared it to the sleep logs during
the same period (Tang & Harvey, 2004). After the actigraph and log review session, the
discrepancy between the two modalities diminished, which suggests that it may be
possible to modify misperception with an exercise in which the client can see the discrepancy. Additionally, by providing an explanation of the hyperarousal phenomena
above, clients can understand that the therapist does not believe that the client is
Adherence and Troubleshooting Barriers
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fabricating or exaggerating their sleep complaints, rather, the therapist suggests that
hyperarousal may be providing confusing feedback to the client’s perceptual systems.
It is important to encourage the client to look for any evidence that they might have
been sleeping so that they can try to catch even an extra minute on the sleep diary.
Clients can be reassured that as the treatment progresses, the misperception will
diminish, which primes them to expect or look for more sleep time.
Additionally, it may be helpful to explore with the client the consequence of selfidentifying as someone who “doesn’t sleep.” There was a study in which those with
insomnia were given fake feedback based on an actigraph they wore (Tang & Harvey,
2004). One group was told that based on their actigraph data, they slept much more
than they thought and the other group was told that based on their actigraph data, they
slept much less than they thought. The next day, the group who were told they slept
better rated their daytime symptoms as less severe than the group who were told that
they slept worse; suggesting that perception of sleep is a key variable to assess and modify.
SSM can be managed better in treatment once clients have an understanding that:
1) extreme lows in average total sleep, especially “no sleep,” are not possible, 2) misperception is a result of a neuropsychological (i.e., extreme cortical hyperarousal) process
in insomnia, 3) misperception diminishes with sleep deprivation, and 4) there is a
negative, self-fulfilling prophesy consequence to labeling oneself as a non-sleeper.
Troubleshooting What Activities to do During
Stimulus Control
Many clients have concerns that leaving the bedroom will make them more alert. They
may be concerned that they will find activities too interesting and they will not become
sleepy. They may have read that light will make them so alert that they will not be able
to return to sleep. Perhaps the first best answer to these concerns is to say that the client
could potentially be right but that maybe it doesn’t matter. There is lots to explore with
this concern. Most light sources in the house will not have the light intensity (e.g., lux)
or high concentrations of blue spectrum light, to significantly activate the person;
however, even if the light provides some activation, the argument is that staying in bed
is more risky and detrimental to sleep than getting out of bed. That is, the rationale for
SC is to recondition the bed to become a cue for sleepiness and sleep rather than arousal
and anxiety. We know that pairing the bed with wakefulness promotes wakefulness.
We don’t know if leaving the room promotes wakefulness. Getting out of bed, unpairs
the bed with wakefulness, increases sleep deprivation, which increases sleep pressure,
and is counter to sleep effort (in other words, the client is now engaged in efforts to
stay awake which will make it more likely that they will become sleepy). It is important for the client to see that none of this relearning is likely to happen in one night.
Stimulus control is not magic. Alternatively, staying in bed could potentially shield the
client from light that may or may not alert them, but now they are: 1) reinforcing
conditioned arousal, 2) engaging in sleep effort, which paradoxically increases the
likelihood of wakefulness, 3) staying in an environment with few distractions from
excessive mentation, and 4) engaging in the same pro-insomnia behavior that they were
unsuccessfully using pre-treatment but hoping for a different result. One way to test
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this concern is to use a BE in which two weeks are spent following SC. The therapist
can use Socratic questioning to help the client see that even if they are awake longer by
getting out of bed, if they don’t compensate for lost sleep and stick to their schedule,
there is a hidden benefit to becoming activated out of bed—this will build healthier sleep
drive and eventually produce better sleep. In CBT-I time should be spent not only
reviewing the numbers on the sleep diary but also the therapist should be asking exactly
how the time spent awake was passed. It is also important to note that clients who
get out of bed but then try not to do anything as a way of getting bored and sleepier
faster, are still engaged in sleep effort and this is not likely to be any more productive
than tossing and turning in bed. Learning to get up and read a good book, even if it is
engrossing, is much more conducive to acceptance and relaxation. In this way, becoming
more awake and getting less sleep in the first nights of treatment can be reframed
as a positive sign that the client is learning to let go of sleep effort and the treatment is
working well. In essence, clients should learn that they might need to lose a few battles
to ultimately win the war. No matter what the therapist should always be checking
on the clients understanding and acceptance of the rationale. Any situations in which
a client is catastrophizing about the possibility that any particular recommendation
will increase sleep deprivation, is an opportunity to ask them about the rationale:
“and if it is true, and you are to remain awake longer, what is the benefit with respect
to sleep drive?”
Is it Time for a Sleep Specialist Consultation?
Troubleshooting mainly consists of two tasks: 1) assessing whether the sleep schedule
is correct and 2) addressing partial or total non-adherence. To assess whether the
schedule is correct, the therapist assesses: 1) whether the scheduled sleep opportunity
is at the right time given the client’s chronotype, 2) whether the TIB is too short (i.e.,
is there too much sleepiness present?), and 3) whether the TIB prescription is too long
of an opportunity (i.e., are the insomnia complaints persisting?) Sleep schedule troubleshooting is contained in Chapter 5, so we will not re-review here; this chapter focused
on nonadherence. If the sleep schedule appears correct and there appears to be good
adherence but no improvement in insomnia, it may be time to refer to a sleep specialist.
Likewise, if insomnia is improved, the client appears to be sleeping well for a reasonable
number of hours and time-in-bed has been sufficiently extended, but sleepiness remains,
this too may signal the need for a referral. CBT-I is a highly successful treatment in
which most clients respond well. However, we know that some people do not have
an optimal response, so it is best to refer them on for a second opinion, as well as an
assessment of possible occult sleep disorders. Some clients do not appear to have risk
factors for sleep disordered breathing or neurological disorders during sleep at intake,
but after failing CBT-I, a sleep study may reveal that an occult sleep disorder either
accounts for resistant insomnia or hampers treatment response. Sleep disorder centers
have multidisciplinary teams that can help the management of complex cases. Thus,
when there is a case of non-response especially when there has been good adherence,
it is important to refer to a sleep specialist.
Adherence and Troubleshooting Barriers
119
Summary
•
•
•
•
•
•
•
Rise-time difficulties may relate to issues of comfort, eveningness, or aversion to
sleep inertia.
Early morning awakenings can be a sign of phase advance rather than insomnia
per se.
Bedtime difficulties may relate to chronotype, as well as too short or too long of a
buffer zone.
Motivation, anhedonia, cognitive issues, and hopelessness are common features of
depression and are workable in the context of CBT-I.
Modifications may be necessary to Stimulus Control rules in those with pain and
mobility issues or medical frailty.
Some instances of non-response may relate to therapist beliefs which results in only
partial or under dosed delivery of the treatment. It is important to be aware of our
own biases when treating clients.
In cases of non-response despite good adherence, the client should be referred to
a sleep specialist for evaluation and further treatment.
8
Rumination Strategies for
Insomnia
Rumination is a common issue for people with depression (e.g., Nolen-Hoeksema,
1991) and it is also an important issue for people with insomnia (see Carney et al., 2006,
2010, 2013). Rumination is a form of repetitive thinking. The content of the repeated
thoughts differs slightly in those with insomnia only versus those with depression;
although there is some overlap in content (Carney et al., 2006). In the presence of fatigue,
the content tends to focus on somatic symptoms and why (i.e., past-focused thoughts)
the symptoms are occurring; inevitably leading to the conclusion that the cause of the
fatigue is the previous night’s sleep. Such is the type of rumination we see in insomnia
but also MDD-I. In contrast, in MDD but not in insomnia only, the thought content
in rumination tends to focus on negative aspects of the self. In the context of anxiety,
thoughts tend to be future-oriented and catastrophizing (i.e., worry). That is, if someone
with insomnia was lying awake, unable to sleep, the content would focus on the future,
e.g., “If I don’t get to sleep, I won’t be able to function tomorrow” (e.g., Carney et al.,
2010; Harvey, 2002). In each of these scenarios, the thoughts are repetitive and difficult
to escape.
Many people with depression and insomnia believe that ruminating helps them to
solve problems; that is that rumination is useful. Indeed, repetitive thought may, at times,
be helpful to solve problems, as this type of reflection can sometimes lead to insights
and the generation of solutions. However, in the presence of negative mood, the types
of thought that tend to be generated are mood-congruent and inherently unhelpful. An
experiential way to help someone reflect on the process of rumination is to engage in
an in-session rumination based on Watkins, Moberly, and Moulds (2008) study
(Watkins et al., 2008). In this study, participants either focused on abstract or concrete
aspects of an emotional scenario, such as a conflict. Thus, in-session, ask the client for
a recent rumination episode; inquire as to how much time was spent on ruminating.
Next, ask what solutions were generated and whether any solutions were implemented.
The answer to this question, if the client is indeed ruminating, is most often no.
Then reflect, for example, “You estimate that you spent 40 minutes ruminating without
a solution? Is it possible that the cost-benefit ratio does not work out in your favor?”
If the client persists in the belief, the therapist can set up a behavioral experiment and
ask the client to test it out.
Therapist: You said that maybe you just didn’t have enough time for rumination to
result in a solution?
Client: Maybe.
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121
Therapist: Can we try a little experiment to see whether that is true? That is, can we
test if rumination is helpful?
Client: OK.
Therapist: I would like to set aside 15 minutes right now to try this experiment. Before
we do, you said that you didn’t have any solutions to the problem with your
neighbor even though you thought about it for 40 minutes this morning causing
you to be late. I wanted to confirm that you don’t have a solution yet?
Client: That’s right. I’m not sure what I can do and it’s driving me crazy.
Therapist: Can I get a mood rating from you right now please?
Client: I’m about 65 percent sad, and about 80 percent frustrated.
Therapist: Ok, thank you. During the 15 minutes, I will ask you to intensify your
thinking about your conflict with your neighbor to generate solutions. I want you
to really analyze why and what caused it to happen, as well as analyze the
implications of the conflict with your neighbor. Can you do that please?
Client: So, why it happened and the implications of it?
Therapist: Yes. Does that sound ok?
Client: Yes, that’s typically what I am thinking about anyway—why and thinking
about how I could prevent it or how I can get rid of the problem.
Therapist: Ok, great. I will set our timer.
After 15 minutes.
Therapist: OK thank you. Can I get another mood rating now please?
Client: I sort of feel worse. My neighbor is such a jerk. The more I think about it, the
more I realize that he is such a jerk to treat me like that.
Therapist: Sounds like this brought up negative thoughts for you. What is your
negative mood rating right now after that exercise?
Client: Frustration is more like 90 percent and I feel really down, maybe 80 percent.
Why do I let people treat me like that?
Therapist: So you were thinking about the “whys”—“Why do I let people treat me like
that?” and it made you feel pretty lousy. What about any new solutions?
Client: [Sighs and shakes head no.]
Therapist: Can we try something else?
Client: Sure
Therapist: Let’s take the same situation, but instead of focusing on the why, start by
exclusively focusing on the “what” of the problem. Tell me the concrete, specifics
details without thinking about why at all. If you find yourself asking a why question,
just take a breath and refocus. Tell me everything in as much vivid detail as possible
and in chronological order. I will set the timer again.
After 15 minutes.
Therapist: OK. Can I get a negative mood rating now please?
Client: I’m calmer now. Maybe because time has passed? Feeling down is like 50 percent
and frustration is lower too, maybe 60 percent. When I think about it, the main
thing he said was that he had some sort of weed killer he could give me. It just
made me mad because I thought he was saying my place is a mess. That I’m not
taking care of my responsibilities, which made me mad because I’m tired and
depressed. I’m doing the best I can. I should take better care of my lawn. I just
didn’t appreciate the insinuation.
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Rumination Strategies for Insomnia
Therapist: This is a pretty big shift in both mood and perspective. In the first 15
minutes, we focused on the why and you had no solution and felt worse. We can
add this to the 40 minutes this morning that resulted in feeling worse, continuing
to feel stuck and being late. You shifted your focus away from trying to figure out
the why to just remaining at the level of what took place and what happened?
Client: I don’t know. I think I have a few possible solutions. I can take the free weed
killer because I sort of know I need to do it or I don’t have to. I don’t really know
if he was trying to be snarky. I can see that maybe he wasn’t and IF he was being
snarky, that seems a little lame to me and maybe not worth getting upset over.
Therapist: When we balance the amount of time rumination takes and the toll on your
mood, along with the observation that it rarely leads to a solution, I wonder if it
shifts your opinion in some way?
Client: It does.
The idea is that rumination, and other repetitive thought processes including worry,
can sometimes change simply by examining the process of thought rather than the
content and observing its outcomes, perhaps through a behavioral experiment or a log
of rumination and its outcomes. In Chapter 9, we discuss that the TRAP and TRAC
worksheet (a blank version is included in Appendix D) can be used to identify triggers
to the rumination (an avoidance pattern) and to develop alternative coping responses
to the rumination. For example, rumination can be addressed behaviorally by using
it as a cue to engage in BA, including activation in the form of Stimulus Control, i.e.,
leaving the bedroom when it occurs in bed. Alternatively, rumination may be addressed
via strategies that reflect on the process rather than the content per se. That is, there
does not have to be any challenge at all; rather there can be a noticing of thoughts without
engagement, acceptance, and through acceptance, paradoxically, comes change. In
addition, when one takes an observing and accepting stance to thoughts, even if a change
in thoughts does not occur, the experience of rumination itself becomes less disruptive.
In other words, the rumination stops generating as much negative emotion. In clients
with insomnia, the tendency to ruminate in response to feeling tired is negatively
correlated with attending to one’s activities in the moment, whereas adopting a nonevaluative stance toward thoughts and feelings, and allowing them to come and go rather
than fighting them, allows one to be more fully engaged in life (Moss Atlin, Atwood,
Khou, Ong, & Carney, 2013).
Such is the premise of mindfulness and acceptance-based techniques. Indeed, in
Mindfulness Based Treatment for Insomnia (MBTI) rumination about insomnia
symptoms as measured by the DISR Scale (Carney et al., 2013b) (see Appendix C)
decreases with mindfulness treatment.
Metacognitive Approaches
Metacognition is, in essence, thinking about thoughts. The mere act of reflecting about
thoughts, one’s thought process, and the consequences of such patterns can be a
powerful agent of change. In Chapter 6, we reviewed a process for direct challenges as
a path to modifying thinking. The process of learning a new way of thinking about
thoughts, that is, that thoughts are not facts and can thus be challenged and modified,
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123
was purported by Beck to be a pathway to establishing a new relationship to thoughts,
or “decentering” (Beck et al., 1979). There is some evidence that interrupting
troublesome thoughts and re-appraising their veracity or utility via CT may result for
some, in decentering (Ingram & Hollon, 1986). However, for many, Socratic questioning
and TRs may not result in decentering. This was part of the impetus for the development
of Mindfulness Based Cognitive Therapy (MBCT). In recognition that mood-triggered
repetitive thought in the form of rumination was the most important predictor of
relapse and recurrence in depression (Nolen-Hoeksema, 1991, 2000; Segal et al., 2006),
the MacArthur Foundation funded three experts in repetitive thought to develop a
preventative strategy for relapse prevention (Segal, Williams, & Teasdale, 2002). Their
focus of finding a preventative treatment was on rumination and facilitating decentering. Thus, we will turn our attention to rumination in the context of MDD-I.
Metacognitive approaches to the treatment of depression are part of the “third
generation” cognitive behavioral therapies and include ACT and MBCT. Before
discussing what these interventions are, we briefly review empirical evidence for their
efficacy in the context of depression and then, after describing the theoretical foundation
and techniques, we discuss the application of these techniques and theoretical constructs
to the context of insomnia, concluding with a brief review of emerging evidence for the
efficacy of metacognitive approaches in the treatment of insomnia.
Empirical Support for Metacognitive Treatments for Depression
There is empirical support for the efficacy of ACT and MBCT for depression treatment,
including evidence for their efficacy when delivered as self-help interventions (Zettle,
2015). Hoffman and colleagues conducted meta-analyses of mindfulness based therapy,
which included both MBCT and Mindfulness Based Stress Reduction (MBSR) interventions for anxiety and depression (Hofmann, Sawyer, Witt, & Oh, 2010). These
investigators identified four studies that included individuals with diagnosis of depression (chronic depression, treatment resistant depression, residual depression, and those
with history of depression) and concluded that there is a large pre- to post-treatment
effect (Hedges’s g = 0.95) for improving mood symptoms in these four samples
(Hofmann et al., 2010). Piet and Hougaard (2011) conducted a systematic review and
meta-analysis of mindfulness-based cognitive therapy for prevention of relapse in
recurrent major depressive disorder and reported that MBCT significantly reduced the
risk of relapse or recurrence, with a relative risk reduction of 34 percent (Piet &
Hougaard, 2011). Two of the six studies reviewed compared MBCT with maintenance
antidepressant medication and found no significant differences in depression relapse
rates (Ruiz, 2012). A review paper of studies that directly compared ACT to CBT for
depression (Ruiz, 2010) reported comparable efficacy (Hedges’s g = 0.25).
Key Concepts and Techniques Used in Metacognitive Treatments
for Depression
Metacognitive approaches are focused on second-order rather than first-order change.
First-order change refers to wholesale alterations in behaviors, for example by changing
frequency and/or intensity or eliminating behaviors or by changing thoughts, beliefs or
124 Rumination Strategies for Insomnia
schemas, in order to change behaviors. In contrast, second-order change aims to change
one’s relationship or the context of one’s thought. ACT and MBCT for depression are
focused on promoting psychological flexibility, responding to stressful situations
reflectively, rather than reflexively, and increasing commitment to valued-based actions
(Bishop et al., 2004). In doing so, these interventions can be viewed as aiming to change
individuals’ relationships with their thoughts and experiences rather than to directly
address their depressive symptoms through altering depression-related behaviors and
thoughts. In the context of these two therapies psychological flexibility refers to
expanding one’s options regarding behavior and thought, while including a willingness
to tolerate negative experience. With such willingness the hope is that one can consider
taking small steps towards a valued goal as a viable course of action.
Acceptance is a central construct in both ACT and MBCT. It involves the active and
aware embrace of all thoughts and experiences and, when appropriate, not attempting
to change them. As opposed to passively tolerating or resigning, acceptance is an active
process that involves a deliberate decision to hold negative thoughts and feelings and
not to avoid or escape the experience. Acceptance is not always intuitive. It is said in
ACT work that minds are programmed to want to find problems and fix them. However
it is the rigid application of this stance that often gets individuals stuck in rumination
without positive outcome. Taking a fixing stance may be helpful in relation to things
over which we have control, but when the same attitude is applied to things over which
we have no control (e.g. sleep and/or mood), this often results in spiraling frustration,
anxiety, and increased depression. Given that it is difficult for minds to grasp the
concept of acceptance, the use of metaphor is often a powerful tool to be employed.
Likening acceptance to experiences that the client can relate to, often can help the client
gain greater understanding of the concept. For example, one metaphor to convey what
it is like to have or hold a thought without engaging the thought (acceptance without
fixing) is that it is like watching the TV news with the ticker scrolling at the bottom of
the picture. It is hard to concentrate on both the story and read the ticker at the same
time, however, one can learn to focus on the story and not read the ticker. The point
is that one does so not by making the ticker go away, but rather keeping it in the periphery
of vision, knowing that it is there, but at the same time not interacting with it. In addition
to metaphor there are several techniques that are used for promoting acceptance,
including a) adopting an observing stance, in which a negative thought or experience
is watched dispassionately, as one might watch leaves floating by on a stream, b)
distancing from a thought by giving it a shape, size, color, or another descriptive quality,
such as “interesting,” c) repeating the thought or a key word out loud until only its
sound without meaning remains, almost as if it were a tongue twister, d) labeling the
thought as merely an event in one’s mind (e.g., “I am having the thought that I am no
good”) rather than a reflection of attending to and fusing with its content (e.g., “I AM
no good”). Acceptance is promoted not as an end in itself but to increase psychological
flexibility by broadening the range of reaction options. This is often accomplished
because as one becomes more accepting of thoughts, feelings, and emotions, by
definition it allows one, in essence, to put a bit of distance between themselves and these
characteristics and therefore to gain a better perspective for what they are as opposed
to the more catastrophic interpretations of what they are. For example, by using the
technique of distancing one might be able to describe a pounding, racing heart as being
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like a basketball that is being dribbled inside their chest. As such one may then be willing
to have the basketball dribbling occur a while longer rather than having to stop it
immediately, because when thinking of it that way they see it as not as bad as they first
thought. Once a person is willing to allow symptoms to be as they are, they are more
able to entertain options for behavioral action. Such acceptance can also be a very
important construct in insomnia.
Commitment to values-based actions is a second central construct in ACT and is the
vehicle for change that complements acceptance of what cannot be changed. It refers to
deliberate actions that are congruent with and motivated by values that are important
to the individual. Depression is associated with reduction in engagement in appetitive
behaviors that were important to the individual in the past. ACT involves helping
individuals with depression identify and reconnect with what really matters to them in life
(i.e., their values) and commit to actions that are congruent with these values. For example,
an individual with depression who valued fitness and health, and therefore was committed
to and derived pleasure from going to the gym may have stopped exercising due to
anhedonia. If this person identifies health promotion as an important value, then commitment to live in accordance with their values in this example would mean committing to
resuming exercising and taking small steps to gradually re-engage in an exercise routine.
In this way value-based action supports BA. In Chapter 9 we discuss why BA may have
important input into the sleep regulatory system.
As discussed above, MBCT was initially developed as an approach to relapse
prevention in depression. Whereas in traditional CBT relapse, prevention is focused on
identifying automatic dysfunctional depressogenic thought and changing their content,
MBCT aims to reduce future risk of relapse and recurrence of depression by focusing
on changing the individual’s relationship with such thoughts. Originally, MBCT was
called Attentional Control Therapy because of the focus on teaching clients to continually bring their attention to a stated target (e.g., the breath, a part of the body, etc.)
