Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach 2nd

Overcoming Insomnia

Editor-In-Chief David H. Barlow, PhD Scientific Advisory Board Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD TREATMENTS THAT WORK

1 TREATMENTS THAT WORK THERAPIST GUIDE JACK D. EDINGER COLLEEN E. CARNEY Overcoming Insomnia A Cognitive-Behavioral Therapy Approach Second Edition

1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trademark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016 © Oxford University Press 2015 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Edinger, Jack D., author. Overcoming insomnia : therapist guide / Jack D. Edinger, Colleen E. Carney. — Second edition. p. ; cm. — (Treatments that work) Includes bibliographical references. ISBN 978–0–19–933938–9 (alk. paper) I. Carney, Colleen, author. II. Title. III. Series: Treatments that work. [DNLM: 1. Sleep Initiation and Maintenance Disorders—therapy. 2. Cognitive Therapy—methods. WM 188] RC548 616.8′498—dc23 2014023893 9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper

v About TREATMENTS THAT WORK Stunning developments in healthcare have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit, but perhaps, inducing harm (Barlow, 2010). Other strategies have been proven effective using the best current standards of evidence, resulting in broad-based recommendations to make these practices more available to the public (McHugh & Barlow, 2010). Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world and healthcare systems and policymakers have decided that the quality of care should improve, that it should be evidence based, and that it is in the public’s interest to ensure that this happens (Barlow, 2004; Institute of Medicine, 2001; McHugh & Barlow, 2010). Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral healthcare practices and their applicability to individual patients. This new series, Treatments ThatWork, is devoted to communicating these exciting new interventions to clinicians on the frontlines of practice.

vi The manuals and workbooks in this series contain step-by-step detailed procedures for assessing and treating specific problems and diagnoses. But this series also goes beyond the books and manuals by providing ancillary materials that will approximate the supervisory process in assisting practitioners in the implementation of these procedures in their practice. In our emerging healthcare system, the growing consensus is that evidence-based practice offers the most responsible course of action for the mental health professional. All behavioral healthcare clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible. This therapist guide and the companion workbook for clients address the treatment of insomnia using cognitive-behavioral therapy (CBT) methods. It is estimated that one in ten U.S.  adults suffers from chronic insomnia. If left untreated, chronic insomnia reduces quality of life and increases risk for psychiatric and medical disorders, especially depression and anxiety. Medication is often prescribed, but can have significant side effects. Unlike pharmacological approaches, CBT insomnia intervention has been shown to yield long-term improvements. The program presented in this updated therapist guide and accompanying workbook outlines a safe and effective treatment that targets the behavioral and cognitive components of insomnia, incorporating updates from the new DSM-5. The program reflects two major changes to the diagnostic criteria for insomnia: 1) there is no longer a distinction between comorbid and primary insomnias, and 2) there is increased recognition of the daytime problems in insomnia; that insomnia is not a sleep disorder but rather a sleep-wake disorder. This therapist guide includes detailed instructions for assessment and troubleshooting, and the corresponding client workbook provides

vii educational information and homework forms. Together, they form a complete insomnia treatment package for a variety of client needs. David H. Barlow, Editor-in-Chief, Treatments ThatWork Boston, MA References Barlow, D. H. (2004). “Psychological treatments.” American Psychologist 59: 869–878. Barlow, D.  H. (2010). “Negative effects from psychological treatments: A perspective.” American Psychologist 65(2): 13–20. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. McHugh, R. K., & Barlow, D. H. (2010). “Dissemination and implementation of evidence-based psychological interventions: A review of current efforts.” American Psychologist 65(2): 73–84.

ix Contents Chapter 1 Introductory Information for Therapists 1 Chapter 2 Pre-Treatment Assessment 17 Chapter 3 Session 1: Psychoeducational and Behavioral Therapy Components 35 Chapter 4 Session 2: Cognitive Therapy Components 55 Chapter 5 Follow-Up Sessions 79 Chapter 6 Considerations in CBT Delivery: Challenging Patients and Treatment Settings 95 Appendix 1 Sleep History Questionnaire 119 Appendix 2 Daytime Insomnia Symptom Response Scale (DISRS) 129 References 131 About the Authors 141

Overcoming Insomnia

1 If you have just acquired this manual to learn the techniques described herein, you represent one of the many additional specialists needed to care for the plethora of patients who may benefit from the skills you will acquire. Cognitive-behavioral therapy (CBT) for insomnia is reasonably easy to learn, simple to implement, and highly efficacious for the management of insomnia. It has proven effective with patients who have both simple and complex forms of this type of sleep difficulty. As such, it currently is recognized as a front-line and preferred therapy by the National Institutes of Health and the British Association of Psychopharmacology. Despite this recognition, patients often have a difficult time accessing this treatment due to a lack of healthcare providers with expertise in this intervention. In fact, the sheer volume of insomnia sufferers who would benefit by the techniques described in this manual will far outstrip the providers of such therapy for many years to come. Your venture into this manual is, thus, welcomed and timely. As you learn the techniques we describe, you should quickly find patients who can benefit from your newly acquired skills. Moreover, we are confident that you will soon find these techniques useful and effective with a wide variety of patients you may encounter in your practice. As its name would imply, cognitive-behavioral insomnia therapy includes techniques designed to alter sleep-disruptive behaviors and cognitions that get in the way of normal sleep and that serve to perpetuate insomnia. The portion of this manual devoted to discussion of techniques that help patients alter their sleep-disruptive behaviors was taken from the treatment manual developed and used to guide therapy during the first author’s (JDE) National Institutes of Mental Health–funded grant (MH 48187) research, entitled “Cognitive-Behavioral Insomnia for Primary Insomnia.” Many of the cognitive therapy techniques Introductory Information for Therapists CHAPTER 1

2 described herein were developed and used to guide therapy during the second author’s (CEC) grant research funded by the National Institute of Nursing Research (NR 010539), entitled “Cognitive Behavioral Insomnia Treatment in Chronic Fatigue Syndrome.” Both the behavioral and cognitive therapy techniques described have been informed and improved by our research and clinical work over the past years since conducting the aforementioned funded studies. The primary purpose of this manual is to aid in the dissemination of cognitive-behavioral insomnia therapy to the cadre of healthcare providers who encounter insomnia patients. This manual has been written in such a manner as to provide other investigators and clinicians an understanding of CBT, as well as step-by-step instructions for replicating treatment procedures. The specific treatment procedures presented herein have been derived from various sources. As described in more detail later in this chapter, the CBT protocol represents a “second generation” multi-component form of therapy that evolved from several decades of cognitive and behavioral insomnia research. This treatment includes selected first generation behavioral treatment strategies that have proven reasonably effective as stand-alone treatments for insomnia or for other conditions. However, the CBT protocol combines several of these therapies to provide a more omnibus intervention designed to address the varying specific treatment needs of the insomnia patients we encounter. This CBT protocol was developed from the first author’s early work (Hoelscher and Edinger 1988; Edinger, Hoelscher, et al. 1992) and from the work of Bootzin (Bootzin 1977), Morin (Morin, Kowatch, et  al. 1989), Spielman (Spielman, Saskin, et al. 1987) and Webb (Webb 1988). The cognitive component was informed by integrative cognitive-behavioral models of Morin (1993) and Harvey (2002). One of the cognitive strategies (i.e., Constructive Worry) was derived from Carney and Waters (2006) and Espie and Lindsay (1987). Much of our own and other’s research has focused on patients who present with insomnia as an isolated disorder occurring independent of any other mental, medical, or sleep disorder. However, as will be discussed in the last chapter of this book, these strategies may be considered for various types of patients who present with insomnia occurring comorbid to another potentially sleep-disruptive condition. In the latter case, the standard CBT protocol may benefit from patient-specific alterations to enhance patient adherence and therapeutic results.

