Insomnia and Anxiety (Series in Anxiety and Related Disorders) (24 page)

ally make your sleep problem worse. The amount of time you spend in bed each night

should “fit” you like your shoe fits. That is, you should be in bed only a little bit longer

than you need to satisfy your sleep requirement. We will use your sleep diary to decide the

amount of time to spend in bed and what times you should go to bed at night and get out

of bed in the morning.

At this juncture, it is necessary to consult the pretreatment sleep diaries to

determine the optimal starting time-in-bed allotment. To demonstrate how this is

done, the diary data shown for the 1-week period in Fig. 6.3 will be used. As can

be determined from simple mathematical calculations, this diary shows an average

time in bed slightly over 9 h (i.e., calculate from the time they get into bed in item

3 to the time they got out of bed in item 9), but they only spend an average of 6 h

sleeping (calculated by subtracting the time spent awake in bed from the time spent

in bed). Different approaches have been suggested for implementing sleep restric-

tion instructions with such data. A common approach (Morin, 1993) is that of

restricting time in bed to whatever the average amount of total sleep time is from

the pretreatment sleep diary. In this case, that amount of time would be 6 h.

However, this approach is somewhat austere and does not take into account the

additional amounts of time people normally are awake in bed at the beginning of

the night and in the middle of the night. It also should be noted that insomnia

sufferers, as a group, tend to underestimate the time they sleep at night (Edinger &

Fins, 1995; Means, Edinger, Glenn, & Fins, 2003). Given these considerations,

limiting the time spent in bed to the average total amount of sleep produced on the

pretherapy sleep diary may actually result in partial sleep deprivation. For these

reasons, we (Edinger & Carney, 2008) have suggested setting the initial time in bed

(TIB) allotment at the average total sleep time observed from the diary plus an

additional 30 min to accommodate normal wake times in bed and the proneness

many people have to underestimate their time slept. Thus, using the diary data

shown in Fig. 6.3 we would allocate 6.5 h as the initial TIB allotment.

Once the initial TIB prescription is determined, it is necessary to help the person

choose a standard wake-up time and earliest bedtime that “fit” with the TIB

prescription. In doing so, it is important to encourage people to think about the

most acceptable bed and rising times. An individual may initially decide that

8:00 A.M. is a desirable rising time. That choice may initially seem reasonable;

however, if the initial TIB prescription is 6 h, this wake-up time would result in an

Addressing Sleep Hygiene Issues

89

earliest
bedtime of 2:00 A.M. Upon discovering this fact, this person may opt to

select an earlier rising time so that the bedtime can also be earlier the preceding

night. In addition, it is helpful to select a time that is at least as early as the earliest

time they have to rise for work or other responsibilities. For example, if three

mornings during the week involve an earlier (7 A.M.) rise time, this person should

consider setting the rise time at 7 A.M. to avoid the jetlag-type of problems we

discussed earlier. It is important to stress that the bedtime is the
earliest
time at

which they can go to bed, but if they are not sleepy, they should still follow the

recommendation above which is to stay out of bed until sleepy. This may result in

some restriction of sleep in the beginnings of treatment, but this will also increase

sleep drive for subsequent nights. Whatever rise times and bed times are chosen, it

is essential to work collaboratively to arrive at a schedule. Adherence to the TIB

prescription will be enhanced when the person takes an active role in selecting the

initial bed and rising times to employ.

Whereas it is useful to discuss the stimulus control and sleep restrictions verbally

during the initial therapy visit, a written summary of the treatment recommenda-

tions helps with remembering the instructions. The instruction sheet shown in

Fig. 6.4 includes the essential points to remember and can be given as a “take-

home” reminder of the protocol to follow. This particular instruction sheet lists the

combined stimulus control and sleep restriction guidelines to follow, and includes

an area where the specific agreed upon bed and rising times can be entered.

Addressing Sleep Hygiene Issues

While the above treatment recommendations form the core of effective treatment, it

is important to address any other factors that disrupt sleep and/or impair daytime

functioning. The generic name for such a recommendation is sleep hygiene. Sleep

hygiene is not an effective standalone treatment (Morin et al., 1999); however, it is

commonly included in CBT to address any sleep-interfering behaviors such as

caffeine overuse or sleeping environments that are not conducive to sleep. Most

people have heard about sleep hygiene and readily accept these recommendations

(Vincent & Lionberg, 2001). However, people may also assert that sleep hygiene

recommendations have not improved their insomnia in the past, so it may be useful

to explain that while instituting sleep hygiene recommendations alone may not be

enough to improve their insomnia, changes in this area may be necessary to derive

maximal benefit from the treatment. That is, while stimulus control and restricting

time in bed may produce considerable improvements, full improvement may be

impeded by excessive caffeine use in the latter part of the day. The exact content of

sleep hygiene instructions may vary somewhat depending upon the needs of the

particular person being treated. However, the following text provides the treatment ratio-

nale and instructional set that is useful with most people. This text can be used

verbatim or paraphrased depending upon therapists’ preferences and patients’ needs.

90

6 Behavioral Strategies for Managing Insomnia

TREATMENT GUIDELINES

1 Select a standard wake-up time.
Use it every day regardless of the sleep

you obtain on any particular night.

2 Use the bed only for sleeping
. Do not read, eat, watch TV, etc. in bed.

Sexual activity is the only exception.