(Segal et al., 2002). MBCT teaches clients in remission from depression to become more
aware of their thoughts and feelings in response to their experiences and relate to
their thoughts and feelings as passing events in the mind. In that way, MBCT helps
individuals to decenter, or disengage from habitual ways of interpreting and responding
to their experiences, which have historically put them at risk for depression recurrence.
Mindfulness mediation is a core technique of MBCT. It involves nonjudgmental
awareness of bodily sensations, thoughts, and feelings. MBCT also includes exercises
designed to help people apply awareness skills into daily life. The aim is to replace
habitual, “automatic” patterns of mindless reacting to cognitive-affective experiences.
Rather, individuals are encouraged to observe these experiences and act intentionally
and mindfully. The idea is that observance and acceptance of automatic depressogenic
thoughts allows for disengagement from the thoughts and increases one’s ability to
identify new ways to deal with challenges and stressful situations.
Metacognitive Approaches to Insomnia
In an elegant series of experiments, Bonnet and Arand provided support to the idea
that insomnia is a disorder of hyperarousal (Bonnet & Arand, 1997). Hyperarousal can
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be experienced physiologically, through body tension and autonomic arousal, emotionally, through negative high arousal emotion, such as anxiety, and through cognitive
processes, such as racing thoughts, and thoughts that increase arousal. CBT-I sometimes
incorporates relaxation methods to address physiological arousal and cognitive therapy
to address cognitive arousal. Ong, Ulmer and Manber (2012) have proposed a two-level
model of arousal in insomnia, which supports the use of metacognitive techniques in
insomnia (Ong et al., 2012). They distinguish between cognitive and metacognitive sleeprelated cognitive arousal.
Primary cognitive arousal refers to thoughts related to the inability to sleep, such a
thought that insufficient sleep will lead to negative and unacceptable daytime
consequences. Secondary or metacognitive arousal refers to how one relates to thoughts
about sleep in terms of the meaning, emotional valence, and degree of attachment one
has to these thoughts. Secondary cognitive arousal is likely to increase primary cognitive
arousal because it could create a bias in the attention to and perception of sleep-related
threats. For example, the degree to which one accepts the middle of the night thought,
“My day is going to be shot unless I fall quickly back to sleep” as fact, rather than an
event in one’s mind will likely lead to additional thoughts about negative outcomes of
not falling asleep, which, in turn, further escalates hyperarousal. By using metacognitive
techniques, without necessarily changing the content of the thought, the person can
detach from the threat perception thus reducing the probability of additional thoughts
about the threats related to insufficient sleep. In this way the person is more likely to
defuse threatening internal experience and decrease hyperarousal. Garland, Gaylord,
and Park (2009) posit that de-centering occurs with mindfulness because mindfulness
can facilitate the reappraisal of stressful events and distressing thoughts (Garland et al.,
2009). Thus, mindfulness allows an individual to “de-center” from initial stress inducing
appraisal (e.g., “my day will be shot”), adapt a different perspective, and reappraise the
situation, which is likely to attenuate the original activation of the stress response
system, thus halting (or at least reducing) further escalation of hyperarousal.
Mindfulness meditation helps cultivate adopting an objective stance about sleeplessness. This applies to the middle of the night experience as well as to the experience during
the day. For example, an objective nonjudgmental awareness of the tendency to attribute
low energy during the day to sleeplessness at night could lead to the insight that being
absorbed in the frustration makes it more likely that the state of low energy will continue
to interfere with the day’s activities. Another metacognitive technique is the Chinese
finger trap analogy, which provides an experiential demonstration of the importance
of letting go of efforts in certain situations, including sleep and fatigue. Below is an
exchange with a client named Kelly, whose case is presented in Chapter 10.
Therapist: So tell me about the increased use of energy drinks this week.
Client: I really can’t take how tired I feel. I think I’m going to end up in the hospital.
Therapist: You worry that you would end up in the hospital because you are tired?
Client: You know when you hear that someone was admitted due to exhaustion?
Therapist: I see. So does the difficulty following the schedule, the difficulty refraining
from napping attempts and the increase in caffeinated drinks all relate to trying to
manage or escape feeling tired?
Client: Yeah. I really hate it. I can’t take it.
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Therapist: You can’t take it. I see. Do you think the strength of your aversion to feeling
tired may play a role in this problem?
Client: You mean it’s all in my head somehow?
Therapist: Not exactly. What I meant to say was whether the fact that you need to
avoid this sensation at all costs, increases your attention to it and may unwittingly
increase the likelihood of detecting any sensations of fatigue?
Client: Maybe. But I do feel tired.
Therapist: I don’t doubt that for a minute. But if all this energy is focused on resisting
the experience of fatigue, isn’t a fair amount of attention and energy being devoted
to the very experience that you don’t like?
Client: Maybe.
Therapist: There is a saying, “that what you resist, persists,” what do you think about
this?
Client: If you are saying I shouldn’t “resist” feeling fatigued, that doesn’t make sense
to me. I can’t take feeling tired, so I have to do something about it.
Therapist: Have you ever heard of a Chinese Finger trap?
Client: I think so.
Therapist: I have one right here [hands it to client]. The person places their index
fingers in each end and they have to solve how to get their fingers out.
Client: [inserts fingers] I can’t. I’m stuck. I can’t pull them out.
Therapist: Often the first solution someone tries is to resist, to pull out, to struggle
against the puzzle, but what happened when you used this strategy?
Client: It starts to squeeze and get tighter and I get stuck. I can’t feel anything to release
it either.
Therapist: What is the opposite of struggling?
Client: Not struggling? Relaxing? That doesn’t seem to be working either. Wait. I
did it.
Therapist: So what did you do?
Client: If you push in, rather than struggle, it works.
Therapist: Why do you think I gave you this puzzle to try?
Client: I guess you don’t want me to struggle with feeling tired? That you want me to
push in? Does that mean you want me to try to feel tired? To induce it?
Therapist: You could induce it, I suppose, but I was thinking of something a little
different. I want you to imagine that you were having a party and there was
someone who you really did not want to come. You didn’t invite them but you
were really focused on the idea about whether they might show up uninvited. You
worried for weeks before the party and tried to think of ways to keep them out if
they showed up. Maybe you even hired security for the door to keep them out. How
much fun is the anticipation for the party and how much fun would you have at
the party, waiting to see if they showed up?
Client: Probably not much fun.
Therapist: And what if they got in anyway? Would it ruin things? How much fun would
you have at your party now?
Client: None. I couldn’t have fun until they were gone.
Therapist: And even if you managed to get rid of them, knowing they could return
would be distracting again, no?
128 Rumination Strategies for Insomnia
Client: OK, I get the finger trap thing and this too, struggling against something NOT
happening makes it worse. It takes up all your energy and ruins the party so to
speak. But what is the equivalent of pushing your fingers in here?
Therapist: You don’t have to like the party guest, in this case fatigue, and you don’t
have to necessarily invite or induce it, but what would happen if you were open to
its presence? What if you focused your attention on the invited guests and the party
at hand instead? Could the shift in attention lessen the negative impact of fatigue?
Client: Maybe. That would be hard.
Therapist: It’s sort of like your low back pain. You told me that the pain improved
after attending the chronic pain group. Given how the pain group did not work on
your herniated disks at all—how would you explain why the group was so helpful?
Client: I learned that I could turn down the volume on the pain. The pain doesn’t go
away but it fades to the background. I focus on other things and the pain decreases.
I get it about feeling tired now. I need to turn down the volume.
In the context of CBT-I mindfulness meditation can also help restore the automaticity
of the process of falling asleep as awareness of levels of alertness, sleepiness, and fatigue
increase and acceptance counteracts sleep effort. The information can be used in a matter
of fact way to guide one’s behavior: if feeling sleepy, go to sleep; if fatigued, rest, but
not in bed; and if in a state of high arousal, focus on behaviors that reduce arousal.
As discussed earlier, individuals who have experienced insomnia for a long time exert
much effort in order to control sleeplessness. In some cases this effort compromises
engagement in other activities that used to promote their sense of well-being and were
consistent with their value system, such as socializing with friends, exercising, etc. For
example, having lost sight of some of their life values in the service of symptom
management they cancel or do not schedule social activities so that they can go to bed
earlier (Carney & Edinger, 2006) or because they do not have the energy, use the time
that was previously dedicated to morning exercise for sleeping in. These avoidant, safety
behaviors were described in the previous chapter. In insomnia, as in depression,
commitment to personal non-sleep-related values can guide deliberate actions that do
not involve sleep effort. Such actions may include adherence to treatment recommendations that might initially appear counter intuitive, such as limiting the time spent
in bed, or not engaging in safety behaviors, such as cancelling social engagement and
sleeping in.
The steps involved in helping clients develop a plan for value-based commitment to
action are: identifying one’s values, and helping clients realize the cost of maladaptive
sleep-related behaviors that are not consistent with those values (e.g., canceling a social
engagement is not consistent with the value of staying connected with people). The
discrepancy can then naturally lead to changes in these maladaptive behaviors. Again,
the other side of this equation is that in order to live in congruence with these values,
one must be more willing to accept the presence of uncomfortable thoughts, feelings,
and emotions (e.g., in the name of valued connection with others, one might have to
accept the thought that “I might fall asleep while sitting listening to my friends”). The
therapist should keep in mind that when asked to state their values clients often respond
with statements about their goals and aspirations rather than their values. However,
values provide a direction for attainable actions but are not in themselves attainable
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targets. The Life Compass (Dahl & Lundgren, 2006) is a tool to help clients identify
their values. The Life Compass exercise encourages clients to rate the importance of
various life domains, such as family, friendships, work, spirituality, etc.
Therapist: You said that your insomnia gets in the way in several areas of your life,
specifically you mentioned that you are no longer socializing or working out. I would
like us to do an exercise called the Life Compass. I want to ask about aspects of
dimensions of your life and I want you to tell me about the importance of these
areas of your life. What about your relationship with your daughter? How
important is this area?
Client: This is one of the most important things in my life. Barb and I have a good
relationship. I wish I were more present with her. I used to call her more often and
go out for lunch with her.
Therapist: I see. So family relationships are a top priority; one of your most important values. Although it sounds as though your current lifestyle may not reflect
this?
Client: Yes. Plain and simple, I am tired. I feel preoccupied with just trying to survive.
Just trying to function, you know? So I try to rest when I can and arranging activities
with my daughter, being present is what I value but not something I feel able to do
given how crappy I feel.
Therapist: I see. What about other relationships, perhaps starting with family
relationships? You mentioned you have a brother?
Client: Absolutely. This is similar. I feel a little disconnected right now from my
brother [starts crying]. It’s the same. I’m tired and I think I am so focused on
surviving that I have lost sight of what’s important.
Therapist: OK. So feeling tired and focusing energy on resting and conserving energy
has disconnected you from living a life in tune with your values?
Client: [nods]
Therapist: What about friendships? How important are friendships in your life?
Client: Yes, very important. Maybe not quite as high as family but pretty close. I have
good friendships. Although, now that I am thinking about it, I have good friends
but I am not really spending time with them or spending much energy on them.
I wish that we went out more and I know that it is me. I don’t say yes so I am letting
how crappy I feel affect my relationships.
Therapist: OK. I was going to ask you about romantic relationships and then I
remembered that you actually told me that while you are feeling depressed and not
sleeping well, you feel ambivalent about relationships because you really wish you
had someone but your motivation is low for trying to meet someone. Do I have
that right? Is this low in importance, or not as valued as other areas of your life?
Client: No, it is something I value. It’s sad. I wish I had someone but I never do anything
about it. When you feel tired and your sex drive is low, it’s so hard.
Therapist: OK. I have written these down in your values or life compass column and
you can see how I wrote down the barriers you cited in the last column. These are
things getting in the way of living your valued life or living in a way that matches
your values. I would like to explore other things you may value like leisure or
hobbies, your work, spirituality, health?
130 Rumination Strategies for Insomnia
Client: OK. But it is going to be the same. Hobbies are important. I like knitting, but
I am not. I want to work out but I don’t. I like yoga and I know it helps my back,
but I haven’t gone for two years. There are ideas I have for work—but I am in a
rut and doing things that don’t work that well and that I don’t enjoy, instead
of trying something that would make me feel more fulfilled. It’s so depressing,
but what am I supposed to do? I am exhausted and just trying to get through
each day.
Therapist: It’s your belief that you have to get rid of the sleeping problem or the
depression to live your valued life?
Client: Well yes. If you are tired, you can’t do anything.
Therapist: In fact you have been doing something, right? You are using a strategy to
get by, and that is to conserve your energy and cut back on everything. Has this
allowed you to live the life you would like? The life you described in your life
compass?
Client: It doesn’t really feel like a choice, but no, it doesn’t give me what I want.
Therapist: Is it possible that the strategies you are currently using actually block you
from your valued life, the life that you want?
Client: Yes, although it seems impossible to think of a way in which it could be
different.
Therapist: I wonder if you could conceive of a life in which living in a way that is more
consistent with your valued life would work better for you? That is, I wonder if we
could explore a world in which you could be living your valued life alongside your
fatigue.
Client: What do you mean by: alongside my fatigue?
Therapist: Well, right now it sounds like you give up a lot of what you value when
you are fatigued. But I wonder, when you are conserving energy does that make
you feel less fatigued, or less depressed?
Client: I don’t think so. In fact, I know there are many times when I go home to rest
but I continue to feel exhausted and sad.
Therapist: At the same time you are missing out on valued pieces of your life, correct?
Client: Without a doubt.
Therapist: So I ask you—which is better, to be fatigued and home alone or fatigued
and with your daughter, or friends?
Client: Well when you put it that way, I guess the answer is simple. I would rather be
with people.
Therapist: Even if you are fatigued?
Client: Yes I guess I would say that.
Therapist: This is what I mean by living a valued life alongside your fatigue.
Client: I can see what you mean and would be excited to think about ways that I could
get back to some of the things that are important to me. I guess we would need to
talk about what that looks like but yes, I am open.
Thus in the example above, the exercise leads the client to re-appraise the strategies
they are currently using to cope as blocking themselves from their valued life. The
ambivalence this exercise creates can help to facilitate change towards living a life more
commensurate with the client’s values.
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Mindfulness-Based Treatment for Insomnia (MBTI)
Ong, Shapiro, and Manber (2008) have developed and tested a mindfulness-based
intervention for insomnia that they later named MBTI (Ong et al., 2008). Although the
treatment was originally developed as a group intervention, there is no reason to believe
it cannot be implemented in an individual therapy format. MBTI combines mindfulness
meditation and three behavioral components of CBT-I, sleep restriction therapy,
stimulus control, and sleep hygiene introduced in a manner consistent with mindfulness
principles. For example, the stimulus control instruction to get out of bed when unable
to sleep is discussed using the language of awareness and acceptance: “I am not in a
state conducive to sleep so I might as well be fully awake.” Similarly the stimulus control
instruction to go to bed only when sleepy is discussed using the language of awareness:
“I notice that I am not sleepy now; I might as well wait until I become sleepy.” MBTI
discourages the therapist from being directive when introducing the behavioral
components of CBT-I. For example, concepts central to the rationale for stimulus
control (i.e., conditioned arousal) and sleep restriction therapy (i.e. the importance of
the sleep drive) are introduced by the therapist who then encourages the clients to discuss
how the ideas apply to them. Barriers to adherence with the behavioral components of
CBT-I are addressed through discussions of mindfulness principles, such as flexibility
and promoting decentering from the immediate distress or re-connecting with commitment to value-based actions. Each session begins with formal mindfulness meditations
that include both quiet (e.g., body scan, breathing, or sitting meditation) and movement
meditation (e.g., yoga, walking, or stretching meditation). Each week, the mindfulness
group facilitator engages the group in inquiry; that is, questions about the experience,
e.g., “What do you notice in your body?” Between session work includes implementation
of the behavioral components of CBT-I and a 30–45 minute daily meditation practice.
The session by session outline is presented in Table 8.1.
Table 8.1 MBTI Session outline
Weekly Topics
Therapy Activities
Introduction
Introduce concept of mindfulness and model of insomnia;
lead through first mindfulness practice
Start with meditation and inquiry; discuss sleep hygiene
Start with meditation and inquiry; discuss sleepiness, fatigue
and wakefulness; introduce sleep restriction
Start with meditation and inquiry; adjust sleep restriction;
introduce stimulus control
Start with meditation and inquiry; troubleshoot
Start with meditation and inquiry; relevance of acceptance
and letting-go
Start with meditation and inquiry; discuss reactions to sleep
(reactions to bad nights); discuss informal meditation
Start with meditation and inquiry; relapse prevention for
insomnia
Stepping out of auto pilot
Paying attention to
sleepiness and wakefulness
Working with sleeplessness
The territory of insomnia
Acceptance and letting go
Revisiting the relationship
with sleep
Eating, breathing, and
sleeping mindfulness
Source: Adapted from Ong and Scholtes (2010)
132 Rumination Strategies for Insomnia
Empirical Support for Metacognitive Treatments for Sleep
Research on the efficacy of metacognitive therapies examined the effects of mindfulness meditation and MBSR on sleep quality in non-insomnia samples with or without
sleep complains (cancer clients, individuals with depression and insomnia, adolescents
with sleep complaints who completed substance abuse program, and adults with
anxiety disorders and sleep dissatisfaction) as well as insomnia samples. Controlled and
uncontrolled studies of MBSR for individuals with a variety of cancer diagnoses (not
selected for insomnia diagnosis) yield some but not definitive evidence for the potential
benefits of MBSR on sleep (Carlson & Garland, 2005; Carlson, Speca, Patel, & Goodey,
2004; Shapiro, Bootzin, Figueredo, Lopez, & Schwartz, 2003). For example, Shapiro
and colleagues found that the practice of mindfulness techniques was associated with
reporting feeling refreshed in the morning but no differences in sleep quality between
the MBSR and the control (Shapiro et al., 2003). Britton and colleagues randomized individuals with depression and insomnia to MBCT or a wait-list control (Britton
et al., 2010). Participants in both groups reported reductions in subjective sleep onset
latency (based on sleep diaries). Within the active treatment group, more time spent in
meditation practice was associated with less self-reported time awake after sleep onset.
However, objectively measured number of middle of the night awakenings using
polysomnography was significantly greater among participants in the MBCT group than
control. They also had more wakefulness, in fact, the amount of time spent in mindfulness meditation practice in that study was positively correlated with these two indices
of cortical arousals. These intriguing findings suggest that the observed improvement
in subjective sleep is not likely to be related to a reduction in hyperarousal. Bootzin and
Stevens (2005) conducted a pilot study that combined a mindfulness component with
CBT-I in adolescents with a substance abuse history and sleep complaints (Bootzin &
Stevens, 2005). This study, which had high attrition rate, found some improvements
in sleep and reductions in relapse of substance abuse among treatment completers. In
an open trial, Yook and colleagues (2008) found that among people with anxiety disorders, MBCT improved sleep quality and reduced scores on a worry questionnaire and
the two effects were related (Yook et al., 2008).
Empirical evidence on the efficacy of mindfulness based interventions in samples
of individuals with confirmed diagnosis of insomnia disorder is promising. Uncontrolled small studies of MBSR (Britton, Shapiro, Penn, & Bootzin, 2003) and MBCT
(Heidenreich, Tuin, Pflug, Michal, & Michalak, 2006) reported improvements in
subjective time awake after sleep onset and total sleep time among individuals with
DSM-IV defined primary insomnia. These studies also found reductions in cognitions
related to rumination and worry. Ong et al. (2008) evaluated an intervention that
combined mindfulness meditation and the behavior components of CBT-I (MBTI) and
found that half of the sample experienced at least 50 percent or greater reduction in
self-reported total wake time and all but two participants no longer had clinically
significant insomnia at the end of the treatment (Ong et al., 2008). This study also found
a significant correlation between the number of meditation practice sessions during
treatment and reduction in hyperarousal (Ong et al., 2008). A 12-month follow-up of
participants supports the long-term benefits of adding mindfulness to behavioral
therapy for insomnia, with 61 percent of participants experiencing no relapse (Ong,
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133
Shapiro, & Manber, 2009). More recently evidence that mindfulness meditation might
be a viable treatment option for adults with chronic insomnia comes from a randomized
controlled pilot study in which participants with insomnia were randomized to MBCT,
MBSR, or a self-monitoring control. The results indicate that those who received a
metacognitive intervention (MBSR or MBTI) had significantly greater reductions in the
number of minutes they spent awake after sleep onset, overall insomnia severity, and
pre-sleep arousal. Importantly, remission and response rates in MBTI and MBSR were
sustained from post-treatment through follow-up and were highest among those who
received MBTI at the 6-month follow-up.
Gross and colleagues (2011) randomized individuals with chronic primary insomnia
to receive either MBSR or eszopiclone. Participants in both groups experienced significant improvements in subjective and objective (actigraphic) sleep from baseline to posttreatment. Within the MBSR group, there were improvements in subjective and
objective latency to sleep onset as well as subjective total sleep time and sleep efficiency.
Because the study was not adequately powered to establish non-inferiority (i.e., equivalent efficacy), the absence of significant differences between groups is not interpretable.
Although we are unaware of a study evaluating ACT as a standalone therapy for
improving sleep or insomnia, there is a case report in which ACT was combined with
CBT-I (Dalrymple, Fiorentino, Politi, & Posner, 2010). Although not definitive, together
these studies suggest that the integration of metacognitive techniques into CBT-I might
contribute to improve outcomes.
Summary
•
•
•
•
•
Rumination has been implicated as a key process in both insomnia and depression.
In depression, rumination is a key predictor of relapse.
There are a variety of strategies for rumination including experiments that teach
clients about the unhelpful outcomes of rumination, and experimenting with
alternative coping responses to rumination including stimulus control at night and
BA during the day, and metacognitive strategies.
