Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach 2nd

88 thinking, it is useful to consider the methods for managing patients’ cognitive errors discussed in the previous chapter. CASE EXAMPLE #8 Ms. S was a 33-year-old female who presented with sleep onset insomnia. She reported prominent worries about sleep and nightly dependence on sleep medications. She had a history of problems with anxiety. An examination of her sleep diaries revealed excessive time-in-bed and variable bedtimes and rise times. CBT recommendations included psychoeducation about sleep need, instructions to reduce her time in bed to match her sleep production (e.g., 7 hours), establishing a regular bedtime and rise time, and to get out of bed when she was unable to sleep (i.e., stimulus control). Ms. S returned to clinic 2 weeks later and reported almost no adherence to the sleep schedule or stimulus control instructions. She explained that she could not adhere to the treatment because she needed 8 hours to function. The next two sessions were devoted to restructuring the belief that she could not function without 8 hours of sleep. Her Thought Records revealed a core belief of helplessness. She believed that she had limited coping abilities and that she was “always one crisis away from becoming permanently disabled.” She had images of herself in a wheelchair in a “mental institution.” These beliefs were formed many years prior when she suffered from debilitating panic attacks. Focusing on the positive instances of coping, which included her gaining mastery over her panic attacks, allowed her to modify her helplessness beliefs. This cognitive shift resulted in almost total adherence to the behavioral recommendations and a mean post-treatment sleep onset latency (SOL) in the normal range (post-treatment SOL  =  21 minutes, instead of the pre-treatment SOL of 184 minutes). CASE EXAMPLE #9 Ms. T. was a 38-year-old single female with chronic insomnia who entered treatment with a motivated and cooperative attitude as she was “very ready” to put her sleep difficulties behind her. She readily implemented the behavioral sleep improvement strategies and sleep hygiene recommendations and adhered to the treatment regimen

89 quite well. However, she still continued to have some sleep difficulties, most often in the form of middle of the night wakefulness. She indicated that she typically felt somewhat anxious about her sleep and worried that friends and coworkers could tell by her appearance when she did not sleep well. She also felt pressure to sleep so she could function optimally in her job in a research laboratory. Specifically, she felt she “could just not function at work” if she had a poor night’s sleep. She admitted that these sorts of worries caused her to feel pressure to sleep well, which in turn made it more difficult for her to sleep without disturbance. To address Ms. T’s problem, she was instructed to use the Thought Record to find evidence for and evidence against her thought that she could just not function at work. Specifically, she was asked to note what she could and could not accomplish at work after a poor night’s sleep. Through repeated efforts she was able to find evidence for and against this thought from noting her day-to-day experiences at work after both good and poor nights of sleep. In addition, the therapist queried as to whether she had any objective evidence that her friends and coworkers could tell when she sleep poorly. At the therapist’s urging, Ms. T. questioned coworkers as to how rested she appeared both after her good and her poor nights of sleep. To her surprise, her coworkers seemed oblivious to her sleep difficulties. In addition, her boyfriend took pictures of her in the A.M. following what she considered good and poor nights of sleep and then showed those to her in a blinded randomized order to determine if she could tell by her appearance if she had sleep poorly. When she discovered that even she could not tell the pictures apart, she became much less concerned that others could tell she was sleeping poorly and thus felt much less pressure to sleep well. When this occurred, her sleep gradually improved, and she eventually showed a full remission of her insomnia complaints. Tracking Down “Missing” Sleep It is not uncommon for some patients to present with a complaint that they “do not sleep” for days, weeks, or even months on end. Patients with this complaint will often produce sleep diaries that show very

90 limited amounts or no sleep on many nights each week. Such cases may require use of special cognitive strategies to conduct some “detective work” so as to uncover the sleep that is “missing.” There are good reasons to do a little detective work in such cases. First, human beings are often unsuccessful with attempts to stay awake for more than a couple of days. “Trying” to stay awake is very difficult, as the body finds a way to produce short or brief unplanned bouts of sleep when confronted with long periods of wakefulness. Sleep-deprivation experiments often must resort to using high degrees of stimulation (i.e., noise and light in a laboratory setting) and experimenter intervention (i.e., talking to the patient) in order to successfully keep someone awake for prolonged periods. What makes the report of no sleep in a person with insomnia even more incredible is that they report not falling asleep under conditions of almost no stimulation at all. For example, they report that they lie awake in bed, in the dark, with no noise, all night long. Also, there are plenty of data to document a discrepancy between objective indices of sleep (i.e., brain wave activity on a polysomnogram or activity monitoring on an actigraph) and subjective reports (i.e., sleep diary) of “I don’t sleep.” There is controversy as to what accounts for the discrepancy, as some other physiological measures (i.e., spectral analysis) have shown increased high frequency activity in the brain of those with a so-called subjective-objective discrepancy. One common cognitive error in such insomnia sufferers is dichotomous thinking. Large amounts of time spent awake is viewed as “no sleep.” There may be a “cost” to believing that one does not sleep (irrespective of whether there is objective data to the contrary). The cost to believing “I don’t sleep” is increased anxiety, and anxiety increases the likelihood of sleep disruption. The following is an example of some “detective work” in investigating the report of “no sleep.” CASE VIGNETTE Therapist: I see on your Thought Record that your thoughts have included: “I can’t believe I went another night without sleeping.” “I haven’t slept in over 2 weeks,” and “Can you die from not sleeping?” I also notice that you have rated frustration and anxiety at 100%. Patient: You’d be anxious and frustrated if you didn’t sleep either.

91 Therapist: I would like us to examine whether there may be a connection between some of these thoughts and your mood. Is there any possible connection between the thought, “I haven’t slept in over 2 weeks” and anxiety or frustration? Patient: Of course. It’s scary to not sleep. Therapist: I can see how thinking you haven’t slept in 2 weeks would be scary. I wanted to make sure that I understand this; you have not slept even one minute in 2 weeks? Patient: Well, very little anyway. Therapist: Oh OK, there has been some sleep, but very little? Patient: Almost none. Therapist: I can see how it would be upsetting to have very little sleep, but I could see how it would be even more upsetting if there was absolutely zero sleep. In fact, I have never had a case with no sleep for 2 weeks so I am relieved to hear there has been at least a little bit of sleep. Can you estimate how much sleep is a “little bit of sleep” over the last 2 weeks? Patient: I don’t know, maybe a few minutes. Therapist: OK, a few minutes. I remember you told me that you were irritated when your husband woke you to tell you that you were snoring. Was this the few minutes we are talking about? Patient: I guess. I was so irritated because I felt as though I was just about to fall asleep and then he nudged me. It didn’t seem like I was sleeping but I guess I must have been. You can’t snore when you’re awake, right? Also, I looked in the mirror yesterday and saw the imprint of my keyboard on the side of my face. So I know I fell asleep yesterday at the computer but I don’t really remember it. So that’s a little more time. Therapist: This is good. We also need to remember that you recorded 2 daytime naps over the last week. It is important for us to “find forgotten sleep,” especially since you have said that thinking you don’t sleep at all increases your anxiety. When you are more anxious, are you more likely to have worse sleep? Patient: Well, yes. Therapist: Then it would be important for us to make sure you are not telling yourself something that makes you more anxious, right?