3 This treatment manual is divided into chapters that describe methods of insomnia assessment and the implementation or our CBT protocol. Each chapter describing the treatment protocol provides a “treatment rationale” to be provided to patients undergoing treatment. Specific information and instructions to be provided to patients are highlighted with italics. Investigators who wish to replicate the procedures described should present the highlighted information and instructions to their patients verbatim. It is also recommended that those who wish to use these treatments in their own insomnia research first review the list of References provided at the end of this text. Nature and Significance of Insomnia The sleep disorder insomnia is characterized by difficulties initiating, sustaining, or obtaining qualitatively satisfying sleep that occur despite adequate sleep opportunities/ circumstances and result in notable waking deficits (Edinger, Bonnet, et al. 2004). Over one-third of the adult population experiences insomnia at least intermittently, whereas 10% to 22% suffer chronic, unrelenting sleep difficulties. Insomnia may result from various medical disorders, psychiatric conditions, substance abuse, and other primary sleep disorders (e.g., sleep apnea). However, between 1% and 2% of the general population suffers from an insomnia disorder that persists either in the absence or independent of any comorbid condition. Whereas middle-aged and older adults are most prone to develop one of the many subtypes of comorbid insomnia, an independent insomnia disorder is the most common diagnosis found in younger age groups. As such, the risk for developing this condition remains relatively stable across the life span. Although many insomnia sufferers go undetected (Ancoli-Israel and Roth 1999), insomnia is common in primary care settings and accounts for over 20% of all insomnia sufferers who present to specialty sleep disorder centers (Coleman, Roffwarg, et  al. 1982; Simon and VonKorff 1997). Thus, insomnia appears sufficiently prevalent and disturbing so as to frequently come to the attention of both sleep specialists and general medical practitioners. Since insomnia may present in the absence of secondary causes, isolated forms of insomnia traditionally have been viewed as less serious than those insomnias co-occurring with sleep disruptive medical,

4 psychiatric, substance abuse, or other sleep disorders (e.g., sleep apnea). However, epidemiologic evidence suggests that insomnia, uncomplicated by comorbid psychiatric, substance abuse, or medical disorders, substantially increases health care utilization/costs (Simon and VonKorff 1997; Weissman, Greenwald, et  al. 1997; Ozminkowski, Wang, et al. 2007). One recent national insomnia survey found that insomnia alone accounted for significantly more days out of role than did other serious conditions including diabetes, hypertension, major depression, and congestive heart failure (Roth, Coulouvrat, et al. 2011). Also, several studies have shown that insomnia dramatically increases subsequent risk for developing a depressive illness, serious anxiety disorder, or substance abuse problem, even after other significant risk factors are controlled (Ford and Kamerow 1989; Vollrath, Wicki, and Angst 1989; Breslau, Roth, et al. 1996; Chang, Ford, et al. 1997; Johnson, Roth, and Breslau 2006). When occurring comorbid to major depression, insomnia often remains as the most common residual symptom once other depressive symptoms resolve, and its presence in this setting dramatically enhances risk for both relapse and eventual suicide. In addition, insomnia contributes to reduced productivity, accidents at work, increased alcohol consumption, serious falls among older adults, and a sense of being in poor health (Johnson and Spinweber 1983; Gislason and Almqvist 1987; Johnson, Roehrs, et al. 1998; Katz and McHorney 1998; Brassington, King, and Bliwise 2000). Thus, when encountered clinically, insomnia patients warrant safe, effective, and enduring treatment. Diagnostic Criteria for Insomnia Disorder Insomnia disorder is a diagnosis listed in the American Psychiatric Association’s sleep/wake disorder classification system, outlined in the fifth edition of its Diagnostic and Statistical Manual (DSM-5). Previous versions of the DSM and other diagnostic manuals conceptualized insomnia as either a primary disorder or a symptom occurring secondary to other sleep-disruptive primary conditions (e.g., depression, chronic pain). However, over time it has been recognized that often, if not typically, insomnia develops partial or total independence from whatever comorbid condition is viewed as its original cause. In such cases, the

5 insomnia itself often warrants separate clinical attention to enhance patients’ overall treatment results. In fact, there is evidence that simultaneous treatment of insomnia and depression produces better results in regard to both depressive and insomnia symptoms of patients with major depression than does treatment of merely the depression alone (Asnis, Chakraburtty, et al. 1999; Fava, McCall, et al. 2006; Manber, Edinger, et al. 2008). Given these considerations, the DSM-5 now provides the diagnostic term insomnia disorder, which may be assigned to patients who have either isolated or comorbid forms of this sleep difficulty. Patients meeting criteria for insomnia disorder report difficulties with sleep onset, sleep maintenance, and/or early morning awakenings that cause clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning. Moreover, such patients have sleep difficulties at least three times per week for 3 or more months, and their sleep problems occur despite allotting sufficient time for sleep and having environmental circumstances that are permissive of sleep. Of course, when patients present with the sort of sleep/wake difficulties described, alternate possible causes of sleep disturbance should be ruled out, including other sleep disorders, a sleep-disruptive medical condition, or substance use or abuse. When these alternative causes can be ruled out, a diagnosis of insomnia disorder would apply. Patients who meet criteria for this diagnosis can and should be considered as candidates for a trial of the treatment techniques outlined in this text. Development of This Treatment Program and Evidence Base It is intuitively obvious that practicing good sleep habits (i.e., following a routine sleep/wake schedule; avoiding daytime napping, etc.) and relaxing before bedtime facilitate nocturnal sleep. As such, it seems reasonable to speculate that psychological and behavioral strategies designed to improve sleep habits and reduce bedtime arousal may be useful for treating insomnia. However, not until the late 1950s did the usefulness of these forms of insomnia interventions receive attention in the scientific literature. In 1959, Schultz and Luthe (1959) were the first to formally report their success in treating a patient with sleep-onset insomnia using the form of relaxation therapy (RT) known as autogenic

6 training. Several years later, Jacobson (1964) reported similar results in a case he treated with his progressive muscle relaxation. However, not until the early 1970s were the first randomized clinical trials conducted to document the efficacy of RTs (Borkovec and Fowles 1973; Nicassio and Bootzin 1974). Although limited in number, these early reports were sufficient to spawn substantial research and clinical interest in the use of psychological and behavioral therapies for insomnia treatment during the past two decades. Arguably one of the more monumental breakthroughs in behavioral insomnia research was Bootzin’s (1972) observation concerning the important role of behavioral conditioning in disrupting or promoting sleep. Indeed, Bootzin was the first to suggest that sleep, like other overt behaviors, should respond to behavioral conditioning. Specifically, Bootzin surmised that insomnia patients developed conditional arousal to their beds and bedrooms from repeated associations of these cues with unsuccessful sleep attempts. Therefore, a treatment paradigm designed to reverse this aberrant conditioning history and associate the bed and bedroom with successful sleep efforts should help patients overcome their insomnia. Consistent with this speculation, Bootzin first presented his innovative stimulus control (SC) insomnia treatment in the early 1970s (Bootzin 1972). In his early reports, he demonstrated that a simple, straightforward counter-conditioning approach, involving standardization of the sleep/wake schedule, eliminating daytime napping, and discouraging sleep-incompatible behaviors in the bed and bedroom, was particularly effective for treating chronic primary insomnia. Perhaps both due to its practical appeal and its general efficacy, SC quickly became one of the most widely used behavioral insomnia treatments (Lacks and Morin 1992). In our early clinical work, we found stimulus control and relaxation therapies to be moderately effective for treating the sleep problems of many of the insomnia patients we encountered. However, these treatments also appeared to have some limitations. Most notably, neither of these treatments included specific strategies for addressing patients’ cognitive symptoms that contribute to their sleep difficulties. Specifically missing from these treatments were strategies to address insomnia sufferers’ tendencies to take their worries to bed, ruminate about the negative consequences of their sleep difficulties, and harbor many unhelpful

7 beliefs that support their sleep-related anxiety and that promote many of their sleep disruptive habits. In addition, many people with insomnia report that cognitive arousal is the most significant factor in the maintenance of their sleep difficulty (Lichstein and Rosenthal 1980; Espie, Lindsay, et al. 1989); however, these treatments did not employ specific strategies shown to be effective for decreasing pre-sleep arousal (Espie and Lindsay 1987; Carney and Waters 2006). Finally, these treatments did not specifically address the practice of spending excessive time in bed displayed by many of the patients with sleep maintenance complaints whom we encountered. Spielman et  al. (1987) were the first to note the importance of addressing time in bed by showing that restricting time in bed led to sleep improvements in a small group of insomnia patients they treated. Given this finding in conjunction with our own observations, we thought a truly omnibus insomnia therapy should include such a strategy. Finally, we noted the need for specific strategies to enhance patients’ treatment adherence. In this regard we found that patients seemed more likely to adhere to treatment recommendations if they were first provided some limited psycho-educational material designed to give them a basic understanding of what regulates the human sleep system and the types of habits that help and hinder the normal sleep process. Given these observations, the need for a multi-component cognitivebehavior therapy for insomnia became apparent. We thus constructed a treatment that included a number of components, including (1) a cognitive module designed to provide psycho-education about factors that regulate the human sleep system and to address unhelpful beliefs about sleep; (2)  standard stimulus control instructions to address patients’ conditioned arousal and to eliminate common sleep disruptive habits (daytime napping; maintaining an erratic sleep/wake schedule); and (3) a protocol for limiting each patient’s time in bed to an individually tailored time-in-bed prescription (which will be discussed in detail in Chapter 3). To test this approach, we conducted two small case-series studies using multiple baseline designs. The first of these studies (Hoelscher and Edinger 1988), which included four primary insomnia patients, provided initial support for our multi-component approach in that three of the four patients treated responded well once treatment was