Metacognitive treatments target the process of repetitive thought rather than the
content. One of the main agents of change is a process called decentering.
Metacognitive treatments include MBCT, MBTI, MBSR, and ACT.
There is promising support for metacognitive approaches in addressing rumination, as well as improving outcomes for depressive relapse (Segal et al., 2002) and
insomnia relapse (Ong et al., 2009).
9
Combining Depression and
Insomnia Therapies
Although there may be subjective sleep benefits with effective depression treatment for
some, there still often remain objective sleep problems and a high rate of residual
subjective sleep problems even after successful depression treatment (Carney et al.,
2007b). The issue of residual sleep problems is of great concern because persistent issues
with sleep are predictive of depressive relapse (Paykel et al., 1995). Thus, it is essential
to target comorbid insomnia along with depression, and fortunately there are several
treatment options available. One possibility is to pair a depression treatment such as
pharmacotherapy or psychotherapy with a sleep medication. There is evidence that
combining sleep and antidepressant medications produces greater depression treatment
response (i.e., almost 10 percent higher remission rates), as well as greater sleep
improvement, than antidepressants alone (Fava et al., 2006). There also exists evidence
for improving sleep by combining antidepressant medications with a low dose of the
sedating antidepressant trazodone (e.g., Kaynak et al., 2004), although, unlike sleep
medications, there appears to be no additive depression benefit. An alternative is to
combine the therapy of choice for chronic insomnia (i.e., CBT-I) with an effective
depression treatment. Indeed CBT-I has amassed considerable evidence for treating
insomnia in those with depression (Edinger et al., 2009a; Kuo et al., 2001; Lichstein
et al., 2000; Morawetz, 2001; Taylor, Lichstein, Weinstock, Sanford, & Temple, 2007;
Vallieres et al., 2000) and even has some evidence for improving depression in the
absence of depression therapy (Morawetz, 2001).
Despite evidence that CBT-I has been shown to produce recovery from depression (e.g.,
Morawetz, 2001), the current state of the literature would suggest that both conditions
receive clinical attention concurrently. One promising option is combining pharmacotherapy for depression with CBT-I. Adding CBT-I to antidepressant medication produces
superior results for both depression and insomnia as opposed to treating depression alone
(Carney, Atwood, & Shapiro, 2013a; Manber et al., 2008). Moreover the effect sizes and
proportion responding to the combined treatment is superior to combining antidepressant therapy and pharmacotherapy for insomnia (Fava et al., 2006) (i.e., when compared
to a hypnotic medication + antidepressant medication, CBT-I + antidepressant medication, it nearly doubles the MDD remission rate) (Manber et al., 2008). Additionally, there
may be drawbacks to pharmacotherapy for depression including resistance to
medications because of personal beliefs, side effects, or failed past antidepressant trials,
Combining Depression and Insomnia Therapies
135
and SSRIs can actually worsen leg movements and disrupt sleep further (Dorsey et al.,
1996). Thus, one option is to combine two psychological therapies.
Cognitive-behavioral therapeutic approaches have several overlapping features that
allow for easy integration, however some parts are so different that one issue that must
be considered is whether to administer the two treatments sequentially or concurrently.
There are no treatment development studies or sequencing studies to inform such
questions. It seems reasonable, and is probably common clinical practice, to use case
formulation to decide when, how and what components to introduce for specific clients
(for more on case formulation, see Manber & Carney, 2015). Alternatively, by combining the treatments concurrently there may be aspects of each treatment that
complement the other. In other words, there may be aspects of CBT-I that may help
with CBT-D and vice versa. For example, there are both depression-specific and sleepspecific reasons to want someone with depression to get out of the bed in the morning.
From a sleep perspective, setting a regular rise time: 1) helps to set the body’s biological
clock, 2) it reinforces stimulus control (i.e., that the bed during particular hours is a
signal for sleep only), and 3) it helps to build the homeostatic sleep pressure needed
for deep sleep on subsequent nights. Likewise, there are also theoretical reasons for an
earlier rise time in those with depression. For example, selective REM sleep deprivation helps with mood (Vogel et al., 1980) and REM sleep is more likely to occur in the
latter half of the night, thus, setting an early and regular rise time has a good chance
to inadvertently restrict some degree of REMS in those with depression. Additionally,
one side effect of CBT-I is decreased time in bed (TIB) both during the day (i.e., naps)
and in the 24-hour period (i.e., refraining from going to bed until sleepy and getting
up at a set rise time each morning). Decreased TIB at night means that there will
be increased time out of bed and greater exposure to light cues and the chance for
increased activity and increased exposure to reinforcers. In other words, getting out of
bed early provides an opportunity for BA. In fact, perhaps some of the depression benefits
of CBT-I (e.g., Lachowski, Maich, & Carney, 2014; Manber et al., 2008) may relate to
inadvertent BA because of the increased time out of bed in a 24-hour period (Lachowski
et al., 2014).
BA has been demonstrated to be an efficacious treatment for depression (Chambless
et al., 1998; Cuijpers, Van Straten, & Warmerdam, 2007; Dimidjian et al., 2006). In
addition to being an effective treatment, the straightforward therapy goals and tasks
make it an attractive therapy in training clinics (Sturmey, 2009). There are two
prominent versions of BA with considerable overlap but some differences in foci. One
version of BA (Lejuez et al., 2001) builds activity scheduling around stated goals that
arise during a structured values assessment. The values assessment queries whether there
are unmet goals or needs in domains in the client’s life such as hobbies, health,
relationships, occupation, etc. For example, a client who is no longer socializing due to
depression, but for whom friendships are an important source of enjoyment, social
activity scheduling component would be an important part of their treatment. A second
version of BA is associated with Neil Jacobson (Dimidjian et al., 2006; Jacobson, Martell,
& Dimidjian, 2001) and although the focus is also on scheduling, the primary target is
to decrease avoidance. These two BA packages have substantial overlap and the skills
and goals of the two approaches have been combined into a single package by others
(e.g., Puspitasari, Kanter, Murphy, Crowe, & Koerner, 2013).
136 Combining Depression and Insomnia Therapies
Behavioral Activation and Behavioral Insomnia Therapy (BABIT):
An Integrated Treatment
While conducting a National Institute of Mental Health funded trial combining antidepressant medication with CBT-I, the first author (CEC) encountered an interesting
problem. Whereas it made sense that participants would be leery of the placebo
antidepressant condition, instead, potential participants declined participation if they
were required to take an active antidepressant medication (over 200 people cited this
as the reason for not participating). This was a problem for the trial but it also
highlighted a problem among some people with both depression and insomnia; negative
attitudes towards pharmacologic remedies. There were some who declined because they
generally disliked taking medications of any kind, and some who declined because
they had previous experiences with medication that they described as negative. We
discovered that many of those with anti-medication attitudes had two or more failed
antidepressant trials in the past. Indeed, it is worth noting that chronic insomnia is
predictive of a poorer response to antidepressant medication therapy (Thase et al., 1997).
We communicated to these potential participants that it was important for them to
receive depression treatments too and there was a willingness to engage in depression
treatment, but a resistance to the intervention if it was pharmacological. Out of this
clinical need, arose an integrated treatment called Behavioral Activation and Behavioral
Insomnia Therapy, or BABIT.
The behavioral components of CBT for insomnia and CBT for depression were
selected because the evidence for behavioral components for insomnia is superior to
the cognitive components (Morin et al., 1999b, 2006). Moreover, as noted above, BA is
a simple treatment to train therapists, it is very brief, and it is effective. We knew that
integrating treatments could make the length of therapy longer, so our aim was to create
an effective therapy that could be easily disseminated (i.e., easy to train novice therapists)
but equally important was the need to keep it relatively brief. There were many possible
ways to integrate the treatments including simple sequencing. The first sequence to
consider was to deliver the depression treatment first, followed by the insomnia therapy
second. This is based on a conventional belief that depression is the more serious of the
two disorders and therefore should be treated first, and perhaps, also, is the fact that
about half of those who recover from depression appreciate a recovery in their insomnia
as well (Carney et al., 2007b). However, this sequence posed a problem in that the
participants were presenting to our sleep programs complaining chiefly of their
insomnia and were willing to forego depression treatment in order to participate in
insomnia-focused treatment. The second sequencing option was to deliver the insomnia
treatment first, followed by the depression treatment second. Those who presented for
the insomnia and depression treatment were people who identified as having both
depression and insomnia, but the chief complaint was most often insomnia. Perhaps of
greater importance is that there is an empirical basis for treating insomnia first in that
insomnia treatments have been shown to boost depression response (Manber et al., 2008)
and even treating insomnia only can lead to depressive remission (e.g., Morawetz,
2001). However, just because clients may view their insomnia as the primary force in
their depression does not mean that this will be true. Therefore a third option was
to treat depression and insomnia concurrently. Treating insomnia and depression
Combining Depression and Insomnia Therapies 137
concurrently is relatively simple because the best evidence for a schedule of CBT-I is
four biweekly sessions (e.g., Edinger, Wohlgemuth, Radtke, Coffman, & Carney, 2007).
This allows for the BA treatment to start in weeks 1 and 2 while simultaneously
collecting the two weeks of baseline sleep diaries, and then to start the behavioral
insomnia treatment in week 3. In such a leap frog type model, depression-focused
treatment could resume while clients were testing out their insomnia strategies, and
then the insomnia strategies could receive troubleshooting attention subsequently on a
biweekly schedule. In combining the two therapies one could also consider the
mechanisms of the two treatments and integrate them more fully to potentiate the two
therapies. For example, as stated, activation helps with fatigue but it also could increase
adherence to the prescribed rise time and restriction of napping strategies. A decreased
time-bed in the 24 hour period allows for greater opportunities for activation. Decreased
time-in-bed also reduces using the bed as an avoidance strategy. Both BA and BIT have
repetitive thought strategies to decrease rumination. Thus, we sequenced the treatment
based on what we viewed as key effective components of the therapies that when
integrated would produce the most synergistic effect.
We began with a manual modeled closely on Lejuez and Hopko’s BA treatment (Lejuez
et al., 2001), however, in discussing mood and mood-related goals, we integrated
discussion of sleep and sleep goals as well. We presented them as having a strong
influence on one another and emphasized that strategies that targeted mood often have
a pro-sleep and pro-energy effect, and pro-sleep strategies often have a positive mood
or antidepressant effect. We formally inserted the insomnia components from (Edinger
& Carney, 2008) at session 4, 6, 8, and 10, but often, because of the potentiating effect
of the mood components (e.g., scheduling activities) two sessions were enough with
check-ins on sleep at the agenda-setting portion of the sessions. We also integrated
components of Martell’s (Martell et al., 2013) BA treatment because avoidance and
rumination were prominent features of those who we were seeing, and we needed a
structured tool for the student therapists to address these target problems. This decision
was made after two focus groups with the study therapists. The first author (CEC)
attended a workshop on BA with Dr. Martell and proposed the integration of an
avoidance model along with the TRAP or TRAC worksheet (see later) and how to use
rumination as a cue for activation during the day or stimulus control at night. At the
same group of meetings, we determined that adding 2 sessions to the 12 session
treatment was permissible if it was not possible to get through all of the material in 12
sessions. At the time of this writing, the session mode and median was 13 and the mean
number of sessions was 12.4 (SD = 1.4). The lowest number of sessions in completers
was 9 and the highest number of session was 14. To determine if an additional session
is needed, we discuss this with participants at session 12 and have them generate pros
and cons of adding additional sessions, and also collaborate on an agenda for how the
additional sessions are to be used. Even at 13 sessions, this is a very brief therapy.
BABIT sessions are conceptualized as occurring across 3 distinct modules of treatment. In Table 9.1, we provide a description of the typical therapy activities across
the three modules. Although the rows match up with the number of sessions, this is
meant as a guide only because therapists are encouraged to work with the clients’ goals
flexibly to drive the focus of the session content. For example, if the Life Area
Assessment reveals relationship goals primarily, then this will drive the focus of that
138 Combining Depression and Insomnia Therapies
domain of the treatment. Some clients may receive only one CBT-I session (with a SRT
and CS focus) and need only one brief check in about the sleep schedule. In such cases,
sleep is quickly resolved and we focus on the other aspects of the case that require
attention, for example, the case formulation may be driven by avoidance and rumination. Other cases require extensive focus on scheduling activities to address sleep and
fatigue. That is, for some, the focus may be decreasing time-in-bed and increasing
activity, while increasing goal-directed and pleasurable activities and exposure to light
during high fatigue periods during the day. Thus, the modules provide an outline of
focus and typical therapy activities but therapists are trained to identify the key
perpetuating factors for the case and adjust focus accordingly. In addition, the case formulation is shared with the client in the first module and we solicit feedback from the
Table 9.1 Description of module content in BABIT
Module BABIT session activities
1
Introduction to BT; monitor activities
Behavior-mood-sleep-energy link; Anti-depressant versus Pro-depression
behaviors
Life area assessment; setting goals; start sleep diary monitoring
2
Refine and set goals; continue sleep diary
Working on sleep-specific goals; Pro-sleep versus Pro-Insomnia behaviors; SRT
and SC
Prescription; Scheduling activities to help with rise time and scheduling a winddown period before bed
Goal setting; scheduling activities with a focus on how these may facilitate sleep
goals (e.g., scheduling evening activities to address evening dozing); avoidance
psychoeducation
Introduce TRAP or TRAC
Adjust TIB if needed and troubleshoot adherence to sleep and activity schedule;
add other CBT-I components if needed; use TRAP or TRAC to target fatigue
avoidance and add alternative pro-energy coping
TRAP or TRAC; scheduling activities; psychoeducation on rumination
Adjust TIB if needed; continue with TRAP or TRAC, goal setting
Use rumination as a cue for SC at night and activation during day
Continue with TRAP or TRAC, goal setting, rumination strategies
Adjust TIB if needed; continue with TRAP or TRAC, goal setting, rumination
strategies
3
Planning for termination; continue working on goals, ensure client can calculate
sleep diary variables and make time-in-bed prescription adjustments independently
Assign Relapse Prevention Letter to Self; discuss what are likely to be future goals
post-termination using the Life Area Assessment
Termination and relapse prevention
Combining Depression and Insomnia Therapies 139
client on whether it matches with their experience. Once there exists some agreement
on the maintaining factors of the case, this allows the client and therapist to collaborate
on mutually agreed upon goals for treatment. The sharing of the case formulation and
devising initial goals for treatment occurs in module 1—a module focused on orienting
to treatment, a life area assessment, establishing a model of depression and insomnia,
and beginning activity monitoring and then sleep monitoring. Once module 1 is complete, most often after 2–4 sessions, we proceed to behavior change in the second
module of the treatment.
Module 1: Introduction, Setting Goals, and Uncovering Behavior-MoodSleep-Energy Link
The premise for BABIT is that there are behaviors that perpetuate depressed mood, as
well as behaviors that facilitate neutral or positive mood. We expand this idea to include
the notion that there are behaviors that perpetuate insomnia and fatigue, and those
that lead to quality sleep, and energy, respectively. The rationale for BABIT provided
at session 1 is based on Hopko and Lejuez’s ideas about identifying perpetuating factors
for depression and behaviors that are antithetical to depressed mood, as well as
Spielman’s (1987) ideas about perpetuating factors in insomnia. In BABIT, these ideas
are broadened to include insomnia, and fatigue. As noted above, the two BA approaches
by Lejuez and colleagues (2001) and Jacobson and colleagues (2001) have different foci
but the skills in each package are largely complementary. As a result, the two approaches
are easily integrated into BABIT wherein values are assessed and treatment goals are
derived across domains. In the same assessment, avoidance patterns and behaviors are
identified that are associated with negative mood, poor sleep and low energy. Avoidance
behaviors are also identified in the activity monitoring that begins in week 1, and
throughout treatment, including when there are instances of non-adherence with
homework. Once these targets are identified, treatment focuses on increased activation,
goal pursuit and replacement of avoidance behaviors with mood-, sleep- and energycongruent behaviors. Mood and energy targets impact sleep positively because of the
greater regularity of activities, which can positively impact the biological clock and
increased activity can generate greater sleep drive. Additionally, there is greater activity
to combat fatigue and the negative arousal associated with negative mood; thus fatigue
and rumination are attenuated.
All sessions begin with a presentation of the agenda for that session and an invitation
for the client to add to the agenda. All sessions also include an assessment of mood,
suicidal ideation, and sleep for the week; we compare this with separate sleep and mood
measures (in our clinic, this is the BDI-II and ISI) and take note of elevations on suicide
items and follow-up with a risk assessment as needed.
Following this, as therapy begins, but before explaining the rationale to the client, we
provide a sheet with two visual analog scales (based on Lejuez et al., 2001) one for
depression and one for insomnia (see Figure 9.1a and b). We explain that depression
encompasses a range of symptoms that can include insomnia and fatigue and they vary
day to day and from person to person. We further explain that at one point or another
when these symptoms are of a particular severity and occur chronically for most of the
day for a minimum of 2 weeks, we arbitrarily call this Major Depressive Disorder and
140
Combining Depression and Insomnia Therapies
make a diagnosis. All clients undergo a pre-treatment Hamilton Rating Scale for
Depression (Hamilton, 1960) and we use this data to encourage clients to talk about
their prominent symptoms. We then ask them to place an X at the place at which best
describes their current depression (i.e., today). We provide the same explanation of
insomnia and insomnia symptoms, which can include depressed mood, and talk
about the point at which we consider an (arbitrary) diagnosis. We ask them to make
an X at the spot on the line that characterizes the severity of their insomnia currently.
The placement of the X allows us to assess how distressing and/or severe their sleep
and mood problems are currently. When someone places the X at the extreme right of
the line, this suggests that this is the most severe depression or insomnia imaginable
for the client. In cases in which this is highly discrepant from the therapist’s assessment
of functioning rating, this provides helpful information for the formulation. For
example, a client insomnia rating at the most severe range, when their functioning is
assessed to be good and their symptoms are not particularly severe, (e.g., the average
sleep efficiency is just below the morbidity cutoff of 79 percent; insomnia is not present
every night), may be experiencing considerable anxiety about sleep.
The second step is to ask the client to consider where they would like to be at the
end of treatment. That is, we ask them to consider their treatment goals with respect
to symptom severity. We do this with Figure 9.1b. On this worksheet we ask them to
place an X at the place at which they would like to be post-treatment. If the response
is at the extreme left pole (see Figure 9.1b) this suggests that the client has some
unrealistic expectations for therapy, and serves as good information for the case
formulation. We provide an explanation that it is normal and functional to feel sadness
occasionally, as well as normal and functional to have occasional sleeplessness, and ask
whether absolutely no sad mood and no fluctuations in sleep quality is a realistic goal.
We also ask them to consider whether setting a reasonable goal is important, and ask
them about what could happen if goals were set too low, too high, or if the plan to pursue
the goal wasn’t adequate to meet the goal? Asking such questions sets up the rationale
for the goal pursuit focus. Lastly, we ask clients to talk about some of the strategies they
X
No
depression
Depression
diagnosis
No
insomnia
Insomnia
diagnosis
Severe
depression
X
Severe
insomnia
Figure 9.1a Establishing insomnia and depression as static conditions with a continuum
of symptoms
Combining Depression and Insomnia Therapies 141
X
No
depression
X
Depression
diagnosis
X
X
No
insomnia
Severe
depression
Insomnia
diagnosis
Severe
insomnia
Figure 9.1b Establishing (achievable) treatment goals
have used to “solve” their depression and sleep problems. This uncovers both strengths
(some effective, adaptive strategies that can be incorporated into the treatment plan) as
well as unhelpful strategies such as trying to repeatedly think about “why people don’t
like me” (i.e., rumination) or “I lay in bed watching TV and wait to fall asleep, and I
have a glass of wine before bed” (i.e., sleep effort). Such a discussion about goal pursuit
uncovers a plethora of useful information for the case formulation.
After agreeing upon realistic treatment goals we provide an introduction to behavioral
therapies (including a disclosure about the importance of between-session homework
and monitoring) and a basic behavioral conceptualization (i.e., behavior affects and is
affected by what we think and how we feel, and changing behavior has a powerful
therapeutic effect on sleep, energy, and mood). To demonstrate this principle we begin
working on a worksheet completed over several sessions of module 1. We present a
divided worksheet (or in our lab we use a white board) with one column labeled ProDepression behaviors and the other column labeled Anti-Depressant Behaviors (Table
9.2). Later, when we discuss avoidance, and introduce the TRAP or TRAC worksheet,
clients easily see the connection between Pro-Depression behaviors as avoidance
patterns and Anti-Depressant Behaviors as Alternative Coping strategies (see Figure 9.4).
We complete a similar sheet for Pro-Fatigue versus Pro-Energy as well as Pro-Sleep
versus Pro-Insomnia if these emerge as priorities in this session, but typically we start
with the depression worksheet and highlight ones that may also worsen sleep or energy
levels. Blank copies of each of these worksheets are provided in the Appendices. Most
often, we return to sleep-specific or fatigue-specific areas when they emerge in
subsequent sessions. The key, however, is to be responsive and flexible about clients’
needs and priorities. At the end of the module, the worksheets may not be complete,
but there are enough entries that clients can begin to see how anti-depressant behaviors,
pro-energy, and pro-sleep behaviors have many similarities; thus they can accomplish
their goal of feeling better by making relatively few changes. That is, changes in one
domain are likely to have a positive impact on the other two. For example, reducing
the time spent inactive in a 24 hour period should increase vigor, set the clock, increase
142
Combining Depression and Insomnia Therapies
Table 9.2 Anti-depressant behaviors and pro-depression behaviors example
Pro-depression behaviors
Anti-depressant behaviors
Don’t go out
Hanging out with Joe
Drinking
Thinking about my problems with my Mom
Skipping meals or eating chips instead of meals
Staying in my pajamas
Fresh air
Hanging out with other friends
Going fishing
Go with friend to a movie
Eat regular meals
Shower and get dressed
a build for deep sleep, and expose the clients to increased opportunities for positive
reinforcement.
