Insomnia and Anxiety (Series in Anxiety and Related Disorders) (22 page)

minutes.

1

case

diary

sleep

1 = very poor 4 = good

2 = poor 5 = excellent

3 = fair.

Sample

DAY OF THE WEEK

CALENDAR DATE

1 = not all rested 4 = rested

2 = slightly rested 5 = well rested

3 = somewhat rested

1. Yesterday I napped from __ to __

(note time of all naps).

2. Last night I took___ mg. of ____ or

____of alcohol as a sleep aid

3. Last night I got in my bed at ____

4. Last night I turned off the lights and

attempted to fall asleep at ____

5. After turning off the lights it took me

about ___minutes to fall sleep.

6. I woke from sleep ____ times.

(Do not count your final awakening)

7. My awakenings lasted ____

(List each awakening separately)

8. Today I woke up at _____

NOTE this is your final awakening.

9. Today I got out of bed for the day at

_____.

10. I would rate the quality of last

night's sleep as:

11. How well rested did you feel upon

rising today?

. 6.1

Fig

Assessing the Sleep Problem Using the Sleep Diary

81

2

Sun

3/11

3

2

None

None

9:15 PM

20 min.

20 min.

20 min

11:20 PM

6:00 AM

6:30 AM

Sat

1

3/10

3

2

None

None

9:00 PM

15 min

15 min

5:50 AM

10:50 PM

6:30 AM

Fri

3/9

2

3

2

None

None

9:15 PM

15 min

15 min

15 min

11:00PM

5:45 AM

6:15 AM

3/8

2

4

3

Thurs

3:30 –

None

5 min

3:35 PM

15 min

10 min

10:00 PM

11:30 PM

6:00 AM

7:00 AM

3/7

2

3

2

Wed

None

None

9:00 PM

30 min

15 min

15 min

10:45 PM

5:45 AM

6:30 AM

2

Tue

3/6

PM

2

2

None

10 min

15 min

45 min

2:15-3:00

10:00 PM

11:15 PM

5:45 AM

6:30 AM

3/5

1

Mon

3

2

None

None

9:30 PM

30 min.

30 min

11:00 PM

6:00 AM

6:30 AM

EXAMPLE

PM

3

2

Monday

3/24/08

2:30-3:15

Ambien

5 mg.

11:00 PM

11:30 PM

40 Min.

2 Times

25 Min. 40 Min.

6:30 AM

7:15 AM

2

case

diary

sleep

1 = very poor 4 = good

2 = poor 5 = excellent

3 = fair.

1 = not all rested 4 = rested

2 = slightly rested 5 = well rested

3 = somewhat rested

Sample

DAY OF THE WEEK

CALENDAR DATE

1. Yesterday I napped from __ to __

(note time of all naps).

2. Last night I took___ mg. of ____

____of alcohol as a sleep aid

3. Last night I got in my bed at ____

4. Last night I turned off the lights and

attempted to fall asleep at ____

5. After turning off the lights it took me

about ___minutes to fall sleep.

6. I woke from sleep ____ times.

(Do not count your final awakening)

7. My awakenings lasted ____

minutes.

(List each awakening separately)

8. Today I woke up at _____

NOTE this is your final awakening.

9. Today I got out of bed for the day at

_____.

10. I would rate the quality of last

night's sleep as:

11. How well rested did you feel upon

rising today?

. 6.2

Fig

82

6 Behavioral Strategies for Managing Insomnia

1

4

5

Sun

4/7

None

None

2:30 AM

2:30 AM

25 min

10 min

10:30 AM

10:40 AM

Sat

4/6

1

5

4

None

None

5 min

2:45 AM

2:45 AM

30 min

11:25 AM

11:30 AM

Fri

4/5

2

3

3

5:00-

6:30 PM

2 beers

3.5 hrs

40 min

30 min

11:30PM

11:30PM

9:00 AM

9:05 AM

4/4

1

1

1

Thurs

None

1 beer

2.5 hrs

20 min

12:00 PM

12:00 PM

8:40 AM

8:45 AM

1

3

2

Wed

4/3

None

1 glass

wine

3.5 hrs

10 min.

11:00 PM

11:00 PM

8:05 AM

8:30 AM

2

3

3

Tue.

4/2

2:00-

None

2 hrs

4:00 PM

25 min

25 min

12:30 PM

12:30 PM

9:30 AM

9:40 AM

1

2

1

Mon.

4/1

None

None

3 hrs

20 min

11:30 PM

11:30 PM

8:30 AM

8:40 AM

EXAMPLE

3

2

PM

5 mg.

Monday

3/24/08

40 min.

2:30-3:15

Ambien

11:00 PM

11:30 PM

2 Times

25 min.

40 min.

6:30 AM

7:15 AM

3

case

diary

sleep

attempted to fall asleep at ____

1 = very poor 4 = good

2 = poor 5 = excellent

3 = fair.

Sample

1 = not all rested 4 = rested

2 = slightly rested 5 = well rested

3 = somewhat rested

DAY OF THE WEEK

CALENDAR DATE

1. Yesterday I napped from __ to __

(note time of all naps).

2. Last night I took___ mg. of ____

____of alcohol as a sleep aid

3. Last night I got in my bed at ____

4. Last night I turned off the lights and

5. After turning off the lights it took me

about ___minutes to fall sleep.

