Cognitive Behavior Therapy for Insomnia in Those with Depression: A Guide for Clinicians 1st

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 treat - ment. 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

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 supple menting 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. Assessment of Insomnia 41

Table 4.1 How to Use a Sleep Diary Essential Item # Computations Interpretations/Significance clinical index Sleep onset Item 3: How An average SOL is calculated by adding the An average SOL greater than 30 minutes is conventionally latency (SOL) long did it SOL values for each night (after converting considered an indication of clinically meaningful problem take you to to the same metric, minutes OR hours) and with sleep initiation, as is presence of SOL values greater than fall asleep? dividing the sum by the number of nights 30 minutes on three or more nights a week. Although there are with available data in the recording period. no quantitative criteria for insomnia. A low average SOL (<10 minutes) suggests sleep duration might be too short for optimal wellbeing. 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. Number of Item 4: How An average NWAK is calculated by adding Three or more awakenings is considered an indication of awakenings many times did the NWAK value for each night and dividing clinically meaningful problem with sleep fragmentation. (NWAK) you wake up, the sum by the number of nights with not counting available data in the recording period. Multiple brief awakenings may suggest the presence of sleep your final apnea or other occult sleep problems. awakening? Wakefulness Item 5: In total, An average WASO is calculated by adding An average WASO greater than 30 minutes is conventionally after sleep how long did the WASO values for each night (after considered an indication of clinically meaningful problem onset these awakenings converting to the same metric, minutes with sleep maintenance, as is presence of WASO values greater (WASO) last? OR hours) and dividing the sum by the than 30 minutes on three or more nights a week. Although number of nights with available data there are no quantitative criteria for insomnia. in the recording period. Early Item 6d: How If 6c is ‘No,’ set 6d to zero. An average An average EMA greater than 30 minutes is considered an morning much earlier EMA is calculated by adding the EMA indication of clinically meaningful problem with early awakening [than planned]? values for each morning (including the morning awakening, as is presence of EMA values greater than (EMA) zero values from the previous step) 30 minutes on three or more nights a week. and dividing the sum by the number

of nights with available data in the Clinical judgment is needed when a client does not have a recording period. 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. Lingering Computed The daily value is the difference between Some of the time spent in lingering in the morning may be in the from items 6a item 6a and item 7. An average index of spent trying to get more sleep (Item 6b) and some of the time morning (What time lingering is calculated by adding the may be staying in bed without necessarily trying to sleep. was your final lingering value for each day and dividing Query about how the time lingering in the morning is spent. awakening?) the sum by the number of nights with The longer the time spent lingering, the more of an and 7 (What available data in the recording period. opportunity for conditioned arousal. This may reflect sleep time did you effort or avoidance or beliefs about what time is reasonable get out of bed to rise. for the day?). Total Wake Computed Nightly TWT=SOL + WASO + EMA, This is an index of overall unwanted wakefulness. For people Time (TWT) from SOL, making sure they all are in the same without insomnia TWT is usually less than 45-60 minutes. WASO and metric (hours or minutes). An average Although there is not a set cutoff of which we are aware, Item 6c TWT is calculated by adding the nightly however it is typical in clinical trials to set TWT>60 minutes TWT values and dividing the sum by the as suggestive of moderately severe insomnia. number of nights with available data in the recording period. If any one of SOL, WASO, or EMA is missing then TWT is considered missing. Time-in- Computed The difference between item 1 and item 7. When TIB is far greater than TST, query why. Some bed (TIB) from item 1 considerations include: 1) high sleep effort (i.e., trying to sleep (What time An average TIB is calculated by adding the by spending more time in bed), 2) using the bed for escape, did you get TIB values for each night and dividing the 3) sedentary life style (i.e., low levels of activity), and 4) feeling into bed?) sum by the number of nights with available sedated due to medications with long sedative half-life. and item 7 data in the recording period. (What time did you get out of bed for the day?). continued . . .

