Insomnia and Anxiety (Series in Anxiety and Related Disorders) (31 page)

anxious. The truth is that I will absolutely sleep and I can’t know how well.” Mr. R

also focused on something that would be helpful in the situation: “I’ve noticed that

yoga helps with my anxiety, so maybe if I do something relaxing, I’ll improve my odds

of sleeping well.” We usually ask the person to rate the “believability” of each adaptive

thought. When believability is low, we usually spend more time revising these state-

ments in session until they are more credible to the person.

Post-Thought Record Mood rating
: The last step is to rerate the original mood.

This process acts as a postintervention point of comparison. The expectation is that

there should be some mood improvement even if it is small. A lack of improvement

most often means that the Thought Record columns should be revisited. Possible

problems include: (1) moods and thoughts were confused; (2) the hot thought was

not uncovered/explored fully; (3) the evidence against the thought was not fully

explored; (4) integrating the evidence into a more adaptive thought was not done

convincingly enough. Sometimes, mood ratings fall victim to all-or-none thinking,

in that a negative mood is either present or 100% absent, and the person does not

perceive the range of degrees within a mood. Similarly, little movement in mood

can also occur in those who tend toward perfectionism. For example, the mood

Decreasing Safety Behaviors and Behavioral Experiments

117

change is not “good enough” to warrant recording. Thus, it is important to carefully

query very low or no mood rating changes.

As stated above, the benefits of Thought Records are manifold: (1) there should

be an immediate reduction in arousal (i.e., mood improvement); (2) it should chal-

lenge thinking (and beliefs) that drive sleep-related anxiety; and (3) the repeated

process of completing these records impose structure on the tendency to think nega-

tively and become distressed – that is, it breaks the sleep-disruptive mental habit.

When someone has an unwanted habit, one of the first steps is to interrupt it. We

rarely ask someone to simply stop the habit outright because it often occurs without

prior thought/intent; it is automatic. However, if we ask someone to interrupt the

process and engage in an exercise that encourages thinking about information other

than the automatic thought (e.g., focusing on evidence against the thought), then we

increase the likelihood that awareness may begin before the automatic sequence

begins. The more this practice occurs, the more likely it is that a disturbing thought

will be met with a more realistic appraisal and challenge rather than an automatic

downward spiral of negative thoughts and emotions.

Decreasing Safety Behaviors and Behavioral Experiments

While it may seem unusual to place a behavioral strategy in a cognitive chapter, we

have opted to include it here because of its presumed reinforcement role for beliefs

(Bennett-Levy et al., 2004). The cognitive model suggests that safety behaviors

play a prominent role in insomnia (Harvey, 2002). Safety behaviors have mainly

been examined in the anxiety disorders literature and are conceptualized as an

attempt to prevent a feared or unwanted outcome from occurring. For example,

some people with insomnia might consume alcohol to avoid a lengthy time to fall

asleep (Harvey, Tang, & Browning, 2005). Across Axis I disorders, safety behav-

iors emanate from unhelpful beliefs about the probability of a feared outcome and/

or an underestimation of one’s ability to cope with an unwanted situation.

Safety behaviors are reinforced when these strategies alleviate short-term dis-

tress; however, the long-term consequence is the maintenance of beliefs that sleep-

related situations and situations in which there is a performance demand are

threatening and must be avoided. It also prevents contact with disconfirming evi-

dence. In our example above, drinking alcohol as a sleep-related safety behavior

may allow the person to avoid a prolonged struggle with delayed sleep onset, but it

is unknown as to whether the person necessarily would have had sleep onset diffi-

culties. In addition, drinking alcohol interferes with later sleep continuity.

Preliminary studies suggest that those with insomnia engage in safety behaviors

(Ree & Harvey, 2004a; Woodley & Smith, 2006). In the anxiety disorder literature,

reducing safety behaviors is associated with improved outcomes (Salkovskis, Clark,

Hackmann, Wells, & Gelder, 1999; Wells et al., 1995). Additionally, an open trial of

Cognitive Therapy for insomnia (Harvey, Sharpley, Ree, Stinson, & Clark, 2007)

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8 Cognitive Strategies for Managing Anxiety and Insomnia

suggests that reducing safety behaviors may be an effective component of insomnia

treatment. The instruction for reducing safety behaviors is simple:

1. Provide an explanation of the role of safety behaviors and avoidance in general.

That is, engaging in these behaviors makes things worse in the long term and

sends a message that you believe that you are incapable of coping with poor

sleep or its daytime consequences.

2. Construct a list of currently operating safety behaviors. The Safety-Related

Behaviors Questionnaire (Ree & Harvey, 2004b) may be helpful. Carney and

Manber (2009) suggest the use of a worksheet that identifies the link between an

unhelpful belief and a safety behavior (Carney & Manber, 2009). For example,

for someone who consumes alcohol before bed, the assumption might be: “I can-

not sleep without alcohol.” Carney and Manber (2009) encourage the design of

an experiment meant to test the assumption by resisting the safety behavior and

tracking the experience with resistance. For example, “I will refrain from alcohol

consumption this week and see if I sleep.”

3. Work collaboratively to construct a plan for resisting engagement in the safety

behavior.

4. Monitor successes and challenges to implementing the plan so that “cheerlead-

ing” for the successful prevention of safety behaviors can occur, or adjustments

can be made if necessary.