8 initiated. In our second case series study (Edinger, Hoelscher, et al. 1992), seven patients underwent baseline monitoring that varied from 2 to 4 weeks in length and then successively completed four weekly sessions of relaxation training, followed by four sessions of our multi-component treatment. Results of this latter trial again suggested that most patients showed marked improvements in key sleep measures and that such improvements occurred only after our multi-component cognitive behavior therapy (CBT) was initiated. Shortly thereafter, Morin et al. (1993) published the first randomized clinical trial that showed that a multi-component CBT similar to our approach was effective (compared to a wait-list condition) for treating older adults with insomnia. Since the time of these early works, a number of larger randomized clinical trials have demonstrated that multi-component CBT insomnia treatment is both efficacious and clinically effective for treating insomnia. In efficacy studies (Morin, Colecchi, et al. 1999; Edinger, Wohlgemuth, et al. 2001, 2007) conducted with thoroughly screened insomnia sufferers without significant comorbidities, CBT has proven superior to relaxation training, sham behavioral intervention, sleep medication (temazepam), a medication placebo, and a no-treatment wait-list for treating insomnia complaints. In larger effectiveness trials (Espie, Inglis, et  al. 2001; Espie, MacMahon, et al. 2007) conducted with insomnia patients seen in primary care clinics, CBT proved more effective than usual medical management strategies (medication and sleep advice) for producing sleep improvements. Moreover, a recent critical literature review (Morin, Bootzin, et al. 2006) concluded that there have been a sufficient number of efficacy and effectiveness studies conducted to conclude that CBT for insomnia is a well-established and proven treatment approach particularly for those with insomnia uncomplicated by sleep-disruptive comorbidities. Admittedly, the majority of patients whom clinicians encounter are those who do have sleep-disruptive comorbidities. As such, it is reasonable to question the utility of this sort of intervention with those types of insomnia patients. Over the past decade there have been a growing number of studies to test the effectiveness of CBT for managing the insomnia complaints that accompany a wide array

9 of comorbid disorders. Results of these studies indicate that CBT produces sleep improvements among insomnia patients with chronic peripheral pain syndromes (Currie, Wilson, et al. 2000), breast cancer (Savard, Simard, et al. 2005), fibromyalgia (Edinger, Wohlgemuth, et  al. 2005), mixed medical disorders (Rybarczyk, Lopez, et  al. 2002), alcoholism (Greeff and Conradie 1998), and depression (Taylor, Lichstein, et al. 2007; Manber, Edinger, et al. 2008). A subset of these studies also suggest that an insomnia-targeted CBT leads to improvements in mood status, enhanced likelihood of depression remission, and reductions in other disease-specific symptoms among patients with various comorbidities (Kuo, Manber, et  al. 2001; Morawetz 2003; Edinger, Wohlgemuth, et al. 2005; Savard, Simard, et al. 2005; Manber, Edinger, et al. 2008). Thus, with reasonable confidence we can offer the treatment strategies outlined in this manual as a “treatment that works” for patients with chronic insomnia disorders. Theoretical Model for Cognitive-Behavioral Insomnia Therapy Spielman’s theoretical model, presented in Figure 1.1, provides a conceptual framework for understanding the evolution of chronic insomnia and the role of CBT for managing this condition. According to this model, 0 100 Premorbid Acute Sub-Acute Chronic Insomnia Threshold Predisposing Precipitating Perpetuating Figure 1.1 Spielman’s Model for Describing the Evolution of a Chronic Insomnia Disorder.

10 predisposing factors, precipitating events, and perpetuating mechanisms all contribute to the development of chronic primary sleep difficulties. Some individuals may be particularly vulnerable to sleep difficulties either by virtue of having a “weak,” “highly sensitive,” biological sleep system or personality traits that dispose them to poor sleep when confronted with stress (Drake, Richardson, et al. 2004). When such individuals are confronted with the proper precipitating circumstances (e.g. a stressful life event, sudden unexpected change in their sleep schedule), they tend to develop an acute sleep disturbance. This sleep problem, in turn, may then be perpetuated by a host of psychological and behavioral factors that emerge in reaction to such sleep difficulty. Thus, predisposing and precipitating factors contribute to the initial development of insomnia, whereas psychological and behavioral factors perpetuate it and serve as the treatment targets for cognitive-behavioral insomnia therapy. The cognitive-behavioral model posits that an interplay of cognitive and behavioral mechanisms act as the key perpetuating mechanisms for insomnia patients. Setting the stage for sustained sleep difficulty is a thinking style that can include: misattributions about the causes of insomnia, attentional bias for sleep-related stimuli, worry and/ or rumination about the consequences of poor sleep, and unhelpful beliefs about sleep-promoting practices (Morin 1993, Morin, Stone, et al. 1993; Edinger, Fins, et al. 2000; Harvey 2002; Harvey, Inglis, and Espie 2002; Carney and Edinger 2006; Carney and Waters 2006). These cognitions, in turn, support and sustain sleep-disruptive habits and conditioned emotional responses that either interfere with normal sleep drive or timing mechanisms or serve as environmental/behavioral inhibitors to sleep (Spielman, Caruso, et al. 1987; Webb 1988; Morin 1993; Dorsey and Bootzin 1997). For example, daytime napping or spending extra time in bed in pursuit of elusive, unpredictable sleep may only serve to interfere with the body’s homeostatic mechanisms that operate automatically to increase sleep drive in the face of increasing periods of wakefulness (i.e., sleep debt). Alternately, the habit of remaining in bed well beyond the normal rising time following a poor night’s sleep may disrupt the body’s circadian or “clock” mechanisms that control the timing of sleep and wakefulness in the 24-hour day. Additionally, the repeated association of the bed and bedroom with unsuccessful sleep attempts may eventually result in sleep-disruptive conditioned arousal in the home sleeping environment. Finally, an

11 excessive worry about sleep, trying hard to sleep, or failure to discontinue mentally demanding work and to allot sufficient “wind-down” time before bed may all serve as significant sleep inhibitors that raise physiological or cognitive arousal levels to the point of making sleep difficult. In sum, all of these factors may contribute to and perpetuate insomnia (Edinger and Wohlgemuth 1999; Bootzin and Epstein 2000; Hauri 2000). As a result, our CBT approach is designed to modify the range of cognitions and sleep-related behaviors that ostensibly sustain or add to patients’ sleep problems. In summary, good sleep is dependent upon having adequate sleep drive (sleep debt), proper timing as a result of a consistent sleep/wake schedule, and low physiological and psychological arousal during the period when sleep is attempted. Conversely, insomnia arises when there is insufficient sleep drive, improper timing, and/or excessive arousal present during the designated sleep period. When managing a specific patient’s insomnia problem, it is important to ascertain and correct the cognitive and behavioral factors that adversely reduce sleep drive, result in improper sleep timing, or make the patient too aroused to sleep. Strategies for addressing these issues are provided in subsequent chapters. Risks and Benefits of CBT for Insomnia Although systematic studies of CBT-related side effects have not been conducted, the experience base with CBT-based insomnia interventions suggests that this intervention is a safe and effective treatment modality. This is not to say that side effects do not occur, but those that do occur are generally transient and are manageable with strategies outlined later in this manual. Perhaps the most common side effect is enhanced daytime sleepiness during the initial stages of treatment, resulting from restricting patients’ times spent in bed. In some patients the initial time-in-bed restriction results in mild partial sleep deprivation and, thus, elevated daytime sleepiness. This sleepiness is usually transient and is corrected by gradual increases in time in bed. Some patients also show elevated anxiety about sleep when limits are placed on their times spent in bed and choices of rise times. This side effect also is easily managed via some relaxation of the treatment protocol, as will be discussed in more detail in Chapter 5.