Following the discussion of pro-depression and anti-depressant behaviors, the
therapist can introduce the first piece of homework for the client, which is to monitor
their activities across the week on The Activity Monitoring form (Figure 9.2). This
homework is typically accepted but occasionally, this exercise can be met with resistance.
Clients may anticipate shame, e.g., “I would be too embarrassed for you to see how little
I do.” This gives an opportunity to the therapist to normalize the presence of avoidance
in depression. It also helps the client to see connections between avoidance and feeling
poorly, and allows both the therapist and client to devise ways to alter avoidance and
obtain a new result. Below is an example of working through this issue. Please note that
the client in this chapter is a fictional client named Blake who differs from the CBT-I
client Kelly presented in Chapter 10 and throughout the rest of the book.
Therapist: It sounds like you are saying that you think you do very little throughout
the week is that right?
Client: Yes. It’s embarrassing.
Therapist: You feel embarrassed?
Client: Normal people DO things and its embarrassing that I don’t.
Therapist: People with depression are often less active than people without depression
precisely because of how poorly they feel, so, in truth, this is not unusual. I find
that we can learn quite a lot about patterns by examining what you do throughout
the week, and this can really help when we are looking for things that might be
helpful to change. Do you suspect that being less active helps the depression or
makes it feel worse?
Client: I know it makes me feel worse, but I feel too badly to do anything about it.
Therapist: I see. So this is a pro-depression behavior that we will probably need to
target, but we would need to come up with a pretty powerful strategy to address
the fact that you feel unable to increase your activity?
Client: Well. . . . yeah.
Therapist: OK. If I have a big obstacle to overcome, I find that I need all the
information possible in order to come up with a good plan. Does that make sense?
Client: Makes sense, yes.
Therapist: I find that these monitoring forms uncover the information we need in order
to come up with a good plan. Are you willing to do this?
Client: OK.
Combining Depression and Insomnia Therapies 143
Clients’ may have other negative predictions that can also create resistance. That is,
they could resist out of hopelessness, such as, “What’s the point? I already know I need
to do something. This won’t help.” The therapist can adopt an open stance to the
possibility that monitoring may not be helpful but ask that the client test out this
notion. For example, the therapist can say,
It is certainly possible that this would not be helpful. But thus far what you have
already been doing does not seem to be working. Would you be willing to test out
the idea at least for this week? We often find at least one thing, one pattern from
activity monitoring that we can use to devise a strategy. So do you see any downside
to testing it?
Progress is slowed when clients come into sessions having not done their homework.
Common reasons have to do with forgetting to do the assignment or forgetting to bring
the paperwork in. Some clients may simply state that they became confused and did
not know what to write on the form. When assigning homework, it may help to
determine ahead of time if there will be any foreseeable barriers to completing the
monitoring. There are a variety of ways to troubleshoot monitoring including having
the client do the monitoring on the calendar of their smart phone, setting smart phone
alarms to serve as reminders to fill out the form, keeping the form in their pocket etc.
It can also save valuable session time later to practice with the form in session a few
times to make sure that the client is clear how to fill it out.
In all sessions, after checking on how the week went (i.e., mood and sleep) the
therapist should ask if there were any problems with the homework. Homework must
be reinforced every session. Failing to ask about homework sends the message that
homework is not important, which in turn will likely lead to less homework getting done.
However it is important not to badger clients over missed homework as this can create
shame and anticipatory anxiety the next time that the homework is not completed.
Beginning with an invitation to learn about struggles the client may have had with the
homework ensures a safe environment. Additionally, a functional behavior analysis of
homework “stuckness” is incredibly useful. Often, the barrier to homework is a ProDepression behavior that can be or has been listed on the form and the client can be
oriented towards troubleshooting by focusing on the Anti-Depressant behaviors that will
“unstick” them. The homework from week 1 is the Activity Monitoring Form (see
Appendix E for a blank form). If someone has not done any of the form it is important
to explore what got in the way. Did they almost do it and got overwhelmed? Did they
ever take the form out of their bag throughout the week? Did they complete the form
and not bring it? Did they complete it but missed a day or two and perfectionism precluded
them from bringing it in? After assessing the nature of the problem, you can complete
a form together based on the previous day, so there is something in-session to work with.
Whatever is finally produced on the activity monitoring form, the goal of going over the
form is to help the client link low mood and low energy with particular activities and
improved mood and alertness with other activities.
Therapist: You did a great job with this form. I can tell you put a lot of work into it.
What did you get out of doing it?
Rate low mood 0 (absent)–100 (severe)
Daily Activity Record
BABIT
Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
6–7 AM
in bed
in bed
in bed
in bed
in bed
in bed
in bed
awake 85
7–8 AM
in bed
in bed
in bed
in bed
in bed
in bed
in bed
awake 80
8–9 AM
in bed
in bed
in bed
in bed
in bed
in bed
in bed
9–10
AM
in bed
in bed
in bed
in bed
in bed
in bed
in bed
10–11
AM
in bed
awake 80
in bed
awake 90
in bed
awake 95
in bed
awake 55
in bed
awake 95
internet
80
in bed
awake 90
11–12
AM
internet 85 bath 60
Internet 80
shower 30 internet 85 Internet 80 internet 85
12–1
PM
internet
85
internet
85
groceries
70
Internet
25
reading
75
back to
bed 70
internet
90
1–2 PM
internet,
read 85
internet
85
breakfast
70
pay bills
55
coffee 65
resting 80
back to
bed 95
2–3 PM
shower 65 TV 80
TV 85
TV 75
TV 90
TV 85
TV 85
3–4 PM
reading
70
internet
80
in bed 80
Internet
80
nap
computer
85
shower 70
4–5 PM
reading
75
phone
(bed) 85
TV 80
Internet
80
lunch 65
shower 65 lunch 60
5–6 PM
reading
85
TV 80
Internet 80
lunch 70
reading
75
cook 50
visit mom
45
6–7 PM
TV 80
TV 80
TV 80
TV 75
TV 90
dinner 55
visit Mom
50
7–8 PM
reading
80
Internet
85
in bed 80
internet
85
nap
computer
75
dinner 65
8–9 PM
dinner 75
TV 85
in bed 85
Internet
85
dinner 65
computer
80
TV 75
9–10
PM
TV 85
TV 85
TV 85
TV 80
TV 85
TV 90
TV 80
10–11
PM
in bed
Internet
80
in bed 85
internet
85
in bed
in bed
in bed
awake 85
11–12
AM
in bed
phone
(bed) 85
in bed 85
internet
95
in bed
in bed
in bed
12–1
AM
in bed
in bed
Internet 80
in bed
in bed
in bed
In bed
1–2 AM
in bed
in bed
in bed
in bed
in bed
in bed
in bed
awake 90
2–3 AM
in bed
in bed
in bed
in bed
in bed
in bed
in bed
awake 90
3–4 AM
in bed
in bed
in bed
in bed
in bed
in bed
in bed
4–5 AM
in bed
in bed
in bed
in bed
in bed
in bed
in bed
5–6 AM
in bed
in bed
in bed
in bed
in bed
in bed
in bed
Figure 9.2 Daily Activity Record
Combining Depression and Insomnia Therapies 145
Client: I learned I don’t do anything.
Therapist: I see a full page here. Can you clarify what you mean by saying that you
didn’t do anything?
Client: I didn’t do anything productive. I watched TV all day and I can’t believe
how much time I spent in bed. I had no idea I stayed in bed so much. It’s
depressing.
Therapist: I noticed your mood is pretty low when you are lying in bed. Is that what
you mean by depressing?
Client: Yes. And I also meant that normal people don’t spend that much time in bed.
Therapist: I see. So would you say that lying in bed is a pro-depression behavior?
Certainly your mood ratings would suggest that you are right about that. Sounds
like we might need to target the extra time in bed, given that your mood and energy
is lowest when you do that and you see it as a depressing or pro-depression
behavior?
Client: Yes, but when I’m out of bed, I’m just lying on the couch, so that’s not that
much better.
Therapist: What do you mean by that? What are your mood ratings when lying on
the couch in comparison to lying in bed?
Client: They are about the same. But I wouldn’t know what else to do.
Therapist: You said earlier that you did absolutely nothing productive but I wonder
if that’s true. I see some instances of goal-directed behavior here, do you?
Client: Taking a shower? I should have done it every day.
Therapist: What do you notice about your mood when you took a shower?
Client: It’s one of the highest mood ratings—still low though.
Therapist: Yes, but your mood did improve. What was the activity when your mood
was highest?
Client: When I saw my Mom. Yes, that was nice. It was also a beautiful day so I liked
the walk over there.
Therapist: So you left the house, went outside, and visited someone, and your mood
was the best it was all week?
Client: This always works to lift my mood but I don’t always have the energy to
do it.
Therapist: Well we can talk about ways around this later, but it sounds as though we
have found some antidepressant behaviors to add to your list?
Client: Yes.
In addition to the idea that activation is an antidepressant behavior, the therapist can
introduce the idea that activity is a pro-energy and pro-sleep behavior. This is
accomplished by helping the client calculate time in bed each day. In Figure 9.2 we see
that the client got into bed on Monday at 10 PM and got out of bed at 11 AM on Tuesday
morning; thus the time spent in bed was 13 hours (include all time in bed during the
day and nap attempts too). This should be done for each day. At this point, the therapist
can explain the homeostatic system to the client. A more formal prescription of a sleep
or wake schedule can be made in module 2 after collecting sleep diary information, but
there is no need to wait a full month before trying to target morning activation. Below
is a sample of how this might be achieved:
146 Combining Depression and Insomnia Therapies
Therapist: I wanted to discuss some pro-sleep behaviors. In a week or two we will
generate a more full list of pro-sleep versus pro-insomnia behaviors, but for now
I would like to focus on one very important pro-sleep behavior. To do that, I need
to explain one of our body’s sleep systems called the homeostatic system. This system
regulates how much deep sleep we obtain on a given night and it is based on how
much time we spent awake and active in a 24 hour period. From the moment we
get out of bed, we build up sleepiness and a pressure to sleep. We have to create
that pressure or we may have difficulty falling asleep, staying asleep, or our sleep
may feel very light. So, suppose there were two people and one went to bed at
midnight and got out of bed at 8 AM and the other went to bed at midnight, got
out of bed at 10:30 AM and spent 2 hours on the couch in the middle of the day.
Who do you think would have a stronger drive for deep sleep; the first or second
person?
Client: I guess the 8 AM person but I could never be someone that gets out of bed at
8 AM—I’ve never been able to get up early.
Therapist: Yes, you are not a morning person. But let me ask the same question but
let’s consider someone who is a bit of a night owl, like yourself. So, if there were
two owls and one went to bed at 3 AM and got out of bed at 11 AM and the other
went to bed at 3 AM, got out of bed at 1 PM and spent 2 hours on the couch in
the middle of the day, which one has a stronger drive for deep sleep?
Client: Ok, yes, I get it. It’s the person who has been out of bed more. I am noticing
I am spending a lot of time on the couch in the middle of the day.
Therapist: Yes, I am seeing some time in bed or on the couch napping on Tuesday,
Wednesday and Friday.
Client: The thing is that I’m tired.
Therapist: So the extra time on the couch and in bed each day is because you’re tired
right?
Client: Exactly.
Therapist: What do you think causes the fatigue?
Client: I don’t sleep well.
Therapist: If we know that the only way to get deep restorative sleep is to be awake
and active for a sufficient amount of time each day, could it be that one reason why
you are so tired? That is, is it that your sleep is not deep and restorative because
you are in bed so much?
Client: I’m not sure.
Therapist: Would you be willing to test this idea over the next two weeks?
Client: I suppose so.
Therapist: In addition, you had said you feel bored during the day. What effect do
you think boredom has on your energy?
Client: Probably not good.
Therapist: After spending a few hours on the couch do you feel rejuvenated and full
of energy or sluggish?
Client: Sluggish and unmotivated.
Therapist: Ever heard of the saying an object at rest stays at rest?
Client: [Smiles].
Combining Depression and Insomnia Therapies 147
Therapist: So can we think of a way to test whether decreasing your time in bed and
scheduling some specific activities may be pro-sleep and pro-energy behaviors?
Client: Looks like I have to get up early . . .
Therapist: Given that your body clock is naturally on the late side, I wouldn’t say early,
but we probably ought to pick a standard get out of bed time that allows for enough
deep sleep drive to build for subsequent nights. This will also allow us to fight some
of the sluggishness caused by the lower levels of activity, including nap attempts,
in the daytime.
Client: As long as I don’t have to get up too early, this sounds like a good idea.
Module 2: Sleep Scheduling, Stimulus Control and Modifying Avoidance
The details of a SC and SRT session are contained in Chapter 5, so we will not go into
much more detail here. Sleep diaries are introduced in Module 1 so SC and SRT can
begin in the second module, although elements of these treatments may already be in
place in Module 1 depending on what arises. For example, it is common that a standard
rise time has already been selected based on environmental constraints (e.g., the rise
time on work days) as a way of increasing time out of bed and increasing activities. The
agenda for the first CBT-I session is to check-in on mood, suicidal ideation, and sleep,
as well as the assigned homework, and to set the agenda to discuss sleep. After presenting
psychoeducation about how sleep is regulated and the three main causes of chronic
insomnia (e.g., irregular or ill-timed schedule given chronotype, inadequate sleep drive
due to decreased activity or increased time resting, and/or arousal problems), we
introduce a worksheet that asks the client to look at their sleep diary and check off any
pro-insomnia behavior they see (see Table 9.2). In our lab, we present an adapted version
of Table 9.3 in which the Pro-Sleep behavior column is blank and the client works on
adding behaviors to this column. The completed form seen in Table 9.3 is for the reader
only (i.e., as an example of a completed form). The therapist can help uncover any proinsomnia behavior the clients are unable to identify. Once target-worthy behaviors are
identified, the client is asked to generate pro-sleep behaviors. This allows the therapist
to check in on what the client remembers about pro-sleep drive behaviors discussed
previously. It also allows therapists to see the extent of accurate and inaccurate
information the client has about sleep. The therapist can use questioning to uncover a
more complete list of pro-sleep versus pro-insomnia behaviors (see Table 9.3).
From the Pro-Sleep list, clients can refine pro-sleep goals using the Goal Tracking
homework form (Figure 9.3), which in most cases will include: 1) a latest possible rise
time, irrespective of how they slept, 2) an earliest bed time, 3) refrain from going to bed
until sleepy, 4) get out of bed when unable to sleep and do not return until sleepy, 5)
no naps, 6) refrain from wakeful activities in bed, and 7) establish a 1-hour wind-down
buffer zone before bed. Please see Chapter 5 for how to show clients how to derive a
sleep schedule. In those taking hypnotic medication chronically, they typically add a
goal of using only the lowest recommended dose (i.e., a consistent low dose and no
addition of other types of sleep aides including alcohol) each night at the same time, or
as directed by the physician. Remaining biweekly sessions are most often devoted
to checking for adherence and troubleshooting as needed (please see Chapter 7 for
more troubleshooting details) as well as possibly teaching clients to assess whether sleep
148
Combining Depression and Insomnia Therapies
Table 9.3 Completed pro-sleep versus pro-insomnia behaviors
Pro-Insomnia Behaviors
Pro-Sleep Behaviors
Ruminate
Try to produce sleep
Go to bed early to catch up on sleep
Doze or attempt to nap
Stay in bed while awake
Vary the time you get out of bed by
an hour or more
Try to sleep-in
Drink alcohol
Stay busy, avoid getting into bed until
the morning hours
Take sleep aides including natural
supplements, over the counter
medications, teas, etc.
Consume caffeinated food or beverages
Sedentary lifestyle
Withdraw from activities, e.g., working
out, socializing, going outside
Cancel obligations because you feel
tired, e.g., call-in sick after a bad night
Read and research about the negative
effects of sleep loss
Worry about sleep
Talk about insomnia
Obsess about or control sleep
environment, e.g., devices to
measure sleep, blackout shades, blue
light filters on device screens, sleep
in separate room from partner out
of fear they will wake you, white
noise machines, eye masks, ear plugs,
refuse to do childcare out of concern
it will disrupt sleep etc.
Out of bed problem-solving and reflection
Have good sleep habits and then let sleep
unfold naturally
Go to bed when sleepy
Stay active if you find yourself dozing
Have a regular rise time daily that does not
vary more than an hour
Get out of bed when you cannot sleep and do
not return until sleepy
Be in bed for about the same amount of time
as you are sleeping
Limit alcohol and marijuana, especially in the
hour or two before bed
Healthy nutrition
Regular exercise, although not vigorously
right before bed
Limit caffeine to a cup or two per day and
never after mid-afternoon
Focus on hydration rather than caffeination
Protect an hour before bed as a wind-down
period
Process problems or concerns earlier in the
evening when at your problem solving best
Keep physically active and schedule active
breaks (i.e., enjoyable activities)
Keep room safe, unlit, and a comfortable
temperature—a strong sleep drive will take
care of the rest
Understand and accept your body takes care
of sleep and compensating for sleep
deprivation naturally
extension as needed. Extending time in bed prescriptions by 15 minutes per week
occurs once clients show signs of sleepiness (e.g., subjective complaint of sleepiness or
evidence of sleepiness in the form of mean sleep onset latency less than 10 minutes or
sleep efficiency greater than 90 percent). Of course, clients need to be taught some basic
calculations from the sleep diary such as sleep efficiency (Computed Total Sleep Time
or Time in Bed) and total sleep time (Intended Sleep Period-Total Wake Time); for
more see Table 4.1 in Chapter 4). The sleep extension conditions above are meant to
be guidelines rather than a rigid set of rules, as the decision should be collaboratively
and flexibly reached, and consider the pros and cons of a change in prescription. For
example, in a client complaining of sleepiness but without much sleep improvement in
the absence of safety concerns, the client may extend sleep to address the sleepiness but
may also consider an additional 2 weeks of the schedule to try and address the remaining
problem before increasing time-in-bed.
N/A
1X
7X
3X
7X
1X
7X
7X
7X
7X
Watch a movie
Eat breakfast before 10:30 AM
Go for evening walk
Wind-down activities 1 hour before bed
Call Mom to check-in
In bed only when sleepy but no earlier
than12:30 AM
No wakeful activities in bed
Out of bed when unable to sleep
No naps
Figure 9.3 Sample Goal Tracking Form
10 min.
3X
Take daughter to the park
N/A
N/A
N/A
N/A
5 min.
N/A
N/A
15 min.
N/A
7X
Showering before noon
N/A
Duration
7X
Frequency
Set GOAL
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
20 min.
20 min.
Y
N
N
Y
Y
T
Y
Y
15 min.
Y
Y
M
20 min.
25 min.
Y
Y
Y
Y
Y
Y
Y
N
Y
20 min.
Y
Y
N
Y
20 min.
Y
N
Y
Y
Y
Y
R
Y
W
Sa
Su
Session Week # 5
Y
N
Y
Y
N
Y
20 min.
Y
N
15 min.
1:00 PM
Y
N
N
Y
N
N
N
N
N
N
N
N
Y
Y
Y
N
Y
N
N
N
N
N
10:00 AM 11:30 AM 10:00 AM
F
Record of Goal Attempts
GOAL TRACKING FORM
Getting out of bed by 7 AM
Activity
Name: Blake_______
150
Combining Depression and Insomnia Therapies
The Goal Tracking homework form (for an example see Figure 9.3; for a blank
handout, see Appendix F) is an essential part of Module 2 and also the last module
because it is used to plan post-therapy goals. The goals are written by the client at the
end of each session. After the goals are generated, the therapist queries about whether
the goals are realistic, behavioral, and measurable. As with sleep diaries during this
module, The Goal Tracking form is assigned as homework each week and reviewed at
the start of every session. The first part of the review is to reinforce (i.e., praise) the
client for bringing in the form, completing the form, attempting homework, and
meeting goals. The second part is to check-in on the experience for the client. In cases
in which goals were not met, the client and therapist conduct an analysis of what got
in the way, which includes the possibility that the goal was too difficult and needs to
be adjusted. In those who exhibit low in self-efficacy, goals can be set too low and
although goals are met, the expectations are so low that it does not generate any
increased self-efficacy. In those who are perfectionistic, setting anything less than very
high goals can be met with resistance. The bulk of Module 2 is spent on teaching clients
how to set and meet goals in a way that is realistic, provides positive reinforcement, and
improves their mood.
The TRAP or TRAC handout (see Figure 9.4 for a completed handout) is likewise
an important part of this active treatment module (adapted from Martell et al., 2013).
Using the TRAP (Trigger → Response → Avoidance Pattern) component of the
worksheet, clients learn about triggers for and the consequences of their avoidance
patterns. In the example presented in Figure 9.4, the client is triggered by situations in
which he is feeling low energy at work. In response to feeling low energy, he begins
ruminating about the symptoms, causes, and consequences, and the result is avoidance
in the form of leaving work and canceling other obligations. This is a frequent avoidance
pattern in insomnia. When clients feel low energy, it is a frequent trigger for rumination
about the daytime symptoms of insomnia (Carney et al., 2010b). The rumination
typically fixates on the presumed cause of feeling low, which is most often attributed
to poor sleep (Harris, Carney, & Edinger, 2009a). The other consequence of rumination is the avoidance of tasks that could increase self-efficacy and the decrease in
activities that could provide a break from fatigue, increase sleep drive, and increase
positive reinforcement. After clients learn how to identify TRAPs, they complete the
TRAC (Trigger → Response → Alternative Coping) component. The TRAC component
encourages clients to identify alternative coping responses to the same triggers to
produce a different, more desirable outcome. In the example provided in Figure 9.4,
the client identifies fatigue coping strategies as an alternative to leaving the task, and
work, altogether. One example of a fatigue coping strategy is taking a break before
returning to the task. Related fatigue strategies could include re-hydrating rather than
caffeinating, or stretching and focusing the eyes away from the screen for rest rather
than staying at the desk and squinting. Alternative coping strategies should be easy to
derive because they are essentially also found in Anti-depressant and Pro-Sleep columns
of their respective worksheets.
