Insomnia and Anxiety (Series in Anxiety and Related Disorders) (26 page)

satisfied with his or her daytime function, therapy termination may be

considered.

References

97

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Chapter 7

Sleep-Related Cognitive Processes

Abstract
The essence of a cognitive model of psychopathology is the implication

of multiple cognitive processes (including schematic, attentional, and perceptual

biases) that predispose and perpetuate a given disorder. Considerable research has

amassed to support this model in insomnia; that is, people with insomnia have

a range of cognitive–emotional processes that make it more likely for the insomnia

to occur and continue (Behav Res Ther 40:869–893, 2002). Harvey (Behav Res

Ther 40:869–893, 2002) presents a comprehensive contemporary cognitive model

of insomnia, which includes a range of sleep-interfering cognitive processes

including beliefs, perception, and attention. We discuss each component of

Harvey’s Cognitive Model of Insomnia and provide evidence in support of such a

model. This chapter sets the stage for a detailed discussion of cognitive strategies

in the subsequent chapter.

Harvey’s (2002) Cognitive Model

Mr. S wakes up in the middle of the night and notices the clock reads 2:40 am. He

thinks, “I’m NEVER going to be able to sleep.” While having this negatively

valenced thought, Mr. S notices that he has a “nervous stomach” and that he feels

tense. He can feel the distress mounting, and he begins to have other thoughts such

as, “I have a big day tomorrow – I’m never going to be able to get through it if I don’t

get some sleep.” He feels even more distressed, and the thoughts and anxiety feed

into each other, creating a vicious cycle. The thought-distress cycle is purportedly

fueled by a core belief (i.e., schema) that Mr. S is unable to cope with stress. While

this is not something Mr. S normally thinks about (i.e., this belief is latent and oth-

erwise out of awareness), performance-laden situations activate his fear that he can-

not cope with and lead to thoughts that are consistent with this belief. In turn, he

interprets the distress and activation he feels in the moment as evidence that he is not

“good at coping” – thus further maintaining this belief. This distressing turn of events

focuses his attention selectively on things that confirm that he will struggle with

returning to sleep. He becomes vigilant for internal signs of evidence (i.e., a physical

state such as anxiety) that would suggest he would have difficulty returning to sleep.

C.E. Carney and J.D. Edinger,
Insomnia and Anxiety
, Series in Anxiety and Related Disorders,

99

DOI 10.1007/978-1-4419-1434-7_7, © Springer Science+Business Media, LLC 2010

100

7 Sleep-Related Cognitive Processes

Perhaps he becomes focused on similar cues in the external environment that might

not have been perceived had they not been aroused, for example, hearing a noise in

the distance and worrying that it will prevent him from resuming sleep. Perhaps, he

monitors the clock and makes calculations for how much more sleep he could

obtain if he were to fall asleep right away. This selective attention and monitoring

for stimuli that are threatening to his ability to produce sleep make it increasingly

likely that these stimuli will be present. In an attempt to deal with this heightened

state of cognitive–emotional arousal, Mr. S tries to manage the aversive situation by

attempting to avoid it. He employs safety behaviors, such as taking an extra dose of

sleeping medication. Unfortunately, this does not alleviate his anxiety, and he

becomes fixated on the idea that he may feel groggier the next day. He decides to

call the voicemail of his supervisor to leave a message that he is sick and unable to

come in to work today. Mr. S feels a slight release in his tension. Although this may

result in a temporary relief of the performance related anxiety, it also strengthens/

confirms the helplessness belief that he cannot cope with and makes it more likely

to become activated in a future similar situation.

It is important to note that the same cognitive process that occurs during the night

operates during the day. Insomnia is most accurately regarded as a 24-h disorder.