92 Patient: I guess. Although I don’t think I am sleeping that much, I don’t usually remember seeing the clock or getting up between 2–6 A.M., so it’s possible that I am sleeping a little during that time. Therapist: So we have a few minutes during the day, a few minutes in the first half of the night, and about a 4-hour window in the second half of the night when there is an undetermined amount of sleep. It looks like your body is really working to give you bits of sleep here and there, even if you are not always aware of it, and even if it doesn’t always feel like it. Does this help at all with the thought that you might die from not sleeping? Patient: Well, I’m probably not going to die. It was just scary to think I wasn’t sleeping at all. I guess I’m sleeping a little. Therapist: Do you think that being less anxious about this may allow you to get even more sleep? Patient: I hope so! Summary Although we have no hard and fast rule about the number of follow-up sessions to provide patients, most of our patients with isolated insomnia disorders respond to treatment in 3–4 sessions total. Of course, there are those who respond more gradually but do achieve a satisfactory outcome. In the end, therapy should be guided by the patient’s sleep performance, reflected by sleep diary data and by the patient’s subjective appraisal. Optimal sleep performance is characterized by sleeping soundly at night and having no daytime symptoms (e.g. fatigue, impaired concentration, distress about sleep) of insomnia. In this case, sleep diaries would show that the patient has a regular sleep/ wake schedule and typically has little difficulty falling asleep or staying asleep through the night. Along with this observation, the diaries and the patient’s self-report should indicate that the final morning awakening typically occurs slightly before the alarm clock sounds. If the patient sleeps soundly but most often is awakened by the alarm, it is likely that the patient could and would sleep a little longer each night had the alarm not been set. In such cases, it is usually useful to expand the TIB window somewhat until the sleep pattern described emerges. However, once the patient achieves a sound sleep pattern at night and

93 is satisfied with his or her daytime function, therapy termination may be considered. When therapy termination is discussed with patients, it is important to review all of the new sleep and insomnia management skills they have learned during the treatment. In this regard, it is important to emphasize that they now have the “tools” they need to manage their sleep problems and to combat any future bouts of insomnia they may confront. It is also useful to emphasize that future nights of poor sleep are not only possible but also are very likely to occur from time to time. However, it is important to emphasize to the patient that he or she now is well equipped to manage such episodes effectively so that they do not persist. In addition to this information, we have found it helpful to give the patient “permission” to schedule any future “refresher sessions” he or she feels are necessary to reinforce what he or she has learned and to help the patient through more difficult episodes. Through use of such strategies we have found a large percentage of those patients we treat are able to continue the treatment on their own with minimal or no further assistance from our clinic.

95 Challenging Patients and Treatment Settings Overview of the Treatment Challenges Thus far, the discussion in this manual has summarized strategies to employ during individual therapy sessions with uncomplicated insomnia patients who are not reliant or dependent upon sleep medications. Of course, many patients who present for treatment do so in the context of ongoing use of sleep medications. Many other treatment-seeking patients have concurrent comorbid medical, psychiatric, or sleep disorders that contribute significantly to their persistent sleep difficulties. Furthermore, not all patients who seek insomnia treatment present to psychologists or other providers who have training and skills in cognitive behavior therapy (CBT) techniques. In fact, the majority of treatment-seeking insomnia patients present to primary care or other types of medical venues where individualized one-on-one sessions with a CBT therapist are either unavailable or not practical. The various types of patients with insomnia, as well as the varied settings in which they present for treatment, present special challenges to those wishing to implement the CBT procedures described herein. The discussion in this chapter thus considers how CBT may be disseminated to the types of patients and settings mentioned. CBT with Hypnotic-Dependent Insomnia Patients As noted in Chapter 1, various medications are commonly employed for insomnia management. Included among these are various types of benzodiazepine receptor agonists (BZRAs) that have been well tested Considerations in CBT Delivery CHAPTER 6

96 and are FDA approved for insomnia treatment. At times, other BZRAs that have FDA approval for treating anxiety, but not insomnia, are prescribed alone or in addition to the approved medications to treat sleep difficulties. In addition, a variety of other medications, including antidepressants such as the sedating tricyclics (e.g., doxepin) and trazodone, and the atypical antipsychotic quetiapine are often used to manage patients’ sleep complaints. Of these latter medications, only doxepin has FDA approval for treating insomnia. The others are used “off-label” for insomnia management. Finally, various over-the-counter medications are available and are used frequently by insomnia patients in their efforts at self-management. Of these, the antihistamine diphenhydramine, the hormone melatonin, and the herbal preparation valerian root are perhaps most commonly used. Over the years, concerns have been raised about protracted use of medications to address chronic insomnia. Although there is considerable “clinical lore” supporting the prescription medications used “off-label” for sleep, currently there are few data to support their safety and efficacy for long-term insomnia management. Likewise, there are extremely limited data concerning the safety and efficacy of those sleep medications available without prescription. With some of the first generation FDA-approved BZRA hypnotics, medication tolerance develops with continued use such that patients experience reduced efficacy while being maintained on stable therapeutic doses for extended periods of time. Abrupt withdrawal of such medications often results in a transient, albeit distressing, worsening of sleep that convinces many patients to quickly resume their medication use. In contrast, some of the longer-acting BZRAs may result in unwanted next-day effects such as sluggishness or “hangover.” Fortunately, the newer generation BZRAs (e.g., zolpidem, eszopiclone, zaleplon) have far less pronounced unwanted properties such as these, and some such agents generally have proven safe and effective over extended periods of continued use. However, a small subset of patients, particularly those with histories of sleepwaking, develop unusual behaviors during sleep such as sleepwalking, sleep eating, or actually driving their motor vehicles while asleep when taking one of these agents. Patients who develop such sleep-related behaviors should discontinue the sleep medication immediately due to the dangers that

97 such behaviors may pose. In the absence of such nocturnal phenomena, long-term use of hypnotics can be problematic to some patients for reasons other than those mentioned thus far. The following case example demonstrates the difficulties that long-term hypnotic use may pose. CASE EXAMPLE 6.1 Ms. R. was a middle-aged married woman who presented to our clinic with insomnia complaints. At the time of her presentation, she reported a history of sleep difficulties dating back about 10 years to a time when she was having ongoing medical problems. She notes that at that time she had undergone surgery on her left leg and the surgical wound did not heal properly. She noted pain, immobility, and general distress over her condition. In that context, she experienced the onset of her sleep difficulties. Shortly after her sleep problem began, she obtained a prescription for lorazepam to treat her sleep difficulty and she had taken that medication almost nightly since that time. She subsequently had received an additional prescription for zolpidem, 10 mg, to help her sleep. Hence, when she presented for treatment, she was taking 10 mg of zolpidem along with .5–1 mg of lorazepam on a nightly basis as sleep aids. Her stated goal for treatment was to learn how to sleep without sleep medications. However, she noted that she became very anxious and unable to sleep without lorazepam, and she admitted that she thought she would be unable to initiate and maintain sleep unless she took both of her sleep medications. In support of this, she noted that her efforts to stop these medications had been met with her experiencing elevated anxiety about sleep and pronounced wakefulness during the subsequent night. With her medications, she indicated that she was able to function in the daytime without severe daytime sleepiness (Epworth Sleepiness Scale = 9). However, she did indicate that her sleep still was not ideal and she experienced a significant level of fatigue many days each week, despite her nightly use of medicinal sleep aids. Her sleep diary (Figure 6.1) shows her sleep pattern at the time of her initial clinic visit. Despite her nightly medication use, she still showed difficulty initiating sleep on two nights and relatively poor quality on several nights. This diary also showed the erratic sleep scheduling common to insomnia patients in general.