3 Get up when you can’t sleep.
When you are unable to sleep, get up and go

to another room until you feel sleepy enough to fall asleep quickly before returning

to bed. Get up again if sleep does not come on quickly.

4 Don’t worry, plan, etc., in bed.

If such mental activities come on automatically

in bed, get up and stay up until you can return to bed without these mental activities

interfering with your sleep.

5 Avoid daytime napping.
Napping, particularly in the late afternoon or early

evening may interfere with your night’s sleep.

6 Go to bed when you are sleepy, but not before the time suggested.
Long

periods of time in bed will lead to shallow, fragmented sleep. You should spend only

the amount of time in bed that you actually need for sleep. Adherence to the

bedtime and wake time suggested for you below should help you overcome your

persistent sleep problem.

Fig. 6.4
Behavioral treatment instructions handout

As a first step, you should limit your intake of caffeine. Foods and beverages that contain

caffeine are items such as coffee, tea, soft drinks with added caffeine or chocolates.

Caffeine is a powerful stimulant that stays in your system for several hours after you

consume it, and it may make it harder for you to sleep well at night. Therefore, you should

limit your caffeine to the equivalent of no more than 3 cups of coffee per day and avoid

caffeine in the late afternoon or evening hours.

It is also important that you limit your use of alcohol. While alcoholic beverages consumed

close to bedtime may make you drowsy and fall asleep more easily initially, as alcohol is

broken down in your body, it produces effects that cause sleep to be less continuous and

The Value of Follow-Up Sessions

91

therefore less restorative. The cost of alcohol consumption at least cancels, and in some

cases outweighs the apparent sleep-initiating benefits. As a result, it is better to avoid con-

suming much alcohol in the evening, and alcohol should not be used as a sleep aid.

Regular exercise can be beneficial to your sleep. Try some regular moderate exercise such

as walking, swimming, or bike riding. Moderate exercise or activities occurring in the late

afternoon or early evening may contribute to deeper sleep at night. Moreover, improving

your fitness level, regardless of when you exercise can improve the quality of your sleep.

However, since exercise does provide a temporary boost in alertness, it is not a good idea

to exercise right before bed because it may make it harder to get to sleep quickly.

Too much mental or physical stimulation just prior to bedtime is usually disruptive. Most

people find it difficult to perform physical or mental work right up to bedtime and then fall

asleep quickly. So you should protect the hour or two before your usual bedtime as a time

to relax and wind-down before you enter bed. If you make this a regular habit, you will find

it is easier to shut off the demands of the day and get to sleep more easily.

Your sleep setting has an important influence on your sleep. Make sure that your bedroom

is quiet and dark. Noise and even dim light may interrupt or shorten your sleep. You can

block out disturbing noise by wearing earplugs, running a fan, or using a “white noise”

machine that is specifically designed to screen sleep-disruptive sounds. Also, when possi-

ble, eliminate the use of nightlights and consider using dark shades in your bedroom so that

light does not awaken you prematurely in the morning. Make sure that the temperature in

your bedroom is comfortable. Generally speaking, excessively warm temperatures (above

75 degrees Fahrenheit) can disrupt sleep. Consider using an air conditioner during hot

weather.

As is the case for the combined stimulus control/sleep restriction regimen, it is

useful to provide written instructions to reinforce these recommendations. Hence,

the list of sleep hygiene recommendations presented in Fig. 6.5 is provided as an

additional take-home handout that can be provided to help people remember and

adhere to these suggestions.

The Value of Follow-Up Sessions

Usually, the combined stimulus control/sleep restriction regimen and the sleep

hygiene instructions can be provided in the context of the first visit. However, a

series of follow-up sessions are typically beneficial for a number of reasons.

First, such sessions are often needed to assist in making adjustments or refinement

in the initial TIB prescriptions. Secondly, follow-up visits provide additional

opportunity to encourage and reinforce treatment adherence. These visits also

enable the therapist an opportunity to evaluate treatment response and “trouble-

shoot” problems enacting the behavioral regimen. Lastly, some people present

with sleep-interfering cognitions that need to be specifically addressed; thus

subsequent sessions may be devoted to cognitive restructuring. We will dis-

cuss cognitive restructuring in the next two chapters. The following discussion

provides separate consideration of the behavioral aspects of the follow-up

sessions.

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6 Behavioral Strategies for Managing Insomnia

SLEEP HYGIENE INSTRUCTIONS

1

Limit your use of caffeinated foods and beverages such as coffee, tea,

soft drinks with added caffeine or chocolates.
Caffeine is a stimulant that may

make it harder for you to sleep well at night.

2

Limit your use of alcohol.
Alcoholic beverages may make you drowsy and

fall asleep more easily. However, alcohol also usually causes sleep to be much

more broken and far less refreshing than normal.

3

Avoid exercise and other physical activity right before bed.
Being too

active right before bed may make it harder to get to sleep quickly.

4

Protect the hour or two before your usual bedtime as a time to relax and

wind-down before you enter bed.
If you make this a practice, you will find it is

easy to “shut of the day” and get to sleep more easily.

5

Try a light bedtime snack that includes such items as cheese, milk, or

peanut butter.
These foods contain chemicals that your body uses to produce

sleep. As a result, this type of bedtime snack may actually bring on drowsiness.

6

Make sure that your bedroom is quiet and dark.
Noise and even dim light