Rehab
3-Day Intensive Training:
Cognitive Behavioral Therapy
for Insomnia (CBT-I)
Evidence-based Insomnia Interventions
for Trauma, Anxiety, Depression,
Chronic Pain, TBI, Sleep Apnea and
Nightmares
Colleen E. Carney, Ph.D.,
Meg Danforth, Ph.D.
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3-Day Intensive Training:
Cognitive Behavioral Therapy
for Insomnia (CBT-I)
Evidence-based Insomnia Interventions
for Trauma, Anxiety, Depression,
Chronic Pain, TBI, Sleep Apnea and
Nightmares
Colleen E. Carney, Ph.D.,
Meg Danforth, Ph.D.
Rehab
ZNM053530
3/18
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102pp
3/18
Rehab
MATERIALS PROVIDED BY
Colleen E. Carney, Ph.D., has been solving sleep issues for the past
15+ years. She is a leading expert in psychological treatments
for insomnia, particularly in the context of co-occurring mental
health issues.
Dr. Carney is the director of the Sleep and Depression Laboratory
at the Department of Psychology at Ryerson University. Her
work has been featured in The New York Times and she has over
100 publications on insomnia. She frequently trains students
and mental health providers in CBT for insomnia at invited
workshops throughout North America and at international
conferences. Dr. Carney is a passionate advocate for improving
the availability of treatment for those with insomnia and other
health problems.
Speaker Disclosures:
Financial: Colleen Carney is a professor at Ryerson University. She receives a speaking
honorarium from PESI, Inc.
Non-financial: Colleen Carney is a member of the Canadian Psychological Association; and the
Association for Behavioural and Cognitive Therapies (ABCT).
Meg Danforth, Ph.D., is a licensed psychologist and certified
behavioral sleep medicine specialist who has been helping
people sleep better without medication for the past 15 years.
She is a clinician and educator at Duke University Medical Center
in Durham, NC. As the director of the Duke Behavioral Sleep
Medicine Clinic, she provides advanced clinical care to patients
with sleep disorders and comorbid medical and mental health
issues. She also provides clinical training and supervision to
psychology graduate students, interns, and fellows. Dr. Danforth
is committed to teaching clinicians from a variety of backgrounds
to deliver CBT-I in the settings in which they practice. Her work
has been featured in the Associated Press and CBS News.
Speaker Disclosures:
Financial: Margaret Marion Danforth is a clinical associate at Duke University Medical Center. She
receives a speaking honorarium from PESI, Inc.
Non-financial: Margaret Marion Danforth is a member of the Association for Behavioral and
Cognitive Therapies.
Materials that are included in this course may include interventions and modalities that are beyond the
authorized practice of mental health professionals. As a licensed professional, you are responsible for
reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of
practice in accordance with and in compliance with your professions standards.
CBT-I:
Evidence-based insomnia interventions
forTrauma, Anxiety, Depression,
Chronic Pain,TBI, Sleep Apnea, and Nightmares
Colleen Carney, Ph.D.
Ryerson University
Meg Danforth, Ph.D. CBSM
Duke University Medical Center
Time
Topics
8:00-10:00
Welcome
Assessment
Sleep and Its Regulation
10:00-10:15 Break
10:15-12:00 Step-by-Step Guide to CBT-I: Stimulus Control and Sleep
Restriction Therapies
12:00-1:00
Lunch
1:00-2:30
Step-by-Step Guide to CBT-I: Cognitive Therapy and
Counterarousal
2:30-2:45
Break
2:45-4:00
Implementation Issues
1
2
*Most CBT trials focus on these types of complaints. There is some controversy
with quantitative criteria (e.g., Lineberger, Carney, Edinger, & Means, 2006)
3
Electrical
Movement
Experience
Prospective
Prospective
Prospective
Objective
Objective
Dubious validity in
insomnia (Littner et
al., 2003)
Dubious validity in
insomnia
(Chambers, 1994)
Insomnia is a
subjective disorder
Essential tool
(Buysse et al., 2006)
(Johns, 1991)
See Buysse et al., 2006 for discussion
4
Treating insomnia with untreated apnea is ineffective and unsafe
Chung et al. (2008)
• Snore
• (Not really tiredness) Sleepiness
• Observed apneas
• High Blood Pressure
• BMI over 35 kg/m2?
• Age: Older than 50 years old?
• Neck size larger than 43 cm (17”+)?
• Gender: Male?
Yes to 2 or more → referral to sleep clinic
www.stopbang.ca/osa/screening.php
8pm
11pm
2am
6am
10am
Conventional Sleep Phase
Delayed Sleep Phase
Advanced Sleep Phase
5
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
11:00
pm
1:30
am
12:30
am
11:00
pm
1:00
am
2:00
am
11:15
pm
120 min
90 min
50 min
35 min
60 min
60 min
120 min
10 min
15 min
5 min
15 min
5 min
5 min
15 min
Wake
time
6
am
6:15
am
6:10
am
6
am
6:05
am
8:00
am
7:50
am
Rise
time
7:50
am
8:30
am
7:45
am
6:15
am
7:45
am
10:45
am
10:30
am
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
12:00
am
1:30
am
12:30
am
12:00
am
2:30
am
3:00
am
12:30
am
180 min
90 min
150 min
170 min
35 min
5 min
120 min
10 min
15 min
5 min
10 min
5 min
5 min
15 min
Wake
time
8
am
8
am
8
am
8
am
8
am
2
pm
2:30
pm
Rise
time
8:30
am
8:45
am
8:30
am
9
am
8:45
am
2:15
pm
2:40
pm
Bedtime
Time to
fall
asleep
Time
awake
during
night
Bedtime
Time to
fall
asleep
Time
awake
during
night
6
7
(See Borbely et al., 2016)
determines the amount and quality of sleep
Sleep
9am
3pm
9pm
3am
9am
Sleep
8
determines the timing of sleep and wakefulness
M
Wake
9am
3pm
9pm
3am
9am
Sleep
• Timing
• Clock determines timing of sleep especially REM sleep
timing AND timing of alertness
• Managing Drift
• There is drift in our clock because it is longer than 24
hours
• Regular bedtimes, regular rise times and regular light
exposure “set” the clock and manage drift
9
We need to keep a schedule or we will suffer from
“social jetlag”
10
Increased Physiological
(Hyper)arousal in Insomnia
Physiological Hyperarousal on
Multiple Sleep Latency Test
Propensity to nap
↓
↓
↑
↑
“Tired but wired”
(Bonnet et al., 2014)
Do wakeful activities in bed – train yourself to be awake
Consider also: hot flashes, pain, nightmares, panic . . .
Ask about “the switch”
11
Precipitating
factor(s)
Coping with the sleep disruption
Homeostatic Disruption
Reduced sleep drive
Circadian Disruption
Improper
Sleep Scheduling
Arousal
Cognitive
Poor sleep habits
Conditioned
arousal
Chronic Insomnia
(Spielman, 1987; Webb, 1988)
12
Monday
Tuesday
Wednesday
Thursday
Saturday
Sunday
11:00
pm
11:30
pm
11:05
pm
10:35
pm
10:55
pm
12:15
am
10:15
pm
Time to
fall
asleep
25
20
40
60
35
15
95
Time
awake
during
night
20
25
15
35
20
45
60
Wake
time
7
am
7
am
7
am
7
am
7
am
8:40
am
7:50
am
7:15
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
11:45
am
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
11:00
pm
12:30
am
1:05
am
10:35
pm
12:55
am
2:15
am
10:15
pm
Time to
fall
asleep
25
20
40
60
35
15
95
Time
awake
during
night
20
25
15
35
20
45
60
Wake
time
6
am
6
am
6
am
6
am
6
am
8:40
am
7:50
am
7:15
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
11:45
am
Bedtime
Rise
time
Bedtime
Rise
time
Friday
13
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
11:00
pm
9:30
pm
11:00
pm
10:35
pm
9:15
pm
12:00
am
10:30
pm
100 min
50 min
60 min
120 min
45 min
55 min
90 min
5 min
15 min
15 min
10 min
15 min
15 min
20 min
Wake
time
6
am
6
am
6
am
6
am
6
am
8:40
am
7:50
am
Rise
time
7:15
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
8:45
am
Bedtime
Time to
fall
asleep
Time
awake
during
night
Treatment
# of Studies Classification
Stimulus Control
6
