Insomnia and Anxiety (Series in Anxiety and Related Disorders) (23 page)

treatment recommendations. Generally, we have found it most helpful to consider

with clients what their actual sleep needs might be since many of them have poorly

conceived notions about their sleep requirements. In addition, most people seem to

benefit from some basic education about how the human sleep system works.

We tell people that we will recommend many changes to the way they currently

approach sleep in order to improve sleep. To prepare for these changes, we say that

it is often helpful to understand why these changes are necessary, and thus we discuss:

what their current sleep needs are and what controls the quantity and quality of sleep;

in short, we hope that understanding how sleep works will help them make the changes

necessary to obtain better sleep. The information below exemplifies the type of infor-

mation we use in psychoeducation to set the stage for behavioral and cognitive change.

Setting the Stage for Treatment Recommendations: The Role of Psychoeducation

85

The information can be paraphrased according to the preferences of the therapist

and needs of the specific patient.

The burning question for many is, “How much sleep do I need each night?”

Many people believe that they already know the answer, but research tells us that

these beliefs are often inaccurate (Carney & Edinger, 2006; Edinger, Wohlgemuth,

Radtke, Marsh, & Quillian, 2001; Morin, Stone, Trinkle, Mercer, & Remsberg,

1993). We like to answer this question with an analogy about shoe size; that is, just

as there is no single “correct” shoe size that fits everyone, there is no single amount

of sleep that is required of everyone either. Sleep needs vary across individuals and

across time and circumstance. On average, most people need between 6 and 9 h of

sleep per night, but a proportion of people need less or more. The purpose of this

piece of psychoeducation is that it is important for people to set aside preconceived

or rigid ideas about how much sleep they need, as their body often has other ideas.

We reassure them that we will let their body tell us how much sleep it needs and

we will follow its lead; doing so will improve the quality of sleep.

Most people including nonsleep specialists often have little idea about how the

body’s sleep system works. The sleep system can be easily explained by focusing

on three main factors or sets of circumstance that have important and controlling

effects on the ability to sleep when making a sleep attempt. The first of these is the

amount of time spent awake before the attempt to sleep again. There is a simple

principle that should be understood about the effect that staying awake has on sleep.

The longer someone is awake between their last sleep episode and the current

attempt to sleep, the higher the sleep drive and the more likely it becomes that they

will be able to fall asleep quickly and sleep for an extended period. In contrast, if

the same person awakens from an extended period of sleep and shortly thereafter

tries to sleep again, it is unlikely they will be very successful because they have not

built up enough sleep debt to warrant more sleep. Therefore, it is important that

people stay awake long enough each day to ensure the build-up of adequate sleep

drive to initiate and sustain sleep through the night.

The second regulatory factor in the sleep system is the body clock. Sleep is best

attempted during a window in the 24 h day that matches the internal clock. Not only

is the circadian clock tied to the sleep-wake system, but it also affects mood, cogni-

tion, and a multitude of bodily systems. As the term circadian implies (“about a

day”), the body clock operates on a roughly 24-h cycle and produces predictable

24-h variations in such things as digestion, body temperature, and the sleep/wake

pattern. Throughout the day, the body clock controls alertness levels so as to keep

people awake and functioning effectively. However, during the night, the body

clock turns off the alerting signals and allows us to fall asleep and stay asleep

through the night. In the morning, the clock again turns on the alerting signal caus-

ing us to awaken for the day. It is important to recognize that the body clock works

at its best, when adhering to a fairly regular sleep/wake schedule. When schedules

(rise times and bedtimes) are erratic, the sleep period fall in-and-out of sync with

the body clock and sleep becomes disrupted. In a sense, following a highly variable

sleep/wake schedule is like making the body clock “shoot at a moving target,” and

under such circumstances it works very poorly. Hence, it is important to follow a

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6 Behavioral Strategies for Managing Insomnia

fairly routine sleep/wake schedule so that attempts to sleep fall in unison with the

body clock’s sleep/wake rhythm.

The last factor we discuss is the importance of protecting the nighttime sleep

period from physical and psychological intrusions. We tell patients: “If you take

your worries to bed or if you do not address physical disturbances such as noise,

phone calls at night, or too much light in the bedroom environment, your sleep can

be disturbed as well, even if have a regular sleep schedule and you have built up

sufficient sleep drive by the time you enter bed.” Therefore, some additional

measures are necessary to eliminate any psychological or physical causes of sleep

difficulties. After providing these explanations of the three factors that regulate

sleep, we spend time asking if they understand the information and whether they

have any questions or concerns.

Presenting Behavioral Insomnia Treatment Recommendations

As noted previously, people with insomnia usually present with a number of

well-established sleep disruptive habits that serve to perpetuate their sleep difficul-

ties. Many such behaviors reflect ineffectual attempts to compensate for ongoing

sleep difficulties. For example, daytime napping to make up for poor nights or

spending an excessive amount of time in bed in an effort to provide an adequate

opportunity to get the sleep they feel they need. Because sleep becomes elusive

and unpredictable, many insomnia sufferers assume that they should sleep when-

ever they are able and, thus, end up with a highly erratic sleep-wake schedule.

