Insomnia and Anxiety (Series in Anxiety and Related Disorders)

Insomnia and Anxiety

Series in Anxiety and Related Disorders

Series Editor:

Martin M. Antony, Professor, Department of Psychology,

Ryerson University, Toronto, Ontario, Canada

For other titles published in this series, go to

www.springer.com/series/6926

Colleen E. Carney ● Jack D. Edinger

Insomnia and Anxiety

Colleen E. Carney

Jack D. Edinger

Department of Psychology

Department of Psychiatry and Behavioral

Ryerson University

Sciences

Toronto ON

Duke University Medical Center

Canada

Durham, NC

[email protected]

USA

[email protected]

ISBN 978-1-4419-1433-0

e-ISBN 978-1-4419-1434-7

DOI 10.1007/978-1-4419-1434-7

Springer New York Dordrecht Heidelberg London

Library of Congress Control Number: 2010922365

© Springer Science+Business Media, LLC 2010

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For Shannon and Sydney

Colleen E. Carney

In loving memory of my parents who

always encouraged my best efforts and

to my wife Wanda who tolerated those

well over the years.

Jack D. Edinger

v

Acknowledgements

We would like to thank our students for their help with this manu-

script and for inspiring us to write it.

vii

Contents

1 Anxiety and Insomnia: An Overview
......................................................

1

What is Insomnia? .......................................................................................

2

Diagnostic Considerations for Insomnias ...................................................

3

The Case of Comorbid Insomnia: More Nosological Issues ......................

4

Cognitive Behavioral Model of Insomnia and Anxiety ..........................

7

Summary .....................................................................................................

9

References ...................................................................................................

9

2 Considerations for Assessment
................................................................ 13

Assessment of Sleep ................................................................................... 13

Actigraphic Measurement of Sleep ............................................................. 15

Subjective Assessment of Sleep .................................................................. 15

Clinical Interview ........................................................................................ 18

Self-report Measurement ............................................................................ 18

Global Sleep Symptom Questionnaires .................................................. 18

Cognitive Insomnia Questionnaires ........................................................ 19

Behavioral Insomnia Questionnaires ...................................................... 20

Daytime Insomnia Symptom Questionnaires ......................................... 20

Assessment of Anxiety ............................................................................... 21

Structured Interviews for Anxiety ............................................................... 22

Clinician-Administered Interviews for Anxiety ..................................... 22

Clinician-Administered Interviews for Specific

Anxiety Disorders ................................................................................... 22

Self-Report Measures for Anxiety Symptoms ........................................ 23

General Measures for Self-Reported Anxiety ......................................... 23

Anxiety Disorder-Specific Self-Report Questionnaires .......................... 24

Case Example 1: Generalized Anxiety Disorder and Insomnia .................. 26

Case Example 2: Sleep-Specific Worry ...................................................... 27

References ................................................................................................... 28

3 Anxiety Disorders and Accompanying Insomnia
................................... 33

Panic Disorder ............................................................................................. 33

Generalized Anxiety Disorder .................................................................... 35

ix

x

Contents

Posttraumatic Stress Disorder: PTSD ......................................................... 37

Obsessive–Compulsive Disorder ................................................................ 40

Social Phobia .............................................................................................. 42

Specific Phobias .......................................................................................... 43

Summary ..................................................................................................... 45

References ................................................................................................... 45

4 Cognitive Behavior Therapy for Insomnia:

Treatment Considerations
........................................................................ 51

What is Cognitive Behavior Therapy and Who Can

Benefit from It? ........................................................................................... 51

Cognitive Behavior Therapy Model ............................................................ 53

The Evidence Supporting CBT for Insomnia ............................................. 55

Treatment Delivery Issues ........................................................................... 56

References ................................................................................................... 59

5 Medication Considerations
...................................................................... 63

Will Cognitive Behavior Insomnia Therapy

Work with Those Who Use Sleep Medications? ........................................ 63

Prescription Hypnotics: Advantages and Disadvantages ............................ 65

Over-the-Counter Medications, Herbal Remedies,

and Alternative Treatments ......................................................................... 66

Antihistamine-Based Sleep Aids ............................................................ 67

Herbal Compounds and Dietary Supplements ........................................ 68

Melatonin ................................................................................................ 68

Alcohol .................................................................................................... 69

Can Common Anxiety Medications Cause Insomnia Symptoms? ............. 70

Combining Sleep Medications with CBT for Insomnia ............................. 71

Sleep Medication Discontinuation Strategies ............................................. 73

References ................................................................................................... 75

6 Behavioral Strategies for Managing Insomnia
....................................... 79

Assessing the Sleep Problem Using the Sleep Diary .................................. 79

Setting the Stage for Treatment Recommendations:

The Role of Psychoeducation ..................................................................... 84

Presenting Behavioral Insomnia Treatment Recommendations ................. 86

Addressing Sleep Hygiene Issues ............................................................... 89

The Value of Follow-Up Sessions ............................................................... 91

Assistance with TIB Changes ..................................................................... 92

Reviewing/Reinforcing Adherence ............................................................. 93

Trouble-Shooting Problems ........................................................................ 94

Case 1 ...................................................................................................... 95

Case 2 ...................................................................................................... 95

Case 3 ...................................................................................................... 96

References ................................................................................................... 97

Contents

xi

7 Sleep-Related Cognitive Processes
.......................................................... 99

Harvey’s (2002) Cognitive Model .............................................................. 99

The Role of Thoughts ................................................................................. 100

Unwanted Repetitive Mental Activity..................................................... 101

The Role of Distress .................................................................................... 102

Beliefs in Insomnia ..................................................................................... 102

Attention and the “Threat” of Sleep ............................................................ 103

The Role of Attributions ............................................................................. 104

Maintaining the Status Quo ........................................................................ 105

References ................................................................................................... 106

8 Cognitive Strategies for Managing Anxiety and Insomnia
................... 109

Worry Management Strategies .................................................................... 109

Constructive Worry Worksheet Example .................................................... 111

Cognitive Restructuring .............................................................................. 112

Thought Record .......................................................................................... 113

Decreasing Safety Behaviors and Behavioral Experiments ........................ 117

Focus on Relapse Prevention ...................................................................... 119

Action Plan for Addressing Insomnia ......................................................... 119

Red Flags for a Possible Problem with Insomnia ....................................... 120

What Tools Work for This Problem? .......................................................... 120

References ................................................................................................... 121