Table 4.1 Continued Essential Item # Computations Interpretations/Significance clinical index Intended Computed The difference between item 2 and item 7. The ISP is the time allotted for sleep. Its duration is shorter sleep period from Item 2 than TIB when a client spends time engaged in wake activities (ISP) (What time An average ISP is calculated by adding the in bed, such as reading and watching television. did you try ISP values for each night and dividing the to go to sleep?) sum by the number of nights with available Some clinician and sleep researchers compute SE as the ratio and Item 7 data in the recording period. between TST and ISP. This alternative is a better (What time approximation of how SE is computed when sleep is did you get measured objectively by actigraphy or polysomnography. out of bed for the day?) Computed Computed TST= ISP – TWT The computed TST does not always agree with the client’s Total Sleep from ISP estimated sleep duration (i.e., response to Item 8: In total, Time (TST) and TWT Average TST is calculated by adding the how long did you sleep?). Discrepancies between computed TST values for each night and dividing TST and the client estimated sleep duration (Item 8) could be the sum by the number of nights with due to a variety of factors that should be explored. Examples available data in the recording period. include: 1) reporting bias (e.g., the client might have not included light sleep as sleep); 2) a systematic error in one or Alternatively, average TST can also be more diary entries (e.g., considering including EMA in determined by subtracting average response to Item 5, in which case the computed TST TWT from average ISP. underestimates actual TST). Sleep Computed SE = TST/TIB SE values range between 0 and 1, wherein 1 means that the Efficiency from TST client slept 100% of the time spent in bed and 0 means the (SE) and TIB An average SE is calculated by adding the client has not slept at all. The average SE in population studies SE values for each night and dividing the is around 85%. A SE above 95% suggests the possibility of sum by the number of nights with available insufficient sleep, possibly because the sleep opportunity data in the recording period. window might be too short.

Nap duration Item 11b If 11a is ‘No,’ set 11b to zero. An average Provides a total amount of nap duration for the day. In clients (In total, how daily nap duration is calculated by adding reporting dozing (i.e., unintentional naps), it is useful to long did you the nap durations for each day (including encourage them to capture dozing with this item too. nap or doze?) the zero values from the previous step) and dividing the sum by the number of days with available data in the recording period. Total sleep Computed TST + Nap duration (item 11b) In most individuals with insomnia TST24 is almost identical time in from TST to TST because most are not able to nap. A difference that is 24 hours and item 11b An average TST24 is calculated by adding more than half an hour might indicate circadian rhythm (TST24) (In total, how the TST24 values for each 24 hour period abnormality or the presence of a comorbid disorder associated long did you and dividing the sum by the number of with daytime sleepiness. In the latter case, it is possible that nap or doze?) 24 hour periods with available data in the daytime sleep interferes with nocturnal sleep. recording period. Lingering Computed The difference between item 1 and item 2. Query about average values greater than half an hour. This in bed in from item 1 Equivalently, this is also the difference could be due to boredom, anhedonia, habit, spending time the evening (What time between TIB and ISP. with a bed partner, or it could imply sleep effort, that is, an did you get attempt to produce sleepiness in the bed in order to fall asleep. into bed?) An average daily lingering in the evening and item 2 is calculated by adding the values for each (What time evening and dividing the sum by the did you try number of days with available data in the to go to sleep?) recording period. Bedtime Derived Identify the earliest and latest bedtimes This provides an estimate of poor input into the clock. In the variability from item 2. (item 2) for the reporting period (typically absence of low activity or other habits that would reduce sleep (BEDVAR) a two-week period). One index of variability drive, regular bed and rise times create a strong drive to is the difference between the earliest and become sleepy around the same time each night and wake up latest bedtimes. For example, if the latest naturally around the same time each morning. In the adjacent bedtime over two weeks was 1AM and the example, 4 hours of variability is the biological equivalent to earliest bedtime was 9 PM, the variability taking a trip from Manhattan to Los Angeles. is 4 hours. continued . . .

Table 4.1 Continued Essential Item # Computations Interpretations/Significance clinical index 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? Rise time Take the latest rise time (item 7) for the This provides an index of poor input into the clock. Regular variability reporting period (typically a two-week bed and rise times create a strong drive to become sleepy (RISEVAR) period) and subtract the earliest rise time around the same time each night and wake up naturally (item 7). For example, if the latest rise around the same time each morning. In the adjacent example, time over two weeks was 11 AM and the 6 hours of variability is the biological equivalent to taking a earliest rise time was 5 AM, the variability trip from Manhattan to Europe. Most people have a fixed rise is 6 hours. 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. TIB Take the prescribed TIB (e.g., 7 hours) Negative values reflect non-adherence to the TIB prescription, prescription and subtract the average TIB value for i.e., increased TIB. In the adjacent example, the TIB variation the recording period (e.g., 8.25 hours). prescription variation is -1.25, in other words, there is an extra (TIBVAR) 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.

