Insomnia and Anxiety (Series in Anxiety and Related Disorders) (8 page)

with catastrophic cognitions respectively, during a panic episode. Preliminary data

on the PACQ and PASQ suggest good internal consistency and utility in discrimi-

nating those with panic disorder from those with other anxiety disorders not associ-

ated with panic attacks (Clum et al., 1990). There are no known studies using these

scales in those with insomnia or nocturnal panic attacks.

The Mobility Inventory for Agoraphobia – MI (Chambless, Caputo, Jasin,

Gracely, & Williams, 1985) is a 27-item inventory of agoraphobic avoidance and

panic attack frequency. For each of the listed situations commonly avoided by people

with agoraphobia, the degree of avoidance when alone versus when accompanied by

another person are rated on 5-point scales (1 = never avoid; 5 = always avoid). There

are demonstrated sound psychometric properties and utility in discriminating

between clinical and nonclinical samples (Chambless et al., 1985). We were not able

to find psychometric evaluations of the MI in sleep-disordered population.

Regardless of the measures employed, it is important to generate a formulation of

the problem and a plan of action for treatment. Below are two abbreviated examples

of assessment in those with insomnia and their related case formulations.

Case Example 1: Generalized Anxiety Disorder and Insomnia

Ms. H is a 36-year-old female with a complaint of sleep onset and maintenance

insomnia. She is unsure what caused the insomnia, but believes that her problem is

currently maintained by her anxiety about sleep. Based on a questionnaire of

insomnia symptom severity, her insomnia is in the moderately severe range

(Insomnia Severity Index = 21). She reports that it is taking several hours for her to

fall asleep, as well as 3–12 awakenings per night. A review of her sleep logs

revealed that she tends to go to bed around 11 p.m. and rise around 7:30 a.m. (mean

total time in bed = 8.7 h). Her average sleep onset latency is 172 min; her average

time being awake after sleep onset is 66 min. Her estimated mean sleep efficiency

for 2 weeks of sleep diaries is very poor (54%). She denied napping. She denied

daytime sleepiness (Epworth Sleepiness Score = 4) but reported significant daytime

fatigue (Fatigue Severity Score = 5.6).

On a scale assessing maladaptive sleep behaviors, she reported reading in bed

each night and remaining in bed when she cannot sleep. She denied any other poor

sleep habits, and denied regular use of caffeine, alcohol, or tobacco products. She

stated that before bed she can “barely keep her eyes open,” but when she gets into

bed she feels “instantaneously awake and irritated.” She begins to have thoughts

such as, “I can’t sleep.” She acknowledged loud snoring, but denied observed

apneas, or symptoms of cataplexy, hypnogogic hallucinations, restless legs, or peri-

odic leg movements during sleep. A previous overnight sleep study conducted

4 months ago was unremarkable. She reported past diagnoses of Post-Traumatic

Stress Disorder and Generalized Anxiety Disorder. She was in psychotherapy for

about 1 year for PTSD, and denies it is a problem any longer. She regarded the

Case Example 2: Sleep-Specific Worry

27

psychotherapy as very helpful. Based on her report it appeared to be an exposure-

based psychotherapy. She denied symptoms of re-experiencing the trauma via

flashbacks, intrusive thought or nightmares, and no longer avoids her family home

(the site of the trauma). She denied any numbing of responsiveness. She currently

takes Celexa (40 mg per day) for anxiety. She reported that her anxiety is much

better currently; however, her responses on a measure of clinically significant

worry would suggest that the current level of worry is in the clinical range (Penn

State Worry Questionnaire = 64). She acknowledged that she is currently worrying

quite a lot about her sleep problem, and when pressed, she acknowledged worries

in other domains, including being late for appointments, work, family, finances, and

global affairs. She also reported having difficulties with depression in the past, but

denied current symptoms. Her responses on a depression symptom measure would

corroborate her report of no depression (Beck Depression Inventory = 10).