Sample Today’s Date 3/25/13 10/19 10/20 10/21 10/22 10/23 10/24 10/25 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. 11:30 PM 12:00 AM 1:00 AM 2:30 AM 12:30 AM 1:30 AM 12:30 AM 3. What time did you try to go to sleep? 11:30 p.m. 11:30 PM 12:00 AM 1:00 AM 2:30 AM 12:30 AM 1:30 AM 12:30 AM 4. How long did it take you to fall asleep? 55 min. 105 min 5 min 5 min 1 min 90 min 5 min 30 min 5. How many times did you wake up, not counting your final awakening? 6 times 2 3 1 Don’t remember 2 3 3 6. In total, how long did these awakenings last? 2 hours 5 min. 5 min 5 min 5 min 5 min 5 min 5 min ? min 5 min 5 min 5 min 5 min 5 min 5 min 5 min 5 min 7. What time was your final awakening? 6:35 a.m. 9:30 AM 7:15 AM 8:45 AM 10:30 AM 10:00 AM 8:00 AM 7:15 AM 8. What time did you get out of bed for the day? 7:20 a.m. 9:30 AM 8:00 AM 8:45 AM 10:45 AM 10:10 AM 8:15 AM 7:45 AM 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): Lorazepam/ Ambien Dose: 1 mg/10 mg Time(s) taken: 11 pm Yes □No Medication(s): Lorazepam/ Ambien Dose: 1 mg/10 mg Time(s) taken: 11 pm Yes □No Medication(s): Lorazepam/ Ambien Dose: 1 mg/10 mg Time(s) taken: 11 pm Yes □No Medication(s): Lorazepam/ Ambien Dose: 1 mg/10 mg Time(s) taken: 11 pm Yes □No Medication(s): Lorazepam/ Ambien Dose: 1 mg/10 mg Time(s) taken: 11 pm Yes □No Medication(s): Lorazepam/ Ambien Dose: 1 mg/10 mg Time(s) taken: 11 pm Yes □No Medication(s): Lorazepam/ Ambien Dose: 1 mg/10 mg Time(s) taken: 11 pm 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 I have a cold Figure 6.1 Sleep Diary—Sleep Medication User.

99 Ms. R’s case highlights many of the characteristics commonly presented by those insomnia patients who use sleep medications on a chronic basis. As her history demonstrates, her sleep medication use began for good reason during a time when she was recovering from a painful medical condition that disrupted her sleep. However, she was initially prescribed a BZRA medication for sleep that has FDA approval for anxiety management but not insomnia. While continued on this medication, she was given an FDA-approved hypnotic as an additional sleep aid. Her history suggests that, over time, she developed a psychological dependence on such medications as sleep aids. Indeed, her efforts to stop these medications were met with increased sleep-focused anxiety and marked sleep disruption. When patients like Ms. R are interviewed thoroughly, they often report a general lack of self-efficacy in regard to their ability to obtain adequate sleep. In a sense, they have lost faith in themselves as sleepers. As a consequence, they come to rely on sleep medication(s) to obtain the sleep they need. Insomnia patients who use hypnotics chronically present with many of the cognitive and behavioral treatment “targets” discussed in previous chapters. Specifically, they have catastrophic beliefs about the daytime effects of their sleep difficulties as well as a misunderstanding of how their sleep habits may contribute to their insomnia. Accordingly they demonstrate many of the common sleep disruptive compensatory practices (e.g., daytime napping, erratic sleep schedules, extended waking periods spent in bed) seen in medication-free insomnia patients. However, they also present a unique set of cognitions and behaviors that require treatment attention. Commonly such patients have strong beliefs that their insomnia is “due to a chemical imbalance” so they conclude that they are unable to sleep without a medication. Many appear rather conflicted, on the one hand believing that long-term sleep medication use is harmful, while on the other hand feeling helpless to sleep without some sort of sleep aid. Some patients who are concerned about their medication use, cut their sleeping pills in half and surprisingly sleep well on sub-therapeutic doses yet are unable to wean themselves completely from such medications without a marked worsening of sleep. Others will intermittently try going to bed without their usual medication to “see how they do” without it. Of course, this latter strategy usually tends to increase vigilance over one’s sleep performance, which, in turn, makes sleeping more difficult. Thus, chronic

100 medication users present additional cognitive and behavioral targets that merit the therapist’s attention. Since many chronic hypnotic users present with the desire to discontinue their sleep medications, it is important to implement a treatment plan that enables them to do so while maintaining or re-establishing a satisfactory medication-free sleep pattern. Current evidence (Morin, Belanger, et al. 2005; Belleville, Guay, et al. 2007; Soeffing, Lichstein, et al. 2007) suggests that a therapy that combines CBT techniques with a structured medication-tapering program produces optimal results with medication-dependent patients. Typically, it is helpful to initially have the patient continue on his or her usual medication, and to plan to take this medication routinely, as prescribed, prior to going to bed each night. While the medication regimen remains stable, treatment should commence by initiating the CBT strategies described in detail in the preceding three chapters. While patients begin implementing the strategies they learn through CBT, they should be dissuaded from making any changes in their sleep medication practices. Specifically, they should be discouraged from changing their medication dosages or experimenting with medication-free nights. During the course of this treatment it may be helpful to identify some unhelpful beliefs about sleep medications and to have patients complete thought records as “homework” to address such beliefs. It is also important to have patients adhere strictly to the behavior strategies discussed in Chapter 3 to produce a consolidated and consistent sleep pattern while they are still taking their medications. Encouraging implementation and adherence to these strategies often results in improved sleep patterns and enhances chances for success in the subsequent medication-tapering process. Once the patient successfully implements the CBT strategies discussed in the previous chapters and shows a stable sleep pattern for at least 2 consecutive weeks, a medication-tapering strategy can be introduced. From a safety viewpoint, many prescription and over-the-counter medications taken for sleep can be discontinued fairly rapidly without untoward medical concerns. However, patients who are dependent on sleep medications usually are more successful discontinuing such medications if allowed to taper them more slowly and deliberately. In this regard, strategies discussed elsewhere (Belleville, Guay, et  al.

101 2007; Soeffing, Lichstein, et al. 2007) have proven efficacious for such patients. These approaches allow a slow, graded “step-down” approach to tapering that offers the patient a gentle pace at fading the medication while allowing some sense of gradually increasing self-efficacy regarding the discontinuation process. For example, the approach described by Belleville et  al. (2007) involves the following sequence of steps:  (1)  setting a goal for medication use/reduction each week; (2) when more than one medication is being used, reduction to a single medication at a stable dose is set as the first goal; (3) the initial dosage of the medication is reduced by 25% every 2 weeks until the lowest available (therapeutic) dosage is reached; (4)  drug-free nights are gradually introduced with drug-free nights being planned in advance; (5) the number of drug-free nights per week are gradually increased until the patient is medication free. While instituting this sort of withdrawal plan, it is important to have the patient continue monitoring his or her sleep with the sleep diary and to continue with the cognitive tools (Thought Records, Constructive Worry worksheets) as needed. It is also important to monitor CBT adherence using the techniques outlined in Chapter 5. Finally it is wise to have the patient consult with his or her prescribing physician before beginning the tapering process since that provider’s collaboration and medical advice are essential to a safe and successful hypnotic withdrawal plan. Whereas the combined CBT plus guided medication-tapering approach tends to produce the best results, patients may vary in the success they achieve. Some show a good response and become able to sleep medication free. Others experience setbacks along the way due to unexpected stressors or other factors. Some patients may view such setbacks as indications of treatment failure, so it is helpful to assist such patients in reframing such occurrences in a constructive manner. Again, use of Thought Records may help with this problem. However, some patients may not succeed with medication discontinuation due to ongoing stressors or other life circumstances that demand their attention. Like other problem areas that merit a certain degree of readiness on the part of the patient to change, discontinuation of hypnotic medication requires a level of readiness and commitment to the treatment processes discussed herein. Hence, a thorough assessment to determine the patient’s readiness for the strategies described may be useful prior to initiation of this approach.