Well-established
Relaxation Therapies
8
Well-established
Paradoxical Intention
3
Well-established
Sleep Restriction Therapy
3
Well-established
CBT (no relaxation)
6
Well-Established
CBT + relaxation
6
Well-Established
EMG Biofeedback
4
Probably efficacious
Other Multi-component
3
Probably efficacious
Cognitive Therapy
0
Not supported
Sleep Hygiene Education
3
Not supported
(Morin et al., 2006)
Perpetuating Factors and CBT-I
Cognitive
Therapy /
Counter-Arousal
Relaxation /
mindfulness
Homeostatic Disruption
Reduced sleep drive
Sleep Restriction
Circadian Disruption
Improper/irregular
Sleep Scheduling
Stimulus Control
Chronic Insomnia
(Adapted from Webb, 1988)
Arousal
Cognitive
Poor sleep habits
Conditioned
arousal
Sleep Hygiene
14
Stimulus Control Therapy:
The Bed-Sleep Connection
(Bootzin, 1972)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
11:00
pm
9:30
pm
11:00
pm
10:35
pm
9:15
pm
12:00
am
10:30
pm
35 min
25 min
15 min
20 min
25 min
15 min
30 min
100 min
50 min
60 min
120 min
45 min
55 min
90 min
Wake
time
6
am
6
am
6
am
6
am
6
am
8:40
am
7:50
am
Rise
time
7:15
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
8:45
am
Bedtime
Time to
fall
asleep
Time
awake
during
night
3 naps attempted this week
15
Activity
Likelihood that it
would prevent
sleepiness from
occurring
Result of the
Experiment
Watch series on Netflix
50/50
Seemed ok. Went
back to bed 40
minutes later
Catch up on social
media
60%
Too interesting.
Stopped after 2 hours
Listen to jazz
10%
Worked well. Fun and
I got sleepy quickly
Adapted from Quiet Your Mind and Get to Sleep (Carney & Manber, 2009)
“I can’t get up at the designated
rise time!”
Find out why.
Difficulty
Action Plan
Rationale not compelling/understood
Review multiple times, check-in,
handouts
Comfort
Consider a transition plan to address
comfort
Anhedonia
Contingencies: Plan activities (that
involve commitment to others); elicit
help from significant others
Alarm
Use multiple, staggered alarm clocks;
elicit help from others
Eveningness
Morning light sets the clock and
increases alertness
16
*Sleep Efficiency (SE) is the percent of time
asleep relative to the time spent in bed
Sleep Restriction Therapy (SRT) or
Time-in-Bed Restriction
In general, we do not prescribe less than 5.5 hours time-in-bed.
(Spielman et al., 1987)
17
Bedtime
Time to
fall
asleep
Time
awake
during
night
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
10:00
pm
9:30
pm
8:30
pm
9:45
pm
8:45
pm
8:30
pm
Sunday
9:30 pm
45 min
60 min
90 min
45 min
120 min
90 min
60 min
M Time in bed (TIB) = 9.85 hours
M Total sleep time (TST) = 7.75 hours
0 min
15 min
30 min
0 min
0 min
60 min
45 min
Wake
time
6:15
am
6:15
am
6:30
am
6:15
am
6:30
am
7:00
am
7:30
am
Rise
time
6:30
am
6:30
am
7:00
am
6:30
am
7:00
am
8:30
am
8:00
am
TIB
8:30
9:00
10:00
8:45
10:15
12:00
10:30
TST
7:30
7:30
7:30
7:45
7:45
8:00
8:45
Sleep opportunity window should consider
Eveningness/morningness
tendency
Life constraints (e.g., work
schedule)
Collaborate to determine out-of-bed (rise) time
Instruct to get out of bed shortly after waking
Determine bedtime based on time-in-bed and rise time
Count back from rise
time
Bedtime
Time to
fall
asleep
Time
awake
during
night
Example: Time in bed=6 hours
Rise time= 6AM  Bedtime =12AM
Monday
Tuesday
Wednesday
Thursday
10:00
pm
9:30
pm
10:00
pm
9:45
pm
Friday
10:30
pm
Saturday
11:00
pm
Sunday
9:30 pm
90 min
120 min
90 min
45 min
120 min
30 min
120 min
M Time in bed (TIB) = 9 hours
M Total sleep time (TST) = 6 hours
60 min
90 min
30 min
90 min
0 min
0 min
30 min
Wake
time
6:30
am
5:30
am
6:00
am
6:15
am
6:15
am
7:00
am
6:00
am
Rise
time
7:00
am
7:00
am
7:00
am
7:15
am
6:30
am
8:00
am
6:30
am
TIB
9:00
9:30
9:00
9:30
8:00
9:00
9:00
TST
6:00
4:30
6:00
6:15
5:45
7:30
6:00
18
*“I can’t stay up that late. I’m too
sleepy!”
Monday
Tuesday
Wednesday
Thursday
Saturday
Sunday
12:00
am
12:30
am
12:30
am
12:00
am
12:30
am
1:30
am
12:15
am
15 min
25 min
20 min
25 min
25 min
20 min
20 min
10 min
15 min
5 min
10 min
5 min
5 min
15 min
Wake
time
6:15
am
6:15
am
6:35
am
6:15
am
6:35
am
8:00
am
7:30
am
Rise
time
6:30
am
6:40
am
7:00
am
6:25
am
7:05
am
8:30
am
8:00
am
6:10
82%
6:30
87%
6:25
88%
7:00
87%
7:45
86%
Bedtime
Time to
fall
asleep
Time
awake
during
night
TIB
SE%
6:30
90%
Friday
6:35
85%
19
Remember: Sleep Hygiene education is not an evidence-based
treatment for insomnia!
20
21
Concern
Solutions
I have to get
the car
serviced
1. After this
exercise I
can look at
the calendar
to see when
I can do this
2. I can ask
my spouse if
they have
time
Reproduced from Overcoming Insomnia: A Cognitive Behavioral Approach
(Edinger & Carney, 2015)
Excessive mentation: Rumination
RCA: Rumination Cues Action!
(Addis & Martell, 2004)
22
Cultivate a practice, not a mindfulness pill!
23
Consequences
Defective
• There is something
wrong with me
Helpless
• There is nothing I can do
about it
And I need to
exert effort to
fix it (Espie et
al., 2006)
Subsequent
anxiety about
failed attempts
to fix it
(Beck, 1999)
Situation
Coming
back to
the office
from my
lunch
break and
noticed
how tired I
was
Mood
(Intensity
0-100%)
Tired
(100%)
Upset
(100%)
Worried
(80%)
Thoughts
I’m going to get
sick if I keep going
like this
I can’t keep going
on like this
Something really
terrible is going to
happen if this
doesn’t get
resolved.
I could get fired
and eventually
become homeless
Evidence for the
thought
Evidence against
the thought
Adaptive/Coping
statement
I’m not exercising
any longer
I usually start to
feel a little better
later in the
afternoon
Although I tend
to feel lousy at
different times
during the day,
the reality is
that I always
make it through
and nothing
bad has ever
happened as a
result of the
insomnia
I don’t feel like
doing things
I got into trouble
for coming to
work late last
month.
99.9% of the time
I am on-time and
have no
problems at work
My sleep
problems have
been going on for
years and
nothing bad has
happened
Do you feel
any
differently?
Tired
(90%)
Upset (50%)
Worried
(45%)
My job is
secure—I am not
going to be fired
(Padesky, 1993)
24
Behavioral Experiments
Belief
Alternative?
Experiment
I have a limited store of
energy
Conserving energy may
increase fatigue
Expend versus conserve
Poor sleep is dangerous
I may be able to cope
reasonably after poor sleep
Restrict sleep and monitor
coping
I can’t control sleep because
my mind is too active
Perhaps because there isn't
time to process the day?
Constructive worry in
evenings versus status quo
Being tired makes me look
bad
Perhaps others are not
particularly attuned to this
Took series of photos and
tested people’s ratings
Monitoring how I feel helps
me to keep track, in case I
have to make an adjustment
Monitoring increases the
likelihood that you will
perceive minor changes in
energy
Monitor external stimuli and
mood for two hours and then
internal stimuli for 2 hours
I need to nap to get through
the day
If I don’t nap, my nighttime
sleep will improve, and I can
cope
Monitor napping, tiredness
and coping for one week of
naps and one week without
(Ree & Harvey, 2004)
(Harvey & Talbot, 2010)
25
Explore what contributes to how
one feels during the day
Paradoxical Intention
26
Combined SRT/ Stimulus Control:
One-session CBT-I
(e.g., Buysse et al., 2011)
Week 1
Psychoeducation, Stimulus Control, Sleep Restriction Therapy,
Sleep Hygiene (if needed), Buffer zone
Week 2
Week 3
At-home implementation
Troubleshoot adherence, determine if changes necessary to
schedule, add counterarousal and cognitive therapy
Week 4
Week 5