6. I woke from sleep ____ times.

(Do not count your final awakening)

7. My awakenings lasted ____ minutes.

(List each awakening separately)

8. Today I woke up at _____

NOTE this is your final awakening.

9. Today I got out of bed for the day at

_____

10. I would rate the quality of last

night's sleep as:

11. How well rested did you feel upon

rising today?

. 6.3

Fig

Assessing the Sleep Problem Using the Sleep Diary

83

maximum amount of sleep possible (for more details on the effect of beliefs on

sleep-interfering behaviors, see Chap. 7). This practice of “chasing” sleep, regard-

less of the timing of sleep, perpetuates the sleep difficulty. As will be described in

many places in this book, sleep quality has more to do with timing and sleep stage

architecture than quantity. This erratic sleep “schedule” and the beliefs that drive it

(e.g., anxiety about getting “enough” sleep) are primary treatment targets for those

who present such diary data.

Figure 6.2 shows diary results for an individual who manifests another common

practice seen frequently among people with insomnia. These data show a pattern of

retiring to bed well in advance of the actual time chosen for attempting to fall

asleep. This can be discerned by examining the discrepancy between the time the

individual got into bed (item #3 on Fig. 6.2) and the time he/she turned out the

lights to attempt to sleep (item #4 on Fig. 6.2). Follow-up queries of a pattern such

as this one commonly reveal practices such as watching television or reading in bed

for an hour or more before intending to fall asleep. Those who engage in such

practices can routinely spend 9 or more hours in bed per night and experience

extended awakenings each night as a result. Indeed, it is difficult for most adults to

produce 9 h of quality sleep. Early bedtimes, a prolonged amount of time in bed,

and accompanying delayed sleep onset latencies require careful follow-up. Those

who produce such a pattern often exhibit a tendency to doze off while watching TV

or reading in bed before their intended “lights-out” period indicated on the diary.

The extra time spent in bed, using the bed for activities other than sleep, occasional

napping, and the unrecorded dozing are important behavioral treatment targets

uncovered by sleep diary monitoring and related questioning. This pattern is often

related to unhelpful and in some cases inaccurate beliefs about sleep needs and

what factors promote good quality sleep. Such beliefs will also be targeted during

treatment (see Chaps. 7 and 8 for further discussion).

Presented in Fig. 6.3 are some data that demonstrate the importance of the sleep

diary during the assessment and treatment planning phase. These data are from a

young adult who complained about difficulty falling asleep each night. Throughout

the week of monitoring, this person spent 2.5–3.5 h awake before falling asleep.

Careful query revealed that unlike the previous case example, this person did not

report any dozing during this period. There were several instances wherein alcohol

was used as a sleep aid. If you calculate when this person falls asleep (by adding

the sleep onset latency to the lights out time), you see that this person tends to fall

asleep within the same hour each night (between 2:30 and 3:30 A.M.). Interestingly,

on weekends, this person goes to bed during this 2:30–3:30 window. When this

person goes to bed close to the time that they normally fall asleep, the sleep onset

latency is much shorter and actually falls within normal limits (£30 min). Also of

note is that the weekend rise times are much later than the rise times during the

week and the sleep quality and restedness ratings improve on the weekends too.

The hypothesis formed at this point may be that the weekend permits a more opti-

mal (i.e., later) sleep schedule for this person, thus allowing them to obtain a full

night’s sleep. This picture is consistent with delayed sleep phase syndrome, a

circadian rhythm disorder in which the person is biologically disposed to fall asleep

84

6 Behavioral Strategies for Managing Insomnia

later than most people and to rise much later than most people. In such people, the

constraints of a work or school schedule can interfere with the natural body clock’s

schedule; thus, sleep-depriving them during the week. The weekend offers a small

respite by matching their schedule to their body clock, but then the person returns

to the problematic schedule on Monday. We do not discuss circadian rhythm disorder

treatments in this book, so when encountering this type of pattern, it is best to refer

to a sleep specialist.

Setting the Stage for Treatment Recommendations:

The Role of Psychoeducation

As the preceding discussion demonstrates, those with insomnia engage in many

practices that sustain and/or exacerbate their sleep difficulties. As a result, most

benefit by making marked changes in their sleep habits and their general

approach toward sleep in general. However, it should be recognized that many

of the attitudes and behaviors they “bring with them” to treatment are logical and

sensible. Moreover, many of their sleep disruptive habits represent reasonable

attempts to cope with or compensate for sleep difficulties. Despite the ineffec-

tiveness of their approach to sleep, they may still be reluctant to make the types

of changes required of them by behavioral insomnia treatment, particularly in

the absence of a convincing rationale supporting the need for such changes.

Indeed, it is not reasonable to expect a high degree of adherence to treatment

recommendations that call for substantial changes in sleep habits unless they are

provided an adequate and convincing treatment rationale. Therefore, presenting

such rationale in the form of psychoeducation has become a mainstay in the

provision of CBT for insomnia.

The educational information provided prior to introducing the specific treatment

recommendations discussed later in this chapter has two primary functions. First, it

helps people overcome their unhelpful, anxiety-provoking beliefs about sleep so

that they may develop more realistic sleep expectations. Secondly, it enables insomnia

sufferers to better understand the rationale for the recommendations in this treat-

ment. This understanding, in turn, increases the likelihood of adherence to