12 In contrast, there are many benefits to this treatment program. As discussed, our CBT treatment is fashioned to address and eradicate the various cognitive and behavioral mechanisms that presumably sustain insomnia and thus enhance chances for sustained improvements long after treatment ends. The fact that this actually occurs is supported by the long term follow-up data reported in CBT trials showing sustained treatment benefits up to 24 months after active treatment (i.e., therapist contact) concludes. As such, this treatment differs from most pharmacological approaches (i.e. sleeping pills) that provide symptomatic relief but fail to address the cognitive and behavioral factors that sustain insomnia. Indeed, there are currently no data available to show that sleep improvements persist long after pharmacotherapy for insomnia is discontinued. In addition to this benefit, it appears that many patients may prefer CBT over medicinal approaches. For example, results of one study (Morin, Colecchi, et al. 1999) showed that patients were more satisfied with behavioral insomnia therapy and rated it as more effective than sleep medication. Findings from another study (Morin, Gaulier, et al. 1992) suggested that patients with chronic insomnia not only preferred CBT to pharmacotherapy, but also expected that CBT would produce greater improvements in daytime functioning, better long-term effects, and fewer negative side effects. Collectively, these data suggest that insomnia patients regard behavioral insomnia therapy as a viable and acceptable treatment for their sleep difficulties. Alternative Treatments Various “stand-alone” behavioral strategies, including relaxation therapies, stimulus control, sleep restriction, and paradoxical intention, have proven efficacy for management of insomnia and currently are regarded as “well-established” insomnia treatments (Morin, Bootzin, et al. 2006). Each of these therapies addresses a specific subset of insomnia-perpetuating mechanisms. In addition to these therapies, cognitive therapy and sleep hygiene education are often employed in insomnia management. Sleep hygiene education has generally proven ineffective as a stand-alone intervention, whereas there is very limited evidence suggesting that cognitive therapy can be used in isolation to treat insomnia. Detailed descriptions of all of these treatments and their applications can be found in a number

13 of sources (e.g., Edinger and Wohlgemuth 1999; Harvey 2002; Edinger and Means 2005; Morin, Bootzin, et al. 2006). As noted previously, we have found our multi-component therapy to be a more omnibus and consistently effective behavioral approach since it is designed to address the cognitive and behavioral mechanisms that perpetuate insomnia in the vast range of insomnia patients we encounter. Other non-medicinal approaches for insomnia management have included forms of yoga and acupuncture. Both of these treatments have shown some efficacy, but neither treatment enjoys the sizable research support that the behavioral insomnia therapies have acquired. Moreover, access to these interventions as applied to insomnia may be much more limited than current access to the behavioral therapies. There are also a number of devices marketed for insomnia treatment. Generally such devices are designed to address the sleep-disruptive arousal manifested by insomnia patients. Currently such devices have either limited or no data supporting their effectiveness, and they are not yet regarded as first-line insomnia treatments. Nonetheless, since it is likely an increasing number of such devices may be available in the future, their efficacy relative to current insomnia therapies will need to be evaluated. Role of Medications The most commonly prescribed FDA-approved sleep medications are benzodiazepine receptor agonists (BzRA). These include several benzodiazepines (e.g., temazepam) and newer non-benzodiazepine agents (e.g., zolpidem, eszopiclone, zaleplon) that act at the same site on the GABAA receptor complex melatonin receptor agonists (e.g., remelteon and the tricyclic antidepressant doxepin). More recently, the orexin/ hypocretin receptor antagonist suvoxen has been developed and should receive Food and Drug Administration (FDA) approval for insomnia management. In addition, the sedating antidepressant medication trazodone (TRZ) and the atypical antipsychotic quetiapine have been widely used “off-label” for insomnia management (Walsh and Schweitzer 1999). The benefit of the medications used for insomnia is that they can have immediate effects on sleep. As such, sleep medications have their greatest advantage over CBT for managing acute and brief forms of

14 insomnia. For example, sleep medications are well suited for treatment of insomnia arising from an abrupt sleep/wake schedule change (e.g., jet lag) or as a stress reaction (e.g., bereavement) to unfortunate life circumstances. In contrast, the role of medications in the management of chronic insomnia has been debated. Some studies (Krystal, Walsh, et al. 2003; Roth, Walsh, et al. 2005) have shown continued efficacy of some sleep medications when taken continuously for periods up to 12 months in duration. However, tolerance and consequent reduction of efficacy may emerge with continued use of some of the sleep-inducing agents, and all sleep medications hold the risk of psychological dependence when used over time. Whereas medications may reduce sleep-related anxiety for some patients, pharmacologic treatment, in general, is not designed to address the range of cognitive and behavioral insomnia-perpetuating mechanisms mentioned previously. Of course, the relative value of BzRA and CBT therapies largely depends upon their comparative efficacies for short- and long-term insomnia management of patients with and without sleep-disruptive comorbidities. Unfortunately, there are currently limited data that speak to the relative efficacy of these two treatment modalities. One study (Sivertsen, Omvik, et al. 2006) compared CBT with the sleep medication zopiclone and showed that CBT produced significantly better short- and longer-term improvements on objective indices taken from electronic sleep recordings but not on subjective measures taken from sleep logs. Some other studies (e.g., Morin, Colecchi, et al. 1999; Jacobs, Pace-Schott, et  al. 2004)  that compared treatments consisting of a sleep medication alone, CBT alone, and a combined CBT/ sleep medication therapy showed little difference in short-term outcomes, but superior longer-term outcomes with CBT alone compared to medication and combined treatment. In a more recent study, Morin and colleagues (Morin, Vallières, et al. 2009) showed that a 6-week combined zolpidem/CBT followed by a medication taper and continued extended period of CBT produced insomnia remission in 70% of those patients receiving this regimen. Hence, it does seem possible that a short-term combined treatment followed by CBT alone may be an optimal treatment approach. However, this study focused on patients with insolated insomnia disorder and did not include patients with sleep disruptive comorbidities. Furthermore, there has yet to be a follow-up study to replicate this study’s dramatic outcomes for

15 those patients receiving the sort of treatment regimen described. Thus, additional studies of the relative values of CBT and sleep medications would be useful. Treatment Program Outline The treatment described in the manual should be preceded by a thorough insomnia assessment, as described in Chapter 2. This assessment session should be conducted to assure that the patient is suitable for CBT and to instruct the patient in collecting the baseline sleep diary data needed in the initial stages of treatment. The subsequent treatment sessions are then employed to address a range of behavioral and cognitive treatment targets (perpetuating mechanisms). The following outline shows the organization and flow of the overall assessment and CBT insomnia intervention. I. Insomnia Assessment—Session 1 a. Assess nature of insomnia and appropriateness for CBT b. Assign baseline (pre-therapy) sleep diary monitoring II. Presenting Primary Behavioral Treatment Components—Session 2 a. Presenting treatment rationale and sleep education module b. Presenting sleep rules—behavioral insomnia regimen c. Calculating initial time in bed prescription d. Homework III. Presenting Cognitive Therapy Strategies—Session 3 a. Review and comment on sleep diary findings showing progress and adherence b. Provide cognitive rationale to patient c. Discuss Constructive Worry technique d. Discuss use of Thought Records e. Assign homework IV. Follow-up/Troubleshooting—Sessions 4 onward a. Adjusting time-in-bed recommendations b. Reviewing and reinforcing treatment adherence c. Troubleshooting—Behavioral Component

16 d. Troubleshooting—Cognitive Component e. Consideration of therapy termination Use of the Workbook A patient workbook has been prepared to accompany the treatment manual. This workbook includes much educational information that is designed to reinforce what is presented in the treatment sessions. The workbook also includes various blank forms such as the Sleep Diary, Constructive Worry sheet, and Thought Record form that patients will use to complete their assigned therapy “homework” from week to week. Since reference will be made to sections of the workbook during the course of therapy, it is recommended that the patient bring the workbook to each CBT session. However, in the event the patient fails to do so, it is suggested that the therapist have a workbook and blank copies of the various forms mentioned available to reference at each session.

17 There are various methods that can be used to diagnose and assess individuals with either isolated or comorbid insomnia complaints. The following sections briefly discuss each method. Clinical Interview The clinical interview is a particularly important component of an insomnia assessment because it provides the basis from which the clinician ascertains etiological factors and formulates a treatment plan. In addition to providing a comprehensive assessment of the individual’s specific insomnia complaint and sleep history, the clinical interview should include evaluation of medication and substance use, as well as identification of contributory medical and psychiatric conditions. Essential elements of an insomnia-focused clinical assessment are outlined in Table 2.1. As suggested by the information shown there, the insomnia-focused interview should provide a thorough descriptive and functional assessment of the sleep complaint, its history, and the psychological and behavioral factors that may sustain it. Moreover, the interview should provide a thorough assessment of the relationship, if any, between comorbid conditions (medical or psychiatric) and the insomnia complaint. To facilitate the assessment process, the patient may be asked to complete a sleep history questionnaire, like the one shown in Appendix 1, prior to the interview. This sort of instrument is designed to gather the pertinent information needed for a thorough insomnia assessment. Clinicians may also choose to employ one of the available semi-structured interviews (Spielman and Anderson 1999; Savard, Savard and Morin 2002)  designed specifically for insomnia Pre-Treatment Assessment CHAPTER 2