Thus, Mr. S’s increased focused on sleep-threat related material will make it more

likely for him to detect and pay careful attention to physical symptoms that will con-

firm the idea that he slept poorly. His thoughts about fatigue or other daytime symp-

toms of insomnia lead to distress, increased attention, and monitoring. Again, this is

all fueled by the belief that he is helpless to cope with the effects of sleep loss. This

might also be linked to safety behaviors such as overuse of caffeine to compensate for

the presumed consequences of sleep loss. This logical safety behavior may have the

unintended effect of perpetuating the insomnia because there would be a need later in

the day to consume more caffeine since the withdrawal effects of caffeine include

fatigue symptoms. Increased caffeine use may also disrupt subsequent sleep. The

distress created by detecting the presumed (threatening) daytime consequences of

insomnia would garner an unhelpful degree of attentional resources, such that Mr. S

would be more likely to perceive further symptoms, which might normally go unno-

ticed and perhaps make inaccurate attributions about their cause. For example, he

may feel tired and attribute that feeling to poor sleep when he may actually be dehy-

drated. This will lead to feeling more anxious and pressured to sleep well the next

night, instead of simply drinking a glass of water and addressing the problem. But is

there any evidence that Mr. S’s experience is typical in insomnia? We attempt to

answer this question by examining the evidence for Harvey’s (2002) model.

The Role of Thoughts

One of the basic components of Harvey’s model is the activational role of negative

thoughts in a sequence characterized by increased arousal/distress and unhelpful

behaviors. Thus, it seems prudent to start here. The majority of work in the area has

focused on the content of presleep cognitions. In insomnia, the presleep thought

The Role of Thoughts

101

content is often negatively valenced (Harvey, 2002) and is characterized by thinking

about “thoughts” or the sleeping environment (e.g., temperature or noise), planning,

problem solving, ruminating about past events, and/or worrying about the inability

to sleep (Harvey, 2000; Levey, Aldaz, Watts, & Coyle, 1991; Watts, Coyle, & East,

1994; Wicklow & Espie, 2000). The more negatively valenced thought content such

as worry and rumination is strongly associated with increased sleep onset latency

(Wicklow & Espie, 2000). In addition to the valence of thoughts, people with

insomnia tend to have greater thought activation, that is, they have intrusive mental

activity while trying to fall asleep. Cognitive overactivity is seen by those with

insomnia as ten times more important than somatic tension in the perpetuation of

their insomnia (Lichstein & Rosenthal, 1980). The content of overactive thinking is

sometimes related to topics from the daytime that continue into the sleep period.

Thus, there is a preponderance of thoughts related to work, family, and mundane

topics, and such thoughts are often characterized by problem solving (Wicklow &

Espie, 2000). In addition, people with insomnia tend to think specifically about

sleeplessness (Fichten et al., 1998; Harvey, 2000; Kuisk, Bertelson, & Walsh, 1989;

Watts et al., 1994; Wicklow & Espie, 2000).

Unwanted Repetitive Mental Activity

In insomnia, one of the most well known instructions in folk psychology to deal

with repetitive thoughts is the advice to count sheep. The idea behind counting

sheep actually makes sense because counting occupies space in the
articulatory

loop
, a construct that refers to the brain’s processing of ongoing information. There

is a limited amount of space in the articulatory loop, so it is difficult to keep both

old and new thoughts in the loop simultaneously. Thus, the focus on new thought

content such as counting sheep essentially ejects previous (unwanted) material from

the loop. The problem is that counting sheep is boring, so it may not readily stay in

the articulatory loop. In a more sophisticated experimental version of counting sheep,

people with insomnia were asked to repeat the word “the” over and over again in

their mind while trying to fall asleep. Interestingly, saying “thethethethethethe”

actually shortened the experience of wakefulness in bed (Levey et al., 1991). So

why do not we prescribe this to those with insomnia? The practical problem with

this is that saying “the” is about as exciting as counting sheep, so it may not be

interesting enough to occupy the loop for long. Some people with insomnia instead

try to suppress unwanted thoughts, but suppression attempts have the opposite