It should be particularly noted that there are redundancies built into this treatment
to acknowledge that attention and retention of information can be difficult for those
with depression. Therefore, when depressed clients are unable to generate alternative
coping strategies, or remember critical information about sleep, it is important for the
Combining Depression and Insomnia Therapies
TRAP
TRIGGER
Feeling tired at
desk
TRAC
TRIGGER
Feeling tired at
desk
RESPONSE
Ruminating
about why I feel
so tired
RESPONSE
Ruminating
about why I feel
so tired
AVOIDANCE
PATTERN
Leave work
ALTERNATIVE
COPING
Take a break with
another activity
Return to activity
after break
151
OUTCOME
Get behind at work—
feel anxious
Lie around at home
feeling tired
Cancel other obligations
OUTCOME
Feel efficacious at work
Feel more energetic
Figure 9.4 TRAP or TRAC Worksheet
therapist to utilize repetition and frequent check-ins about what the client remembers
from session to session (e.g., check-ins are done after agenda setting at the start of each
session).
Module 3: Relapse Prevention and Termination Work
By session 12 (for some clients this is a 12 session treatment so it will occur around
session 10), clients have had multiple weeks of goal setting practice, appraising strategies
to meet goals and readjusting goal setting when needed. They have also had ample
practice with the TRAP or TRAC worksheets so that they have been practicing
alternative antidepressant, pro-sleep, and pro-energy behaviors in response to triggers
that previously triggered avoidance behaviors. Lastly, their sleep should be sufficiently
improved and adjustments in time-in-bed are likely no longer necessary. For those who
responded early in treatment and these skills are solidified, we may discuss whether the
client would like to terminate at this point. If this is desirable for both parties, the
therapist and client devise a relapse prevention letter and the client makes a list of posttreatment goals. In short, for some clients this module can be condensed into one session.
More often however, clients see the benefit of additional sessions to practice their skills
and build self-efficacy. In this case, the client and therapist contract for two more
sessions and agree on the content and focus for the remaining sessions.
In addition, an important part of this module is termination planning, which requires
checking in with the client about how they are feeling about the impending end of
therapy. For some, this is seen as a positive time—perhaps it is viewed as an accomplishment. For others, there is trepidation about whether they can continue the momentum
gained during therapy after sessions stop. No matter how the client is feeling about
termination, it is important to take time to check-in and make plans for the remaining
sessions as well for post-treatment.
152 Combining Depression and Insomnia Therapies
In planning for termination, there needs to be an appraisal of the areas in which the
client wants to focus. Some clients may want to tackle a particularly challenging goal
left on their list. Some clients want to loosen some of the sleep rules and want guidance
on how they can proceed. Some anticipate a change or challenge to their sleep in the
future (e.g., a trip to Europe, a new baby, or a change in work schedule) and want to
discuss how they will adjust their current routine in the future. For others, the desire
may be to continue working on goals to increase their confidence. It is important to
navigate this final module collaboratively, but by this stage the client should be capable
of assuming more of the leadership role. Conversely, in the first module or two, the
process is collaborative, but the therapist takes on a more didactic role to teach skills.
By the end, the therapist should mainly observe and fine-tune the plans and homework
the clients set. It is imperative that clients have competencies in: 1) calculating their
total sleep time, total time in bed and sleep efficiency from sleep diaries, 2) determining
a time-in-bed schedule based on their total sleep time, 3) determining whether an
increase in time-in-bed is needed (based on sleep efficiency greater than 90 percent,
subjective sleepiness, and/or sleep onset latency less than 10 minutes), 4) setting or
achieving realistic goals for activities, and 5) successfully completing the TRAP or
TRAC worksheet. If clients do not exhibit independence on any of these tasks, there
should be a focus on fostering autonomy in the remaining sessions. In other words, it
should always be an explicit goal of treatment to eliminate the therapist from the
equation.
One relapse prevention tool used in depressive relapse prevention (e.g., Bieling &
Antony, 2003) is the “letter to self.” When one considers Teasdale’s “mind in place”
theory of depression, this is a particularly sensible approach (Teasdale, 1997). The
“mind in place” idea is that in depression a different mindset is dominant, one that is
pro-depression and largely impenetrable to disconfirming antidepressant ideas and
behavioral possibilities. Throughout depression treatment, increasing activation of
antidepressant areas through behavioral change leads to a different mindset, or, a
different, mind in place. Because relapse may result again in a different, pro-depression
mindset, the client writes a letter to the future depressive mind, acknowledging that the
way they may be thinking, feeling and acting may more closely resemble themselves at
pre-treatment. They write a future relapse-self a letter to remind themselves of all the
behavior changes that were helpful in shifting out of this mindset. This is assigned as
one of the last pieces of homework. The therapist should ask clients to include what
behavioral changes were helpful for sleep and fatigue as well. We invite the client to
read the letter at the last session, but we also respect that many clients want this letter
to remain private. The writing of the letter is more important than reading it aloud.
The client can be reminded to put the letter in a spot that they can easily access it when
feeling low or having trouble sleeping.
Lastly, because the letter is quite personal and may not have all the behavioral
recommendations we would like the client to remember, the therapist can also prepare
a letter using a template, and fill-in some more personally relevant material in the letter
with the client. The letter contains all of the most common elements of treatment but
leaves room to write in some idiosyncratic recommendations. Next to the common
therapy elements are boxes that can be checked off if they apply to the client—this is
done collaboratively. At the end of the letter, there is a reminder about red flags for a
Combining Depression and Insomnia Therapies 153
mood or sleep problem returning, and a reminder to start monitoring activity and sleep
to determine if all of the checked recommendations are currently implemented. This
orients the client to start implementing the checked-off recommendations that were
previously successful in addressing their sleep and mood problem. The pre-treatment
and final assessment scores (e.g., BDI-II and ISI) are graphed for clients to see their
progress in addressing their complaints. We use this as an opportunity to reflect on
their therapy experience. See Figure 10.10 in Chapter 10 for Kelly, the case study in
Chapter 10, for graphed ISI scores from CBT-I treatment. Although this client was not
treated with BABIT the same graphic depiction is used in both treatments to display
treatment progress.
Preliminary Evidence for BABIT: An Open Trial
Both Behavioral Activation and Behavioral Insomnia Therapy are efficacious treatments
so a randomized controlled trial confirming the efficacy is unnecessary. However,
establishing that we can achieve large effect sizes (that match the effect size in the
literature) across both conditions, without adding substantial length to the treatment,
in novice therapists and without high dropout rates, would provide support for the utility
of this combined approach. Although data collection is still ongoing for BABIT below
we provide some initial data.
Participants
There were 15 enrolled participants and 13 people completing the study at the time of
this writing (enrollment is ongoing). This study is being conducted at Ryerson
University’s Sleep and Depression Laboratory. Reasons for dropout included clinical
nonresponse (at session 13) and travel (i.e., long commute to treatment sessions). Ages
ranged from 18–69 years old (mean age was 48.8 years old). There were more females
than males (n = 4), which is typical of MDD trials. Participants were predominantly
Caucasian; there was one person who identified as West Asian and one who identified
as Aboriginal Canadian. There were 8 participants taking antidepressant medications
and 10 reporting taking sleeping medication; none met criteria for hypnotic dependence
on the DSISD.
Procedures
The study enrolled those complaining of both MDD and comorbid insomnia.
Participants included both clinic-referred clients and individuals solicited from other
ongoing research studies or via media advertisements. Women and men were
considered for inclusion if they: (1) were aged 18–74 years old; (2) had an insomnia
complaint of at least one month duration that met the Research Diagnostic Criteria
(Edinger et al., 2004a) for an Insomnia Disorder; (3) showed a mean sleep efficiency
(SE = [Total Sleep Time ÷ Time in Bed] ⫻ 100 percent) < 85 percent during one screening
week of sleep diaries with the Consensus Sleep Diary; and (4) met criteria for a Major
Depressive Episode (without psychotic features) as verified by the mood module of the
SCID; and (5) evidenced at least moderate depression symptom severity by having a
154
Combining Depression and Insomnia Therapies
score of > 15 on the 17-item HAM-D administered at a screening appointment. We
selected the HAM-D cut-off because it denotes full depressive symptomatology
according to consensus definitions in the field (Frank et al., 1991), approximates the
moderate level of depression seen at specialty sleep clinics or primary care settings
(Gaynes et al., 2005), and allowed for sufficient severity to detect symptom change. We
enrolled only those who were able to understand and complete study procedures, benefit
from the treatments offered, undergo study procedures without undue discomfort or
safety risks, and had no competing primary sleep, psychiatric, or medical disorders, or
ongoing treatments that would limit or confound their treatment responses. Thus,
excluded from the trial were those who: (1) need immediate psychiatric (e.g.,
imminently suicidal clients) or medical care (e.g., clients with acute cardiac symptoms),
or with an attempted suicide in the past 6 months; (2) had a sleep-disruptive comorbid
medical condition (e.g., moderate to severe rheumatoid arthritis; (3) score < 27 on the
Mini-Mental Status Exam (MMSE) (Folstein, Folstein, & McHugh, 1975); (4) met
criteria for Bipolar Disorder, Schizophrenia or any other psychotic disorders on the basis
of a SCID interview; (5) met criteria for Antisocial Personality Disorder or Borderline
Personality Disorder on the basis of a SCID II interview schedule; (6) reported frequent
travel across time zones or work rotating or night shifts; (7) met criteria for sleep apnea,
restless legs syndrome, or Circadian Rhythm Sleep Disorder on the basis of the Duke
Structured Interview of Sleep Disorders; and (8) had a history of alcohol, narcotic,
benzodiazepine, or other substance abuse or dependence in the 6 months prior to
screening. Participants were permitted to use sleeping medications if they were taking
them, as long as they were not hypnotic dependent and as long as they were agreeable
to taking the medications noncontingently during the trial.
Participants were screened using the MMSE, SCID, and DSISD to rule-out cognitive
impairment, to confirm the presence of RDC for an Insomnia disorder (DSISD) and
DSM-IV-TR criteria for MDD on the SCID respectively. The SCID was also used to
exclude those with suspected Bipolar disorder diagnoses, Psychotic disorders, and
substance-related disorders. The DSISD was used to rule-out those with hypersomnolence, suspected sleep apnea, or circadian rhythm disorders. Upon initial acceptance
they monitored their sleep prospectively for one week to determine if they met sleep
diary criteria (e.g., mean sleep efficiency less than 85 percent). If participants continued
to meet entry criteria, they completed a battery of pre-treatment measures that included
the Beck Depression Inventory, Second Edition (BDI-II) (Beck et al., 1996) and the ISI
(Morin, 1993). The other measures are not reported here as they will be part of the published effectiveness paper. After completing the battery of questionnaires, participants
monitored their sleep prospectively for two weeks. The same battery and sleep diary
monitoring procedures were repeated after the last treatment session and at one month
post-treatment.
Results
Figure 9.5 depicts the mean pre-post changes on the BDI-II and ISI. On t-tests, both
sleep and depression significantly decreased from pre-treatment (t(12) = 7.38, p < .001
and t(12) = 4.38, p = .001, respectively). This was true even for the BDI-II with sleep
item 16 removed (t(12) = 5.74, p < .001). Using Cohen’s d (Cohen, 1992), the effect
Combining Depression and Insomnia Therapies
155
35
31.4
30
d = .83
d = 2.2
25
22.6
20
15
13.6
10.6
10
5
0
Beck Depression Inventory II
Insomnia Severity Index
Pre-treatment
Post-treatment
Figure 9.5 BABIT Depression and insomnia symptom outcomes N.B. The dashed lines
denote the clinical cutoff for each measure.
sizes for insomnia (d = 2.2) and depression (d = .83) were large. The mean scores at
post-treatment for BDI-II and ISI were below the clinical cut-offs for the measure.
Conclusions
Thus, in this initial open trial of BABIT, BA, and BT for insomnia were feasibly and
easily integrated without adding substantively to the length of treatment. This treatment
was highly effective, even though the treatment was delivered by novice graduate student
therapists. There were both statistically and clinically significant improvements for
sleep and depression. Moreover the magnitude of the improvement was large—this
mirrors the literature on these therapies when delivered alone. Although in particular
settings, particularly sleep settings, CBT-I may be used on its own with positive effects
for mood in addition to sleep, CBT-I is not a depression-specific therapy and we have
no data to tell us whether the mood improvements are sustained. Thus a combined
approach is a reasonable approach to address both sleep and mood, and both CBT-I
and BA show long-term benefits (Dobson et al., 2008; Edinger et al., 2001). BABIT is
only one possible version of combined therapy and it is unknown as to whether
combining the cognitive elements of treatments for depression and insomnia would
enhance outcomes. Nonetheless, BABIT is a simple treatment that was easy to train and
supervise and thus should be considered at graduate student training clinics where the
issue of comorbid insomnia and depression would be highly prevalent.
It is perhaps not surprising that combining approaches is so effective. It is, however,
exciting that a combined therapy is simple and quick to deliver. This trial originated
out of necessity to address the needs of those who were unable or unwilling to take
medication, and thus, ineligible for our NIH trial. Reviewers for the NIH trial also asked
us to raise the age of entry for the trial out of fear of giving antidepressant medications
to those under the age of 21 years. Thus, there are multiple advantages for BABIT. There
156 Combining Depression and Insomnia Therapies
is no reason to think that CBT approaches for insomnia and depression could not be
similarly combined, although CBT approaches tend to be longer in duration than BA
and BT for insomnia, so treatment duration may increase. Nonetheless, given the
importance of insomnia in depression and the ease at which it can be treated, BABIT
holds much promise for access to brief, efficacious, easily disseminated treatment.
Summary
•
•
•
Combined evidence-based approaches for depression and insomnia are the best
choice for MDD-I clients.
Combining behavioral activation and behavioral insomnia therapy is easily
achieved in a brief integrated treatment package delivered by therapy novices—the
effect sizes associated with BABIT are large and comparable to those reported with
the monotherapies.
BABIT has three modules: 1) an orienting or assessment-focused phase from which
a case formulation is formed, 2) an active module that involves: scheduling activities
including the sleep schedule using goal tracking forms; using rumination as a cue
for activation during the day and stimulus control at night, identifying alternative
coping strategies to avoidance patterns, and 3) relapse prevention and termination
planning.
10 Case Study
Kelly
Throughout the book we have provided sample dialogues between therapist and client
based on a fictional client named Kelly. Although fictional, Kelly is an amalgam of
numerous examples of cases that are in many respects quite typical of clients with MDDI. In this chapter, we present session by session information about Kelly to provide an
example of what the treatment looks like in practice.
Assessment Session
Kelly is a 60 year old female with current MDD and a presenting complaint of sleep
maintenance insomnia and fatigue. She arrived at the clinic early with all of her
requested materials including her completed sleep monitoring forms. She is self-referred
and lists her reason for coming to the clinic, as “I can’t sleep.” Kelly was interviewed
today with a clinical interview and the Duke Structured Interview for Sleep Disorders.
Prior to the interview, she completed an Epworth Sleepiness Scale, medical history
checklist, Fatigue Severity Scale, Dysfunctional Beliefs and Attitudes about Sleep Scale,
the Daytime Insomnia Symptom Response Scale, Beck Depression Inventory, Second
Edition, Penn State Worry Questionnaire, State-Trait Anxiety Inventory, and the ISI.
Kelly also reports that she is in menopause. She is a full-time school teacher. She is
divorced with a 21 year old daughter named Barb. Although she complained of lifelong
sleeping difficulties, further query about sleep during childhood revealed that as a child
and adolescent she actually slept reasonably well and that the complaint of insomnia
appeared to originate in her early twenties, around the time of a major depressive episode
and a highly stressful life event. She started medical school in her twenties and then
switched programs to attend teachers’ college. She reports three MDD episodes
(including this current episode): the first of which was in her twenties when she was
struggling to make the decision about whether or not to switch programs. This episode
lasted three years and resolved without treatment. The second major depressive episode
began coincident with a separation and eventual divorce from her partner at age 42;
this episode resolved a year later after several months of taking a prescribed tricyclic
antidepressant. However, she appeared to remain somewhat dysthymic post-recovery
until her most recent, and ongoing episode, which started 6 years ago (age 54). She
takes 20 mg of citalopram each morning and reports she finds it helpful, although she
still suffers from pervasive depressed mood, fatigue, insomnia, self-critical thoughts,
increased appetite, concentration problems, and anxiety. She reports having had suicidal
158
Case Study
ideation in the past but denies any current ideation, and denies any past or current intent
or plan for self-harm. She was prescribed trazodone for sleep (50 mg at bedtime) but
because she does not like the way she feels the next day, she takes it intermittently. She
acknowledges a tendency towards all or none, perfectionistic thinking and engages in
harsh self-talk when she views herself as “screwing up.” She reports a problem with
rumination, although she views rumination as problem-solving, i.e., it gives her a chance
to figure things out.
Kelly reports having sleep onset problems, although her main complaint was that she
cannot stay asleep throughout the night, and the sleep produced is experienced as
“light.” She has occasional hot flashes (about three to six times per month). She is
currently on hormone replacement therapy which she reports as helpful in decreasing
the frequency of hot flashes. When asked what she does during hot flashes, she reports
fanning herself in bed and drinking water. She reports that it takes “hours” to get back
to sleep after a hot flash. She attempts to nap at her desk at work or on the couch on
weekends but is unable to fall asleep. However, she reports that she occasionally dozes
unintentionally while watching television in the evening. Despite feeling very tired in
the evening when she goes to bed, she feels instantaneously alert and has difficulty falling
asleep. If she is unable to fall asleep within an hour she takes a trazodone. She stated
that one of her goals is getting off the trazodone because it makes her groggy the next
day. She uses blackout shades and a white noise machine to control the light and noise
in her bedroom. She describes her time awake in the beginning of the night as
unbearable and says that she cannot “shut off” her brain. Her score on the Dysfunctional
Beliefs and Attitudes about Sleep Scale (DBAS16 = 5.1) suggests a high degree of
unhelpful beliefs about sleep.
Kelly’s Epworth Sleepiness Scale score was a 3 which is not suggestive of clinically
relevant daytime sleepiness. During the Duke Structured Interview for Sleep Disorders
she met criteria for an Insomnia Disorder. Despite the reported dozing in the evening
particularly in front of the television, she did not meet criteria for hypersomnolence.
She denied any symptoms suggestive of circadian rhythm disorders, restless leg
syndrome, periodic limb movement disorder, sleep disordered breathing or narcolepsy;
she denied any unusual behaviors during sleep (e.g., parasomnias). Her medical forms
indicate a history of gall bladder problems starting in her 40s and low back pain (two
herniated disks) for the past 12 years for which she takes non-steroidal antiinflammatory medication (NSAIDs). Her Fatigue Severity Scale score was clinically
elevated (FSS = 5) and suggested a high degree of fatigue symptoms severity. Her score
on the Daytime Insomnia Symptom Response Scale (DISRS = 59) is suggestive of a
pervasive tendency to respond to feeling tired with repetitive, ruminative thought about
her symptoms. Her score on the Penn State Worry Questionnaire was below the clinical
cutoff for the measure, as was her trait score on the State-Trait Anxiety Inventory. Her
responses on the ISI were suggestive of severe insomnia symptoms (ISI = 28).
Kelly was mailed the core version of the Sleep Diary; an expanded one is typically
preferred in complicated cases, especially for cases in which it is important to track
medication, alcohol and/or caffeine use (see Figures 10.4, 10.6, and 10.8 for an expanded
sleep diary). For sleep diary summaries, we used the most recent week for ease of
presentation, it is advisable to enter the two weeks and use the mean of both weeks
during the assessment session (see Figures 10.5, 10.7, and 10.9 for examples of calculated
Case Study 159
diaries). Kelly attempted to monitor her sleep on the sleep diary, but she reported some
difficulty in completing all of the entries and returned diaries with missing data (see
Figure 10.1). She expressed concern about whether she was estimating correctly. Followup inquiry revealed some degree of perfectionism in approaching the task, she was
however fairly easily redirected to providing a “guesstimate” and she reported that she
did not anticipate a problem completing diaries in the future. The partially completed
diaries provided some corroboration of her sleep onset and maintenance difficulties.
The diaries suggested that she lingers in bed in the morning after the final awakening
and there was some (e.g., over 2 hours) variability in her rise time. She took trazodone
on two nights and Advil PM on one night as sleep aides during the monitored week.
She reported that she took them because she “couldn’t take another night without sleep.”
When queried about whether she did not sleep on the previous nights, she acknowledged that she slept, albeit poorly. There was no evidence of Sleep State Misperception.
Kelly reports that she feels wide awake and then frustrated when getting into bed.
She also reports worrying and occasionally experiencing hot flashes in bed. During
interview, there were instances suggestive of sleep effort-related beliefs. She stated that
she tries to get “every scrap of sleep” possible, thus lingering in the morning and
attempting to nap. She acknowledged that because she feels so tired during the day, she
has decreased her activities. Specifically, she no longer works out, she only occasionally
socializes or engages in leisure activities. She currently has two cups of coffee (one in
the morning and one after lunch) and will drink an energy drink or two in the afternoon
if she is very tired. She denied use of any energy drinks during the last week.
Formulation or Proposed Treatment Plan: Four biweekly sessions focused on the
following:
1.
2.
3.
4.
5.
Light, fragmented sleep is likely due to diffused sleep drive. The inadequate sleep
drive may be due to dozing, delaying build-up of sleep drive by lingering in the
morning, nap attempts, and decreased activity. Although occasional low back pain
and NSAIDs may contribute, the LBP is episodic (and not currently active) so this
is not a major factor at this time. Plan: Sleep restriction and scheduling activities.