102 Treating Insomnia Patients with Comorbid Disorders Whereas many insomnia patients encountered clinically suffer only from insomnia, a far greater proportion of all treatment-seeking insomnia patients present with complex comorbid conditions. A variety of medical conditions, particularly those that result in chronic pain, breathing difficulties, or immobility, can give rise to insomnia problems. Likewise, a large proportion of psychiatric conditions have insomnia as a primary presenting symptom. Furthermore, many medications prescribed for the treatment of medical and psychiatric conditions may have insomnia as a common side effect. Finally, excessive use of alcohol, caffeine, and various illicit substances may cause or add to insomnia problems. In a sizable proportion of patients, a mixture of medical, psychiatric, and substance-related causes of insomnia coexist and complicate insomnia management. In cases of comorbid insomnia, it is always helpful to optimize management of the comorbid medical/psychiatric conditions to ensure the best insomnia treatment outcomes. In some cases, successful treatment of the comorbid disorder(s) results in insomnia remission. However, frequently this is not the case since factors in addition to or other than the comorbid condition may sustain insomnia over time. Although the onset of insomnia may relate to endogenous physiological changes or acute stress reactions to the onset of a comorbid illness, a host of cognitive and behavioral factors may perpetuate insomnia over time. Even among individuals whose sleep disturbance initially emerged as a symptom of the comorbid condition, the nightly experience of unsuccessful sleep attempts can result in conditioned arousal and subsequent efforts to make up for lost sleep by spending excessive time in bed each night or napping during the day. These practices can result in prolonged sleep difficulties because they adversely affect homeostatic and circadian mechanisms that control the normal sleep/wake rhythm. Since such sleep-disruptive cognitions and habits may play important roles in perpetuating insomnia in comorbid patients, CBT strategies may be useful as primary or adjunctive insomnia treatment for these individuals. A growing number of randomized clinical trials have investigated the efficacy of CBT for treating insomnia patients with various types of

103 comorbid conditions. Various studies have focused on medical disorders and have suggested that CBT is efficacious for treating insomnia in chronic pain patients (Currie, Wilson, et  al. 2000), fibromyalgia patients (Edinger, Wohlgemuth, et  al. 2005), older medical patients with mixed medical disorders (Rybarczyk, Lopez, et al. 2002), and cancer survivors (Savard, Simard, et al. 2005; Espie, Fleming, et al. 2008). In addition, several case series and randomized clinical trials (Kuo, Manber, et  al. 2001; Morawetz 2003; Taylor, Lichstein, et  al. 2007; Manber, Edinger, et al. 2008) have suggested that CBT is effective for treatment of insomnia in patients with comorbid depression. Though additional randomized trials are needed to test CBT with comorbid patients, it is useful to consider how CBT insomnia treatment might be adapted for patients with various types of comorbidities. Chronic Pain Chronic pain tends to fragment sleep and decrease the depth of sleep; acute pain, in contrast, tends to rouse people out of sleep or prevent them from falling asleep. Thus, the primary target in those with chronic pain tends to be increasing the drive for deep sleep (i.e., by restricting the time spent in bed in a 24-hour period and increasing activity modestly). Asking people to spend less time inactive, or less time in bed or resting, can be met with resistance. Part of this may be cognitively mediated, “I should rest,” or “My doctor told me I need to be napping and resting.” It is important to encourage patients to use pain relief. Some patients exhibit all-or-none thinking and refrain from any pain medications because the medication does not eliminate 100% of the pain. Ask patients to consider whether 20% pain relief has a more positive impact on sleep than 0% pain relief. Encourage patients to consult with their doctor to ensure that their doctor has cleared them for less inactive time. Once the doctor has cleared them to make modest decreases in the time they spend in bed or at rest, assess for beliefs such as, “It is better to stay and try to sleep than to leave the bed,” or “If I get up it will aggravate my pain.” It is often more effective to focus on whether such beliefs are helpful in the goal of addressing the insomnia rather than whether such beliefs are true. Fragmented sleep is associated with increased pain so addressing the sleep quality of those

104 with chronic pain can help with pain as well as sleep. Ask patients to look at their sleep diaries and their current time in bed and ask them to reflect on how they slept and felt during the day. Ask the patient to engage in a behavioral experiment over the next 2 weeks that tests whether reducing the amount of time in bed has a more positive effect on pain and sleep. With patients concerned about not being able to rest, explore ways they can rest when needed without the likelihood of falling asleep or remaining inactive for long periods of time. For example, encourage the patient to refrain from resting in a supine position or in a location such as a recliner, where they might doze off to sleep. Some patients may have concerns about injury or for other medical reasons find it too difficult to get out of bed during the night when they have difficulty initiating or maintaining sleep. For such patients it may be best to employ a counter-control strategy that requires them to sit up in bed or preferably move to the other side of the bed, rather than leaving the bed or bedroom, until sleepy again (Davies, Lacks, et al. 1986). Counter-control also may be a good solution for patients at risk for falls during the night, such as those who are elderly or very medically ill. Sleep-Disordered Breathing Many patients who have breathing-related sleep disorders, such as those with obstructive sleep apnea, will suffer from a comorbid insomnia disorder as well. When the apnea remains untreated, it may be difficult to ascertain which of the patient’s sleep complaints are related to apnea and which represent a separate insomnia disorder. This is the case because the repeated breathing disturbances resulting from the sleep apnea fragment sleep and may lead to the sorts of sleep maintenance complaints presented by many insomnia sufferers. However, the evidence (Caetano Mota et al. 2012) suggests that over 50% of apnea sufferers continue to have insomnia symptoms after they receive effective apnea treatment, whereas slightly over 20% of all apnea patients may develop insomnia de novo once they begin the most commonly prescribed apnea therapy, positive airway pressure (PAP). Since PAP therapy requires the patient to wear a nasal or full face mask that forces pressurized air through the nose or mouth during sleep, it is not difficult to understand that many patients have difficulty tolerating this

105 therapy and thus continue to have or develop a new insomnia after PAP therapy commences. Alternatively, some apnea patients are treated with a dental appliance that repositions the lower jaw to open the airway, and intolerance to this treatment can at times contribute to or exacerbate insomnia complaints. To date there have been a limited number of studies that have tested CBT for the treatment of insomnia in comorbid sleep apnea. Although one fairly large study (Lack, Hunter, et al. 2011) showed that sleep apnea patients treated solely with CBT appreciate improvements in their sleep and waking function, other studies (Krakow, Melendrez, et al. 2004; Guilleminault, Davis, and Huynh 2008) have indicated that the best outcomes are achieved when CBT is combined with an effective apnea therapy. However, it is important to confirm that the concurrent apnea therapy is effectively controlling the apnea at the time CBT is provided for the comorbid insomnia disorder. It is also essential to determine that the patient is indeed sufficiently adherent to the apnea therapy to derive sufficient benefits from this. If either the apnea therapy is not fully effective or the patient is insufficiently treatment adherent, sleep disturbance will remain even if CBT for insomnia effectively eradicates the patient’s sleep-disruptive habits and cognitions. As implied by the foregoing discussion, successful CBT intervention for patients with comorbid sleep apnea requires not only monitoring of the patient’s follow-through on CBT interventions, but also consideration of the patient’s response and adherence to the apnea therapy. Since a majority of apnea patients are treated with some form of PAP, information about treatment effectiveness and adherence is monitored objectively and stored in most currently available PAP devices. Such information is periodically downloaded by sleep center personnel who are following the patient for his or her sleep apnea and/or by the home healthcare company that supplies the PAP device to the patient. Hence, it is useful to partner with one or the other such colleagues who can obtain and interpret this information so that can be considered in the overall management of the patient’s sleep complaints. When such data suggest good treatment adherence (i.e., used most or all of the night on at least 70% of all nights) and control of the patient’s apnea (i.e., the patient is having fewer than 5 events of sleep-disordered breathing per hour of sleep), then it can generally be surmised that the remaining