Table 2.1 Factors to Consider in Conducting a Clinical Interview for Insomnia History, Symptoms, and Perpetuating Factors Nature of complaint (pattern, onset, history, course, duration, severity) Etiological factors Factors that exacerbate insomnia or improve sleep pattern Sleep schedule Daytime symptoms (fatigue, cognitive impairment, distress about sleep) Social/vocational impact Maladaptive conditioning to bedroom Physiological/cognitive arousal at bedtime Unhelpful sleep-related beliefs Symptoms of other sleep disorders Bedtime routines and sleep-incompatible behaviors in bed Lifestyle (daily activity, exercise pattern) Treatment history (self-help attempts, coping strategies, response to previous treatments) Treatment expectations Medication and Substance Use Sleep medication—prescription and over-the counter remedies Other routine prescription and non-prescription medications Alcohol, tobacco, caffeine Illicit substances Medical History/Exam Medical disorders associated with sleep disruption Chronic pain Reflux disease Menopausal status (women) Prostate disease (men) Any recent relevant laboratory tests results (e.g., abnormal thyroid function) Psychiatric Factors Depression Anxiety Other mental disorders General day-to-day stress level Other Sleep Disorders Sleep apnea Restless legs syndrome

19 to guide their inquiries. Whatever method is chosen for querying the insomnia sufferer, an interview with her or his bed partner about the patient’s sleep pattern and habits can reveal important diagnostic information, such as symptoms of other sleep disorders. Sleep Diaries Prior to providing any treatment instructions, it is useful to have the patient monitor his or her sleep pattern for a period of at least 2 weeks using a sleep diary. Blank copies of the Consensus Sleep Diary (Carney, Buysee, et al. 2012), which we developed for this purpose, are provided for the patient in the corresponding workbook; a single blank copy of this diary is shown in Figure 2.1. This instrument is a particularly valuable tool that allows for prospective monitoring of the patient’s sleep habits and pattern over time. The diary is designed to solicit information relevant to each night’s sleep, including whether any naps were taken the previous day, whether any medication or alcohol was ingested at bedtime to facilitate sleep, the time the patient entered bed, the time the patient attempted to fall asleep, the number of minutes it took to fall asleep, the number and length of awakenings during the night, the time of the final morning awakening, and the time of actually arising from bed. The diary also queries about the quality of each night’s sleep, an aspect of sleep that may have some independence from the relative amounts of sleep and wake time that the patient reported during the night. As may be noted from Figure 2.1, the diary is designed to allow entry of 1 week’s worth of sleep information on a single sheet. To assure the greatest accuracy and usefulness of the data obtained, the patient should be encouraged to complete the sleep diary each morning within the first 30 minutes or so after arising. We find the sleep diary to be the quintessential tool in our work with insomnia patients since it provides much useful assessment information and it guides the implementation of our cognitive and behavioral therapy strategies. As an insomnia assessment tool, the diary provides important information about the patient’s sleep-disruptive habits, as well as some insights into implicit cognitive treatment targets. In some instances, sleep diary data may also be useful for identifying diagnostic subtypes who may not be good candidates for the treatment program

Figure 2.1 Sleep Diary. ID/NAME:  Sample Today’s Date 4/5/08 1a. How many times did you nap or doze? 2 times 1b. In total, how long did you nap or doze? 1 hour 10 min. 2. What time did you get into bed? 10:15 p.m. 3. What time did you try to go to sleep? 11:30 p.m. 4. How long did it take you to fall asleep? 55 min. 5. How many times did you wake up, not counting your final awakening? 6 times 6. In total, how long did these awakenings last? 2 hours 5 min. 7. What time was your final awakening? 6:35 a.m. 8. What time did you get out of bed for the day? 7:20 a.m. 9. Did you take any over-the-counter or prescription medication(s) to help you sleep? Yes □ No Medication(s): Relaxo-Herb Dose: 50 mg Time(s) taken: 11 pm □ Yes □ No Medication(s): Dose: Time(s) taken: □ Yes □ No Medication(s): Dose: Time(s) taken: □ Yes □ No Medication(s): Dose: Time(s) taken: □ Yes □ No Medication(s): Dose: Time(s) taken: □ Yes □ No Medication(s): Dose: Time(s) taken: □ Yes □ No Medication(s): Dose: Time(s) taken: □ Yes □ No Medication(s): Dose: Time(s) taken: 10. How would you rate the quality of your sleep? □ Very poor Poor □ Fair □ Good □ Very good □ Very poor □ Poor □ Fair □ Good □ Very good □ Very poor □ Poor □ Fair □ Good □ Very good □ Very poor □ Poor □ Fair □ Good □ Very good □ Very poor □ Poor □ Fair □ Good □ Very good □ Very poor □ Poor □ Fair □ Good □ Very good □ Very poor □ Poor □ Fair □ Good □ Very good □ Very poor □ Poor □ Fair □ Good □ Very good 11. Comments (if applicable) I have a cold

21 described in this guide. To demonstrate the specific types of information that may be gleaned from the diary, the ensuing discussion provides a number of case examples. CASE EXAMPLE #1 Figure 2.2 shows 1 week of sleep diary data for an individual who manifests a practice seen all too frequently among our insomnia patients. This individual shows a pattern of retiring to bed for the evening well in advance of the actual time chosen for beginning the night’s sleep. During review of the sleep diary with the therapist, the patient noted a practice of watching television in bed for an hour or more before intending to fall asleep. This practice resulted in the patient spending 9 or more hours in bed many nights during the week and usually experiencing extended awakenings during the course of the night. Careful querying, however, led to the discovery that the patient often dozed off while watching TV in bed well before the designated “lights-out” time indicated on the diary. For this patient, the excessive time spent in bed, using the bed for activities other than sleep, and the unrecorded “dozing” are important behavioral treatment “targets” uncovered by these sleep diary data. The observed behavioral pattern also may herald underlying misconceptions that the patient may have about sleep needs and sleep-promoting practices that should be addressed in treatment. CASE EXAMPLE #2 Figure 2.3 highlights another pattern commonly seen among insomnia patients. The most obvious problem shown by this diary is the patient’s erratic sleep schedule. Indeed, the information recorded shows that the patient’s bedtimes varied by over 5 hours, whereas the chosen rise times varied by over 3 hours during the week shown. The resulting sleep pattern shown accordingly is erratic and, from the patient’s perspective, highly unpredictable. Patients who show such patterns often stray from a routine sleep/wake schedule in an effort to get what sleep they do obtain, whenever they are able to obtain it. Hence, if they are able to sleep in an extra few hours following a disrupted night with extended waking periods, they do so to make up for the sleep they feel they lost during the night. Unfortunately, this

Sample Today’s Date 4/5/08 4/2 4/3 4/4 4/5 4/6 4/7 4/8 1a. How many times did you nap or doze? 2 times None None None None 1 None None 1b. In total, how long did you nap or doze? 1 hour 10 min. 5 min 2. What time did you get into bed? 10:15 p.m. 9:30 PM 10:00 PM 9:00 PM 9:15 PM 10:00 PM 9:45 PM 9:00 PM 3. What time did you try to go to sleep? 11:30 p.m. 11:00 PM 11:15 PM 10:45 PM 11:00 PM 11:30 PM 11:45 PM 10:45 PM 4. How long did it take you to fall asleep? 55 min. 25 min 20 min 15 min 45 min 20 min 15 min 30 min 5. How many times did you wake up, not counting your final awakening? 6 times 2 3 2 3 2 1 2 6. In total, how long did these awakenings last? 2 hours 5 min. 80 min 90 min 90 min 1 hour 30 min 25 min 75 min 7. What time was your final awakening? 6:35 a.m. 6:00 AM 5:45 AM 5:00 AM 4:45 AM 6:00 AM 6:45 AM 5:50 AM 8. What time did you get out of bed for the day? 7:20 a.m. 6:30 AM 6:35 AM 6:30 AM 6:00 AM 7:00 AM 7:30 AM 6:30 AM 9. Did you take any over-the-counter or prescription medication(s) (or alcohol) to help you sleep? Yes □ No Medication(s): Relaxo-Herb Dose: 50 mg Time(s) taken: 11 pm □ Yes No Medication(s): Dose: Time(s) taken: □ Yes No Medication(s): Dose: Time(s) taken: □ Yes ☑ No Medication(s): Dose: Time(s) taken: □ Yes No Medication(s): Dose: Time(s) taken: □Yes No Medication(s): Dose: Time(s) taken: □Yes No Medication(s): Dose: Time(s) taken: □Yes No Medication(s): Dose: Time(s) taken: 10. How would you rate the quality of your sleep? □ Very poor Poor □ Fair □ Good □ Very good □ Very poor □ Poor Fair □ Good □ Very good □ Very poor □ Poor Fair □ Good □ Very good □ Very poor □ Poor Fair □ Good □ Very good Very poor □ Poor □ Fair □ Good □ Very good □ Very poor □ Poor Fair □ Good □ Very good □ Very poor □ Poor □ Fair Good □ Very good Very poor □ Poor □ Fair □ Good □ Very good 11. Comments (if applicable) I have a cold Figure 2.2 Sleep Diary: Case Example #1.