It is also possible that the antidepressant medication may be fragmenting sleep—
plan: proceed with CBT-I first and assess response.
Conditioned arousal due to staying in bed while awake, frustrated, worrying,
ruminating, and in the midst of a hot flash. Plan: Stimulus Control during
wakefulness.
Daytime fatigue may be due to irregular circadian input and excessive resting. There
was over 2 hours of variability between the earliest and latest rise time on the sleep
diary which may be producing jetlag symptoms. Plan: Psychoeducation about jetlag
and the circadian system, and Stimulus Control (i.e., set standard rise time 7 days
per week). Encourage client to increase activities. A scheduled evening activity may
also help with the current problem of evening dozing.
Eliminate contingent use of trazodone or other aides such as Advil PM.
Belief that one cannot cope with sleep loss: challenge via behavioral experiments
and eliminate sleep effort behaviors (e.g., contingent use of caffeine and sleep
medications).
Poor
Fair
Good
Very
good
6 times
2 hours
5 min.
6:35 AM
7:20 AM
Very
poor
✓ Poor
Fair
Good
Very
good
4. How many times did you wake up, not counting your final
awakening?
5. In total, how long did these awakenings last?
6. What time was your final awakening?
7. What time did you get out of bed for the day?
Figure 10.1
9. Comments (if applicable)
I have a
cold
✓ Very
poor
55 min.
3. How long did it take you to fall asleep?
8. How would you rate the quality of your sleep?
7:10 AM
11:30
PM
2. What time did you try to go to sleep?
Very
good
Good
Fair
Poor
✓ Very
poor
7:10 AM
6:30 AM
?
2–3
?
10:45
PM
10:45
PM
1/10/14
trazodone Advil PM
50mg
Very
good
Good
Fair
Poor
✓ Very
poor
?
6:30 AM
15 min.
80 min.
6:30 AM
2
?.
10:45
PM
3
30–45
min.
11:15
PM
1/9/14
10:45
PM
1/8/14
10:15
PM
11:15
PM
4/5/08
1. What time did you get into bed?
Sample
Today’s Date
Consensus Sleep Diary-Core (Please Complete Upon Awakening)
1/11/14
Very
good
Good
Fair
Poor
✓ Very
poor
7:15 AM
6:30 AM
30 min.
1
45–60
min.
11 PM
11 PM
Very
good
Good
Fair
Poor
✓ Very
poor
6:30 AM
6:30 AM
90 min.
3
?
11 PM
11 PM
1/12/14
1/14/14
Fair
Good
Very
good
Fair
Good
✓ Very
good
trazodone
50mg
Poor
✓ Very
poor
8:45 PM
7:45 AM
?
1
?
11 PM
11 PM
✓ Poor
Very
poor
8:30 AM
8:10 AM
45 min.
2
?
10:45
PM
10:45
PM
1/13/14
NAME: Kelly
Case Study 161
6.
7.
Rumination: Challenge belief that it is advantageous or productive with behavioral
experiment. Use counter arousal strategies to manage rumination. Consider
mindfulness as a strategy for repetitive thought.
Perfectionistic beliefs: Challenge via Socratic questioning and thought records.
Assessment Session Homework: Continue monitoring with sleep diaries. Return to
clinic next week to begin CBT-I.
Session 1 Plan
•
•
•
•
Reinforce sleep diary completion and troubleshoot any issues.
Make calculations of sleep efficiency.
Introduce Stimulus Control, Sleep Restriction, and the Buffer Zone.
Establish non-contingent medication use.
Session 1 Notes
ISI was completed; score was suggestive of severe insomnia (ISI = 29). Suicidal ideation
check revealed no current ideation. Her BDI score was suggestive of moderately severe
depression (BDI-II = 26). She correctly and consistently completed the sleep diaries;
the following mean sleep indices (see Figure 10.2) are calculated from the sleep diaries:
mean sleep onset latency was about 50 minutes, wakefulness after sleep onset (WASO)
was an hour and forty minutes, total sleep time was about 5.6 hours and sleep efficiency
was 61 percent. There were 3 hours of variability in the earliest and latest rise times
during the recording period. She reported that these values were fairly representative
of her sleep generally.
Based on information during the assessment of dozing in the evening, followed by
sleep onset problems when relocating to the bedroom, the therapist used this information to explain the concept of conditioned arousal and the rationale for Stimulus
Control. In delivering this information, the therapist learned the client has concerns
that getting out of bed will limit her sleep opportunity.
Therapist: I want to make sure I understand. You have concerns that if you get out
of bed when you are unable to sleep, you won’t get “enough” sleep?
Client: That’s right. If I stay in bed, at least there is a chance that I could sleep.
Therapist: I suppose it is possible that you could fall asleep quickly but if your report
and the diaries are true, it would appear that once you wake up, it takes you
considerable time to fall back to sleep. In other words, when you wake up, you are
not ready to return to sleep right away, so it doesn’t seem like this strategy gets you
what you want.
Client: What’s the alternative?
Therapist: You said you were worried that it could take you longer to fall asleep if you
got out of bed, let’s say that you are right, what is the advantage of staying up longer
with respect to your sleep the next night?
Client: It’s hard to think of it like an advantage, but I guess you would build-up more
sleep drive?
Poor
Fair
Good
Very
good
6 times
2 hours
5 min.
6:35 AM
7:20 AM
Very
poor
✓ Poor
Fair
Good
Very
good
4. How many times did you wake up, not counting your final
awakening?
5. In total, how long did these awakenings last?
6. What time was your final awakening?
7. What time did you get out of bed for the day?
8. How would you rate the quality of your sleep?
Figure 10.2
I have a
cold
✓ Very
poor
✓ Very
poor
55 min.
3. How long did it take you to fall asleep?
9. Comments (if applicable)
7:40 AM
7:10 AM
11:30
PM
6:30 AM
6:30 AM
Very
good
Good
Fair
Poor
60 min.
80 min.
1
40 min.
40 min.
1
10:30
PM
11:15
PM
10:30
PM
2. What time did you try to go to sleep?
11:15
PM
10:15
PM
1/16/14
1. What time did you get into bed?
1/15/14
4/5/08
Sample
Today’s Date
Consensus Sleep Diary-Core (Please Complete Upon Awakening)
Very
good
Good
Fair
Poor
✓ Very
poor
7:10 AM
6:30 AM
100 min.
2
80 min.
9:15 PM
9:15 PM
1/17/14
Good
Very
good
Good
Very
good
Very
good
trazodone
50mg
Fair
Good
Poor
Fair
Fair
✓ Very
poor
9:45 AM
7:55 AM
120 min.
3
60 min.
10:45
PM
10:45
PM
1/21/14
✓ Poor
Very
poor
9:00 AM
8:10 AM
90 min.
3
40 min
10:45
PM
10:45
PM
1/20/14
Poor
✓ Very
poor
7:30 AM
6:30 AM
180 min.
2
50 min.
11:20
PM
11:20
PM
1/19/14
trazodone Hot flash
50mg
Very
good
Good
Fair
Poor
✓ Very
poor
7:30 AM
6:30 AM
90 min.
1
40 min.
11 PM
11 PM
1/18/14
NAME: Kelly
Case Study
163
Therapist: And what is the advantage with respect to conditioned arousal? In other
words, if you are wide awake when you get into bed and wide awake when you
wake up in bed, how would getting out of bed help with getting rid of that
association?
Client: It’s supposed to get rid of it but this sounds horrible.
Therapist: Do you play chess?
Client: A little.
Therapist: I wonder if giving up a night or two to get rid of the conditioned arousal,
especially knowing that you would be rewarded with deeper sleep subsequently is
sort of like giving up a pawn to clear the path to take your opponent’s king?
Client: I see what you mean.
Therapist: Staying in bed won’t win the game because we see that it is associated with
insomnia for you. It is kind of difficult to give up “trying” to sleep if you stay in
bed.
Client: I would be willing to give up my pawn I guess [smiles] but I am a little
skeptical.
Therapist: Fair enough. Can we re-evaluate whether it was worth it after two
weeks?
Client: OK.
Given the TST of 5.6 hours, the time-in-bed prescription was set at 6 hours. The client
selected 6:30 AM as the standard rise time, which means that the bedtime was 12:30
AM. However, the therapist pointed out that there were no times at which the client
stayed up until 12:30 AM currently and in fact, the client reported dozing in the evening.
The therapist suggested to move the bedtime earlier to 11:30 PM and set the rise time
at 5:30 AM, to correspond to the client’s early circadian tendency. The therapist
reviewed the rationale and rule of beginning wind-down activities (i.e., the Buffer zone)
an hour before the prescribed bedtime.
The therapist requested that the client either keep the medication dose and timing
every night throughout treatment or discontinue it altogether. The client expressed
ambivalence about taking the medication but ultimately decided to keep it steady
throughout the treatment and to discuss this plan with her family doctor at her
scheduled appointment this week.
The therapist provided a summary of treatment recommendations (see Figure 10.3).
The therapist discussed the caffeine recommendation and they agreed that the client
would limit use to two cups per day (with the last cup around 1 PM).
Assigned Homework Session 1
•
•
•
•
•
Complete two weeks of diaries.
Follow the prescription on client summary (schedule is 10:30 PM–5:30 AM) and
institute Stimulus Control.
Take trazodone at same time each night.
Limit caffeine to two cups of coffee.
Return to clinic in two weeks.
164 Case Study
My plan for better sleep
Over the next two weeks, I will do the following:
1. I will use a standard get-up-out-of-bed time, seven days per week, regardless of the
sleep I obtain on any particular night. My latest time out of bed is: 5:30 AM . To
accomplish this I will set an alarm for every morning at this time.
2. I will go to bed only when I am sleepy, but never before my earliest possible bedtime. My
earliest bedtime is 11:30 PM .
3. I will get up out of bed when I can’t sleep. I will give up the effort to sleep, and go to
another room until I feel sleepy enough to fall asleep quickly before returning to bed.
4. If I still cannot fall asleep when I return to bed, repeat step 3.
5. I will avoid doing wakeful things while in bed. In other words, I will use the bed for
sleeping only. If sexual activity is not alerting, this can be an exception to the rule.
6. If I find myself worrying, problem-solving, ruminating, planning in bed, or engaging in
sleep effort, I will get up and stay out of bed until this thinking dissipates and I feel sleepy
enough to return to bed. This includes if I wake up because of a hot flash.
7. I will avoid daytime napping or spending time lying down throughout the day except in
the case of safety.
8. I will fill out my sleep diary each morning, preferably within an hour of rising, so that I can
track the impact of this plan on my sleep.
Other helpful hints:
I will limit caffeine to one drink as far away from bedtime as possible, and attempt to refrain
from alcohol and smoking, including marijuana. I will ensure my bedroom is quiet, dark, and
cool. I will attempt to exercise, although not right before bed.
Figure 10.3 Treatment plan summary example: Kelly
Session 2 Plan
•
•
•
•
Review diaries, complement completion and/or troubleshoot incomplete sleep
diaries.
Check-in on homework and troubleshoot any adherence issues.
Assess for whether sleep extension is warranted (i.e., check for an elevated sleep
efficiency on the sleep diary or ask about subjective sleepiness).
Time permitting, add some activity scheduling to help with fatigue, combat dozing,
and challenge the idea that life stops when experiencing fatigue.
Session 2 Notes
ISI was completed; score was suggestive of moderately severe insomnia (ISI = 21).
Suicidal ideation check revealed no current ideation. Her BDI score was suggestive of
Case Study 165
moderate level of depression (BDI-II = 21). She correctly and consistently completed
the sleep diaries; the following mean sleep indices are calculated from the sleep diaries:
mean sleep onset latency was reduced from session 1 (M = 20 minutes) and within
normal limits, WASO was reduced from session 1 (M = 25 minutes) and now within
normal limits, total sleep time was about the same 6.2 hours and sleep efficiency was
improved from 74 percent to 80 percent. She reported that the diaries were
representative of her sleep generally.
The session began with a complement about her completion of the diaries, a mood
and sleep check and an invitation to talk about her experience in following the new
sleep rules. The client reported some difficulty following the recommendation to get
out of bed by 5:30 AM. Figure 10.4 depicts a summary of the sleep diary data from the
most recent week. Again, we typically use 2 weeks’ worth of data but for ease of
presentation, we are using the most recent week. The mean rise time was 6 hours and
57 minutes which is almost an hour and a half later than the prescribed rise time. The
average final awakening was over 30 minutes later than the prescribed wake-up time
(6:05 AM) and further query with the client confirmed that she stopped setting the alarm
clock about 4 days after the previous session. The client cited a few reasons for this
difficulty which included not wanting to feel cold when getting out of bed. The client
agreed to take the blanket to a transition spot to stay warm and also to keep socks by
her bed to put on before getting out of bed. The therapist used an analogy of willingness
to sacrifice a pawn and experiencing less time in bed to experience better quality sleep.
The client agreed to test it out by setting an alarm every morning. This discussion also
uncovered some anxiety about sleep loss. Anxiety about the consequences of sleep loss
was cited as a reason for non-adherence to the caffeine recommendations, i.e., evidence
of increased use of energy drinks in the late afternoon. Upon further exploration, the
client revealed a high degree of anxiety and aversion to the experience of fatigue. The
therapist explored whether openness to the experience of fatigue would be a helpful
new stance (see Chapter 9 for the exchange). The client acknowledged that contingent
caffeine use was an unhelpful avoidance strategy and she agreed to eliminate the energy
drinks.
The client reported following stimulus control recommendations to get out of bed
in the middle of the night, including when the awakening was caused by a hot flash.
There was one hot flash in the past week and the client reported that she got out of bed
and read until she was sleepy again. Of note is that her WASO improved from almost
an hour to within normal limits (WASO M = 25 minutes).
The client reported some difficulty following the recommendation to go to bed no
earlier than 11:30 PM. The average bedtime was 30 minutes earlier than the prescribed
11:30 PM bedtime (see Figure 10.5). The client also reported some dozing in the evening.
To address this issue, the therapist discussed the sleepiness or fatigue distinction and
they discussed activities that would decrease the likelihood of dozing in the evening.
In a discussion of fatigue, it was revealed that the client felt bored and was somewhat
inactive. A life compass exercise revealed that fatigue and insomnia prevented her from
living a life consistent with her values. Moreover she often felt isolated because of her
lack of activities outside the home. The client agreed to schedule at least 2 activities and
to monitor her activity level on a monitoring form.
1
1
60 min.
5:30 AM
4. How many times did you wake up, not counting your final awakening?
5. In total, how long did these awakenings last?
6a. What time was your final awakening?
10 min.
✓ Very
poor
5:30 AM
✓ Very
poor
Poor
Fair
Good
Very
good
7. What time did you get out of bed for the day?
Figure 10.4 Consensus Sleep Diary © 2011
Poor
Fair
Good
Very
good
5:45 AM
N/A
8. How would you rate the quality of your sleep?
No
N/A
No
6c. Did you wake up earlier than you planned?
15 min.
5:30 AM
6d. If yes, how much earlier?
6b. After your final awakening, how long did you spend in bed trying to sleep? 0
20 min.
30 min.
Poor
Fair
Good
Very
good
✓ Very
poor
6 AM
N/A
No
30 min.
5:30 AM
40 min.
2
40 min.
Poor
Fair
Good
Very
good
✓ Very
poor
6:20 AM
N/A
No
45 min.
5:30 AM
10 min.
1
5 min.
11:20
PM
Poor
Fair
Good
Very
good
✓ Very
poor
6:45 AM
N/A
No
30 min.
6:15 AM
40 min.
2
40 min.
10:30
PM
Fair
Good
Very
good
Very
poor
✓ Poor
7:50 AM
N/A
No
1 hour
6:20 AM
25 min.
1
30 min.
11 PM
Poor
Fair
Good
Very
good
✓ Very
poor
9 AM
N/A
No
2 hours
6:40 AM
10 min.
1
20 min.
11:10
PM
11:10
PM
3. How long did it take you to fall asleep?
10:45
PM
11 PM
11:30
PM
10:30
PM
11:30
PM
11:20
PM
2. What time did you try to go to sleep?
10:45
PM
11:30
PM
1. What time did you get into bed?
11:30
PM
11/22/14 11/23/14 11/24/14 11/25/14 11/26/14 11/27/14 11/28/14
ID/NAME: Kelly
Today’s Date
Consensus Sleep Diary-M (Please Complete Upon Awakening)
N/A
Trazodone
50 mg
N/A
2
1 PM
Trazodone
50 mg
10b. What time was your last drink?
11a. How many caffeinated drinks (coffee, tea, soda,
energy drinks) did you have?
11b. What time was your last drink?
12. Did you take any over-the-counter or prescription
medication(s) to help you sleep?
Figure 10.4 Continued
13. Comments (if applicable)
10:30 PM
N/A
0
0
10a. How many drinks containing alcohol did you have?
If so, list medication(s), dose, and time taken
0
0
11 PM
1:15 PM
12:45 PM
9:45 PM
50 mg
Trazodone
2
2
15 min.
1
0
0
0
9a. How many times did you nap or doze?
9b. In total, how long did you nap or doze?
11/24/14
11/23/14
11/22/14
Today’s Date
Consensus Sleep Diary-M (Please Complete Upon Awakening)
11 PM
50 mg
Trazodone
4:10 PM
3
N/A
0
25 min.
1
11/25/14
9:30 PM
50 mg
Trazodone
1 PM
2
N/A
0
20 min.
1
11/26/14
ID/NAME: Kelly
10 PM
50 mg
Trazodone
4 PM
3
N/A
0
0
0
11/27/14
10 PM
50 mg
Trazodone
4:45 PM
3
9:30 PM
1
20 min.
1
11/28/14
11:30
PM
20 min.
11:30
PM
2. What time did you try to go to sleep?
Very
poor
✓ Poor
Fair
Good
Very
good
Very
poor
✓ Poor
Fair
Good
Very
good
8. How would you rate the quality of your sleep?
Figure 10.4 Continued
6:15 AM
6 AM
7. What time did you get out of bed for the day?
No
N/A
No
15 min.
6a. What time was your final awakening?
6b. After your final awakening, how long did you spend in bed trying to sleep? 10 min.
N/A
5:50 AM
5:45 AM
5. In total, how long did these awakenings last?
6c. Did you wake up earlier than you planned?
20 min.
10 min.
4. How many times did you wake up, not counting your final awakening?
6d. If yes, how much earlier?
1
5 min.
1
3. How long did it take you to fall asleep?
Fair
Good
Very
good
Very
poor
✓ Poor
6 AM
N/A
No
10 min.
5:50 AM
30 min.
1
30 min.
10:45
PM
Fair
Good
Very
good
Very
poor
✓ Poor
6:20 AM
N/A
No
45 min.
5:35 AM
10 min.
1
5 min.
11:20
PM
11:20
PM
10:45
PM
11:30
PM
1. What time did you get into bed?
11:30
PM
12/2/14
11/29/14 11/30/14 12/1/14
ID/NAME: Kelly
Today’s Date
Consensus Sleep Diary-M (Please Complete Upon Awakening)
Fair
Good
Very
good
Very
poor
✓ Poor
6:45 AM
N/A
No
30 min.
6:15 AM
45 min.
1
40 min.
10:30
PM
10:30
PM
12/3/14
Fair
Good
Very
good
Very
poor
✓ Poor
8:50 AM
N/A
No
2 hour
6:40 AM
20 min.
1
25 min.
11 PM
11 PM
12/4/14
Fair
Good
Very
good
Very
poor
✓ Poor
8:30 AM
N/A
No
2 hours
6:40 AM
40 min.
1
20 min.
11:10
PM
11:10
PM
12/5/14
50 mg
Trazodone
50 mg
12. Did you take any over-the-counter or prescription
medication(s) to help you sleep?
Figure 10.4 Continued
13. Comments (if applicable)
10:30 PM
Trazodone
1 PM
11b. What time was your last drink?
If so, list medication(s), dose, and time taken
1 PM
2
11a. How many caffeinated drinks (coffee, tea, soda,
energy drinks) did you have?
11 PM
2
N/A
N/A
10b. What time was your last drink?
0
0
0
0
9b. In total, how long did you nap or doze?
0
9a. How many times did you nap or doze?
10a. How many drinks containing alcohol did you have?
0
11/29/14
Today’s Date
11/30/14
9:45 PM
50 mg
Trazodone
1:15 PM
2
N/A
0
10 min.
1
12/1/14
Consensus Sleep Diary-M (Please Complete Upon Awakening)
11 PM
50 mg
Trazodone
4 PM
3
N/A
0
15 min.
1
12/2/14
9:30 PM
50 mg
Trazodone
1 PM
2
N/A
0
10 min.
1
12/3/14
ID/NAME: Kelly
Hot flash
10 PM
50 mg
Trazodone
6 PM
4
9 PM
1
10 min.
1
12/4/14
10 PM
50 mg
Trazodone
4:35 PM
3
N/A
0
15 min.
1
12/5/14
22:45
22:45
30.00
30.00
5:50
0.00
6:00
23:30
23:30
20.00
20.00
5:50
0.00
6:15
23:30
23:30
5.00
10.00
5:45
0.00
6:00
0.00
6:20
10.00
5:35
5.00
23:20
23:20
day 4
0.00
6:45
45.00
6:15
40.00
22:30
22:45
day 5
0.00
8:50
20.00
6:40
25.00
23:00
23:00
day 6
0.00
8:30
40.00
6:40
20.00
23:10
23:10
day 7
6.75
7.25
9.33
6.50
8.25
8.25
7.00
9.83
5.67
6.08
6.50
6.00
6.33
5.75
6.00
6.92
69.70% 92.31% 84.00% 83.86% 85.71% 76.73% 70.40% 69.67%
day 3
day 2
day 1
Figure 10.5 Kelly sleep diary calculations from week 2 of session 2
Time in Bed (TIB)
Total Sleep Time (TST)
Sleep Efficiency (SE) %
sample
11/29/14–12/5/14
1/1/2011
Dates
23:30
Bedtime (Time went into bed)
23:45
Lights out (Try to go to sleep)
Latency to sleep (minutes to fall
30
asleep)
Minutes awake in middle of night
60
(how long awakenings last)
7:00
Wake time (time of final awakening)
Mins awake too early (how many
30
minutes earlier)
8:00
Out of bed (out of bed for the day)
7.84 Time in Bed
6.21 Total Sleep Time
80.38% Sleep Efficiency
0.00 Minutes awake too early
6:57 Out of bed for day
25.00 Mins. awake in middle of night
6:05 Wake time
20.71 Latency to fall asleep
23:06 Bedtime
23:08 Lights out
AVERAGE
Case Study
171
Assigned Homework: Session 2
•
•
•
•
•
•
•
•
•
•
•
•
Complete two weeks of diaries. Follow the prescription on client summary
(schedule is 11:30 PM–5:30 AM).