106 insomnia symptoms represent reasonable treatment targets for CBT, particularly for patients who show the common sleep-disruptive habits and cognitions presumed to perpetuate insomnia per se. However, when PAP adherence is poor or a greater than desired level of apnea remains with PAP therapy, then intervention by the patient’s sleep disorder specialist will be necessary to fully address the patient’s sleep/ wake complaints. In addition to such considerations, it may be necessary to alter the CBT behavioral treatment regimen somewhat to accommodate the apnea patient. Some such patients remain very sleepy in the daytime, even when adequate treatment for their sleep apnea is being provided. Such patients may have trouble adhering to sleep restriction requirements and/or the admonition against daytime napping. In such cases, relaxing time in bed restrictions somewhat or allowing limited (30–45 minutes) daytime napping in the morning or early afternoon hours may be needed to optimize treatment adherence and therapeutic outcomes. Also, those patients using PAP therapy may find it inconvenient or more sleep disruptive to get out of bed at night when awake then they do to stay in bed. This is true since getting out of bed requires removal of the PAP mask and then placing it back on the face when returning to bed to reinitiate sleep. This process can be viewed as an excessive burden that adds to their sleep disruption instead of reducing it. Hence, in such circumstances use of the counter-control procedure mentioned earlier may be the best solution. With this procedure the patient can remain in bed without removing the PAP device and thus can be poised to return to sleep more easily when sleepiness returns. Depression Major depressive disorder is a disorder that can pose special challenges related to depression symptoms such as anhedonia, avoidance, and diurnal mood worsening. To escape from the chronic experience of low mood, many people with depression retreat to their bed or bedroom, or engage in very little activity. Bedrooms have little distraction, and when there is little distraction, patients are likely to continue to ruminate, which results in their continuing to feel terrible. When patients with

107 depression become trapped in a cycle of feeling poorly and ruminating about how poorly they feel, they typically engage in little activity and spend excessive amounts of time in bed as an [ineffective] avoidance strategy. It is not unusual for those with depression to come home from work, change into their nightclothes, and do very little for the remainder of the evening. Inactivity reduces sleep drive, increases the likelihood of dozing, increases the likelihood of rumination, and limits exposure to positive reinforcers in the environment. In working with depressed patients it is therefore important to ask about evening activities. Such questioning can provide some clues as to whether there may be dozing, avoidance, or rumination occurring. It is also useful to calculate the time in bed in the 24-hour period (including naps) to determine if it seems unusually high. It is common to find depressed patients spending greater than 9 hours in bed in the 24-hour period. Spending large amounts of time in the bedroom or bed without sleeping can create conditioned arousal. The bed should have a strong stimulus value for sleep and increased periods of time in bed while not sleeping will disrupt this association. Additionally, excessive time in bed can diffuse the homeostatic drive for deep sleep. Whereas providing an explanation of this factor through psychoeducation may be enough for most patients to stop this behavior, some patients will need alternative strategies to address the reasons they are engaging in avoidance. Ask them to monitor their mood, sleep, and activity over the next week. Review the log with them to encourage them to see the links between inactivity, low mood, and poor sleep. Assess whether they are more likely to engage in rumination when experiencing low mood and/or fatigue. Provide a model of rumination, low mood, inactivity, and poor sleep. The following interchange demonstrates the sort of dialogue that can be helpful with such patients. THERAPIST: When you are experiencing low mood, it is like a burning fire. When you ruminate, it is like continuously pouring gas on the fire. What happens if you pour gas on the fire? PATIENT: It continues to burn? Probably even worse, too. THERAPIST: What would happen if you were distracted from the fire and walked away from the fire pit? PATIENT: I guess you wouldn’t be thinking about the fire? THERAPIST: And what would happen to the fire? PATIENT: Eventually it would go out, I guess.

108 THERAPIST: Would you be willing to try an experiment this week? We have seen what happens when you spend all evening in your bedroom—there is little to distract you and you spend some time dozing and then have difficulty sleeping later at night. I wonder what you would find if this week you engaged in one activity in the evening meant to distract you and essentially keep you out of bed until later in the evening. Are you willing to try it and see if there is any noticeable difference from staying in your room all evening? Asking patients to try an alternate activity can lead to some positive results. In cases wherein the target is not rumination, ask the patient whether it would be more or less likely for them to doze off if they were out with a friend versus lying on their couch? Ask the patient to test out scheduling activities to increase their response to the sleep treatment. Sometimes, spending increased time in bed or in the bedroom can occur in the morning as well. A key component of behavioral insomnia treatment is fixing a standard rise time. It provides a cue for the body clock, and begins the accumulation of wake time needed for adequate sleep drive. It is important to encourage patients to refrain from the temptation of trying to compensate for sleep loss by sleeping in or to use lingering in bed as a strategy to avoid starting their day. However, responding to feelings of fatigue or low mood by staying in bed is common and a difficult barrier to overcome. Often explaining the negative effects of staying in bed in the morning via psychoeducation can be enough to overcome the barrier; however, sometimes more is necessary. Identifying the barrier is the first step. In cases where mood is lowest in the morning, it may be difficult to feel motivated to follow the rise time “plan.” Share with the patient that it is important to find a way to address barriers to getting up in the morning. Ensure that the patient understands the rationale behind the recommendation. Using an activity log that simultaneously monitors mood can help patients see the link between their lowest mood and inactivity. It is often helpful to suggest an experiment in which the patient could get out of bed at a set time to determine if there were any effects on mood or fatigue. Ask if there are any strategies that could be tried over the next week to attempt to help him or her make this important change, for example, scheduling something pleasurable in the morning, particularly with another

109 person, or enlisting the help of another person to help him or her get out of bed. Activities that involve light, preferably sunlight, and movement can be particularly helpful in setting the clock, reducing fatigue, and lifting mood. Alcohol Abuse Alcohol is a central nervous system depressant that has relaxing and soporific effects that can ease the onset of sleep. However, alcohol is very rapidly metabolized by most individuals, so alcohol withdrawal symptoms emerge a few hours after alcohol is consumed. The latter become problematic when alcohol is consumed too close to bedtime. In such cases, the alcohol withdrawal process actually will contribute to sleep fragmentation and wake-ups during the course of the sleep period. It is not uncommon for insomnia sufferers to resort to alcohol as a sleep aid given its fairly immediate relaxing effects. However, in doing so, they can actually make their sleep problems worse, particularly if they routinely have sleep maintenance difficulties. It is not uncommon to encounter insomnia occurring comorbid to chronic alcohol dependence or abuse. In fact, chronic insomnia is one common reason given by patients for their chronic patterns of alcohol use. Moreover, residual insomnia in patients who become abstinent from alcohol is the most common reason for relapse into patterns of alcohol dependence/abuse. Although very limited, there is some evidence (Arnedt, Conroy, et al. 2011) that CBT is an effective intervention for patients who have insomnia comorbid to chronic alcohol abuse patterns. However, with such patients special challenges related to their alcohol use often emerge. Such patients often experience a rebound insomnia or worsening of their sleep at the time they withdraw from alcohol. If this withdrawal process is ongoing at the time CBT is initiated, it certainly will slow the therapy process and blunt the initial treatment response. Conversely, many patients with long-term alcohol dependence/abuse patterns find they have continued objective sleep disruption long after they achieve abstinence, likely as a consequence of the deleterious effects of long-term alcohol use on the central nervous system.