At-home implementation
Troubleshoot adherence, determine if changes necessary to
schedule, continue with cognitive therapy, introduce termination
issues, relapse prevention homework
Week 6
Week 7
At-home implementation
Troubleshoot adherence, determine if changes necessary to
schedule, cognitive therapy, termination issues and relapse
prevention
(Edinger & Carney, 2015)
27
28
29
(Qaseem et al., 2016)
30
Sateia et al., 2017
A WEAK* recommendation reflects a
lower degree of certainty in the
outcome
31
More on this tomorrow!
32
CBT-I:
Evidence-based insomnia interventions
forTrauma, Anxiety, Depression,
Chronic Pain,TBI, Sleep Apnea, and Nightmares
Colleen Carney, Ph.D.
Ryerson University
Meg Danforth, Ph.D. CBSM
Duke University Medical Center
Time
Topics
8:00-10:00
Welcome
Review/Bridging
10:00-10:15 Break
10:15-12:00 Depression and Anxiety
12:00-1:00
Lunch
1:00-2:30
Trauma and TBI
2:30-2:45
Break
2:45-4:00
Chronic Pain
Hypnotic Discontinuation
Precipitating
factor(s)
Coping with the sleep disruption
Homeostatic Disruption
Reduced sleep drive
Circadian Disruption
Improper
Sleep Scheduling
Chronic Insomnia
(Spielman, 1987; Webb, 1988)
Arousal
Cognitive
Poor sleep habits
Conditioned
arousal
Go to bed early
Drink alcohol
Worry about sleep
problem
Try to sleep-in
Try to nap…
33
Session One/One session handout
Sleep Rules
6:00 AM
11:30 PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Bedtime
11:00 pm
11:30 pm
11:15 pm
11:00 pm
11:30 pm
1:15 am
11:00 pm
Time to
fall asleep
25 min
10 min
35 min
20 min
35 min
5 min
20 min
60 min
45min
90 min
75 min
30 min
15 min
60 min
Wake time
7
am
7:15
am
6 :45
am
6:50
am
7
am
8:40
am
9:20 am
Rise time
8:15
am
8:20
am
7:50
am
8:30
am
8:15
am
10:50
am
10:45
am
TIB
9:15
8:50
9:35
11:45
Time
awake
during
night
8:35
9:30
7:45
34
Monday
Tuesday
Wednesday
Thursday
Saturday
Sunday
11:00
pm
9:30
pm
11:00
pm
10:35 pm
9:15
pm
12:00
am
10:30
pm
35 min
25 min
15 min
20 min
25 min
15 min
30 min
100 min
50 min
60 min
120 min
45 min
55 min
90 min
Wake time
6
am
6
am
6
am
6
am
6
am
8:40
am
7:50 am
Rise time
7:15
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
8:45
am
Bedtime
Time to
fall asleep
Time
awake
during
night
Friday
Average total sleep time for the 2 weeks is 6.5 hours
Unaltered* CBT-I is efficacious
35
Perpetuating Factors in Comorbid Insomnia
Kohn & Espie, 2005
Carney, Edinger, Manber,
et al., 2007
PI=MDD-I DBAS
Cognitive Factors
PI=CI sleep effort beliefs
Unhelpful Beliefs
Worry & intrusive thoughts
Kohn & Espie, 2005
PI=CI variability
Homeostatic Disruption
Excessive nocturnal TIB
Daytime Napping
Circadian Disruption
Improper
Sleep Scheduling
Kohn & Espie, 2005
PI=CI excessive TIB
Chronic Insomnia
Inhibitory Factors
Poor sleep hygiene
Conditioned arousal
Kohn & Espie,
2005 PI=CI
arousal
36
Combinations of sleep and
insomnia treatments
Remember
it is 37%
in
STAR*D
SSRI
SLEEP MED
SSRI
37
Compensatory Etiological Model
STRESS
Shared
vulnerability
(e.g., neurochemical
sensitivity,
beliefs,
ruminative
tendency
∆ in chemical activity, life event, illness
Disrupted
sleep
Comorbid
condition
Coping
(↑safety
bx and ↑
effort)
Circadian,
homeostatic
dysregulation,
arousal
I
N
S
O
M
N
I
A
Edinger, Means, Carney & Manber (2011)
Selected evidence for unaltered
CBT-I in MDD
Case Study: Comorbid Insomnia
and Depression
38
Monday
Tuesday
Wednesday
Thursday
Saturday
Sunday
9:00
pm
11:30
pm
11:05
pm
10:35
pm
10:55
pm
11:15
pm
11:15
pm
25
20
40
60
35
15
95
20
25
15
35
20
45
60
Wake
time
8:30
am
7:30
am
7 :30
am
7:15
am
7:20
am
8:40
am
8:50
am
Rise time
9:15
am
8:20
am
8:15
am
8:25
am
7:35
am
8:50
am
11:45
am
Bedtime
Time to
fall
asleep
Time
awake
during
night
Friday
Average Time in Bed = 10 hours
Average Total Sleep Time = 7.93 hours
“I don’t feel like getting up.”
PLAN
OUTSIDE
→ IN
ACTION
CONTINGENCIES
INSIDE
→ OUT
WAIT FOR
MOTIVATION
ACTION
LESS LIKELY
Martell, Dimidjian, & Herman-Dunn (2010)
39
Coping Card
• “I will get up by 7:30 AM every day this week.”
Plan
• I know this will help improve my sleep.
• I will go the coffee shop around the corner and read the
paper. I enjoy doing this.
• I will meet with Joe at the Gym at 8:00 AM on Mondays
and Wednesdays.
Contingencies
• It is hard, but I have to do it if I want to sleep better.
• I can handle getting out of bed at 7:30 AM.
Troubleshooting Dan’s Rising
Adherence Problems
Mood worsening?
7 am
MON
TUES
WED
THURS
FRI
SAT
SUN
SLEEP
SLEEP
SLEEP
SLEEP
SLEEP
SLEEP
SLEEP
8 am
SLEEP
IN BED 8
IN BED 7
IN BED 8
CAFÉ 2
SLEEP
SLEEP
9 am
IN BED 7
LAPTOP 8
GYM 3
LAPTOP 8
WALK 3
SHOWER 5
IN BED 8
10 am
SHOWER 5
LAPTOP 8
BRFT 6
PHONE 5
SHOP 3
IN BED 8
IN BED 8
11 am
BRFT 7
TV 8
GAMING 6
SHOWER 4
BILLS 5
TV IN BED 8
READING 8
12 pm
SCHOOL 5
SCHOOL 5
GAMING 7
SCHOOL 5
SHOWER 4
GAMING 7
SHOWER 6
1 pm
SCHOOL 5
SCHOOL 5
GAMING 7
SCHOOL 5
LUNCH 5
GAMING 6
BRFT 7
2 pm
SCHOOL 5
SCHOOL 5
GAMING 7
SCHOOL 5
TV 8
GAMING 7
NAP 7
3 pm
SCHOOL 5
LAPTOP 8
GAMING 7
SCHOOL 5
COUCH 8
LAPTOP 8
NAP
4 pm
NAP 7
LAPTOP 8
SHOWER 6
LAPTOP 8
COUCH 8
LAPTOP 8
LAPTOP 8
5 pm
READING 5
LAPTOP 8
READING 6
LAPTOP 8
READING 7
LAPTOP 8
LAPTOP 8
6 pm
COOK 4
GAMING 7
GAMING 7
GAMING
GAMING 8
LAPTOP 8
DINNER 4
7 pm
DINNER 5
GAMING 8
NAP 6
GAMING
GAMING 8
GAMING 7
GAMING 5
8 pm
GAMING 8
DINNER 4
DINNER 5
DINNER 4
DINNER 5
READING 6
PHONE 3
9 pm
IN BED 7
GAMING 7
GAMING 6
GAMING 6
GAMING 7
GAMING 7
GAMING 6
READING 8
10 pm
IN BED 6
TV 7
LAPTOP 6
IN BED 7
GAMING 7
DINNER 7
11 pm
TV IN BED 6
TV IN BED 6
TV IN BED 6
TV IN BED 6
TV IN BED 8
IN BED 8
IN BED 7
12 am
TV IN BED 9
TV IN BED 6
TV IN BED 7
TV IN BED 6
TV IN BED 7
TV IN BED 8
IN BED 8
1 am
SLEEP
SLEEP
SLEEP
SLEEP
TV IN BED 8
SLEEP
SLEEP
40
FEELING
THOUGHT
sluggish
MOST
LIKELY
THOUGHT:
THOUGHTS
ABOUT FATIGUE
OR THE
WEATHER?
BEHAVIOR
MOST
LIKELY
BEHAVIOR:
ACTION OR
INACTION?
OUTCOME
MOST
LIKELY
OUTCOME
WITH
ACTION?
INACTION?
Behavioral experiment: test same trigger (mood) but an alternative behavioral
coping response. Does it result in a different, more desired outcome?
Sleep/the Bed as an escape
41
Peripheral, afferent nerves or lower motor neuron issue
Peripheral fatigue
Fatigue
experience
Resting/
avoidance
Central fatigue
Decreased motivation due to perceived imbalance
Chaudhuri & Behan (2004)
42
Bedtime
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
11:00 pm
11:30 pm
11:15 pm
11:00 pm
11:30 pm
1:15 am
11:00 pm
No sleep
No sleep
No sleep
No sleep
No sleep
No sleep
No sleep
8:15
am
8:20
am
7:50
am
8:30
am
8:15
am
10:50
am
10:45
am
Friday
Saturday
Time to
fall
asleep
Time
awake
during
night
Wake
time
Rise time
6 hour sleep
sleepneed
sleep6 hour sleep need
Hours spent in bed
Monday
Tuesday
11:00
pm
11:30
pm
11:05
25
20
20
Wake
time
Rise time
Bedtime
Time to
fall
asleep
Time
awake
during
night
Wednesday
pm
Thursday
Sunday
10:35
pm
10:55
pm
12:15
am
10:15 pm
40
60
35
15
95
25
15
35
20
45
60
7
am
7
am
7
am
7
am
7
am
8:40
am
7:50 am
7:15
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
11:45
am
43
p < .001
p = .392
Significant
group effect
MANOVA
(p < .001)
p = .003
Carney, Harris & Edinger, 2009
(e.g., Lichstein et al., 2001; Riedel, Lichstein & Dwyer, 1995)
44
(Davies, Lacks, Storandt,& Bertelson, 1986)
High sleep-anxiety
High arousal in bed
Stimulus
Control
May need countercontrol instead of
strict Stimulus
Control
Use Stimulus Control
and emphasize counterarousal
Sleep
Restriction
Therapy
May need sleep
Use SRT and emphasize
compression instead
counter-arousal
of SRT
Cognitive therapy
45
Insomnia vs. PTSD targets
Common Targets
Insomnia
only
PTSD +
insomnia
Erratic sleep scheduling