Sample Today’s Date 4/5/08 5/7 5/8 5/9 5/10 5/11 5/12 5/13 1a. How many times did you nap or doze? 2 times None None None None None None None 1b. In total, how long did you nap or doze? 1 hour 10 min. 2. What time did you get into bed? 10:15 p.m. 11:00 PM 10:45 PM 10:30 PM 11:30 PM 11:20 PM 2:45 AM 9:30 PM 3. What time did you try to go to sleep? 11:30 p.m. 11:00 PM 10:45 PM 10:30 PM 11:30 PM 11:20 PM 2:45 AM 9:30 PM 4. How long did it take you to fall asleep? 55 min. 20 min 45 min 10 min 65 min 35 min 10 min 120 min 5. How many times did you wake up, not counting your final awakening? 6 times 1 2 2 2 1 1 2 6. In total, how long did these awakenings last? 2 hours 5 min. 50 min 50 min 135 min 130 min 55 min 5 min 140 min 7. What time was your final awakening? 6:35 a.m. 6:05 AM 8:30 AM 9:00 AM 6:40 AM 5:15 AM 7:25 AM 7:20 AM 8. What time did you get out of bed for the day? 7:20 a.m. 6:30 AM 8:40 AM 9:05 AM 7:30 AM 5:20 AM 7:30 AM 7:40 AM 9. Did you take any over-the-counter or prescription medication(s) (or alcohol) to help you sleep? Yes □ No Medication(s): Relaxo-Herb Dose: 50 mg Time(s) taken: 11 pm □Yes No Medication(s): Dose: Time(s) taken: □ Yes No Medication(s): Dose: Time(s) taken: □ Yes No Medication(s): Dose: Time(s) taken: □ Yes No Medication(s): Dose: Time(s) taken: □ Yes No Medication(s): Dose: Time(s) taken: □ Yes No Medication(s): Dose: Time(s) taken: □ Yes No Medication(s): Dose: Time(s) taken: 10. How would you rate the quality of your sleep? □ Very poor Poor □ Fair □ Good □ Very good □ Very poor □ Poor Fair □ Good □ Very good □ Very poor □ Poor □ Fair □ Good Very good Very poor □ Poor □ Fair □ Good □ Very good Very poor □ Poor □ Fair □ Good □ Very good □ Very poor □ Poor □ Fair Good □ Very good Very poor □ Poor □ Fair □ Good □ Very good Very poor □ Poor □ Fair □ Good □ Very good 11. Comments (if applicable) I have a cold Figure 2.3 Sleep Diary: Case Example #2.

24 practice only helps to sustain the insomnia. As might be surmised from this discussion, both the noted erratic sleep pattern and the sleep-related beliefs and anxiety that underlie this pattern are treatment targets that the sleep diary has helped to uncover. CASE EXAMPLE #3 Figure 2.4 highlights the diagnostic usefulness of sleep diary data. These data were collected by a college student who presented to our clinic complaining about extreme difficulty falling asleep each night. This diary clearly shows that the student has marked difficulty getting to sleep on most nights. Throughout the week, the student takes 2.5 to 3.5 hours to fall asleep, despite use of alcohol as a sleep aid on several nights. As a result, the usual sleep onset time on most weekday nights occurs between 2:30 and 3:30 A.M. However, on weekend nights when the student chooses a bedtime more proximal to this usual sleep onset time, the sleep latency is markedly reduced. Moreover, the weekend rise times occur much later and afford the student greater opportunity to obtain a full night’s sleep given the delayed time of sleep onset. All of these indicators suggest that the student likely suffers from delayed sleep phase syndrome, a circadian rhythm sleep/wake disorder wherein the endogenous sleep/wake rhythm is markedly phase delayed. As such, the student is biologically disposed to fall asleep in the early morning hours and sleep through much of the morning if allowed to do so. However, on weekdays the student is required to arise to attend morning classes, so the sleep period is artificially shortened on these days. Patients with this sort of sleep problem typically require treatments other than the one described in this guide, so data such as those shown in Figure 2.4 are useful for identifying patients who are not good CBT candidates. As the treating clinician, you will likely find these diaries useful for identifying the most salient treatment targets in each of your insomnia patients. As described in greater detail in the ensuing chapter, you will use completed sleep diaries to develop patient-specific Time in Bed (TIB) prescriptions as a part of your treatment recommendations (see Chapter 3 for more detail).

Today’s Date 4/5/08 10/1 10/2 10/3 10/4 10/5 10/6 10/7 1a. How many times did you nap or doze? 2 times None None None None None None None 1b. In total, how long did you nap or doze? 1 hour 10 min. 2. What time did you get into bed? 10:15 p.m. 11:00 PM 12:30 AM 11:30 PM 12:00 AM 2:20 AM 2:45 AM 11:30 PM 3. What time did you try to go to sleep? 11:30 p.m. 11:00 PM 12:30 AM 11:30 PM 12:00 AM 2:20 AM 2:45 AM 11:30 PM 4. How long did it take you to fall asleep? 55 min. 3.5 hours 3 hours 2.5 hours 3.5 hours 40 min 30 min 3 hours 5. How many times did you wake up, not counting your final awakening? 6 times 1 2 2 1 1 1 1 6. In total, how long did these awakenings last? 2 hours 5 min. 10 min 25 min 25 min 40 min 30 min 20 min 20 min 5 min 20 min 7. What time was your final awakening? 6:35 a.m. 8:05 AM 9:30 AM 9:00 AM 8:40 AM 12:15 PM 11:25 AM 8:30 AM 8. What time did you get out of bed for the day? 7:20 a.m. 8:30 AM 9:40 AM 9:05 AM 8:45 AM 12:20 PM 11:30 AM 8:40 AM 9. Did you take any over-the-counter or prescription medication(s) (or alcohol) to help you sleep? Yes □ No Medication(s): Relaxo-Herb Dose: 50 mg Time(s) taken: 11 pm □ Yes No Medication(s): 3 drinks Dose: Time(s) taken: 9:20 p.m. □ Yes No Medication(s): Dose: Time(s) taken: □ Yes No Medication(s): 3 drinks Dose: Time(s) taken: 10:30 p.m. □ Yes No Medication(s): Dose: Time(s) taken: □ Yes No Medication(s): 3 drinks Dose: Time(s) taken: 11:20 p.m. □ Yes No Medication(s): 3 drinks Dose: Time(s) taken: 11:40 p.m. □Yes No Medication(s): 2 drinks Dose: Time(s) taken: 9:50 p.m. 10. How would you rate the quality of your sleep? □ Very poor Poor □ Fair □ Good □ Very good □ Very poor □ Poor Fair □ Good □ Very good □ Very poor □ Poor Fair □ Good □ Very good □ Very poor □ Poor Fair □ Good □ Very good Very poor □ Poor □ Fair □ Good □ Very good □ Very poor □ Poor Fair □ Good □ Very good □ Very poor □ Poor □ Fair Good □ Very good Very poor □ Poor □ Fair □ Good □ Very good 11. Comments (if applicable) I have a cold Figure 2.4 Sleep Diary: Case Example #3.