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 per - fectionistic 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 respons - ive 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. Assessment of Insomnia 47

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 48 Assessment of Insomnia

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 Assessment of Insomnia 49

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, & 50 Assessment of Insomnia

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 Assessment of Insomnia 51

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. 52 Assessment of Insomnia

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 necessi - tates 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). Assessment of Insomnia 53

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 approx - imately 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 54 Assessment of Insomnia

Table 4.2a Sleep Diary for Client #1 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Bedtime 11:00 PM 1:30 AM 12:30 AM 11:00 PM 1:00 AM 2:00 AM 11:15 PM Time to fall 120 min 90 min 50 min 35 min 60 min 60 min 120 min asleep Time awake 10 min 15 min 5 min 15 min 5 min 5 min 15 min during night 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 Table 4.2b Sleep Diary for Client #2 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Bedtime 12:00 AM 1:30 AM 12:30 AM 12:00 AM 2:30 AM 3:00 AM 12:30 AM Time to fall 180 min 90 min 150 min 170 min 35 min 5 min 120 min asleep Time awake 10 min 15 min 5 min 10 min 5 min 5 min 15 min during night 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

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 contra indicated 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 56 Assessment of Insomnia

sleep-related medications or medications taken to affect sleep, in addition to medica - tions 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-pharmaco - logical, 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 Assessment of Insomnia 57

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. 58 Assessment of Insomnia

• 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). Assessment of Insomnia 59

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. Stimulus Control (Bootzin, 1972): a set of sleep rules to address conditioned arousal. 2. Sleep Restriction (Spielman et al., 1987b): a technique to increase sleep drive by matching the time spent in bed with current sleep production time. 3. Cognitive Therapy: a set of techniques to modify catastrophizing beliefs about sleep and fatigue that cause or exacerbate insomnia (discussed in Chapter 7). 4. 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. 5. 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

comorbid disorders, and determine whether there are any issues that would contra - indicate 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? Behavioral Strategies for Insomnia 61

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 62 Behavioral Strategies for Insomnia

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., psycho education) 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 inter actively 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 psycho - education and practice how to respond to each in turn. Such Socratic delivery may be particularly important in those with comorbid depression because the cognitive impair - ments 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. Go to bed only when sleepy. 2. Get out of bed when unable to sleep and only go back to bed when sleepiness returns. 3. Get out of bed at a consistent time each morning regardless of the amount of obtained sleep. 4. Use the bed and bedroom only for sleep. 5. 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. Behavioral Strategies for Insomnia 63

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. 64 Behavioral Strategies for Insomnia

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. Behavioral Strategies for Insomnia 65

Below are the specific Stimulus Control Rules and rationale for their use: 1. 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. 2. 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. 3. 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. 4. 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 66 Behavioral Strategies for Insomnia

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. 5. 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. Behavioral Strategies for Insomnia 67

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. 68 Behavioral Strategies for Insomnia

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? Behavioral Strategies for Insomnia 69

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 straight forward 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 70 Behavioral Strategies for Insomnia

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 Behavioral Strategies for Insomnia 71

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 72 Behavioral Strategies for Insomnia

(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 experi - enced 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. Behavioral Strategies for Insomnia 73

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. 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. 2. 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. 3. 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. 4. 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. 5. 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 prob - lems (Shaheen et al., 2008). Second, eating upon awakening can create conditioned arousals to eat at the same time each night. 6. 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. 74 Behavioral Strategies for Insomnia

Behavioral Strategies for Insomnia 75 7. 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. 8. 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 environ - ment. 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

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 76 Behavioral Strategies for Insomnia

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 Behavioral Strategies for Insomnia 77 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

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 trouble shooting any possible nonadherence to the sleep schedule or stimulus control instruc tions 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., condi - tioned 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 78 Behavioral Strategies for Insomnia

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 recom - mendations (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

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. 80 Cognitive Factors and Treatment

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 neuro - psychological 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 influ - enced 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 Cognitive Factors and Treatment 81

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 82 Cognitive Factors and Treatment

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 Cognitive Factors and Treatment 83

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 84 Cognitive Factors and Treatment

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 Cognitive Factors and Treatment 85

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 86 Cognitive Factors and Treatment

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? Cognitive Factors and Treatment 87 Figure 6.1 Thought Record example Situation Mood (rating 0–100) Thoughts Evidence for the thought Evidence against the thought Balanced thought Re-rate mood (0–100) Watching television in the evening Exhausted 80% Anxious 90% What if I can’t sleep again tonight? I can’t believe how tense I feel. I am never going to be able to sleep without a pill. This is ridiculous. I have had this problem for a while. I feel tense right now so I am probably going to have some trouble falling asleep. I eventually sleep, just not well. Sometimes I am tense an hour before bed but somehow manage to fall asleep. I was out of town and forgot my pill and still fell asleep. The pill doesn’t work that great all the time. Thinking about how tense I am may make it more likely to fall asleep. I may or may not have trouble falling asleep later— thinking about it may make it worse. Even if I have trouble falling asleep, it doesn’t mean I will never fall asleep without a pill—I have slept without a pill before Exhausted 60% Anxious 45%

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. 88 Cognitive Factors and Treatment

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 Cognitive Factors and Treatment 89