Daytime napping


Alcohol to aid sleep


Hyper-arousal as bedtime approaches


Unhelpful beliefs about sleep-conducive habits/needs


Excessive time in bed*


Sleep avoidance – limiting time in bed at night
Using bed for non-sleep activities*


Hypervigilance during sleep – on guard/checking
Unhelpful beliefs that raise anxiety about sleep loss*
Unhelpful beliefs that raise anxiety about being asleep


46
47
48
Chronic pain
11-55%
39-75%
Obstructive
Sleep Apnea
(OSA)
50-88%
Insomnia 1020%
4-20%
49
(Davies, Lacks, Storandt, & Bertelson, 1986; Hoelscher & Edinger, 1988)
Class
Effect of pain relievers on sleep architecture
N1 and N2
SWS
REMS
NSAIDs
TCAs (amitryptaline)
↑
Variable
SNRIs (duloxetine)
-
↓
↑
-
Anticonvulsants
(gabapentin)
Antispasmotics
(baclofen)
↓
↑
↓
-
↑
-
↑
Opioids*
↓
↓
↓
Cairnes (2007)
50
51
Good = improved sleep + improved daytime function + able to cope with sleep problem
Reasonable = improvement in at least 1 of these 3 areas
No Change = no perceived improvement
52
• “CBT-I works whether you are on or off medications, so
what would you like to do?”
SUSTAINED
RECOVERY
SLEEP SYSTEM
BASELINE
MED
USE
DISSASTISFIED
WITH SLEEP OR
PILLS
CBT-I
SLEEP
IMPROVEMENT
PILLS?
53
CLASSICAL
CONDITIONING OF
PILL TAKING
54
Safety behavior
What message are
you sending yourself
by engaging in this
behavior?
What will you do to
show that it is not
true?
Result of the
experiment
I take a sleeping
pill in the middle of
the night when I
notice I am
“worked-up.”
That I have lost all
confidence in my
ability to sleep.
I’ll refrain from taking
the pill in the middle
of the night and see
what happens.
I felt less groggy on
days in which I didn’t
take the pill
It was initially
frightening but I
noticed that I fell
back to sleep only a
few minutes sooner if
I took the pill
That I don’t think I
can cope with feeling
“worked-up”
Reproduced from Quiet Your Mind and Get to Sleep: Solutions for Insomnia in those with Depression,
Anxiety or Chronic Pain (Carney & Manber, 2009)
Mood (Intensity
0-100%)
Worried
(80%)
Thoughts
I can’t keep going
on like this
I’ve got to take a
pill I’m never
going to get
through
I’ll never
get today
to
sleep I’m
if I going
don’t to
mess
take a
pillup
I need to get
some sleep
I can’t
concentrate
Evidence for the
thought
Evidence against the
thought
Do you feel any
differently?
When I take a pill I
eventually fall
asleep
Eventually I would
fall asleep anyway
Worried (50%)
When I run out of
pills, it’s not like I
don’t sleep at all
I feel crappy the
next day after
taking a pill
anyway
Adapted from: Overcoming Insomnia (Edinger & Carney, 2008)
55
Cognitive Therapy
Review Evidence From Sleep Diary
Martell, Dimidjian, & Herman-Dunn (2010)
TRAP
TRIGGER
RESPONSE
AVOIDANCE
PATTERN
OUTCOME
DELAY IN
FALLING
ASLEEP
ANXIETY
TAKE PILL
DAYTIME
SYMPTOMS
TRIGGER
RESPONSE
ALTERNATIVE
COPING
OUTCOME
DELAY IN
FALLING
ASLEEP
ANXIETY
REGROUP ON
THE COUCH
TRAC
?
GATHER DATA
56
57
CBT‐I:
Evidence‐based insomnia interventions
forTrauma, Anxiety, Depression,
Chronic Pain,TBI, Sleep Apnea, and Nightmares
Colleen Carney, Ph.D.
Ryerson University
Meg Danforth, Ph.D. CBSM
Duke University Medical Center
Time
Topics
8:00‐10:00
Welcome
Working effectively with those with sleep apnea
10:00‐10:15 Break
10:15‐12:00 Circadian Rhythm Sleep Disorders
Imagery Rehearsal Therapy for Nightmares
12:00‐1:00
Lunch
1:00‐2:30
Case Formulation
2:30‐2:45
Break
2:45‐4:00
Case Exercises and Remaining Issues
58
59
60
Physical
Comfort
Mechanical
Problems
Social
Factors
Psychological
Factors
61
Recognizing Stages of Change
(Prochaska & Norcross, 2002)
62
63
64
65
*Some cases are so severe a mental health professional is needed
66
67
8pm
2am
11pm
6am
10am
Conventional Sleep Phase
COMPLAINT?
Delayed Sleep Phase
Advanced Sleep Phase
COMPLAINT?
Wake
Sleeping
here?
Alerting
signals
9am
3pm
Wake
Melatonin
secreted
9pm
3am
9am
Sleep
68
Morgenthaler et al., 2007
Morgenthaler et al., 2007
69
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
11:00 PM
12:00 AM
1:00 AM
2:00 AM
3:00 AM
4:00 AM
5:00 AM
6:00 AM
Strength of Alerting Signal
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
11:00 PM
12:00 AM
1:00 AM
2:00 AM
3:00 AM
4:00 AM
5:00 AM
6:00 AM
Strength of Alerting Signal
Morgenthaler et al., 2007
Wake
Light or
activity
here
advances
the clock;
↑alertness
Rest
Time
Leveraging the circadian system
Wake
Light here ↑alertness
Rest
Light here ↑alertness
Light
here
may
delay
the
clock
Time
70
SCHEDULE
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
WORK
SHIFT
15:00-23:00
15:00-23:00
15:00-23:00
OFF
07:00-15:00
07:00-15:00
07:00-15:00
CURRENT
24:00-08:30
25:00-08:30
01:00-09:30
01:00-10:30
23:00-06:00
22:30-06:15
22:00-05:45
PROPOSED
24:00-07:00
24:00-07:00
24:00-07:00
23:30-07:00
23:00-06:00
23:00-06:00
23:00-06:00
USE NAPS IF NEEDED
USE LIGHT, MOVEMENT IN A.M.
Imagery rehearsal training for nightmares
Nightmares
71
Differential diagnosis: Nightmares
We don’t use PSG except to rule
out: breathing disorders, seizure
disorder, narcolepsy, RBD
72
Casement & Swanson, 2012
73
Treating Nightmares:
Imagery Rescripting and Rehearsal
74
75
76
77
Imagery Rescripting and Rehearsal
Summary
78
From: Manber, R. & Carney, C.E. (2015). Treatment Plans and Interventions: Insomnia. A Case
Formulation Approach.
Domains
1. Sleep Drive: Are
there any factors
weakening the sleep
drive?
Targets
Excessive time‐in‐bed in relation to the
average total sleep time?
Dozing?
Napping?
Substances that block sleep?
Decreased physical activity in a 24‐
hour period?
Lingering in bed greater than 30
minutes post‐wake in the morning?
Manber & Carney, 2015
79
Assessing low sleep drive on Sleep Log
Bedtime
Time to
fall
asleep
Time
awake
during
night
Monday
Tuesday
11:00
pm
11:30
pm
Wednesday
11:05
pm
Thursday
Friday
Saturday
Sunday
10:35
pm
10:55
pm
12:15
am
10:15
pm
25
20
40
60
35
15
95
Average total sleep time (ATST) = 7 hours; Average time in bed (TIB) over 9 hrs.
7.07 total sleep time / 9.33 time-in-bed = 78% Sleep Efficiency
20
25
15
35
20
45
60
Wake
time
7
am
7
am
7
am
7
am
7
am
8:40
am
7:50
am
Rise time
7:15
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
11:45
am
80
*Actually a treatment to address conditioned arousal, so we will
revisit
Bootzin, 1972
Domains
Targets
1. Sleep Drive: Are
there any factors
weakening the
sleep drive?
√ Excessive time‐in‐bed in relation to
the average total sleep time?
Dozing?
Napping?
√ Substances that block sleep?
√ Decreased physical activity in a 24‐
hour period?
√ Lingering in bed greater than 30
minutes post‐wake in the morning?
Manber & Carney, 2015
(Fredholm, Yang, & Wang, 2017)
• Caffeine – timing and reduction
• Nicotine reduction/elimination
• Prescribed exercise ‐ timing
• Light bedtime snack (milk, peanut butter)
• Avoid middle of the night eating
• Reduce alcohol & other substances
• Optimize environment: light, noise, temperature
81
Domains
2. Biological clock: Are there
factors weakening the signal
from the biological clock?
Targets
 An hour or more variability
in rise time
 An hour or more variability
in bedtime
 Are they a night owl
keeping an early bird’s
schedule, or reverse?
Manber & Carney, 2015
Finding clock irregularity in diaries
Monday
Tuesday
Wednesday
11:00
pm
12:30
am
1:05
Time to
fall
asleep
25
20
40
Time
awake
during
night
20
25
Wake
time
6
am
7:15
am
Bedtime
Rise
time
Saturday
Sunday
10:35
pm
12:55
am
2:15
am
10:15
pm
60
35
15
95
15
35
20
45
60
6
am
6
am
6
am
6
am
8:40
am
7:50
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
11:45
am
am
Thursday
Friday
JETLAG
Domains
2. Biological clock: Are there
factors weakening the signal
from the biological clock?
Targets
√ An hour or more variability

in rise time
√ An hour or more variability

in bedtime
 Are they a night owl
keeping an early bird’s
schedule, or reverse?
Manber & Carney, 2015
82
Domains
Targets
√ Rituals to produce sleep even when sleep continues
3. Arousal: Any 
to be bad, e.g., no alarm clock, sleeping separate
evidence of
from bed partner, knockout shades, white noise
hyperarousal?
machine/masks, tv…?
Any behaviors
engaged to
“produce
sleep” (i.e.,
sleep effort)?
 Are they worried about sleep?
√
 Are they worried about other things (in bed)?
 Are they wide awake upon getting into bed?
√

√ Do they stay in bed when awake?