26 Insomnia Severity Index The Insomnia Severity Index (ISI; Morin 1993) is a 7-item questionnaire that provides a global measure of perceived insomnia severity based on the following indicators: difficulty falling asleep, difficulty staying asleep, and early morning awakenings; satisfaction with sleep; degree of impairment with daytime functioning; degree to which impairments are noticeable; and distress or concern with insomnia symptoms. Each item is rated on a 5-point (0 to 4)  Likert scale, and the total score ranges from 0 to 28. The following guidelines are recommended for interpreting the total score: 0–7 (no clinical insomnia), 8–14 (sub-threshold insomnia), 15–21 (insomnia of moderate severity), and 22–28 (severe insomnia). The ISI has good internal consistency (Cronbach’s alpha = 0.91) and test-retest reliability (r = 0.80). It has been validated against sleep diaries and objective electronic sleep recordings (Bastien, Vallieres, and Morin 2001) and has proven sensitive to therapeutic changes in several treatment studies of insomnia (Morin, Colecchi, et al. 1999). In recent years, the ISI has become increasingly popular in insomnia work and now is recommended as a standard assessment tool in insomnia research studies (Buysse, Ancoli Israel, et  al. 2006). Since the ISI has the mentioned guidelines for score interpretation, this instrument can be used easily in clinical venues for judging initial insomnia severity and the clinical significance of improvements achieved during insomnia treatment. Pittsburgh Sleep Quality Index The Pittsburgh Sleep Quality Index (PSQI; Buysse, Reynolds, et al. 1989), like the ISI, is a widely used and currently recommended (Buysse, Ancoli Israel, et al. 2006) tool for assessing sleep disturbance in insomnia patients as well as in patients with other types of sleep disorders. The PSQI is composed of 4 open-ended questions and 19 self-rated items (0–3 scale) assessing sleep quality and disturbances over the previous 1-month interval. Domains assessed include sleep onset latency, sleep duration, sleep efficiency (i.e., the proportion of time in bed that is actually spent asleep), sleep quality, disturbances

27 to sleep, medication use, and daytime dysfunction. A  summation of these seven component scores yields a global score of sleep quality, ranging from 0 to 21. Previous research (Buysse, Reynolds, et al. 1989) has shown that a PSQI total score of > 5 has good sensitivity (89.6%) and specificity (86.5%) in discriminating those with insomnia from good sleepers. As such, a post-treatment PSQI score < 6 has been used in some studies as indicating insomnia remission. However, it should be noted that the PSQI provides a global sleep quality assessment and is not specifically or exclusively designed for insomnia assessment. Moreover, we (Carney, Edinger, et al. 2006a) have found that elevated levels of anxiety may contribute to PSQI score elevations in some types of insomnia patients. Hence, the patient’s anxiety level at the time of PSQI administration should be considered when interpreting the summary score obtained. Insomnia Symptom Questionnaire The Insomnia Symptom Questionnaire (ISQ) developed by Spielman et al. (1987) is an alternative insomnia assessment instrument that can be used for assessing the pateint’s sleep/wake-related symptoms. This questionnaire consists of a 13-item self-report instrument designed to assess sleep (e.g., sleep onset difficulty, wakefulness during sleep) and waking (e.g., daytime fatigue, sleep worries) symptoms of insomnia. Each item is accompanied by a 100-mm visual-analog scale (i.e., horizontal line) that is labeled “not at all” at its left extreme and “always” at its right extreme. In responding to this instrument, respondents draw a vertical line through the point on each item’s analog scale (i.e., 100-mm line) to indicate their responses. The distance from the left end of the line to a subject’s response line serves as an analog measure of the degree to which the respondent has the symptom noted by the item. The mean score across all 13 items is used to represent overall insomnia severity. In our previous work (Edinger, Wohlgemuth, et al. 2001; Edinger and Sampson 2003), we have found that the ISQ has acceptable internal consistency (Cronbach’s α = 0.73) and sensitivity to treatment-related sleep improvements. In our research we have used a total ISQ score < 41 as the clinical cutoff connoting insomnia remission, given our early findings, which suggested that this cutoff has a 92% sensitivity

28 and 64% specificity for discriminating normal sleepers from primary insomnia sufferers. However, in more recent unpublished work with a large validation sample, we have determined that an ISQ total score < 36.5 may be a better benchmark since this cutoff has 89% sensitivity and 86.5% specificity for discriminating patients with primary insomnia from normal sleepers. Dysfunctional Beliefs and Attitudes About Sleep Questionnaire The Dysfunctional Beliefs and Attitudes About Sleep Questionnaire (DBAS) is a valuable tool for identifying unhelpful sleep-related beliefs and attitudes presumed to help perpetuate insomnia problems. Currently both the original parent version and an abbreviated version are available for clinical and research use. The original DBAS-30 (Morin, Stone, et al. 1993) includes 30 items that comprise five subscales designed to assess (1) beliefs about the effects of insomnia (e.g., “I am concerned that chronic insomnia may have serious consequences on my physical health”); (2) beliefs about loss of control over sleep and the unpredictability of sleep (e.g., “I am worried that I may lose control over my abilities to sleep”); (3) perceived sleep needs and sleep expectations (e.g., “Because I am getting older, I need less sleep”); (4) misattributions about causes of insomnia (e.g., “I feel insomnia is basically the result of aging and there isn’t much that can be done about this problem”); and (5) expectations about sleep-promoting habits (e.g., “When I don’t get the proper amount of sleep on a given night, I need to catch up the next day by napping or the next night by sleeping longer”). A 100-mm analog scale (i.e., horizontal line) labeled “strongly disagree” at its far left extreme and “strongly agree” at its far right extreme accompanies each item and is used by respondents to indicate their degree of endorsement. When completing the DBAS-30, respondents are required to draw a vertical line through the point on the 100-mm scale to indicate their degree of agreement or disagreement with each item. The distance in mm between the far left extreme of the analog scale and the response line then is used at the item’s “score.” With one exception, all items are structured so that higher scores (i.e., stronger item agreement) connote more dysfunctional beliefs.

29 An abbreviated 16-item version (DBAS-16) (Morin, Vallieres, et  al. 2003) of the original DBAS-30 also is available. This abridged version is similar in format to the original instrument, but it uses 10-point Likert scales superimposed on visual analog scales for indicating agreement/ disagreement with the various items. For each of the 16 beliefs, the number corresponding to the degree to which the respondent endorses the belief (i.e., 10 = agree completely) is circled. A total score is calculated by summing the item scores and dividing the resultant sum by 16 (i.e., a mean item score). Both the DBAS-30 and DBAS-16 have shown acceptable levels of internal consistency (Cronbach’s alpha values >.80). Furthermore we (Carney, Edinger, et al. 2010) have found DBAS-16 total scores > 3.8 to be suggestive of the level of unhelpful beliefs common among individuals with clinically significant insomnia problems. Both DBAS instruments can be used to identify specific problematic beliefs to target in treatment and to assess belief changes resulting from our cognitive behavioral intervention. Daytime Insomnia Symptom Response Scale The Daytime Insomnia Symptom Response Scale (DISRS; Carney, Harris, et al. 2013) is a 20-item scale that assesses how frequently people with insomnia engage in rumination about their insomnia symptoms when feeling tired. All responses are rated on a 4-point scale ranging from 1 (almost never) to 4 (almost always). The measure queries the extent to which one responds to the experience of fatigue with repetitive thinking about a related symptom, such as: “I think about how hard it is to concentrate.” The scale is scored by summing the individual item scores such that total scores range from 20 to 80, and higher scores indicate higher levels of rumination. People with insomnia often engage in unwanted repetitive information processing about the daytime experiences of their insomnia (Thomsen, Mehlsen, et al. 2003; Carney, Edinger, et al. 2006b; Carney, Harris, et al. 2010). Specifically, when those with insomnia are feeling fatigued, they tend to ruminate on how badly they feel. Repeatedly thinking about how badly one feels has been linked to chronic insomnia in contemporary cognitive models (e.g., Harvey 2002). Although those with insomnia also tend to engage in worry, another form of repetitive thinking, rumination, as measured

30 by the DISRS, may be most linked to sleep disturbance (Carney, Harris, et al. 2010). Additionally, insomnia rumination scores predict insomnia even after controlling for depression (Thomsen, Mehlsen, et al. 2003; Carney, Edinger, et al. 2006b; Carney, Harris, et al. 2010); thus this is not merely a depressive process. In addition to the validity findings noted earlier, the DISRS has shown good reliability across a range of sleep profiles, including those with comorbid insomnia as well as poor sleepers (Cronbach’s alpha was .94 and .93 respectively). An elevated score on the DISRS suggests that arousal may be an issue, and strategies such as cognitive therapy or adjunct therapies such as mindfulness may be particularly important. A copy of this instrument is included in the book as Appendix 2. Epworth Sleepiness Scale The Epworth Sleepiness Scale is an 8-item self-report questionnaire designed to assess daytime sleepiness in common day-to-day situations such as “Watching TV” or “Sitting and talking to someone.” Respondents are instructed to indicate how likely they are to fall asleep in each situation using a 4-point rating scale (0 = would never doze to 3 = high chance of dozing). The ESS score is obtained by summing all item responses, so scores may range from 0 to 24, with higher scores suggesting greater daytime sleep tendency. A score greater than 10 is considered to indicate clinically significant daytime sleepiness. A score of 18 or more connotes someone who is very sleepy. This instrument has shown very acceptable internal consistency (Cronbach’s α = 0.88) and test-retest reliability (r  =  .82) within both non-complaining groups and in groups of clinical sleep-disordered patients (Johns 1991, 1994) Additionally, Epworth ratings have been found to correlate significantly (r = −.514, p <.01) with objective tests of daytime sleepiness (Johns 1991). Whereas some insomnia patients will obtain scores in the “sleepy” range on this instrument, they commonly do not obtain scores indicating they are very sleepy. Overweight patients who report loud nocturnal snoring and who score above the clinical cutoff are likely to suffer from sleep apnea and should be referred to a sleep specialist for thorough evaluation of this possibility.