Formulation
: Ms. H appears to have developed a psychophysiologic insomnia. She

also meets the criteria for GAD. She has good insight into her sleep problem, but

is less willing to acknowledge a more pervasive worry problem. Ms. H may benefit

from augmenting her pharmacologic treatment of anxiety with psychotherapy to

address worry. It is unknown as to whether her medication is contributing to her

sleep problem, but the sleep problem predated the medication and did not appear to

worsen when she began taking the medication. Sleep focused treatment should

target the belief that she cannot cope with her sleep problem and the conditioned

hyperarousal (i.e., the abrupt switch into alertness when she gets into her bed).

Going to bed only when she is sleepy and getting out of bed during prolonged

awakenings (stimulus control) should reduce the conditioned arousal she is cur-

rently experiencing. Ms. H would also likely benefit from a relaxation practice and

worry control training.

Case Example 2: Sleep-Specific Worry

Ms. T is a 28-year-old woman attending graduate school with a complaint of sleep

maintenance insomnia. For the past 2 months, Ms. T has been waking after about

4–5 h of sleep and is unable to return to sleep. Occasionally, during these awaken-

ings, she reports that her heart is beating fast and she feels anxious. Her family

physician apparently told Ms. T that she was depressed and prescribed Prozac. She

stated that she did not “feel” depressed (i.e., she did not have sad mood or depres-

sive thoughts), but the Prozac was helpful in eliminating her “blah mood” and her

social avoidance. She indicated that the Prozac was not helpful in reducing her

awakenings or daytime fatigue.

Her score on a measure of insomnia symptom severity (Insomnia Severity

Index = 17) would suggest that the insomnia is of moderate severity. A review of her

sleep logs revealed several nights of excessive time in bed (up to 9 h). She appeared

to obtain 6–8 h of sleep. On a measure of sleep-interfering behaviors, she denied

using alcohol, caffeine, or any form of tobacco products. She reported that she read

28

2 Considerations for Assessment

in bed 7 nights per week for 10 min – she denied any other sleep disruptive behav-

ior. Her responses to a questionnaire would not suggest significant daytime sleepi-

ness (Epworth Sleepiness Scale = 6), but her score on the Fatigue Severity Scale

would corroborate her report of significant fatigue (Fatigue Severity Scale = 6.1).

During the clinical interview, she denied loud snoring, restless legs, observed

apneas, periodic leg movements during sleep, cataplexy, sleep paralysis, hyp-

nogogic hallucinations, nightmares, or any form of parasomnia.

Her report of daytime worry about her sleep and the possible consequences it

has on her health and her performance at school was corroborated by a high score

on a scale assessing unhelpful beliefs about sleep, including sleep worries

(Dysfunctional Beliefs and Attitudes about Sleep Scale = 4.9). Her score on a

measure of general worry (Penn State Worry Questionnaire = 39) was suggestive

of a tendency toward worry and anxiety, although this score was well below the

clinical cutoff for pathological worry or GAD. Her responses on a questionnaire

that assesses depression symptoms was below the suggested cutoff for moderate,

clinically significant depression (Beck Depression Inventory score = 11). During

the clinical interview, she denied depressed mood or anhedonia, but acknowledged

fatigue, difficulty concentrating, and insomnia.

Formulation
: Although a mood episode may have precipitated the insomnia

complaint, the mood episode appears to have resolved, and the insomnia remains.

It is clear that she has considerable worry about her ability to sleep and the possible

consequences that the insomnia will have on her health. She endorsed some unre-

alistic expectations and beliefs about sleep. It appears that the anxiety generated by

her unrealistic beliefs, as well as some excessive time in bed in the morning may

be currently maintaining her insomnia. She has been taking the Prozac for only

4 weeks, thus it remains a possibility that her awakenings will resolve after some

more time on the antidepressant. In the meantime, I have instructed her to: (1) limit

her time in bed to 6.5 h; (2) get out of bed each morning by 7 a.m.; (3) eliminate

“resting” periods in the morning and throughout the day, so that she will avoid the

possibility of an unintended nap; (4) focus on ways to cope with fatigue symptoms

(e.g., engage in activating activities, take breaks during mundane tasks and fresh

air); (5) complete Thought Records so that we can challenge her catastrophic think-

ing about sleep loss; and (6) if she awakens in the morning and cannot return to

sleep within 20 min, she is to leave the bedroom and start her day.

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