√ Do they feel frustrated/anxious/distressed while
awake in bed?
Manber & Carney, 2015
Bootzin, 1972
See any possible sleep effort behaviors?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
11:00
pm
9:30
pm
11:00
pm
10:35
pm
9:15
pm
12:00
am
10:30
pm
35 min
25 min
15 min
20 min
25 min
15 min
30 min
100 min
50 min
60 min
120 min
45 min
55 min
90 min
Wake
time
6
am
6
am
6
am
6
am
6
am
8:40
am
7:50
am
Rise
time
7:15
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
8:45
am
TIB
7:15
10:50
8:00
7:50
10:00
10:50
10:15
Bedtime
Time to
fall
asleep
Time
awake
during
night
Note: 3 daytime naps attempted
83
Domains
Targets
√ Rituals to produce sleep even when sleep continues
3. Arousal: Any 
to be bad, e.g., no alarm clock, sleeping separate
evidence of
from bed partner, knockout shades, white noise
hyperarousal?
machine/masks, tv…?
Any behaviors
engaged to
“produce
sleep” (i.e.,
sleep effort)?
 Are they worried about sleep?
√
 Are they worried about other things (in bed)?
 Are they wide awake upon getting into bed?
√

√ Do they stay in bed when awake?

√ Do they feel frustrated/anxious/distressed while
awake in bed?
Manber & Carney, 2015
Case Formulation Form: Unhelpful
sleep behaviors?
Domains
Targets
√ Excessive or late caffeine?
4. Unhealthy

√ Alcohol?
sleep behaviors: 
Any sleep
 Marijuana?
√ Short‐acting sleeping pills?
behaviors that 
interfere with
 Nocturnal eating?
sleep
 Vigorous evening exercise?
depth/continuity
?
Manber & Carney, 2015
84
Case Conceptualization: Medications
that Impact Sleep
85
Rule for CBT‐I:
Noncontingency
“CBT‐I works whether you are on or off
medications, so what would you like to do?”
SUSTAINED
RECOVERY
SLEEP SYSTEM
BASELINE
MED
USE
CBT-I
SLEEP
IMPROVEMENT
DISSASTISFIED
WITH SLEEP OR
PILLS
PILLS?
Case Formulation Form: Unhelpful
sleep behaviors?
Domains
Targets
√ Excessive or late caffeine?
4. Unhealthy

√ Alcohol?
sleep behaviors: 
Any sleep
 Marijuana?
√ Short‐acting sleeping pills?
behaviors that 
interfere with
 Nocturnal eating?
sleep
 Vigorous evening exercise?
depth/continuity
?
Manber & Carney, 2015
Domains
6. Comorbidities:
Any co‐occurring
conditions that
impact sleep?
Targets
 Sleep apnea, if yes, is it adequately treated?
 Restless Leg Syndrome, if yes, is it adequately
treated?
 Periodic Limb Movement, if yes, is it adequately
treated?
 Chronic pain, if yes, is it adequately treated?
√ PTSD

√ Others?

Manber & Carney, 2015
86
Case Conceptualization
Comorbidities
What comorbidities affect client’s presentation and how?
Concurrent/integrated or
Successive?
• CBT‐I takes 8 weeks (4 biweekly individual
sessions or 7 sessions for group) – doable
but…
• What if you only have 12 sessions allowable?
• What if sleep is as important as pain, panic…?
• What if your case formulation suggests their
problems are all interrelated?
Sequential versus integration
• No real empirical guidance
• Considerations
• Primacy of sleep goals
– Don’t put CBT‐I on your list just because they
meet criteria: low stage of readiness
• Complementary techniques and targets
allows you to strengthen rationale/buy‐in
87
Pain Cycle Psychoeducation
Disuse (2◦ pain, deconditioning)
Disability
Plan: Present model,
psychoeducation,
goal setting, exercise
and paced ↑
activities, relaxation
training, challenge
catastrophizing
Monitoring for aversive
sensations
Decreased Use
Increased Resting
Re-injury fear; poor
performance under pain
conditions
Event
Low back
injury
Pain, distress
Threatening
..about pain
Insomnia Cycle Psychoeducation
Event
Increased insomnia
Calling in sick
Plan: Present model,
psychoeducation,
goal setting, stimulus
control, ↑ day me
ac vi es, ↓ me in
bed, relaxation
training, challenge
catastrophizing
Monitoring for
fatigue/arousal
sensations
Alcohol Use
Increased Resting
Lost control of sleep; poor
performance under
insomnia conditions
Bedridden
during back
injury
Sleeplessness,
fatigue, distress
Threatening
..about insomnia
Combined Psychoeducation
Increased insomnia;
increased 2◦ pain
Calling in sick; depression
Monitoring for
pain/fatigue/arousal
sensations
Alcohol Use
Increased Resting
Cancelling
Event
Back injury and
prolonged timein-bed
Sleeplessness,
fatigue, increased
pain, distress
Increase activities;
decrease time-in-bed
Lost control of sleep; poor
performance under
insomnia/fatigue/pain
conditions; re-injury
Test whether
control/effort helps/hurts
Threatening
..about sleep loss
and pain
Test whether this
helps/hurts
88
Commonalities
• Assessment
• Orient to CBT
• Present model through CBT lens
• Monitoring
• Challenge unhelpful thinking
• Try new alternative coping behaviors (to replace avoidance)
• Skills training (e.g., relaxation, problem solving)
• Disorder specific skills (undo conditioned arousal, exposure
hierarchy, increase activities)
• Relapse prevention and discharge
Case Formulation Form:
Comorbidities
Domains
6. Comorbidities:
Any co‐occurring
conditions that
impact sleep?
Targets
 Sleep apnea, if yes, is it adequately
treated?
 Restless Leg Syndrome, if yes, is it
adequately treated?
 Periodic Limb Movement, if yes, is it
adequately treated?
 Chronic pain, if yes, is it adequately
√ treated?
√ PTSD

 Others?
Manber & Carney, 2015
Case Formulation Form:
Other factors
Domains
7. Any other factors?
Consider sleep
environment, care
taking duties at night,
life phase sleep
issues; mental status,
and readiness for
change.
Targets
 Sleep environment optimal?
 Care taking or on‐call duties at
night?
 Cognitive or learning issues?
 What stage of readiness for change?
√ Any resistance to engaging in short‐