To address issues with feeling cold when getting up, place socks by bed and take
blanket to a second location to transition.
Set alarm all 14 days.
Schedule some activities out of the house as well as some evening activities to
minimize dozing, and track progress on activity monitoring form.
Return to clinic in two weeks. Session 3 Plan:
Review diaries, complement completion and/or troubleshoot incomplete sleep
diaries.
Check-in on homework and troubleshoot any adherence issues.
Assess for whether sleep extension is warranted (i.e., a self-report of sleepiness or
elevated mean sleep efficiency on the sleep diary).
Time permitting, add a mindfulness activity to help with repetitive thought.
Challenge perfectionistic thinking about functioning or sleep.
Check-in on thoughts and feelings about termination.
Assign Letter to Self for relapse prevention.
Session 3 Notes
The ISI was completed and the score was suggestive of moderate insomnia (ISI = 15).
Suicidal ideation check revealed no current ideation. Her BDI score was suggestive of
moderate level of depression (BDI-II = 17). She correctly and consistently completed
the sleep diaries; the following mean sleep indices are calculated from the sleep diaries:
mean sleep onset latency reduction from session 1 was maintained (M = 18 minutes)
and within normal limits, WASO was again reduced from session 1 (M = 25 minutes)
and is within normal limits, total sleep time remains around 6 hours and sleep efficiency
was improved to 82 percent (61 percent at pre-treatment), and not suggestive of
objective sleepiness. She reported that the diaries were representative of her sleep
generally.
The diaries and her self report revealed continued problems with adherence to the
rise time prescription. Her average rise time was 6:40 AM; over an hour from the
scheduled rise time. See Figures 10.6 and 10.7. Her final awakening was variable and
the average time was 6:02 AM (30 minutes later than the scheduled alarm time). Followup inquiry confirmed that the client was not consistently setting an alarm. The solution
proposed by the client was to keep a sticky note to remind herself to set the alarm.
There were several instances during the session in which the client exhibited
unhelpful thinking styles (e.g., perfectionism about sleep). These were challenged via
Socratic questioning and also a thought record done in session. The client reported that
the TR was helpful and agreed to complete TRs between sessions when encountering a
troublesome thought. Similarly, the client reported that she ruminates less at night
because she is sleepier but was distressed about rumination during the day this week.
The therapist initiated an in-session behavioral experiment to test if rumination is
helpful. The result was that thinking about concrete “what’s” of the situation worked
Good
Very
good
1
10 min.
5:30 AM
15 min.
No
N/A
5:45 AM
Very
poor
Poor
✓ Fair
Good
Very
good
1
30 min.
5:30 AM
30 min.
No
N/A
6 AM
Very
poor
✓ Poor
4. How many times did you wake up, not counting your final awakening?
5. In total, how long did these awakenings last?
6a. What time was your final awakening?
6b. After your final awakening, how long did you spend in bed trying to
sleep?
6c. Did you wake up earlier than you planned?
6d. If yes, how much earlier?
7. What time did you get out of bed for the day?
8. How would you rate the quality of your sleep?
Figure 10.6 Consensus Sleep Diary © 2011
Very
poor
Poor
✓ Fair
15 min.
30 min.
3. How long did it take you to fall asleep?
Fair
Good
Very
good
5:45 AM
11:30
PM
11:30
PM
2. What time did you try to go to sleep?
N/A
No
15 min.
5:30 AM
0
0
10 min.
11:45
PM
11:45
PM
11:30
PM
11:30
PM
12/8/14
12/7/14
12/6/14
Today’s Date
Very
poor
Poor
Fair
✓ Good
Very
good
Very
good
6:15 AM
N/A
No
45 min.
5:30 AM
40 min.
1
10 min.
11:30
PM
11:30
PM
Good
Very
good
Very
poor
Poor
✓ Fair
7 AM
N/A
No
1.5
hours
5:30 AM
15 min.
1
30 min.
11:20
PM
11:20
PM
Very
good
Very
poor
Poor
Fair
✓ Good
7 AM
N/A
No
1.5
hours
5:30 AM
10 min.
1
20 min.
11:30
PM
11:30
PM
12/10/14 12/11/14 12/12/14
Very
poor
Poor
Fair
✓ Good
5:50 AM
N/A
No
15 min.
5:30 AM
10 min.
1
15 min.
11:30
PM
11:30
PM
12/9/14
ID/NAME: Kelly
1. What time did you get into bed?
Consensus Sleep Diary-M (Please Complete Upon Awakening)
50 mg
Trazodone
50 mg
12. Did you take any over-the-counter or prescription
medication(s) to help you sleep?
Figure 10.6 Continued
13. Comments (if applicable)
10:30 PM
1 PM
11b. What time was your last drink?
If so, list medication(s), dose, and time taken
Trazodone
2
11a. How many caffeinated drinks (coffee, tea, soda,
energy drinks) did you have?
0
10:30 PM
1:45 PM
2
10:45 PM
50 mg
Trazodone
1:15 PM
2
N/A
0
0
N/A
0
N/A
0
11 PM
50 mg
Trazodone
1 PM
2
N/A
0
0
0
0
0
10b. What time was your last drink?
0
10:30 PM
50 mg
Trazodone
1 PM
2
N/A
0
0
0
12/10/14
ID/NAME: Kelly
12/9/14
12/8/14
12/7/14
10a. How many drinks containing alcohol did you have?
0
9b. In total, how long did you nap or doze?
12/6/14
9a. How many times did you nap or doze?
Today’s Date
Consensus Sleep Diary-M (Please Complete Upon Awakening)
10 PM
50 mg
Trazodone
1 PM
2
N/A
0
0
0
12/11/14
10 PM
50 mg
Trazodone
12:45 PM
2
N/A
0
0
0
12/12/14
20 min.
1
20 min.
5:50 AM
15 min.
5 min.
1
10 min.
5:30 AM
4. How many times did you wake up, not counting your final awakening?
5. In total, how long did these awakenings last?
6a. What time was your final awakening?
6b. After your final awakening, how long did you spend in bed trying to sleep? 10 min.
Good
Very
good
Figure 10.6 Continued
Good
Very
good
Very
poor
Poor
✓ Fair
Very
poor
Poor
Fair
✓ Good
8. How would you rate the quality of your sleep?
Very
good
Very
poor
Poor
✓ Fair
6:15 AM
6 AM
7. What time did you get out of bed for the day?
6 AM
N/A
No
No
N/A
No
N/A
6c. Did you wake up earlier than you planned?
6d. If yes, how much earlier?
10 min.
5:50 AM
30 min.
1
20 min.
Very
good
Very
poor
Poor
Fair
✓ Good
6:20 AM
N/A
No
45 min.
5:35 AM
10 min.
1
5 min.
11:30
PM
Very
good
Very
poor
Poor
Fair
✓ Good
6:45 AM
N/A
No
30 min.
6:15 AM
45 min.
1
30 min.
11:30
PM
Good
Very
good
Very
poor
Poor
✓ Fair
7:50 AM
N/A
No
1 hour
6:40 AM
20 min.
1
25 min.
11:30
PM
Very
good
Very
poor
Poor
Fair
✓ Good
7:30 AM
N/A
No
1 hour
6:40 AM
40 min.
1
20 min.
11:30
PM
11:30
PM
3. How long did it take you to fall asleep?
11:45
PM
11:30
PM
11:30
PM
11:30
PM
11:30
PM
11:30
PM
2. What time did you try to go to sleep?
11:45
PM
11:30
PM
1. What time did you get into bed?
11:30
PM
12/13/14 12/14/14 12/15/14 12/16/14 12/17/14 12/18/14 12/19/14
ID/NAME: Kelly
Today’s Date
Consensus Sleep Diary-M (Please Complete Upon Awakening)
1 PM
1 PM
Trazodone
12b. What time was your last drink?
13. Did you take any over-the-counter or prescription
medication(s) to help you sleep?
Figure 10.6 Continued
14. Comments (if applicable)
10:30 PM
50 mg
2
N/A
2
11b. What time was your last drink?
12a. How many caffeinated drinks (coffee, tea, soda,
energy drinks) did you have?
If so, list medication(s), dose, and time taken
N/A
0
11a. How many drinks containing alcohol did you have?
Don’t see
the point
of the
trazodone
—stopped
0
0
0
10b. In total, how long did you nap or doze?
No
1:15 PM
2
N/A
0
0
0
0
0
10a. How many times did you nap or doze?
12/15/14
12/14/14
12/13/14
Today’s Date
Consensus Sleep Diary-M (Please Complete Upon Awakening)
No
1 PM
2
N/A
0
0
0
12/16/14
No
1 PM
2
N/A
0
0
0
12/17/14
ID/NAME: Kelly
No
1 PM
2
N/A
0
0
0
12/18/14
No
1:35 PM
2
9:30 PM
1
0
0
12/19/14
23:45
23:45
20.00
30.00
5:50
0.00
6:00
23:30
23:30
20.00
20.00
5:50
0.00
6:15
23:30
23:30
5.00
10.00
5:30
0.00
6:00
30.00
45.00
6:15
5.00
10.00
5:35
0.00
6:20
0.00
6:45
23:30
23:30
23:30
23:30
23:30
23:30
0.00
7:50
20.00
6:40
25.00
day 6
day 5
day 4
0.00
7:30
40.00
6:40
20.00
23:30
23:30
day 7
8.00
6.75
6.83
7.25
8.25
6.50
6.25
8.33
6.17
5.67
5.83
5.50
5.75
5.75
5.25
6.42
69.70% 88.46% 84.00% 84.00% 85.36% 75.86% 77.07% 77.13%
day 3
day 2
day 1
Figure 10.7 Kelly sleep diary calculations from week 2 of session 3
Time in Bed (TIB)
Total Sleep Time (TST)
Sleep Efficiency (SE) %
sample
12/3/14–12/19/14
1/1/2011
Dates
23:30
Bedtime (Time went into bed)
23:45
Lights out (Try to go to sleep)
Latency to sleep (minutes to fall
30
asleep)
Minutes awake in middle of night
60
(how long awakenings last)
7:00
Wake time (time of final awakening)
Mins awake too early (how many
30
minutes earlier)
8:00
Out of bed (out of bed for the day)
7.13 Time in Bed
5.80 Total Sleep Time
81.70% Sleep Efficiency
0.00 Minutes awake too early
6:40 Out of bed for day
25.00 Mins. awake in middle of night
6:02 Wake time
17.86 Latency to fall asleep
23:32 Bedtime
23:32 Lights out
AVERAGE
Case Study
177
better than thinking about the “whys”. The client agreed it was not helpful and agreed
on a plan to use rumination as a cue for getting out of the bed at night, and BA during
the day. During this conversation, the client reported attending a Mindfulness Based
Stress Reduction group in the past. She stated that it was helpful for her rumination but
had since stopped mindfulness practice. The therapist explored ways in which mindfulness may allow her to take a step back from thoughts that excessively draw her
attention. The client agreed to reintroduce mindfulness to her life by adding mindfulness to her early evening walk.
Assigned Homework: Session 3
•
•
•
•
•
•
•
Complete two weeks of diaries. Follow the prescription on client summary
(schedule is 11:30 PM–5:30 AM).
Continue to place socks by bed and take blanket to a second location to transition.
Continue to set alarm all 14 days; put sticky note on alarm clock to remember to
set each night.
Schedule some activities (e.g., evening walk, joining the weekend card game) out
of the house as well as some evening activities to minimize dozing, and track
progress on activity monitoring form.
Add mindfulness to evening walk.
Write “Note to Self” for Relapse Prevention.
Return to clinic in two weeks.
Session 4 Plan
•
•
•
•
•
•
•
Review diaries, complement completion and/or troubleshoot incomplete sleep
diaries.
Check-in on homework and troubleshoot any adherence issues.
Assess for whether sleep extension is warranted (i.e., a self-report of sleepiness or
elevated mean sleep efficiency on the sleep diary).
Challenge perfectionistic thinking about functioning or sleep.
Check-in on thoughts and feelings about termination.
Review Letter to Self; relapse prevention.
Enter ISI score into spreadsheet and share progress with client (see Figure 10.10).
Session 4 Notes
The ISI was 9 suggestive of mild sub-syndromal symptoms. In reviewing the ISI graph
(Figure 10.10), the client expressed that the graph matched her experience of gradual
improvement and being satisfied with her sleep currently. She had one remaining
complaint: daytime sleepiness. There were notable improvements in her depression
symptoms (BDI-II = 13), beliefs about sleep (DBAS16 = 2.7; below the clinical cutoff
for the measure), fatigue (FSS = 3.4), and rumination in response to feeling tired (DISRS
= 39). Of note, the BDI-II score at pre-treatment was in the moderately severe range
and is now below the clinical cutoff for the measure (BDI-II = 13). The client remains
178
Case Study
on citalopram. She voluntarily discontinued nightly trazodone use 3 weeks ago without
any rebound or other discontinuation issues.
A review of her sleep diaries (see Figure 10.8 for diaries and Figure 10.9 for a
summary) revealed 8.57 minutes in wakefulness during the night, a sleep efficiency just
above 90 percent, and a sleep onset latency of 10 minutes. The therapist and client
discussed whether the time-in-bed prescription should be increased. It was agreed that
the client should try a 15 minute extension and assess sleepiness after the period. The
client demonstrated a good understanding of how to make the sleep diary calculations
and how to assess whether an extension is needed. Both the diaries and self-report suggest
that the client is now adherent to the rise time schedule; she reported that the sticky
note reminder to set her alarm was helpful.
The client read aloud her Letter to Self. She stated the following changes were
particularly helpful: setting an alarm to maintain a regular rise time, scheduling activities
so that she is not bored and prone to dozing, getting out of bed when she cannot sleep,
particularly when she has a hot flash, and accepting the experience of fatigue. The client
reported that the mindful walk has been helpful and she has instigated a 20 minute
mindfulness practice with her colleagues over the lunch hour. The client expressed
gratitude that she feels able to connect with her valued life and said that she feels
confident that she could enact these strategies in the future if the insomnia returned.
It should be noted that based on the remaining adherence issues in Session 3, an extra
session could have been added. Based on the notable improvements (e.g., steadily falling
ISI score and a sleep efficiency above 80 percent) and the fact that the therapist was
confident that the remaining adherence would be improved in time for the last session,
the therapist kept to a typical 4-session protocol.
Assigned Homework: Session 4
•
•
•
Continue with diary monitoring to assess the impact of the 15-minute sleep
extension on current sleepiness. Extend an additional 15 minutes if sleepiness
unresolved. Provided her with link for sleep diaries: www.drcolleencarney.com.
Continue with treatment plan including the prescription (schedule is 11:15 PM5:30 AM), socks by the bed, alarm 7 days a week, mindfulness evening walks and
scheduling activities.
Follow-up with clinic in the future if sleep extension does not resolve the sleepiness or if new sleep symptoms arise, particularly, excessive daytime sleepiness,
breathing-related symptoms such as loud snoring, choking; repeated urges to move
the legs in the evening.
In most cases, four sessions (sometimes less) is sufficient to resolve insomnia symptoms.
At the end of the four sessions, there may be planned adjustments to time-in-bed for
the upcoming weeks and months after treatment (most commonly extending timein-bed). Thus, it is important to have a written plan and decision guide for the client
to make adjustments. A primary goal in CBT-I is to increase sleep self-efficacy, so it is
important that the client receive training in how to make calculations and adjustments
to their time-in-bed so that they can confidently change their sleep habits independently.
5:30 AM
15 min.
5:30 AM
6a. What time was your final awakening?
6b. After your final awakening, how long did you spend in bed trying to sleep? 30 min.
Figure 10.8 Consensus Sleep Diary © 2011
Good
Very
good
Good
Very
good
Fair
Good
Very
good
Very
poor
Poor
✓ Fair
Very
poor
Poor
✓ Fair
Very
poor
✓ Poor
8. How would you rate the quality of your sleep?
5:45 AM
N/A
N/A
5:45 AM
N/A
6 AM
7. What time did you get out of bed for the day?
No
15 min.
5:30 AM
0
0
10 min.
6d. If yes, how much earlier?
No
10 min.
30 min.
5. In total, how long did these awakenings last?
No
1
1
4. How many times did you wake up, not counting your final awakening?
6c. Did you wake up earlier than you planned?
15 min.
30 min.
3. How long did it take you to fall asleep?
11:45
PM
Very
poor
Poor
Fair
✓ Good
Very
good
Very
good
6:15 AM
N/A
No
45 min.
5:30 AM
40 min.
1
10 min.
11:30
PM
Very
poor
Poor
Fair
✓ Good
5:50 AM
N/A
No
15 min.
5:30 AM
10 min.
1
15 min.
11:30
PM
Good
Very
good
Very
poor
Poor
✓ Fair
7 AM
N/A
No
1.5
hours
5:30 AM
15 min.
1
30 min.
11:20
PM
Very
good
Very
poor
Poor
Fair
✓ Good
7 AM
N/A
No
1.5
hours
5:30 AM
10 min.
1
20 min.
11:30
PM
11:30
PM
11:30
PM
11:20
PM
11:30
PM
11:30
PM
2. What time did you try to go to sleep?
11:30
PM
11:30
PM
11:30
PM
1. What time did you get into bed?
11:45
PM
12/20/14 12/21/14 12/22/14 12/23/14 12/24/14 12/25/14 12/26/14
ID/NAME: Kelly
Today’s Date
Consensus Sleep Diary-M (Please Complete Upon Awakening)
Trazodone
50 mg
1 PM
Trazodone
50 mg
11b. What time was your last drink?
12. Did you take any over-the-counter or prescription
medication(s) to help you sleep?
Figure 10.8 Continued
13. Comments (if applicable)
10:30 PM
1:45 PM
2
11a. How many caffeinated drinks (coffee, tea, soda,
energy drinks) did you have?
If so, list medication(s), dose, and time taken
2
N/A
10b. What time was your last drink?
10:30 PM
10:45 PM
50 mg
Trazodone
1:15 PM
2
N/A
0
0
0
N/A
0
0
0
9b. In total, how long did you nap or doze?
10a. How many drinks containing alcohol did you have?
12/22/14
0
12/21/14
0
12/20/14
0
9a. How many times did you nap or doze?
Today’s Date
Consensus Sleep Diary-M (Please Complete Upon Awakening)
11 PM
50 mg
Trazodone
1 PM
2
N/A
0
0
0
12/23/14
10:30 PM
50 mg
Trazodone
1 PM
2
N/A
0
0
0
12/24/14
ID/NAME: Kelly
10 PM
50 mg
Trazodone
1 PM
2
N/A
0
0
0
12/25/14
10 PM
50 mg
Trazodone
12:45 PM
2
N/A
0
0
0
12/26/14
10 min.
1
15 min.
5:30 AM
15 min.
5 min.
1
10 min.
5:30 AM
3. How long did it take you to fall asleep?
4. How many times did you wake up, not counting your final awakening?
5. In total, how long did these awakenings last?
6a. What time was your final awakening?
6b. After your final awakening, how long did you spend in bed trying to sleep? 15 min.
5:45 AM
Very
poor
Poor
Fair
✓ Good
Very
good
N/A
5:45 AM
Very
poor
Poor
Fair
✓ Good
Very
good
6d. If yes, how much earlier?
7. What time did you get out of bed for the day?
8. How would you rate the quality of your sleep?
Figure 10.8 Continued
No
N/A
No
6c. Did you wake up earlier than you planned?
Good
Very
good
Very
poor
Poor
✓ Fair
5:45 AM
N/A
No
15 min.
5:30 AM
10 min.
1
10 min.
11:30
PM
Very
good
Very
poor
Poor
Fair
✓ Good
5:40 AM
N/A
No
30 min.
5:30 AM
10 min.
1
5 min.
11:30
PM
Good
Very
good
Very
poor
Poor
✓ Fair
Very
poor
Poor
Fair
✓ Good
Very
good
6:20 AM
N/A
No
1 hour
6:20 AM
5 min.
1
15 min.
11:30
PM
6:00 AM
N/A
No
30 min.
5:30 AM
0
0
5 min.
1:00 AM
11:30
PM
11:30
PM
1:00 AM
11:30
PM
11:30
PM
2. What time did you try to go to sleep?
11:30
PM
11:30
PM
1. What time did you get into bed?
11:30
PM
12/27/14 12/28/14 12/29/14 12/30/14 12/31/14 1/1/15
ID/NAME: Kelly
Today’s Date
Consensus Sleep Diary-M (Please Complete Upon Awakening)
Very
good
Very
poor
Poor
Fair
✓ Good
5:30 AM
N/A
No
1 hour
5:30 AM
10 min.
1
20 min.
11:30
PM
11:30
PM
1/2/15
N/A
2
1 PM
N/A
2
1 PM
No
10b. What time was your last drink?
11a. How many caffeinated drinks (coffee, tea, soda,
energy drinks) did you have?
11b. What time was your last drink?
12. Did you take any over-the-counter or prescription
medication(s) to help you sleep?