110 In implementing CBT with this patient group, it is important to consider the patient’s current status vis-à-vis alcohol use. If the patient is routinely using alcohol as a sleep aid, it may be best to have the patient hold their current use pattern constant while you commence with CBT for insomnia, just as you would when intervening with hypnotic-dependent patients. Once the patient has stabilized his or her sleep with this therapy, you can then negotiate a gradual alcohol-fading plan. If the patient has evidence of more severe alcohol dependence/ abuse, it is usually wise to encourage enrollment in a formal substance abuse treatment program. When working with a patient who has become abstinent after long-term use of alcohol, it is often helpful to provide some education about the residual sleep disturbance that may persist after achieving abstinence. This education helps the patient develop realistic expectations for treatment outcomes. Whereas the CBT intervention may markedly improve sleep in such patients, there still may remain a less than optimal sleep pattern. For healthy patients, the addition of routine aerobic exercise may compliment CBT’s effects and may help improve sleep quality. In other patients, treatment with CBT and hypnotic medications may lead to optimal outcomes. If the latter is the case, it is best to partner with the patient’s prescribing physician to achieve optimal results. Anxiety Disorders Insomnia is frequently accompanied by subsyndromal anxiety, so treating insomnia in the presence of a comorbid anxiety disorder is often different in the degree of the anxiety symptoms only. There are, however, some notable exceptions, including panic disorder and post-traumatic stress disorder. When treating those with panic attacks, it should be noted that sleep deprivation is linked to a reduced panic attack threshold. Sleep restriction will ideally result in some increased sleepiness if the treatment is working, but this also renders the patient more susceptible to panic attacks. It should be noted that those with previous hypomanic or manic episodes, as well as those with a history of seizures, are vulnerable to possible mania/hypomania or seizures, respectively, as a result of the increased sleep deprivation. One solution is to emphasize stimulus control or to restrict time in bed to a lesser degree. Sleep compression is a technique whereby patients gradually reduce the

111 time spent in bed by weekly 30-minute decreases, rather than starting at the desired time-in-bed target (Riedel, Lichstein, and Dwyer 1995). By proceeding gradually, there may be less chance of inducing panic attacks, or other issues such as mania/hypomania or seizures. Post-Traumatic Stress Disorder In contrast to depression, where there can be excessive time in the bedroom and in bed, people with post-traumatic stress disorder (PTSD) often have avoidance of the bed and bedroom. Sleep can be a vulnerable time for someone who believes they must be vigilant for signs of danger throughout the 24-hour period. The night may also be a time in which nightmares are common; thus an ambivalence can develop regarding the sleep opportunity. The following case example shows the potential usefulness of CBT strategies with a patient with chronic insomnia and a comorbid anxiety disorder. CASE EXAMPLE 6.2: INSOMNIA AND COMORBID ANXIETY DISORDER The patient was a 56-year-old married man who participated in a CBT insomnia treatment study at a VA hospital. The patient has been seen for treatment at the hospital for a number of years in relation to the combat-related post-traumatic stress disorder he developed as a result of his service experience during the Vietnam War. At the time the patient presented for the study, he reported a 15-year history of chronic insomnia problems. Specifically, he reported that he would typically sleep soundly for only about 2.5 hours per night and then he would toss and turn the remainder of the night. He reported that he was receiving ongoing pharmacotherapy (Citalopram) for his PTSD, and his symptoms other than his sleep difficulty were relatively well controlled. As part of his initial evaluation for the treatment study, he underwent diagnostic sleep monitoring (polysomnography) in order to rule out sleep disorders not detectable from interview (e.g., sleep apnea). Results showed no evidence of sleep apnea or other medically based primary sleep disorders. However, the recording showed

very poor sleep with a sleep onset latency of 63 minutes, 90 minutes of wakefulness during the middle of the night, and a total sleep time of only 4 hours. A sleep diary maintained by the patient for several weeks prior to treatment corroborated the findings from his sleep recording. Specifically, this sleep diary showed an average sleep onset latency of 82 minutes, an average wake time during the night of 165 minutes, and an average sleep time of only 4 hours and 25 minutes per night. The patient’s sleep diary for the first week of this monitoring period, which captures this general pattern of sleep difficulty, is shown in Figure 6.2. This diary shows the patient’s variable sleep schedule as well as his penchant to allot excessive times each night for sleep. To treat this condition the patient received four biweekly 30–60 minutes sessions that included the psychoeducational information and sleep improvement recommendations presented in Chapter 3. During this time period, no changes were made in his pharmacological treatment for his PTSD condition. Over the course of the CBT treatment, the patient’s sleep improved markedly. Sleep diaries maintained by the patient immediately following treatment showed an average sleep onset latency of 15 minutes per night, an average wake time during the night of slightly under 31 minutes, and an average total sleep time of 5 hours and 45 minutes. Figure 6.3 shows the first week of these sleep diary data collected by the patient following treatment. This diary shows the marked improvements in the patient’s sleep pattern as well as greater stability in his chosen sleep schedule. When a follow-up of this patient was conducted 6 months after he completed treatment, his sleep pattern continued to show the improvement displayed immediately after treatment, with virtually no change in his sleep or wake-time measures. A particular challenge to treating PTSD patients arises from their hypervigilance, which is prominent during the sleep period. Those individuals who develop PTSD as a result of childhood sexual abuse may have a proneness to remain vigilant during the nighttime when their sexual abuse historically took place. Alternatively, it is not uncommon for military veterans with combat-related PTSD to remain on alert during the nighttime and thus have difficulty initiating and/or maintaining sleep. Moreover, such patients often will show patterns of

Sample Today’s Date 3/25/13 9/21 9/22 9/23 9/24 9/25 9/26 9/27 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. 10:30 PM 11:30 PM 8:20 PM 9:35 PM 8:20 PM 10:40 PM 10:35 PM 3. What time did you try to go to sleep? 11:30 p.m. 10:30 PM 11:30 PM 8:20 PM 9:35 PM 8:20 PM 10:40 PM 10:35 PM 4. How long did it take you to fall asleep? 55 min. 90 35 60 90 70 45 60 5. How many times did you wake up, not counting your final awakening? 6 times 2 1 3 2 1 2 1 6. In total, how long did these awakenings last? 2 hours 5 min. 45 40 65 65 45 35 60 7. What time was your final awakening? 6:35 a.m. 5:30 AM 5:15 AM 6:00 AM 6:15 AM 7:00 AM 6:35 AM 5:30 AM 8. What time did you get out of bed for the day? 7:20 a.m. 8:15 Am 8:30 AM 7:10 AM 6:45 AM 7:25 AM 7:05 AM 8:15 AM 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 I have a cold Figure 6.2 Sleep Diary—Baseline.

Sample Today’s Date 3/25/13 9/21 9/22 9/23 9/24 9/25 9/26 9/27 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. 11:45 PM 11:35 PM 12:00 AM 12:10 AM 11:40 AM 11:30 PM 11:40 PM 3. What time did you try to go to sleep? 11:30 p.m. 11:45 PM 11:35 PM 12:00 AM 12:10 AM 11:40 AM 11:30 PM 11:40 PM 4. How long did it take you to fall asleep? 55 min. 15 15 15 15 20 15 15 5. How many times did you wake up, not counting your final awakening? 6 times 1 1 1 1 1 1 1 6. In total, how long did these awakenings last? 2 hours 5 min. 15 15 30 25 25 25 35 7. What time was your final awakening? 6:35 a.m. 5:31 AM 5:40 AM 5:50 AM 6:20 AM 5:50 AM 6:00 AM 6:50 AM 8. What time did you get out of bed for the day? 7:20 a.m. 5:35 Am 6:55 AM 6:50 AM 6:20 AM 6:00 AM 6:00 AM 6:50 AM 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 I have a cold Figure 6.3 Sleep Diary—Post-CBT.