term behavior changes?
89
When CBT‐I goals conflict with
client goals: MI?
Goal (often not stated)
Problem
CBT‐I conflict
Avoid fatigue
CBT‐I ↑ fa gue, more
typically sleepiness
Challenge sleep‐fatigue link,
tolerate fatigue ST
Produce 8 hours (or more) of
sleep
Typically limits TIB to under 8 CBT‐I values quality not
hours
quantity
Get more done during the
day
Over‐valuing productivity
over rest periods can lead to
anxiety and fatigue and
insomnia
CBT‐I challenges
perfectionism and schedules
a wind‐down (and relaxation)
Experience unconsciousness
during sleep
Perfectionism about sleep
(disregards that wake is part
of sleep)
Accept that sleep has varying
depths and part of sleep is
wake
Enjoy sleep again
Wants to sleep well but also
loves/loved sleeping in on
weekends
Limits TIB and typically
results in earlier rise time
Recognizing Stages of Change
(Prochaska & Norcross, 2002)
Enhancing motivation
• Support and increase awareness of the motivation to
use tools in contemplation:
– “It sounds like you are concerned that you have tried stimulus control
before and were not able to stick with it 100%. You keep persisting
however, so obviously it is pretty important to you.”
• Support concrete goals in preparation
– “I think I could shave off an hour from my time in bed.”
– “That sounds like a good start. We can assess if you are happy
with the results, and go from there?”
• Empathy allows safe exploration of ambivalence:
– “You seem to have a lot on your plate right now and you feel like
following a schedule is adding stress. But you also feel really tired.”
90
Problem Plan
Tool
Fatigue
Eliminate jetlag
Reduce time-in-bed
Increase activation out of bed
Address cognitive factors
Increase relaxation skills
Increase blue light exposure
Fatigue management
Stimulus control
Sleep restriction
Behavioral activation
Cognitive Therapy
Relaxation therapy
Schedule light
H.E.L.M.
Repetitive
thoughts
Eliminate in bed
Test alternative coping
Schedule processing
Stimulus control
Behavioral Activation (TRAC)
Pennebaker, Scheduled Worry
Using bed
as escape
Teach model of conditioned arousal,
insomnia, avoidance
Test whether it is helpful
Avoid avoidance
Psychoeducation and Cognitive Therapy
Lingering in Set clock earlier (advance the sleep
phase to get up earlier)
bed in
Outside-in plan
morning/
going to bed
too late
Behavioral experiment
Test other coping skills
Stimulus control & Sleep restriction,
morning light
Behavioral Activation
CBT‐I in isolation
• CBT‐I validated as a package but also
evidence for isolated SC and isolated SRT
• The monotherapies allow us to use case
formulation for integration into other
protocols (e.g., CBT for worry)
• CBT‐I as a package is typically delivered as a
4 session biweekly treatment (e.g., Edinger
& Carney, 2014)
QUESTIONS
91
Selected Readings and Resources
Selected Author Books
Carney, C. E., & Edinger, J. D. (2010). Insomnia and anxiety. New York, NY: Springer.
Carney, C. E., & Manber, R. (2009). Quiet your mind and get to sleep: Solutions to insomnia for those
with depression, anxiety, or chronic pain. Oakland, CA: New Harbinger.
Carney, C. E., & Posner, D. (2015). Cognitive behavior therapy for insomnia in those with depression: A
guide for clinicians. Abingdon-on-Thames, UK: Routledge.
Edinger, J. D., & Carney, C. E. (2015). Overcoming insomnia: a cognitive behavioral therapy approach,
therapist guide (2nd ed.). Oxford, UK: Oxford University Press.
Manber, R., & Carney, C. E. (2015). Treatment plans and interventions for insomnia: a case formulation
approach. New York, NY: Guilford.
Links to Selected Assessment Tools
1. STOPBANG to assess for possible apnea (refer those with scores of 3 or above)
http://www.stopbang.ca/osa/screening.php
2. Epworth Sleepiness Scale to assess for excessive sleepiness
http://epworthsleepinessscale.com/
3. Please feel free to use our free app, CBT-I Coach, developed for our training in the US VA
system:
https://itunes.apple.com/ca/app/cbt-i-coach/id655918660?mt=8
https://play.google.com/store/apps/details?id=com.t2.cbti&hl=en
Bibliography for Workshop
Addis, M. E., & Martell, C. R. (2004). Overcoming depression one step at a time. Oakland, CA: New
Harbinger.
Armitage, R. (2000). The effects of antidepressants on sleep in patients with depression. Canadian
Journal of Psychiatry, 45, 803-809.
Baglioni, C., Battagliese, G., Feige, B., Spiegelhalder, K., Nissen, C., Voderholzer, U, . . . Riemann, D.
(2011). Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal
epidemiological studies. Journal of Affective Disorders, 135, 10-19.
Beck, A. T. (1999). Psychoevolutionary view of personality and axis I disorders. In C. R. Cloninger (Ed.),
Personality and psychopathology (pp. 411-429). Washington, DC: American Psychiatric Press.
92
Belleville, G., Guay, C., Guay, B., & Morin, C. M. (2007). Hypnotic taper with or without self-help
treatment of insomnia: a randomized clinical trial. Journal of Consulting and Clinical Psychology,
75, 325-335.
Bernert, R. A., & Nadorff, M. R. (2015). Sleep disturbances and suicide risk. Sleep Medicine Clinics, 10,
35-39.
Blom, K., Jernelov, S., Kraepelien, M., Bergdhal, M. O., Jungmarker, K., Ankartjarn, L., . . . Kaldo, V.
(2015). Internet treatment addressing either insomnia or depression, for patients with both
diagnoses: a randomized trial. Sleep, 38, 267-277.
Bonnet, M. H., & Arand, D. L. (1992). Caffeine use as a model of acute and chronic insomnia. Sleep, 15,
526-536.
Bonnet, M. H., & Arand, D. L. (1995). 24-hour metabolic rate in insomniacs and matched normal
sleepers. Sleep, 18, 581-588.
Bonnet, M. H., & Arand, D. L. (1996). Insomnia-nocturnal sleep disruption-daytime fatigue: the
consequences of a week of insomnia. Sleep, 19, 453-461.
Bonnet, M. H., & Arand, D. L. (1998). The consequences of a week of insomnia II: patients with insomnia.
Sleep, 21, 359-368.
Bonnet, M. H., & Arand, D. L. (2010). Hyperarousal and insomnia: state of the science. Sleep Medicine
Reviews, 14, 9-15.
Bonnet, M. H., & Arand, D. L. (2014). Physiological and medical findings in insomnia: implications for
diagnosis and care. Sleep Medicine Reviews, 18, 111-122.
Bootzin R. R. (1972). A stimulus control treatment for insomnia. Proceedings of the American
Psychological Association, 7, 395-396.
Borbély, A. A. (1982). A two process model of sleep regulation. Human neurobiology, 1, 195-204.
Borbely, A. A., Daan, S., Wirz-Justice, A., & Deboer, T. (2016). The two-process model of sleep regulation:
a reappraisal. Journal of Sleep Research, 25, 131-143.
Broomfield, N. M., & Espie, C. A. (2003). Initial insomnia and paradoxical intention: an experimental
investigation of putative mechanisms using subjective and actigraphic measurement of sleep.
Behavioural and Cognitive Psychotherapy, 31, 313-324.
Buscemi, N., Vandermeer, B., Hooton, N., Pandya, R., Tjosvold, L., Hartling, L., . . . Vohra, S. (2005). The
efficacy and safety of exogenous melatonin for primary sleep disoders. A meta-analysis. Journal
of General Internal Medicine, 20, 1151-1158.
Buysse, D. J., Ancoli-Israel, S., Edinger, J. D., Lichstein, K. L., & Morin, C. M. (2006). Recommendations for
a standard research assessment of insomnia. Sleep, 29, 1155-1173.
93
Buysse, D. J., Germaine, A., Moul, D. E., Franzen, P. L., Brar, L. K., Fletcher, M. E., . . . Monk, T. H. (2011).
Efficacy of brief behavioral treatment for chronic insomnia in older adults. Archives of Internal
Medicine, 171, 887-895.
Casement, M. D., & Swanson, L. M. (2012). A meta-analysis of imagery rehearsal for post-trauma
nightmares: effects on nightmare frequency, sleep quality, and posttraumatic stress. Clinical
Psychology Reviews, 32, 566-574.
Carney, C. E., Buysse, D. J., Ancoli-Israel, S., Edinger, J. D., Krystal, A. D., Lichstein, K. L., & Morin, C. M.
(2012). The Consensus Sleep Diary: Standardizing prospective sleep self-monitoring. Sleep, 35,
287-302.
Carney, C. E., & Edinger, J. D. (2006). Identifying critical dysfunctional beliefs about sleep in primary
insomnia. Sleep, 29, 440-453.
Carney, C. E., Edinger, J. D., Kuchibhatla, M., Lachowski, A. M., Bogouslavsky, O., Krystal, A. D., &
Shapiro, C. M. (2017). Cognitive behavioral insomnia therapy for those with insomnia and
depression: a randomized controlled clinical trial. Sleep, 40.
Carney, C. E., Edinger, J. D., Manber, R., Garson, C., & Segal, Z. V. (2007). Beliefs about sleep in disorders
characterized by sleep and mood disturbance. Journal of Psychosomatic Research, 62, 179-188.
Carney, C. E., Edinger, J. D., Meyer, B., Lindman, L., & Istre, T. (2006). Daily activities and sleep quality in
college students. Chronobiology International, 23, 623-637.
Carney, C. E., Harris, A. L., Falco, A., & Edinger, J. D. (2013). The relation between insomnia symptoms,
mood, and rumination about insomnia symptoms. Journal of Clinical Sleep Medicine, 9, 567-575.
Carney, C. E., & Waters, W. F. (2006). Effects of a structured problem-solving procedure on pre-sleep
cognitive arousal in college students with insomnia. Behavioral Sleep Medicine, 4, 13-28.
Chambers, M. J. (1994). Actigraphy and insomnia: a closer look. Part 1. Sleep, 17, 405-408.
Chaudhuri A., & Behan, P. O. (2004). Fatigue in neurological disorders. Lancet, 363, 978-988.
Chung, F., Yegneswaran, B., Liao, P., Chung, S. A., Vairavanathan, S., Islam, S., Khajehdehi, A., & Shapiro,
C. M. (2008). STOP questionnaire: a tool to screen patients for obstructive sleep apnea.
Anesthesiology, 108, 812-821.
Colvonen, P. J., Masino, T., Drummond, S. P., Myers, U. S., Angkaw, A. C., & Norman, S. B. (2015).
Obstructive sleep apnea and posttraumatic stress disorder among OEF/OIF/OND veterans.
Journal of Clinical Sleep Medicine, 11, 513-518.
Craske, M. G., Lang, A. J., Aikins, D., & Mystkowski, J. L. (2006). Cognitive behavioral therapy for
nocturnal panic. Behavior Therapy, 36, 43-54.
94
Currie, S. R., Wilson, K. G., Pontefract, A. J., deLaplante, L. (2000). Cognitive-behavioral treatment of