Behavioral experiments
are an important part of cognitive restructuring as they

may be even more important than verbal methods (Tang & Harvey, 2006). When

actigraphs were used to show people the discrepancy between how they thought

they slept and how they actually slept (rather than simply telling people verbally

that there was a discrepancy), there are greater cognitive shifts towards perceiv-

ing the “missing” sleep on subsequent nights (Tang, Schmidt, & Harvey, 2006).

In addition to correcting sleep misperception, behavioral experiments have been

used in cognitive therapy for insomnia (Harvey et al., 2007) to modify beliefs

about having a limited ability to cope with fatigue or beliefs that poor sleep is

dangerous (Ree & Harvey, 2004a). Harvey and colleagues (2004), for example,

encouraged a 45-year-old man with insomnia to conduct an experiment that

would test the idea that he needed to conserve energy because he had, in his view,

a limited amount of coping resources. This man was asked to spend 3 h conserv-

ing energy (e.g., resting and avoiding anything taxing), and then 3 h generating

energy (e.g., returning phone calls, going for a short walk, socializing, getting a

drink). He later repeated the experiment but in reverse order and monitored the

effects of the experiment on his mood and energy levels. He reported that his

mood and energy levels were actually improved by expending/generating energy.

Similarly, to test the idea that poor sleep is dangerous, Harvey and colleagues

(2004) encouraged a 49-year-old woman with GAD to delay her bedtime and

restrict her time in bed to 6.5 h. The woman was encouraged to monitor the

effects of the experiment on her sleep on sleep diaries and also to monitor her

coping ability, her tiredness, productivity, and mood. The woman reported that

she was surprised to learn that (contrary to her prediction) she coped fairly well

Action Plan for Addressing Insomnia

119

and that she did not trigger poor sleep the next night. These are examples of the

power that behavioral experiments can exert on cognitive change. Behavioral

experiments like the ones described were part of a trial of CT for insomnia that

showed efficacy for this therapy when used as a stand-alone intervention

(Harvey et al., 2007).

Focus on Relapse Prevention

Whereas insomnia has not traditionally been conceptualized as a recurrent condi-

tion, evidence would suggest that it tends to be a persistent condition characterized

by relapses. In a large 3-year follow-up study, insomnia was shown to have a fairly

long course and to be recurrent in almost one third of those with insomnia at base-

line (Morin et al., 2009). If insomnia tends to recur in those vulnerable to it, it

would make sense to follow the model of other persistent disorders such as Major

Depressive Disorder and incorporate a relapse prevention component to treatment.

In treatment, this can be as simple as reminding people of what worked and also

reminding them that they can return for a refresher appointment if needed (Edinger

& Carney, 2008). Alternatively, you can design a worksheet to provide people when

preparing for termination. This can be a standard document given to everyone you

treat (see sample sheet), or it is often useful to devise a blank form that you con-

struct jointly with the patient that will look like the sample provided below. The

general components of a relapse prevention strategy include the following:

1. Provide guidelines for determining if insomnia has returned. This is generally

not a problem for someone with insomnia. In fact, in our clinical experience, the

opposite problem often occurs. That is, someone becomes alarmed about not

sleeping when in actuality their sleep efficiencies and time spent awake in bed

are within normal limits. Nonetheless, it is usually a productive exercise to con-

struct a list of red flags

2. Foster a new sense of sleep self-efficacy. We know that CBT increases self-effi-

cacy (Carney & Edinger, 2006), so it is important to remind people of their

newfound sleep-related confidence. People need to form a new self-concept of

themselves as good sleepers who occasionally have sleep problems that can be

simply managed if/when they emerge. Termination-related conversations should

foster this concept by encouraging them to remember that they mastered their

sleep and can do it again in the future.

Action Plan for Addressing Insomnia

Insomnia can return, but now that you have the tools to address it, you need not worry

about the possibility of its recurrence. Below we will outline some signs of chronic

insomnia that alert you to the need to put the skills you learned back into place.

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8 Cognitive Strategies for Managing Anxiety and Insomnia

Red Flags for a Possible Problem with Insomnia

1. You are spending more than 30 min awake while in bed trying to sleep at least

half the days. Alternatively, if you calculate your average sleep efficiency and

determine it is less than 85% (i.e., on average you are sleeping for less than 85%

of the time you spend in bed) or, if your sleep feels chronically nonrestorative

(i.e., you wake up tired each morning and it persists throughout the day).

2. You have trouble during the day on at least half of the days of the week: For

example, you feel tired, your mood is anxious/depressed/agitated/upset, you

have difficulty concentrating or paying attention, and it is more difficult to func-

tion (at work, home or school).

3. You notice some uncharacteristic thinking; that is, you are preoccupied with

worries about not sleeping or not being able to function the next day. This type

of thinking is probably linked with feeling distressed too.

What Tools Work for This Problem?

• Restrict your time in bed to the amount of sleep you are currently producing. Do

this by calculating your average amount of sleep and by adding 30 min to this

average. Schedule this new amount of time in bed by picking the schedule that

works best for your body and/or works best for your obligations such as work.

• Set this rise time and “earliest” bedtime 7 days per week. Adjusting these times

for the weekend can produce a jetlag syndrome that will persist into the week.

Be sure to set an alarm. You should go to bed no earlier than your scheduled

bedtime, but you should not go to bed unless you are sleepy.

• Get out of bed whenever it is obvious you would not be able to sleep for the next

20–30 min. If you are upset, you should immediately get out bed. Do something

relaxing and nonarousing until you are sleepy and then return to bed. Do not try

to make up for this time you are spending out bed.

• Avoid wakeful activities in bed or the bedroom. This means that anything you