31 Other Psychological Testing Because depressed mood and anxiety symptoms are common among insomnia patients, routine psychological screening is often recommended. Brief psychological questionnaires, such as the current version of the Beck Depression Inventory (BDI-II), the Beck Anxiety Inventory, the Spielberger State-Trait Anxiety Inventories, and the Brief Symptom Inventory, are all useful in this regard. Although they have limited value when used in isolation, these questionnaires may provide important supplemental information not apparent from the clinical interview. It should be noted that such inventories may have issues when using them in people with insomnia; for example, sleep problems can artificially elevate scores on such inventories due to the symptom overlap between insomnia and both depression and anxiety (Carney, Ulmer, et al. 2009; Carney, Moss, et al. 2011). In some cases, it may be necessary to conduct a more thorough psychological assessment. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is an extensive psychological questionnaire that produces personality profiles for a wide range of psychopathology. Validity scales provide information on response biases such as patients’ attempts to either deny or exaggerate psychopathological symptoms. Individuals with insomnia produce specific MMPI-2 profiles characterized by depression, anxiety, and somatization of emotional conflict. While some sleep disorders centers routinely administer the MMPI-2 to all patients as part of the intake evaluation, it may be considered too lengthy and time-consuming for some venues. Actigraphy Actigraphy is another technique to assess individuals’ rest/activity patterns over time. Actigraphs are small, wrist-worn devices (about the size of a wristwatch) that measure movement. They contain a microprocessor and on-board memory and can provide objective data on daytime activity. Computer software that accompanies most brands of actigraphs include scoring algorithms for estimating sleep and wake time for each night the actigraph is worn. Most such software also allows for outputting a day-to-day plot of the sleep/wake schedule

32 when the patient is asked to wear the actigraph day and night for a series of days. Actigraphy is used to clinically evaluate insomnia, circadian rhythm sleep disorders, excessive sleepiness, and restless leg syndrome. It is also used in the assessment of the effectiveness of treatments for these disorders, including behavioral therapy. Actigraphy has not traditionally been used in routine diagnosis of sleep disorders but is increasingly being employed in sleep clinics to assess patients’ sleep patterns over time in an objective fashion. Its value to CBT intervention efforts is that of providing an objective verification of the patient’s sleep/wake schedule and adherence to recommended rising times and TIB prescriptions. Detailed discussion of these treatment components is included in the treatment recommendations discussed in the next chapter (see Chapter 3). With the advent of smart phones, a variety of downloadable applications have become available for monitoring sleep. Like traditional actigraphy, these rely on either movement detectors contained in the smart phones or a wristband that records movement data that can then be downloaded into the phone for analysis with the associated downloadable application. Some of the available applications purport to provide information about sleep stages or sleep depth along with estimates of sleep and wake time. As many of these applications lack formal validation data, they cannot at this time be viewed as replacements for the more traditional actigraphic devices manufactured specifically for formal sleep assessment. Polysomnography Polysomnography is a diagnostic test during which a number of physiologic variables are measured and recorded during sleep. Physiologic sensor leads are placed on the patient in order to record the following: • Brain electrical activity • Eye and jaw muscle movement • Leg muscle movement • Airflow

33 • Respiratory effort (chest and abdominal excursion) • Electrocardiogram (EKG) • Oxygen saturation. This test has traditionally been conducted in a sleep disorders center but home sleep testing is increasingly being employed for diagnostic purposes. In most cases, polysomnography is not necessary for diagnosing insomnia, although in some cases it is helpful in determining whether or not there is another primary sleep disorder that is the cause for the patient’s sleep problems (e.g., sleep apnea or periodic limb movements during sleep). Summary In summary, the evaluation of insomnia is a complex process that may include a variety of assessment procedures. In most cases of insomnia, the information needed for diagnosis and treatment decision-making can be gleaned from the sleep history, clinical interview, and sleep diary. Indeed, these sources usually provide sufficient information to identify pertinent cognitive and behavioral treatment targets in the insomnia patient. However, the additional assessment methods mentioned herein may provide much needed diagnostic and assessment information in selected cases of insomnia in patients who have underlying sleep disorders or complex comorbid disorders.

35 (Corresponds to Chapters 2 and 3 of the Workbook) Materials Needed • Audiotape to record sleep education segment of session (optional) • Circadian Temperature Rhythm Graph • Circadian Temperature Rhythm Graph Showing Desired Sleep/ Wake Schedule • Patient’s completed sleep diaries Outline • Present rationale for treatment • Provide sleep education • Review “sleep rules” and provide brief summary of each • Make time-in-bed (TIB) recommendations • Assign homework Treatment Rationale Usetheinformation from Chapter 1 to present the client with a brief overview of cognitive-behavioral therapy (CBT) for primary insomnia (PI). Review with the patient Spielman’s 3-P model of insomnia and how it suggests that predisposing factors (e.g., biological or personality traits) and Session 1: Psychoeducational and Behavioral Therapy Components CHAPTER 3

36 precipitating events (events or circumstances that are stressful or otherwise disruptive to normal sleep/wake routines) can lead to the development of sleep problems. These problems arethen made worse by various perpetuating mechanisms, including unhelpful misconceptions about sleep, anxiety about sleeping poorly, conditioned arousal to the bed and bedroom, and various sleep disruptive habits (e.g., daytime napping, spending excessive time in bed). Explain that this treatment program is designed to correct those unhelpful sleep-related beliefs and anxiety as well as common sleep-disruptive habits that maintain or contribute to insomnia. You may use the following sample dialogue: We have conducted a thorough evaluation of your sleep problem and, based on our findings, we believe that you will benefit from some information about sleep and some recommendations designed to help you change your sleep habits. When sleep problems linger on, as they have in your case, usually unhelpful sleep-related beliefs and habits develop and add to the sleep problem. The treatment you receive will educate you about your sleep problem and help you correct those unhelpful beliefs and habits you have so that you can again develop a more normal sleep pattern. Then, move on to providing the patient information about sleep. Sleep Education The sleep education provided to patients during CBT has two primary functions. First, it helps patients overcome their misconceptions and anxiety-provoking beliefs about sleep so that they may develop realistic sleep expectations. Also, it enables patients to better understand how the human biological sleep system functions. Since much of the behavioral portion of CBT is fashioned to re-establish normal functioning of the patient’s sleep system, the education helps the patient to understand the rationale for the behavioral regimen used in this treatment. This understanding, in turn, increases the likelihood that patients will adhere to treatment recommendations. During this first session of treatment, provide the patient with information on sleep norms, circadian rhythms, the effects of aging on sleep,

37 and sleep deprivation. If you wish, you may audiotape this part of the session and give a copy of the tape to the patient to review at home. This information also appears in the corresponding patient workbook. You may use the following sample dialogue: This treatment will require you to make some major changes in your sleep habits so you can improve your sleep. However, before you learn these new habits, it is important that you have a better understanding of your sleep needs and what controls the amount and quality of sleep you obtain. The information I’m about to give you will help you understand how your body’s sleep system works and will prepare you for the specific treatment suggestions you will be given. Before you make any changes in your sleep habits, it is important that you ask the question, “How much sleep do I need each night?” Generally speaking, there is no one amount of sleep that “fits” everyone. Most normal adults sleep 6 to 8 hours per night. However, some people need only 3 or 4 hours of sleep each night, whereas others require 10 to 12 hours of sleep on a nightly basis. At this point, it is important to set aside any previous notions or beliefs you might have about your sleep needs. These beliefs may be wrong and may hinder your progress. The treatment you are about to receive will help you discover the amount of sleep that satisfies your needs and lets you feel alert and energetic during the day. In addition to getting rid of any old ideas you have about your sleep needs, it is important that you learn some facts about how your body’s sleep system works. People, like many animals, have powerful internal “clocks” that affect their behavior and bodily functioning. The “body clock” works in roughly a 24-hour period and produces 24-hour cycles in such things as digestion, body temperature, and the sleep/wake pattern. For example, if we record a person’s body temperature for several days in a row, we will see a consistent up-and-down pattern or rhythm in temperature across each 24-hour day. The temperature will be at its lowest point around 3 or 4 A.M, will rise through the morning and early afternoon, and will hit its peak around 3 or 4 P.M. Then, once again the temperature will begin to fall until it hits its low point in the early morning hours.