insomnia secondary to chronic pain. Journal of Consulting and Clinical Psychology, 68, 407-416.
Davies, R., Lacks, P., Storandt, M., & Bertelson, A. D. (1986). Countercontrol treatment of sleepmaintenance insomnia in relation to age. Psychology and Aging, 1, 233-238.
Defense and Veterans Brain Injury Center (2016). Research review on mild traumatic brain injury and
posttraumatic stress disorder. Falls Church, VA: Defense and Veterans Brain Injury Center.
Edinger, J. D., Means, M. K., Carney, C. E., & Manber, R. (2011). Psychological and behavioral treatments
for insomnia II: implementation and specific populations. In M. H. Kryger, T. Roth, & W. C.
Dement (Eds.), Principles and practice of sleep medicine (5th ed.) (pp. 884-904). Philadelphia, PA:
Saunders.
Edinger, J. D., Olsen, M. K., Stechuchak, K. M., Means, M. K., Lineberger, M. D., Kirby, A., & Carney, C. E.
(2009). Cognitive behavioral therapy for patients with primary insomnia or insomnia associated
predominantly with mixed psychiatric disorders: a randomized clinical trial. Sleep, 32, 499-510.
Edinger, J. D., Wohlgemuth, W. K., Krystal, A. D., & Rice, J. R. (2005). Behavioral insomnia therapy for
fibromyalgia patients: a randomized clinical trial. Archives of Internal Medicine, 165, 2527-2535.
Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Coffman, C. J., & Carney, C. E. (2007). Dose-response
effects of cognitive-behavioral insomnia therapy: a randomized clinical trial. Sleep, 30, 203-212.
Epstein, D. R., Babcock-Parziale, J. L., Herb, C. A., Goren, K., & Bushnell, M. L. (2013). Feasibility test of
preference-based insomnia treatment for Iraq and Afghanistan war veterans. Rehabilitation
Nursing, 38, 120-132.
Espie, C. A., Broomfield, N. M., MacMahon, K. M., Macphee, L. M., & Taylor, L. M. (2006). The attentionintention-effort pathway in the development of psychophysiologic insomnia: a theoretical
review. Sleep Medicine Reviews, 10, 215-245.
Espie, C. A., Fleming, L., Cassidy, J., Samuel, L., Taylor, L. M., White, C. A., . . . Paul, J. (2008). Randomized
controlled clinical effectiveness trial of cognitive behavior therapy compared with treatment as
usual for persistent insomnia in patients with cancer. Journal of Clinical Oncology, 26, 46514658.
Evenson, K. R., Goto, M. M., & Furberg, R. D. (2015). Systematic review of the validity and reliability of
consumer-wearable activity trackers. International Journal of Behavioral Nutrition and Physical
Activity, 12, 159.
Fava, M., McCall, W. V., Krystal, A., Wessel, T., Rubens, R., Caron, J., . . . Roth, T. (2006). Eszopiclone coadministered with fluoxetine in patients with insomnia coexisting with major depressive
disorder. Biological Psychiatry, 59, 1052-1060.
95
Ford, D. E., & Kamerow, D. B. (1989). Epidemiologic study of sleep disturbances and psychiatric
disorders: an opportunity for prevention? Journal of the American Medical Association, 262,
1479-1484.
Fredholm, B. B., Yang, J., & Wang, Y. (2017). Low, but not high, dose caffeine is a readily available probe
for adenosine action. Molecular Aspects of Medicine, 55, 20-25.
Gehrman, P. R., Hall, M., Barilla, H., Buysse, D., Perlis, M., Gooneratne, N., & Ross, R. J. (2016). Stress
reactivity in insomnia. Behavioral Sleep Medicine, 14, 23-33.
Germain, A., Shear, M. K., Hall, M., & Buysse, D. J. (2007). Effects of a brief behavioral treatment for
PTSD-related sleep disturbances: a pilot study. Behaviour Research and Therapy, 45, 627-632.
Germain, A., Richardson, R., Stocker, R., Mammen, O., Hall, M., Bramoweth, A. D., ... & Buysse, D. J.
(2014). Treatment for insomnia in combat-exposed OEF/OIF/OND military veterans: Preliminary
randomized controlled trial. Behaviour Research and Therapy, 61, 78-88.
Haponik, E. F., Frye, A. W., Richards, B., Wymer, A., Hinds, A., Pearce, K., . . . Konen, J. (1996). Sleep
history is neglected diagnostic information. Challenges for primary care physicians. Journal of
General Internal Medicine, 11, 759-761.
Harvey, A. G., & Farrell, C. (2003). The efficacy of a Pennebaker-like writing intervention for poor
sleepers. Behavioral Sleep Medicine, 1, 115-124.
Harvey, A. G., & Payne, S. (2002). The management of unwanted pre-sleep thoughts in insomnia:
distraction with imagery versus general distraction. Behaviour Research and Therapy, 40, 267277.
Harvey, A. G., & Talbot, L. S. (2010). Behavioral experiments. In M. Perlis, M. Aloia, & B. Kuhn (Eds.),
Behavioral treatments for sleep disorders (pp. 71-77). New York: Academic Press.
Hoelscher, T. J., & Edinger, J. D., (1988). Treatment of sleep-maintenance insomnia in older adults: Sleep
period reduction, sleep education, and modified stimulus control. Psychology and Aging, 3, 258263.
Howell, D., Oliver, T. K., Keller-Olaman, S., Davidson, J., Garland, S., Samuels, C., . . . Taylor, C. (2012). A
Pan-Canadian practice guideline: prevention, screening, assessment and treatment of sleep
disturbances in adults with cancer. Toronto, Canada: Canadian Partnership Against Cancer
(Cancer Journey Advisory Group) and the Canadian Association of Psychosocial Oncology.
Jacobs, G. D., Pace-Schott, E. F., Stickgold, R., & Otto, M. W. (2004). Cognitive behavior therapy and
pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Archives of
Internal Medicine, 164, 1888-1896.
Johns, M. W. (1991). A new method for measuring daytime sleepiness: the Epworth sleepiness scale.
Sleep, 14, 540-545.
96
Jungquist, C. R., O’Brien, C., Matteson-Rusby, S., Smith, M. T., Pigeon, W. R., Xia, Y., . . . Perlis, M. L.
(2010). The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain.
Sleep Medicine, 11, 302-309.
Kales, A., Soldatos, C. R., Bixler, E. O., & Kales, J. D. (1983). Early morning insomnia with rapidly
eliminated benzodiazepines. Science, 220, 95-97.
Karp, J. F., Buysse, D. J., Houk, P. R., Cherry, C., Kupfer, D. J., & Frank, E. (2004). Relationship of variability
in residual symptoms with recurrence of major depressive disorder during maintenance
treatment. American Journal of Psychiatry, 161, 1877-1884.
Kay, D. B., Karim, H. T., Soehner, A. M., Hasler, B. P., Wilckens, K. A., James, J. A., . . . Buysse, D. J. (2016).
Sleep-wake differences in relative regional cerebral metabolic rate for glucose among patients
with insomnia compared with good sleepers. Sleep, 39, 1779-1794.
Kohn, L., & Espie, C. A. (2005). Sensitivity and specificity of measures of the insomnia experience: A
comparative study of psychophysiologic insomnia, insomnia associated with mental disorder
and good sleepers. Sleep, 29, 104-112.
Kuo, T., Manber, R., & Loewy, D. (2001). Insomniacs with comorbid conditions achieved comparable
improvement in a cognitive behavioral group treatment program as insomniacs without
comorbid depression. Sleep, 14, A62.
Krakow, B., Hollifield, M., Johnson, L., Koss, M., Schrader, R., Warner, T. D., . . . Prince, H. (2001). Imagery
rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress
disorder: a randomized controlled trial. Journal of the American Medical Association, 286, 537545.
Krupinski, J., & Tiller, J. W. (2001). The identification and treatment of depression by general
practitioners. Australian and New Zealand Journal of Psychiatry, 35, 827-832.
Kyle, S. D., Morgan, K., Spiegelhalder, K., & Espie, C. A. (2011). No pain, no gain: an exploratory withinsubjects mixed-methods evaluation of the patient experience of sleep restriction therapy (SRT)
for insomnia. Sleep Medicine, 12, 735-747.
Levey, A. B., Aldaz, J. A., Watts, F. N., & Coyle, K. (1991). Articulatory suppression and the treatment of
insomnia. Behaviour Research and Therapy, 29, 85-89.
Lew, H. L., Pogoda, T. K., Hsu, P. T., Cohen, S., Amick, M. M., Baker, E., . . . Vanderploeg, R. D. (2010).
Impact of the “polytrauma clinical triad” on sleep disturbance in a department of veterans
affairs outpatient rehabilitation setting. American Journal of Physical Medicine & Rehabilitation,
89, 437-445.
97
Lichstein, K. L., Riedel, B. W., Wilson, N. M., Lester, K. W., & Aguillard, R. N. (2001). Relaxation and sleep
compression for late-life insomnia: a placebo-controlled trial. Journal of Consulting and Clinical
Psychology, 69, 227-239.
Lichstein, K. L., Wilson, N. M., & Johnson, C. T. (2000). Psychological treatment of secondary insomnia.
Psychology and Aging, 15, 232-240.
Lineberger, M. D., Carney, C. E., Edinger, J. D., & Means, M. K. (2006). Defining insomnia: Quantitative
criteria for insomnia severity and frequency. Sleep, 29, 479-485.
Littner, M., Hirshkowitz, M., Kramer, M., Kapen, S., Anderson, W. M., Bailey, D., Berry, R. B., . . .
Woodson, B. T. (2003). Practice parameters for using polysomnography to evaluate insomnia: an
update. Sleep, 26, 754-760.
Mahmood, O., Rapport, L. J., Hanks, R. A., & Fichtenberg, N. L. (2004). Neuropsychological performance
and sleep disturbance following traumatic brain injury. Journal of Head Trauma Rehabilitation,
19, 378-390.
Manber, R., Edinger, J. D., Gress, J. L., San Pedro-Salcedo, M. G., Kuo, T. F., & Kalista, T. (2008). Cognitive
behavioral therapy for insomnia enhances depression outcome in patients with comorbid major
depressive disorder and insomnia. Sleep, 31, 489-495.
Mantua, J., Gravel, N., & Spencer, R. M. (2016). Reliability of sleep measures from four personal health
monitoring devices compared to research-based actigraphy and polysomnography. Sensors, 16,
646.
Martell, C. R., Dimidjian, S., & Herman-Dunn, R. (2010). Behavioral activation for depression: a clinician’s
guide. New York, NY: Guilford.
Mathias, J. L., & Alvaro, P. K. Prevalence of sleep disturbances, disorders, and problems following
traumatic brain injury: a meta-analysis. Sleep Medicine, 13, 898-905.
Means, M. K., & Edinger, J. D. (2007). Graded exposure therapy for addressing claustrophobic reactions
to continuous positive airway pressure: a case series report. Behavioral Sleep Medicine, 5, 105116.