When finding themselves awake in bed, many insomnia sufferers engage in behaviors

such as tossing and turning, watching the clock, or just lying in bed thinking

how poorly they will feel the next day because of the inadequate sleep they are

getting. For some, sleep difficulty arises due to a practice of taking worries to bed

or engaging in stimulating mental (e.g., studying for an exam) or physical (e.g.,

physical exercise) activity too close to bedtime. Not uncommonly, people with

insomnia present with a multitude of these behavioral targets that need to be

addressed for effective insomnia management.

Various behavioral insomnia treatment strategies are available for addressing

one or more of the practices mentioned, but a combination of stimulus control

(Bootzin, 1972) and sleep restriction (Spielman, Saskin, & Thorpy, 1987) instruc-

tions provides an omnibus treatment for these problematic behaviors. This combi-

nation of treatment recommendations, standardizes the sleep/wake schedule,

eliminates sleep incompatible behaviors occurring in the bed and bedroom, and

restricts time in bed (TIB) to produce a consolidated sleep pattern. Most recom-

mendations included in this regimen are standard for everyone. However, the TIB

prescriptions provided are derived from the sleep diary completed during a 2-week

period prior to instituting active treatment. Accordingly, TIB prescriptions may

vary across people, so these prescriptions allow for some tailoring of treatment to

fit each person’s specific sleep needs. Nonetheless, it is important to have people

Presenting Behavioral Insomnia Treatment Recommendations

87

complete sleep diaries for a period of time, preferably 2 weeks before beginning

treatment (Wohlgemuth, 1999), so the diary data can be available to ascertain the

TIB prescription.

For most people, we present the combined stimulus control/sleep restriction

treatment recommendations in a standard fashion. The following italicized text

exemplifies how these recommendations are typically presented. Subsequently, we

provide text that may be used verbatim or paraphrased depending on therapists’

preferences and patients’ needs.

In order to overcome your insomnia and improve your sleep pattern, you should first

select a standard rising time and stick to that time each regardless of how well or poorly

you sleep on any specific night. Changes in your sleep-wake schedule can disturb your

sleep and contribute to your insomnia problem. When you vary your sleep schedule, you

create the type of sleep problem that occurs in jetlag. In a sense, varying your sleep sched-

ule causes you to sleep in and out of sync with your body clock, and this produces a very

unreliable and unpredictable sleep pattern. The best way for you and your body clock to

work together is for you to stick to a standard rising time each and every day. This routine

rising time will send a strong and consistent signal to your body clock and, in turn,

you body clock will begin working with you to produce a very strong and consistent

sleep-wake rhythm.

Secondly, you should use the bed solely for sleep and sexual activity. You should not read,

watch T.V., eat, study, use the phone, or do other things that require you to be awake

while you are in bed. If you routinely use your bed for these sorts of activities, you are

unintentionally training yourself to be awake in bed. If you avoid these activities while in

bed, your bed will eventually become a place where it is easy to go to sleep and stay asleep.

In fact, you may eventually find that you become even sleepier when you retire to bed and

consequently fall asleep easily.

Thirdly, it is important that your bed remains a very pleasant place for you to be. It should

not be a place that you dread going or where you agonize about your sleep. To avoid these

feelings, you should never stay in bed, either at the beginning of the night or during the

middle of the night, for long periods without being asleep. Lying awake in bed for long

periods of time usually leads to tossing and turning, becoming frustrated, or worrying about

not sleeping. Having these understandable reactions actually make it more difficult to get

to asleep. If you cannot fall asleep or return to sleep quickly (within 15–20 minutes), or

you do not feel as though you are about to go to sleep, it is preferable to get up and leave

the bedroom. While in another room, try and find something relaxing (but not activating)

to do for a while. It is best if you do what you do in a seated position and that you avoid

activities that are stimulating or that hold your attention. Often activities such as light,

recreational reading, watching TV, or listening to soft music are helpful. Only return to bed

when you feel sleepy enough to fall asleep quickly.

Next, it is important that you avoid worrying, contemplating problems, planning future

events, or engaging in other thinking while you are in bed. These activities can uninten-

tionally become mental habits, and the best way to break a habit is to interrupt it when

it occurs. So, if you cannot turn off your thoughts, it is best to get up and go to another

room and stay up until your mind is clear. While you are up, it is a good idea to

engage in the types of relaxing activities we just discussed. If you find your disruptive

thinking occurs frequently, you may find it helpful to routinely set aside a time early

each evening to do the thinking, problem-solving, and planning you need to do. When

done on a consistent basis, this practice should result in fewer of these thoughts follow-

ing you to bed.

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6 Behavioral Strategies for Managing Insomnia

It is also important that you eliminate all daytime napping. Naps count toward your 24-hour

sleep requirement. If you take a 2-hour afternoon nap, you are likely to sleep much more

poorly that following night. Therefore, if you want satisfying sleep at night, you should

avoid napping.

Finally, you should go to bed when you feel sleepy but not so early that you find yourself

spending much more time in bed each night than you need for sleep. Spending much more

time in bed at night is like buying yourself a shoe that is much bigger than you need. If for

example you bought a shoe that was two sizes larger than you require, your foot would not

grow to fill the shoe but would, rather, flop around inside it. Likewise, if you spend far

more time in bed than your body needs for sleep, your sleep needs will not increase to fill

the extra time you are spending in bed. Instead, you will find that this practice results in

you spending a lot of time awake in bed. If you spend too much time in bed, you may actu-