115 “checking the perimeter,” wherein they repeatedly check all the door locks and windows in their homes in a compulsive fashion to assure the safety of their families and themselves. With these sorts of problems it is often helpful to probe underlying cognitions that perpetuate the need for remaining vigilant at nighttime. Use of Thought Records may be indicated to help patients challenge beliefs of nighttime danger in their current home situations relative to the original situations that precipitated their PTSD. When repeated checking behaviors are observed, it may be useful to place limits on the amount of checking that the patient can do each night. For some patients it is helpful to develop a paper checklist they can complete each night to document that they actually have checked all doors and windows for their security. Once they complete this checklist, they can then place it on their nightstand or other location near their bed to remind them that they have done all of the checking they need for the night in question and they can feel more at ease about going to sleep. Summing It Up Whereas CBT strategies are well suited for treating those with comorbid insomnia, the foregoing discussion shows that adaptations of CBT need to be considered with distinctive comorbid groups. Admittedly, there is much to be learned about optimizing outcomes with these individuals. Indeed, there are many questions yet to be answered. Among the more pertinent are (1) How can we best combine CBT with pharmacotherapy and other medical management of the existing comorbid disorder? (2) Do the specific sleep-focused CBT techniques need to be altered or augmented in any way to maximize outcomes with comorbid insomnia? (3) Should CBT for insomnia be incorporated into more global cognitive behavior protocols that exist for various comorbid conditions (e.g., depression, anxiety disorders, etc.)? (4) Does CBT for insomnia in comorbid patients require more extended therapy and follow-up than commonly required for insomnia without an accompanying other disorder? These, among many other questions, will merit attention before this treatment can be most effectively adapted to insomnia sufferers with various types of sleep-disruptive comorbidities. For a more thorough discussion of this topic, the reader is referred to

116 the recent excellent review article by Smith et al. (2005). Nonetheless, the research conducted to date and the results with cases such as the ones presented here encourage further applications of this modality for addressing comorbid insomnia problems. Dissemination of CBT Across Settings Whereas CBT have proven efficacy for insomnia management, it is currently challenging to make this therapy available to all who may benefit from it. Whereas 10% to 22% of the population have chronic insomnia, there are currently a paucity of trained providers who offer the treatment described in this manual. Furthermore, those who are trained and skilled in these techniques tend to be found in larger medical centers or specialty sleep centers and not in the general medical practice settings where most treatment-seeking insomnia patients present for their care. Thus, expanding the provider pool and exporting this treatment to the venues where most insomnia patients receive their initial treatment remain as challenges to this therapeutic modality. In efforts to facilitate dissemination of CBT for insomnia, some investigators have tested treatment models suitable for medical practice settings or the public at large. Given that insomnia sufferers typically present first in primary care settings, it seems reasonable to consider providing CBT training to those healthcare professionals (e.g., nurses, general practitioners) commonly found in such settings. Two studies designed to test the efficacy of such an approach have demonstrated that both family physicians (Baillargeon, Demers, and Ladouceur 1998) and office-practice nurses (Espie, Inglis, et al. 2001; Espie, MacMahon, et al. 2007) can effectively administer CBT components in general medical practice settings. In contrast, Oosterhuis and Klip (1997) reported delivery of behavioral insomnia therapy via a series of eight 15-minute educational programs broadcast on radio and television in the Netherlands. Over 23,000 people ordered the accompanying course material, and data from a random subset of these showed that sleep improvements and reductions in hypnotic use, medical visits, and physical complaints were achieved by this educational program. Thus, it appears that behavioral insomnia

117 treatments can be effective delivered by various providers, and delivery of such treatment even through mass media outlets may provide benefits to some insomnia sufferers. Of course, the relative efficacy of these alternative treatment modes of treatment delivery vis-à-vis more traditional treatment with experienced CBT therapists is yet to be determined. Other efforts aimed at treatment dissemination have tested treatment protocols that can be self-administered outside the clinic setting. Mimeault and Morin (1999), for example, tested a self-help CBT book-based treatment (i.e., bibliotherapy) with and without supportive phone consultations against a wait-list control. Compared to the control condition, those treated with the bibliotherapy showed substantially greater sleep improvements, and these improvements were maintained at a 3-month follow-up. The addition of phone consultations with a therapist provided some advantage over bibliotherapy alone, at least in the short term. Over the past decade there have been considerable efforts to provide automated CBT delivery through the development of interactive Internet-based self-help CBT interventions. To date, a total of seven studies have tested these sorts of interventions with generally positive results. These Internet approaches vary in nature; some provide video-based material delivered by expert therapists (Ritterband, Bailey, et al. 2012), whereas others use animated characters to deliver treatment recommendations (Espie, Kyle, et al. 2012). To date, such interventions have some promise and perhaps fill an important gap in CBT’s availability. However, a number of questions about these sorts of interventions remain, such as what types of patients benefit most from such self-help interventions and which sorts of patients require more intensive therapist-directed treatment? Also, does a less than optimal response to these self-help treatments reduce a patient’s acceptance or response to therapist directed therapy? And finally, can these self-help treatments be combined with therapist-directed CBT to enhance treatment adherence and outcomes? Nonetheless, these studies provide some initial ideas for wider dissemination of CBT strategies. Such efforts may be useful to fill the void until a sufficient number of traditional providers are trained in these strategies and the more challenging insomnia patients will be able to access the comprehensive CBT they ultimately may need.

119 Appendix 1 Sleep History Questionnaire Sleep Disorders Center Duke University Medical Center Part I: General Information Name: _______________________________ Date: ____________________ Address: ______________________________ Phone: ___________________ _____________________________________ Age: ____________________ Sex: F M (circle one) Education (years of school): _____________ Occupation: __________________________ Marital Status: _______________________ Years: __________ Children: ____________________________

120 Part II: Sleep History A. Nighttime Sleep I. Please describe your sleep disturbance. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 2. Estimate how many hours of sleep you get. . . a) on a good night ___________ b) on a bad night ___________ 3. How long does it take you to fall asleep. . . a) on a good night? ___________ b) on a bad night? ___________ 4. How many times do you wake up during the night. . . a) on a good night? ___________ b) on a bad night? ___________ 5. How long are you awake during the night after initially falling asleep. . . a) on a good night? ___________ b) on a bad night? ___________ 6. How long have you had this problem? ___________ Has it increased in severity, and if so, over what period of time? __________ 7. What do you feel is the major cause(s) of your sleep problem? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 8. Did you have sleep problems as a child? Yes No (circle one) Please describe the problem(s). _______________________________________________ _________________________________________________________________________

121 B. Daytime Functioning: 1. Do you have a problem with severe sleepiness (feeling very sleepy or struggling to stay awake during the daytime? Yes No (circle one) If yes, how many days during the average week? _________________ 2. Do you often have a problem with your performance at work because of sleepiness? Yes No (circle one) 3. Have you ever had car accidents because of sleepiness (not due to alcohol or drugs)? Yes No (circle one) 4. Have you ever had near car accidents (for example, driving off the road) because of sleepiness (not due to alcohol or drugs)? Yes No (circle one) 5. Do you fall asleep without meaning to during the day? Yes No (circle one) If yes, how many times during the average week? _______________________ 6. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Situation Chance of dozing Sitting and reading ___________________ Watching TV ___________________ Sitting inactive in a public place (e.g., a theater or a meeting) ___________________ As per passenger in a car for an hour without a break ___________________