Mellman, T. A., & Uhde, T. W. (1989). Sleep panic attacks: New clinical findings and theoretical
implications. American Journal of Psychiatry, 146, 1204-1207.
Minkel, J., Moreta, M., Muto, J., Htaik, O., Jones, C., Basner, M., & Dinges, D. (2014). Sleep deprivation
potentiates HPA axis stress reactivity in healthy adults. Health Psychology, 33, 1430-1434.
Morawetz, D. (2003). Insomnia and depression: Which comes first? Sleep Research Online, 5, 77-81.
98
Morgenthaler, T. I., Lee-Chiong, T., Alessi, C., Friedman, L., Aurora, R. N., Boehlecke, B., . . . Zak, R.
(2007). Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep
disorders. An American Academy of Sleep Medicine report. Sleep, 30, 1445-1459.
Morin, C. M. (1993). Insomnia: Psychological assessment and management. New York, NY: Guilford
Press.
Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A., & Lichstein, K. L. (2006).
Psychological and behavioral treatment of insomnia: Update of the recent evidence (19982004). Sleep, 29, 1398-1414.
Morin, C. M., Culbert, J. P., & Schwartz, S. M. (1994). Nonpharmacological interventions for insomnia: A
meta-analysis of treatment efficacy. American Journal of Psychiatry, 151, 1172-1180.
Morin, C. M., Hauri, P. J., Espie, C. A., Spielman, A. J., Buysse, D. J., & Bootzin, R. R. (1999).
Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine
review. Sleep, 22, 1134-1156.
Morin, C. M., Stone, J., McDonald, K., & Jones, S. (1994). Psychological management of insomnia: A
clinical replication series with 100 patients. Behavior Therapy, 25, 291–309.
Morin, C. M., Vallieres, A., Guay, B., Ivers, H., Savard, J., Merette, C., . . . Baillargeon, L. (2009). Cognitive
behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized
controlled trial. Journal of the American Medical Association, 301, 2005-2015.
National Institutes of Health (2005). NIH State of the Science Conference statement on manifestations of
chronic insomnia in adults. Journal of Clinical Sleep Medicine, 1, 412-421.
Nierenberg, A. A., Keefe, B. R., Leslie, V. C., Alpert, J. E., Pava, J. A., Worthington, J. J., . . . Fava, M.
(1999). Residual symptoms in depressed patients who respond acutely to fluoxetine. Journal of
Clinical Psychiatry, 60, 221-225.
Ong, J. C., Manber, R., Segal, Z, Xia, Y., Shapiro, S., & Wyatt, J. K. (2014). A randomized controlled trial of
mindfulness meditation for chronic insomnia. Sleep, 37, 1553-1563.
Ong, J. C., Shapiro, S. L., & Manber, R. (2008). Combining mindfulness meditation with cognitivebehavior therapy for insomnia: a treatment-development study. Behavior Therapy, 39, 171-182.
Ong, J. C., Shapiro, S. L., & Manber, R. (2009). Mindfulness meditation and cognitive behavioral therapy
for insomnia: a naturalistic 12-month follow-up. Explore, 5, 30-36.
Orff, H. J. (2009). Traumatic brain injury and sleep disturbance: a review of current research. Journal of
Head Trauma Rehabilitation, 24, 155-165
Ouellet, M. C., Beaulieu-Bonneau, S., & Morin, C. M. (2015). Sleep-wake disturbances after traumatic
brain injury. Lancet Neurology, 14, 746-757.
99
Ouellet, M. C., & Morin, C. M. (2004). Cognitive behavioral therapy for insomnia associated with
traumatic brain injury: a single-case study. Archives of Physical Medicine and Rehabilitation, 85,
1298-1302.
Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic
insomnia disorder in adults: a clinical practice guideline from the American College of Physicians.
Annals of Internal Medicine, 165, 125-133.
Padesky, C. A. (1993). Socratic questioning: changing minds or guiding discovery? Keynote address
delivered at the meeting of the European Congress of Behavioural and Cognitive Therapies,
London, UK.
Prochaska, J. O., & Norcross, J. C. (2001). Stages of change. Psychotherapy: Theory, Research, Practice,
Training, 38, 443-448.
Raskind, M. A., Peskind, E. R., Hoff, D. J., Hart, K. L., Holmes, H. A., Warren, D., . . . McFall, M. (2007). A
parallel group placebo controlled study of prazosin for trauma nightmares and sleep disturbance
in combat veterans with post-traumatic stress disorder. Biological Psychiatry, 61, 928-934.
Raskind, M. A., Peskind, E. R., Kanter, E. D., Petrie, E. C., Radant, A., Thompson, C. E., . . . McFall, M.
(2003). Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: a
placebo-controlled study. American Journal of Psychiatry, 160, 371-373.
Ree, M., & Harvey, A. G. (2004). Insomnia. In J. Bennet-Levy, G. Butler, M. Fennell, et al., (Eds.), Oxford
guide to behavioral experiments in cognitive therapy (287-305), Oxford, UK: Oxford University
Press.
Riedel, B. W., Lichstein, K. L., & Dwyer, W. O. (1995). Sleep compression and sleep education for older
insomniacs: Self-help versus therapist guidance. Psychology and Aging, 10, 54-63.
Riedner, B. A., Goldstein, M. R., Plante, D. T., Rumble, M. E., Ferrarelli, F., Tononi, G., & Benca, R. M.
(2016). Regional patterns of elevated alpha and high frequency electroencephalographic activity
during nonrapid eye movement sleep in chronic insomnia: a pilot study. Sleep, 39, 801-812.
Rybarczyk, B., Lopez, M., Benson, R., Alsten, C., & Stepanski, E. (2002). Efficacy of two behavioral
treatment programs for comorbid geriatric insomnia. Psychology and Aging, 17, 288-298.
Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., and Heald, J. L. (2017). Clinical practice
guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy
of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13, 307-349.
Savard, J., Simard, S., Ivers, H., & Morin, C. M. (2005). Randomized study on the efficacy of cognitivebehavioral therapy for insomnia secondary to breast cancer, part II: Immunologic effects.
Journal of Clinical Oncology, 23, 6097-6106.
100
Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical guideline for the
evaluation and management of chronic insomnia in adults. Journal of Clinical Sleep Medicine, 4,
487-504.
Siriwardena, A. N., Apekey, T., Tilling, M., Dyas, J. V., Middleton, H., & Orner, R. (2010). General
practitioners’ preferences for managing insomnia and opportunities for reducing hypnotic
prescribing. Journal of Evaluation in Clinical Practice, 16, 731-737.
Smith, M. T., Huang, M. I., & Manber, R. (2005). Cognitive behavior therapy for chronic insomnia
occurring within the context of medical and psychiatric disorders. Clinical Psychology Review, 25,
559-592.
Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., Giles, D. E., & Buysse, D. J. (2002).
Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia.
American Journal of Psychiatry, 159, 5-11.
Spielman, A. J., Caruso, L. S., & Glovinsky, P. B. (1987). A behavioral perspective on insomnia treatment.
Psychiatric Clinics of North America, 10, 541-553.
Spielman, A. J., Saskin, P., & Thorpy, M. J. (1987). Treatment of chronic insomnia by restriction of time in
bed. Sleep, 10, 45-56.
Swift, N., Stewart, R., Andiappan, M., Smith, A., Espie, C. A., & Brown, J. S. (2012). The effectiveness of
community day-long CBT-I workshops for participants with insomnia symptoms: a randomised
controlled trial. Journal of sleep research, 21, 270-280.
Taylor, H. R., Freeman, M. K., & Cates, M. E. (2008). Prazosin for treatment of nightmares related to
posttraumatic stress disorder. American Journal of Health-System Pharmacy, 65, 716-722.
Troxel, W. M., Kupfer, D. J., Reynolds, C. F., Frank, E., Thase, M. E., Miewald, J. M., & Buysse, D. J. (2012).
Insomnia and objectively measured sleep disturbances predict treatment outcome in depressed
patients treated with psychotherapy or psychotherapy-pharmacotherapy combinations. Journal
of Clinical Psychiatry, 73, 478-485.
Verbeek, I., Schreuder, K., & Declerck, G. (1999). Evaluation of short-term nonpharmacologic treatment
in a clinical setting. Journal of Psychosomatic Research, 47, 369-383.
Vitiello, M. V., Rybarczyk, B., Von Korff, M., & Stepanski, E. J. (2009). Cognitive behavioral therapy for
insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and
osteoarthritis. Journal of Clinical Sleep Medicine, 5, 355-362.
Vincent, N., & Lionberg, C. (2001). Treatment preferences and patient satisfaction in chronic insomnia.
Sleep, 24, 411-417.
Warden, D. (2006). Military TBI during the Iraq and Afghanistan wars. Journal of Head Trauma
Rehabilitation, 21, 398-402.
101
Watanabe, N., Furukawa, T. A., Shimodera, S., Morokuma, I., Katsuki, F., Fujita, H., . . . Perlis, M. L.
(2011). Brief behavioral therapy for refractory insomnia in residual depression: an assessorblind, randomized controlled trial. Journal of Clinical Psychiatry, 72, 1651-1658.
Waters, W. F., Hurry, M. J., Binks, P. G., Carney, C. E., Fuller, K. H., Betz, B., . . . Tucci, J. M. (2003).
Behavioral and hypnotic treatments for insomnia subtypes. Behavioral Sleep Medicine, 1, 81101.
Webb, W. B. (1988). An objective behavioral model of sleep. Sleep, 11, 488-496.
Wilson, S. J., Nutt, D. J., Alford, C., Argyropoulos, S. V., Baldwin, D. S., Bateson, A. N., . . . Wade, A. G.
(2010). British Association for Psychopharmacology consensus statement on evidence-based
treatment of insomnia, parasomnias and circadian rhythm disorders. Journal of
Psychopharmacology, 24, 1577-1600.
Woznica, A. A., Carney, C. E., Kuo, J. R., & Moss, T. G. (2015). The insomnia and suicide link: Toward an
enhanced understanding of this relationship. Sleep Medicine Reviews, 22, 37-46.
Wright, K. M., Britt, T. W., Bliese, P. D., Adler, A. B., Picchioni, D., & Moore, D. (2011). Insomnia as
predictor versus outcome of PTSD and depression among Iraq combat veterans. Journal of
Clinical Psychology, 67, 1240-1258.
Wyatt, J. K., Dijk, D. J., Ritz-de Cecco, A., Ronda, J. M., & Czeisler, C. A. (2006). Sleep-facilitating effect of
exogenous melatonin in healthy young men and women is circadian-phase dependent. Sleep,
29, 609-618.
Zayfert, C., & DeViva, J. C. (2004). Residual insomnia following cognitive behavior therapy for PTSD.
Journal of Traumatic Stress, 17, 69-73.
102
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