Insomnia and Anxiety (Series in Anxiety and Related Disorders) (32 page)

would do when awake should not be done in your bed/bedroom. Sex can be an

exception to this rule.

• Challenging the negative thought distress connection by completing a Thought

Record.

• Complete a Behavioral Experiment that challenges whether a safety behavior is

helpful in the long term.

• If anxiety is a significant problem, enact your anxiety management strategies

during the day to reduce the likelihood that they will be an issue at night.

– If the anxiety is specific to sleep, use Thought Records throughout the day to

interrupt the negative thought–emotion cycle and use Constructive Worry in

the evening.

– Consider starting a daily relaxation practice particularly if it has been helpful

in the past.

References

121

• Maintain healthy sleep behaviors such as refraining from caffeine, alcohol, or

tobacco consumption within hours of bedtime.

If I have enacted all of these strategies and continue to have problems, I will

contact my health provider and schedule a refresher session.

If I notice new sleep-related symptoms, I will contact my health provider and

schedule an appointment. Such symptoms can include:

– Loud snoring

– Stopping breathing, breathing pauses, gasping or snorting during sleep

– Falling asleep unintentionally during the day

– A creepy-crawly sensation in your lower legs in the evening accompanied by an

irresistible urges to move your legs to alleviate the sensation

– Very frequent leg jerking during the night

– Other unusual new experiences

Remember, you mastered the insomnia before, and you will master it again.

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Chapter 9

Other Issues in Managing the Sleep of Those

with Anxiety

Abstract
We have presented the core treatment strategies of CBT for insomnia

in the previous chapters, but there are potential challenges unique to those suffer-

ing from comorbid anxiety problems that should be discussed. Herein, we present

specific instructions/protocols for managing sleep problems in the context of

anxiety and anxiety disorders, including relaxation-based strategies (focusing

specifically on Progressive Muscle Relaxation), Cognitive Behavioral Treatment of

Nocturnal Panic (Craske et al., Behavior Therapy 36:43–54, 2005), treating claus-

trophobia for those using CPAP for sleep apnea, and dream/nightmare rescripting.

While a major goal of this text is that of providing practitioners guidance in the

use of psychological strategies for the management of sleep problems with anxiety

as a prominent feature, the problems discussed may represent only a subset of the

varied forms of sleep disturbances that may present as primary or comorbid sleep

disorders. Many people with such conditions require and benefit from one or more

consultations with a sleep specialist. Hence, we provide discussion and a resource

for use in determining whether the type of sleep problem and circumstances

warrant a sleep specialty referral.

Relaxation-Based Strategies

Since cognitive and physiological arousal is a hallmark symptom of anxiety disorders

in general, psychological treatments designed to reduce arousal have long been popu-

lar for the management of such conditions. In fact, as early as the 1930s, Jacobson

noted the usefulness of a structured progressive muscle relaxation (PMR) exercise for

reducing arousal symptoms. During the latter half of the twentieth century, various

forms of relaxation therapies evolved from Jacobson’s early observations and became

popular for managing the arousal symptoms in the various anxiety disorders. Meta-

analytic studies and systematic reviews have generally supported their efficacy for

C.E. Carney and J.D. Edinger,
Insomnia and Anxiety
, Series in Anxiety and Related Disorders, 123

DOI 10.1007/978-1-4419-1434-7_9, © Springer Science+Business Media, LLC 2010

124

9 Other Issues in Managing the Sleep of Those with Anxiety

anxiety management. These reports have indicated that the relaxation therapies are

effective as either stand-alone treatments or adjunctive measures for the management

of conditions such as generalized anxiety disorder, panic disorder, social anxiety, and

phobic conditions (Clum, Clum, & Surls, 1993; Futterman & Shapiro, 1986; Jorm

et al., 2004; Norton & Price, 2007; Siev & Chambless, 2007; Stetter & Kupper, 2002).

Thus, relaxation therapy has become a staple one among the psychological treatments

offered to those with anxiety problems.

As noted in Chap. 2, cognitive and physiological arousal (resulting from

behavioral conditioning), tendencies to worry in bed, and sleep-related perfor-

mance anxiety all are well-recognized perpetuating mechanisms for chronic

insomnia. Consequently, relaxation therapies would seem an obvious treatment

choice for insomnia management. In fact, relaxation approaches were among the

first behavioral treatments applied to insomnia problems. Initially, there was suc-

cess in treating someone with sleep-onset insomnia using a form of relaxation

therapy known as autogenic training (Schultz & Luthe, 1959). A few years later,

there were similar results in an insomnia case treated with progressive muscle

relaxation training (Jacobson, 1964). However, not until the early 1970s were the

first randomized clinical trials conducted to document the efficacy of relaxation

approaches (Borkovec & Fowles, 1973; Nicassio & Bootzin, 1974). Nonetheless,

these early reports were sufficient to foster substantial research and clinical inter-

est in the use of relaxation therapies for insomnia treatment during the past sev-

eral decades.

Currently, there is sufficient evidence to conclude that relaxation training is