122 7. On the graph below, indicate how sleepy you generally feel at the times indicated by choosing the most appropriate corresponding number from the scale below and circling that number on the graph. 1 = Feeling active and vital; wide awake 2 = Functioning at a high level, but not at peak; able to concentrate 3 = Relaxed, awake; not full alertness; responsive 4 = A little foggy; not at peak; let down 5 = Fogginess; beginning to lose interest in remaining awake; slowed down 6 = Sleepiness; prefer to be lying down; fighting sleep; woozy 7 = Almost in reverie; sleep onset soon; lost struggle to stay awake 8. How many naps do you take during the average week? ____________ How long is your average nap? _______________________________________________ C. Bedtime Characteristics: 1. a) On average, what is your normal bedtime? ___________ b) On average, what time do you get out of bed in the morning? __________ 2. Do you have a standard wake-up time that you use. . . a) 7 days per week? Yes No b) 5 days per week? Yes No 3. Does your job require that you change shifts? Yes No (circle one) 4. How often do you travel across time zones? __________ times per month 9:oo AM 1 2 3 4 5 6 7 Noon 1 2 3 4 5 6 7 6:oo PM 1 2 3 4 5 6 7 9:oo PM 1 2 3 4 5 6 7 Lying down to rest in the afternoon when circumstances permit ___________________ Sitting and talking to someone ___________________ Sitting quietly after lunch without alcohol ___________________ In a car, while stopped for a few minutes in the traffic ___________________

123 5. Do you have a bed partner? Yes No (circle one) If yes, are you and your bed partner having any problems that might be interfering with your sleep? Yes No (circle one) If yes, please describe: _______________________________________________________ _________________________________________________________________________ 6. How often do you do the following activities in bed during the average week? A Read in bed:  ___________ times per week B Watch TV in bed:  ___________ times per week C Eat in bed:  ___________ times per week D Work in bed:  ___________ times per week E Argue in bed:  ___________ times per week E Worry in bed:  ___________ times per week 7. How many nights during the average week do you lie in bed for at least 30 minutes either trying to fall asleep or trying to return to sleep? ___________ nights per week. 8. How many mornings during the average week do you wake up at least I hour before your normal wake-up time and cannot return to sleep? ___________ mornings per week. 9. Please circle a number from 1 to 10 to indicate how much difficulty you have relaxing your body at bedtime. 10. Please circle a number from 1 to io to indicate how much difficulty you have “slowing down” or “turning off” your mind while trying to sleep. no difficulty some difficulty great difficulty 1 2 3 4 5 6 7 8 9 10 no difficulty some difficulty great difficulty 1 2 3 4 5 6 7 8 9 10

124 D. Additional Sleep Complaints: If you have a bed partner, ask him/her to assist you in answering the next three questions about your sleep. 1. Has anyone ever told you that you snore loudly? Yes No (circle one) If yes, has your snoring caused people to refuse to sleep in the same room with you? Yes No (circle one) 2. Has anyone ever told you that you seem to stop breathing while you sleep, or that you wake up gasping for breath? Yes No (circle one) If yes, how often has this been noted? __________ If yes, how long is the time that you stop breathing? __________ 3. Has anyone ever noticed your legs periodically twitching during the night? Yes No (circle one) 4. Have you ever been unable to move when falling asleep or immediately upon waking? Yes No (circle one) 5. Have you ever had episodes of sudden muscular weakness (paralysis or inability to move) when laughing, angry, or in other emotional situations? Yes No If yes, how often has this happened? 6. Indicate how many times per month you have noticed that you. . . a) Wake up with a morning headache _________ times per month b) Notice a deep, creeping sensation inside your calves or thighs during the night _________ times per month c) Wake up confused and wander during the night _________ times per month d) Have nightmares _________ times per month e) Have fearful thoughts or images as you are falling asleep _________ times per month

125 E. Medication History: 1. Currently, how many times during the month do you use medications to help you sleep? ______________________ times per month 2. Currently, how much alcohol do you use to help you sleep? _________________ times per month _____________________ amount per night _________________ how long 3. Please list all medications, prescribed and over-the-counter, you are presently taking or have recently stopped taking and the reason for taking these medications. 4. How much of the following do you consume during the average day? Alcohol _________________________________________ Coffee (with caffeine) _____________________________ Tea (with caffeine) ________________________________ Soft drink (with caffeine) __________________________ Cigarettes _______________________________________ Other tobacco products ____________________________ 5. Describe any other treatments you have had to help your sleep and how well the previous treatments worked. _________________________________________________________________________ _________________________________________________________________________ Medication Dosage/times per day Reason Current?

126 F. Sleep Expectancy: I believe a normal person my age without a sleep problem should. . . get about _____________________ hours of sleep per night. take about _____________________ minutes to fall asleep at the beginning of the night. wake up about _____________________ times per night. spend about _____________________ minutes awake in bed during the night. Part Ill: General Medical History 1. Please check (√) in the boxes beside those medical problems you have now or have had in the past. Please describe other problems not listed above: √ Problem √ Problem √ Problem Arthritis Asthma Chronic pain Depression Diabetes Memory/Concentration Problems Emphysema Epilepsy Headaches Heartburn/Ulcers High Blood Pressure Hallucinations/Delusions Kidney Problems Hiatal Hernia Childhood Hyperactivity Panic Attacks Nose/Throat Problems Alcohol/Drug Problems Sexual Problems Anxiety/Nervousness Loss of Sex Drive Stroke Suicide Attempts Swelling Ankles Thyroid Problems Cold/Heat Intolerance Trouble Breathing at Night Changes in Hair or Skin

127 2. What is (or was) your body weight? A. Now ________ (lbs) B. 6 months ago ________ (lbs) C. When age 20 ________ (lbs) D. When heaviest ever ________ (lbs) 3. What is your height? ________ feet ________ inches 4. Allergies _________________________________________________________________ _________________________________________________________________________ 5. Have you ever been treated by a psychiatrist, psychologist, or other mental health professional? Yes No (circle one) If yes, please indicate when you were treated and for what reason. _________________________________________________________________________ _________________________________________________________________________ 6. Has anyone in your family ever had any of the following problems? A. Depression:  Yes No (circle one) If yes, list relationship to you (for example, grandfather, sister, etc.) ________________________________________________ B. Alcohol or drug problems: Yes No (circle one) If yes, list relationship. ________________________________________________ C. Suicide or suicide attempts: Yes No (circle one) ________________________________________________ D. Sleep problems: Yes No (circle one) ________________________________________________

128 7. Have you or anyone in your family ever had your sleep recorded in a sleep laboratory? Yes No (circle one) If yes, please give details and describe the results of the recording(s) if you are aware of them. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Part IV: Other Information In the spaces provided below, please add any information that you feel is important. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

129 Appendix 2 Daytime Insomnia Symptom Response Scale (DISRS) People think and do many different things when they feel tired. Please read each of the items below and indicate whether you almost never, sometimes, often, or almost always think or do each one when you feel tired. Please select only one answer. Please indicate what you generally do, not what you think you should do. 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always 1 2 3 4 1. Think, “I won’t be able to do work because I feel so bad” 1 2 3 4 2. Think about your feelings of fatigue 1 2 3 4 3. Think about how hard it is to concentrate 1 2 3 4 4. Think about how unmotivated you feel 1 2 3 4 5. Think about how your thoughts are cloudy/muddled 1 2 3 4 6. Think about how everything requires more effort than usual 1 2 3 4 7. Think, “Why can’t I get going?” 1 2 3 4 8. Think about how sad you feel 1 2 3 4 9. Think about how you don’t feel up to doing anything 1 2 3 4 10. Think about your feelings of achiness 1 2 3 4 11. Think about how bad you feel 1 2 3 4 12. Think about how hard it is to keep your mind on task 1 2 3 4 13. Think about how tired you feel 1 2 3 4 14. Think, “I can’t shake this feeling off” 1 2 3 4 15. Think about how irritable you feel 1 2 3 4 16. Think about how sleepy you feel 1 2 3 4 17. Think, “I can’t seem to pay attention” 1 2 3 4 18. Think, “I’m so forgetful” 1 2 3 4 19. Think, “I can’t be around people when I’m feeling this way” 1 2 3 4 20. Think about how you don’t have the energy to get through the day

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