Figure 10.8 Continued
13. Comments (if applicable)
If so, list medication(s), dose, and time taken
No
0
0
0
9b. In total, how long did you nap or doze?
0
0
0
9a. How many times did you nap or doze?
10a. How many drinks containing alcohol did you have?
12/28/14
12/27/14
Today’s Date
No
No
1 PM
2
1:15 PM
N/A
2
0
0
0
12/30/14
No
1 PM
2
12 AM
2
0
0
12/31/14
ID/NAME: Kelly
N/A
0
0
0
12/29/14
Consensus Sleep Diary-M (Please Complete Upon Awakening)
New Year’s
Eve
No
1 PM
2
N/A
0
0
0
1/1/15
No
1:35 PM
2
N/A
1
0
0
1/2/15
23:30
23:30
10.00
10.00
5:30
0.00
5:45
23:30
23:30
10.00
15.00
5:30
0.00
5:45
23:30
23:30
5.00
10.00
5:30
0.00
5:45
0.00
5:40
10.00
5:30
5.00
23:30
23:30
day 4
0.00
6:00
0.00
5:30
5.00
1:00
1:00
day 5
0.00
6:20
5.00
6:20
15.00
23:30
23:30
day 6
0.00
5:30
6.11 Time in Bed
5.60 Total Sleep Time
91.49% Sleep Efficiency
0.00 Minutes awake too early
5:49 Out of bed for day
8.57 Mins. awake in middle of night
8:52 Wake time
10.00 Latency to fall asleep
20.00
10.00
5:30
23:34 Bedtime
23:34 Lights out
AVERAGE
23:30
23:30
day 7
6.00
6.25
5.00
6.25
6.17
6.25
6.83
8.25
5.50
5.58
4.42
5.67
5.75
5.75
6.50
5.75
69.70% 92.00% 89.28% 90.72% 93.19% 88.40% 95.16% 91.67%
day 3
day 2
day 1
Figure 10.9 Kelly sleep diary calculations from week 2 of session 4
Time in Bed (TIB)
Total Sleep Time (TST)
Sleep Efficiency (SE) %
sample
1/1/2011
Dates
23:30
Bedtime (Time went into bed)
23:45
Lights out (Try to go to sleep)
Latency to sleep (minutes to fall
30
asleep)
Minutes awake in middle of night
60
(how long awakenings last)
7:00
Wake time (time of final awakening)
Mins awake too early (how many
30
minutes earlier)
8:00
Out of bed (out of bed for the day)
35
30
25
20
15
10
5
0
Assessment
Session 1
Session 2
Session 3
Session 4
Figure 10.10 Kelly’s Insomnia Severity Index scores throughout treatment
Lastly, it is important that the therapist models a curious, open stance to problem-solving
so that the client can remain confident, when troubleshooting independently. When
clients understand their sleep system and experience improvements based on implementing their behavioral change strategies, they will be confident in the post-treatment
phase. CBT-I is a robust, durable treatment, and effective insomnia treatment may have
preventative or ameliorative effects on the depression; thus, CBT-I is an easy and
important clinical endeavor.
Appendix A: Core Sleep Diary
General Instructions
What is a Sleep Diary? A sleep diary is designed to gather information about your daily
sleep pattern.
How often and when do I fill out the sleep diary? It is necessary for you to complete
your sleep diary every day. If possible, the sleep diary should be completed within one
hour of getting out of bed in the morning.
What should I do if I miss a day? If you forget to fill in the diary or are unable to finish
it, leave the diary blank for that day.
What if something unusual affects my sleep or how I feel in the daytime? If your
sleep or daytime functioning is affected by some unusual event (such as an illness, or
an emergency) you may make brief notes on your diary.
What do the words ‘bed’ and ‘day’ mean on the diary? This diary can be used for people
who are awake or asleep at unusual times. In the sleep diary, the word ‘day’ is the time
when you choose or are required to be awake. The term ‘bed’ means the place where
you usually sleep.
Will answering these questions about my sleep keep me awake? This is not usually a
problem. You should not worry about giving exact times, and you should not watch the
clock. Just give your best estimate.
186 Appendix A
Item Instructions
Use the guide below to clarify what is being asked for each item of the Sleep Diary.
Date: Write the date of the morning you are filling out the diary.
1. What time did you get into bed? Write the time that you got into bed. This may not be the
time that you began ‘trying’ to fall asleep.
2. What time did you try to go to sleep? Record the time that you began ‘trying’ to fall asleep.
3. How long did it take you to fall asleep? Beginning at the time you wrote in question 2, how
long did it take you to fall asleep?
4. How many times did you wake up, not counting your final awakening? How many times
did you wake up between the time you first fell asleep and your final awakening?
5. In total, how long did these awakenings last? What was the total time you were awake
between the time you first fell asleep and your final awakening? For example, if you woke
3 times for 20 minutes, 35 minutes, and 15 minutes, add them all up (20+35+15= 70 min
or 1 hr. and 10 min).
6. What time was your final awakening? Record the last time you woke up in the morning.
7. What time did you get out of bed for the day? What time did you get out of bed with
no further attempt at sleeping? This may be different from your final awakening time
(e.g. you may have woken up at 6:35 AM but did not get out of bed to start your day
until 7:20 AM)
8. How would you rate the quality of your sleep? ‘Sleep Quality’ is your sense of whether your
sleep was good or poor.
9. Comments If you have anything that you would like to say that is relevant to your sleep
feel free to write it here.
11:30
PM
55 min.
3 times
1 hour
10 min.
6:35 AM
7:20 AM
Very
poor
✓ Poor
2. What time did you try to go to sleep?
3. How long did it take you to fall asleep?
4. How many times did you wake up, not counting your final
awakening?
5. In total, how long did these awakenings last?
6. What time was your final awakening?
7. What time did you get out of bed for the day?
8. How would you rate the quality of your sleep?
9. Comments (if applicable)
10:15
PM
1. What time did you get into bed?
I have a
cold
Fair
Good
Very
good
4/5/11
Today’s Date
Sample
Very
poor
Poor
Fair
Good
Very
good
Consensus Sleep Diary Core-M (Please Complete Upon Awakening)
Very
poor
Poor
Fair
Good
Very
good
Very
poor
Poor
Fair
Good
Very
good
Very
poor
Poor
Fair
Good
Very
good
Very
poor
Poor
Fair
Good
Very
good
Very
poor
Poor
Fair
Good
Very
good
ID/NAME: ______________________________
Very
poor
Poor
Fair
Good
Very
good
Appendix B: Expanded Sleep Diary
General Instructions
What is a Sleep Diary? A sleep diary is designed to gather information about your daily
sleep pattern.
How often and when do I fill out the sleep diary? It is necessary for you to complete
your sleep diary every day. If possible, the sleep diary should be completed within one
hour of getting out of bed in the morning.
What should I do if I miss a day? If you forget to fill in the diary or are unable to finish
it, leave the diary blank for that day.
What if something unusual affects my sleep or how I feel in the daytime? If your
sleep or daytime functioning is affected by some unusual event (such as an illness, or
an emergency) you may make brief notes on your diary.
What do the words ‘bed’ and ‘day’ mean on the diary? This diary can be used for people
who are awake or asleep at unusual times. In the sleep diary, the word ‘day’ is the time
when you choose or are required to be awake. The term ‘bed’ means the place where
you usually sleep.
Will answering these questions about my sleep keep me awake? This is not usually a
problem. You should not worry about giving exact times, and you should not watch the
clock. Just give your best estimate.
Appendix B 189
Sleep Diary Item Instructions
Use the guide below to clarify what is being asked for each item of the Sleep Diary.
Date: Write the date of the morning you are filling out the diary.
1. What time did you get into bed? Write the time that you got into bed. This may not be
the time you began ‘trying’ to fall asleep.
2. What time did you try to go to sleep? Record the time that you began ‘trying’ to fall
asleep.
3. How long did it take you to fall asleep? Beginning at the time you wrote in question 2,
how long did it take you to fall asleep?
4. How many times did you wake up, not counting your final awakening? How many times
did you wake up between the time you first fell asleep and your final awakening?
5. In total, how long did these awakenings last? What was the total time you were awake
between the time you first fell asleep and your final awakening? For example, if you
woke 3 times for 20 minutes, 35 minutes, and 15 minutes, add them all up
(20+35+15= 70 min or 1 hr. and 10 min).
6a. What time was your final awakening? Record the last time you woke up in the morning.
6b. After your final awakening, how long did you spend in bed trying to sleep? After the last
time you woke-up (Item #6a), how many minutes did you spend in bed trying to sleep?
For example, if you woke up at 8 AM but continued to try and sleep until 9 AM, record
1 hour.
6c. Did you wake up earlier than you planned? If you woke up or were awakened earlier
than you planned, check yes. If you woke up at your planned time, check no.
6d. If yes, how much earlier? If you answered ‘yes’ to question 6c, write the number of
minutes you woke up earlier than you had planned on waking up. For example, if you
woke up 15 minutes before the alarm went off, record 15 minutes here.
7. What time did you get out of bed for the day? What time did you get out of bed with no
further attempt at sleeping? This may be different from your final awakening time (e.g.
you may have woken up at 6:35 AM but did not get out of bed to start your day until
7:20 AM)
8. In total, how long did you sleep? This should just be your best estimate, based on when
you went to bed and woke up, how long it took you to fall asleep, and how long you
were awake. You do not need to calculate this by adding and subtracting; just give your
best estimate.
9. How would you rate the quality of your sleep? ‘Sleep Quality’ is your sense of whether
your sleep was good or poor.
10. How restful or refreshed did you feel when you woke up for the day? This refers to how
you felt after you were done sleeping for the night, during the first few minutes that you
were awake.
190 Appendix B
11a. How many times did you nap or doze? A nap is a time you decided to sleep during the
day, whether in bed or not in bed. ‘Dozing’ is a time you may have nodded off for a few
minutes, without meaning to, such as while watching TV. Count all the times you
napped or dozed at any time from when you first got out of bed in the morning until
you got into bed again at night.
11b. In total, how long did you nap or doze? Estimate the total amount of time you spent
napping or dozing, in hours and minutes. For instance, if you napped twice, once for 30
minutes and once for 60 minutes, and dozed for 10 minutes, you would answer ‘1 hour
40 minutes.’ If you did not nap or doze, write ‘N/A’ (not applicable).
12a. How many drinks containing alcohol did you have? Enter the number of alcoholic drinks
you had where one drink is defined as one 12 oz. beer (can), 5 oz. wine, or 1.5 oz. liquor
(one shot).
12b. What time was your last drink? If you had an alcoholic drink yesterday, enter the time of
day in hours and minutes of your last drink. If you did not have a drink, write ‘N/A’
(not applicable).
13a. How many caffeinated drinks (coffee, tea, soda, energy drinks) did you have? Enter the
number of caffeinated drinks (coffee, tea, soda, energy drinks) you had where for coffee
and tea, one drink = 6-8 oz.; while for caffeinated soda one drink = 12 oz.
13b. What time was your last caffeinated drink? If you had a caffeinated drink, enter the time
of day in hours and minutes of your last drink. If you did not have a caffeinated drink,
write ‘N/A’ (not applicable).
14. Did you take any over-the-counter or prescription medication(s) to help you sleep? If so,
list medication(s), dose, and time taken: List the medication name, how much and when
you took EACH different medication you took tonight to help you sleep. Include
medication available over the counter, prescription medications, and herbals (example:
Sleepwell 50 mg 11 PM). If every night is the same, write “same” after the first day.
15. Comments: If you have anything that you would like to say that is relevant to your sleep
feel free to write it here.
11:30
PM
55 min.
6 times
2 hours
5 min.
6:35 AM
45 min.
2. What time did you try to go to sleep?
3. How long did it take you to fall asleep?
4. How many times did you wake up, not counting your final
awakening?
5. In total, how long did these awakenings last?
6a. What time was your final awakening?
6b. After your final awakening, how long did you spend in bed
trying to sleep?
6d. If yes, how much earlier?
1 hour
✓ Yes
No
10:15
PM
1. What time did you get into bed?
6c. Did you wake up earlier than you planned?
4/5/11
Today’s Date
Sample
Yes
No
Consensus Sleep Diary-M (Please Complete Upon Awakening)
Yes
No
Yes
No
Yes
No
Yes
No
ID/NAME: ______________________________
Yes
No
Yes
No
Very
poor
Poor
Fair
Good
Very
good
Not at
all
rested
Slightly
rested
Somewhat
rested
Wellrested
Very
wellrested
7:20 AM
4 hours
10 min.
Very
poor
✓ Poor
Fair
Good
Very
good
Not at
all
rested
✓ Slightly
rested
Somewhat
rested
Wellrested
Very
wellrested
7. What time did you get out of bed for the day?
8. In total, how long did you sleep?
9. How would you rate the quality of your sleep?
10. How rested or refreshed did you feel when you woke-up for
the day?
Very
poor
Poor
Fair
Good
Very
good
Not at
all
rested
Slightly
rested
Somewhat
rested
Wellrested
Very
wellrested
Very
poor
Poor
Fair
Good
Very
good
Not at
all
rested
Slightly
rested
Somewhat
rested
Wellrested
Very
wellrested
Not at
all
rested
Slightly
rested
Somewhat
rested
Wellrested
Very
wellrested
Very
poor
Poor
Fair
Good
Very
good
Not at
all
rested
Slightly
rested
Somewhat
rested
Wellrested
Very
wellrested
Very
poor
Poor
Fair
Good
Very
good
Not at
all
rested
Slightly
rested
Somewhat
rested
Wellrested
Very
wellrested
Very
poor
Poor
Fair
Good
Very
good
Not at
all
rested
Slightly
rested
Somewhat
rested
Wellrested
Very
wellrested
Very
poor
Poor
Fair
Good
Very
good
9:20 PM
2 drinks
3 :00
PM
12a. How many drinks containing alcohol did you have?
12b. What time was your last drink?
13a. How many caffeinated drinks (coffee, tea, soda, energy
drinks) did you have?
13b. What time was your last drink?
© Consensus Sleep Diary 2011
15. Comments (if applicable)
If so, list medication(s), dose, and time taken
Dose:
Time(s)
taken:
Dose:
Time(s)
taken:
Dose:
50 mg
Time(s)
taken:
11 PM
I have a
cold
Medication(s):
Yes
No
Medication(s):
Yes
No
Dose:
Time(s)
taken:
Time(s)
taken:
Medication(s):
Yes
No
Dose:
Medication(s):
Yes
No
Time(s)
taken:
Dose:
Medication(s):
Yes
No
ID/NAME: ______________________________
Medication(s):
RelaxoHerb
✓Yes
No
3 drinks
11b. In total, how long did you nap or doze?
14. Did you take any over-the-counter or prescription
medication(s) to help you sleep?
2 times
1 hour
10 min.
11a. How many times did you nap or doze?
4/5/11
Today’s Date
Sample
Consensus Sleep Diary-M (Please Complete Upon Awakening)
Time(s)
taken:
Dose:
Medication(s):
Yes
No
Time(s)
taken:
Dose:
Medication(s):
Yes
No
Appendix C: Daytime Insomnia
Symptom Response Scale
People think and do many different things when they feel tired. Please read each of the
items below and indicate whether you almost never, sometimes, often, or almost always
think or do each one when you feel tired. Please select only one answer. Please indicate
what you generally do, not what you think you should do.
1 = Almost Never
2 = Sometimes
3 = Often
4 = Almost Always
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
1. Think, “I won’t be able to do work because I feel so bad”
2. Think about your feelings of fatigue
3. Think about how hard it is to concentrate
4. Think about how unmotivated you feel
5. Think about how your thoughts are cloudy or muddled
6. Think about how everything requires more effort than usual
7. Think, “Why can’t I get going?”
8. Think about how sad you feel
9. Think about how you don’t feel up to doing anything
10. Think about your feelings of achiness
11. Think about how bad you feel
12. Think about how hard it is to keep your mind on task
13. Think about how tired you feel
14. Think, “I can’t shake this feeling off”
15. Think about how irritable you feel
16. Think about how sleepy you feel
17. Think, “I can’t seem to pay attention”
18. Think, “I’m so forgetful”
19. Think, “I can’t be around people when I’m feeling this way”
20. Think about how you don’t have the energy to get through the
day
Appendix D: TRAP or TRAC
Worksheet
TRAP
TRIGGER
RESPONSE
AVOIDANCE
PATTERN
OUTCOME
TRAC
TRIGGER
RESPONSE
ALTERNATIVE
COPING
OUTCOME
Appendix E: Daily Activity
Monitoring Form
Time
6–7 AM
7–8 AM
8–9 AM
9–10 AM
10–11 AM
11–12 AM
12–1 PM
1–2 PM
2–3 PM
3–4 PM
4–5 PM
5–6 PM
6–7 PM
7–8 PM
8–9 PM
9–10 PM
10–11 PM
11–12 AM
12–1 AM
1–2 AM
2–3 AM
3–4 AM
4–5 AM
5–6 AM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Appendix F: Goal Tracking Form
Name: ________________________
Session Week # ____
GOAL TRACKING FORM
Activity
Set GOAL
Record of Goal Attempts
Frequency Duration
M
T
W
T
F
Sa
Su
Appendix G: Blank Pro-Depression
and Anti-Depressant Worksheet
Pro-Depression Behaviors
Anti-Depressant Behaviors
Appendix H: Blank Pro-Sleep versus
Pro-Insomnia Worksheet
Pro-Insomnia Behaviors
Pro-Sleep Behaviors
Appendix I: Blank Pro-Energy versus
Pro-Fatigue Worksheet
Pro-Fatigue Behaviors
Pro-Energy Behaviors
Appendix J: BABIT Continuum
Exercise
Establishing Insomnia and Depression
on a Continuum of Symptoms
No
depression
Depression
diagnosis
No
insomnia
Insomnia
diagnosis
Severe
depression
Severe
insomnia
Appendix K: Behavioral
Experiment Monitoring
Belief to test:
Week One Experiment:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Wednesday
Thursday
Friday
Saturday
Sunday
Week Two Experiment:
Monday
Tuesday
References
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Index
abbreviated behavioral and cognitive
therapy (ABCT) 29
actigraph 34, 48, 114
American Academy of Sleep Medicine:
guidelines for treating insomnia 14–15
arousal system: dysregulation 8
assessment of sleepiness 49–50
behavioral activation (BA) 49, 90–91, 105,
108, 122, 125, 133, 135, 136–154
Behavioral Activation with Behavioral
Insomnia Therapy (BABIT) 67, 136–156
behavioral experiments (BE) 89–93, 99, 105,
108, 120, 122, 171, 177
bibliotherapy for CBT-I 34
brief behavioral insomnia therapy (BBIT)
29
Buysse, D. J 1–2, 10, 14–15, 26, 29, 41, 48,
115
chronotype 6
Circadian Psychoeducation script 7–8
Circadian Rhythm Disorders 54–56
circadian system dysregulation 5–8
Cognitive Behavior Therapy for Insomnia
(CBT-I) 15, 24, 26–36
Cognitive Model of insomnia 81
Cognitive Therapy 32, 60, 83
conditioned arousal 9, 63, 66, 163
Consensus Sleep Diary 41, 185–193
contraindications for CBT-I 27, 36
Coping Cards 93–94
counter arousal strategies 32, 60, 75–77, 78,
161
early morning awakenings (EMAs) 9,
100–101, 119
Electroconvulsive therapy (ECT) 19–20
Espie, C. 9, 12, 13, 18, 24, 26, 28–29, 39,
75–76, 81–82, 107
etiology of insomnia 2–3
etiology of insomnia in MDD 12–13
excessive daytime sleepiness 49–50
Group Therapy CBT-I 32–3
Harvey, A. 9, 12, 18, 24, 48, 76, 81–83, 86,
93, 95, 107, 116–117, 120
Homeostatic Psychoeducation script
3–5
Homeostatic System dysregulation 3–5
hypnotic medication discontinuation
30–32
hypnotic medications 20–1
internet-delivered CBT-I 35
Kupfer, D. 1, 10, 41, 111
Manber, R. 2, 13, 26, 28–29, 34–35, 62–63,
96, 113, 126, 131, 134–136
melatonin supplements 23
metacognition 122–125
Mindfulness Based Treatment for Insomnia
122, 123, 131
Morin, C. 1, 15, 24, 26, 28, 30–32, 40–41, 49,
58, 60, 63, 68, 73, 76, 81, 83, 95, 107, 136,
154
narcolepsy 53
Diphenhydramine (off-label use) 22
Doxepin 21–22
obstructive sleep apnea (OSA) 50–52
226
Index
Pennebaker technique 76
periodic limb movement disorder 53
polysomnography (PSG) 34, 47, 114, 132
positive airway pressure (PAP) device 20,
27, 51
smart phone applications 33
Socratic questioning 86–89
Spielman’s 3P Model 2
Stimulus Control 60, 63–67
St. John’s Wort 19
rapid eye movement sleep markers in
depression 9–11
relaxation therapies 76
resources for those with insomnia and
depression 35
restless leg syndrome (RLS) 17, 52
Riemann, D. 10–11, 14, 16, 28
rumination 12, 18, 48, 80, 82, 120–122
Thase, M. 2, 136
Thought Records 84–86, 87
Transcranial magnetic stimulation 20
trazodone 16–17
troubleshooting avoidance 105–106
troubleshooting cognitive difficulties 112
troubleshooting eveningness/night owl
problems 99–100
troubleshooting problems with anhedonia
104–105
troubleshooting problems with fatigue
106–109
troubleshooting problems with mobility
109–110
sleep diaries 41, 61, 114
sleep disordered breathing 50–51, 118
sleep effort 12, 58, 67, 82
sleep hygiene 60, 72–75
sleep inertia 98–99
sleep restriction 60, 68-72
sleep state misperception 115
slow wave activity marker in depression 9
Vagus nerve stimulation 20
5-Hydroxytryptophan (5-HTP) 24
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