Insomnia and Anxiety (Series in Anxiety and Related Disorders) (25 page)

may interrupt or shorten your sleep.

7

Make sure the temperature in your bedroom is comfortable.
Generally

speaking excessively warm temperatures cause unwanted wake-ups from sleep.

Notes:

Fig. 6.5
Sleep hygiene instructions handout

Assistance with TIB Changes

A minimum of 1 week and preferably two weeks are needed with most people to

provide a test of the initial TIB prescription they are given. If upon the first return

visit they are sleeping soundly at night and feeling generally alert and functional in

Reviewing/Reinforcing Adherence

93

the daytime, no adjustments to the initial TIB prescription are needed. However, if

there continues to be an undesirable amount of nighttime wakefulness, it may be

necessary to decrease the TIB somewhat. What constitutes an “undesirable amount

of wakefulness” can vary somewhat from person to person, but recent studies

(Lichstein, Durrence, Taylor, Bush, & Riedel, 2003; Lineberger, Carney, Edinger,

& Means, 2006) suggest that sleep onset times or periods of wakefulness in the

middle of the night exceeding 30 min are outside the common experience of normal

sleepers. Hence, when the average sleep onset time or the average time awake in

the middle of the night exceeds this amount of time, it is useful to consider a reduc-

tion in TIB to encourage a more consolidated sleep pattern. Unless, an excessively

large amount of wake time remains, a 15–30 min downward titration in the initial

TIB prescription is usually all that is needed to achieve an optimal sleep pattern.

In contrast, if at the first follow-up visit the sleep diary shows consistently solid

sleep, yet there are complaints about ongoing daytime fatigue or sleepiness, then an

upward titration of the initial TIB is indicated. One signal that this is needed is that

the patients report being woken by their alarm clock most mornings. Arguably, such

circumstances suggest they could routinely sleep longer in the morning if the alarm

had not sounded. When this is the case, titrating the TIB upward slowly in 15-min

increments from visit to visit is typically the best approach. Alternately, the person

may find it difficult to stay awake until the prescribed bedtime, fall asleep quickly

each night (i.e., within 5–15 min), sleep solidly throughout the night, and complain

of daytime sleepiness. In this case, one can consider titrating the 15 min by setting

an earlier bedtime. The optimal TIB prescription is reached when the average sleep

onset time and wake time after sleep onset are each <30 min, the person reports

routinely awakening slightly before the alarm each day, and there is an absence of

significant daytime sleepiness and fatigue.

Reviewing/Reinforcing Adherence

It is not difficult to appreciate the central importance of treatment adherence in

ensuring the efficacy of the treatment strategies discussed in this chapter. These

behavioral changes require considerable commitment, and adherence to them is

recognized as one of the most critical factors affecting treatment success

(Chambers & Alexander, 1992; Morin & Wooten, 1996). Approximately 15% of

research participants fail to follow through and complete behavioral insomnia

therapy (Perlis, Aloia, & Millikan, 2000), but some studies suggest that this rate

may approach 40% in clinical venues (Ong, Kuo, & Manber, 2008; Perlis et al.,

2000). Factors which have been linked to nonadherence and attrition include

greater sleep impairment, poorer perceived general health, higher levels of

depression, less favorable ratings of behavioral treatment strategies, and a greater

tendency to view the therapist as critical and confrontive (Constantino et al.,

2008; Morgan, Thompson, Dixon, Tomeny, & Mathers, 2003; Ong et al., 2008;

Perlis et al., 2000; Vincent & Walker, 2001). Monitoring adherence and reinforc-

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6 Behavioral Strategies for Managing Insomnia

ing proper treatment enactment, thus, is critical to the outcome of these insomnia

interventions.

Therapists should nonjudgmentally ask about adherence difficulties and review

sleep diary information to assess any variance from stimulus control, sleep

restriction, and sleep hygiene recommendations. The therapist should freely compli-

ment attempts at following treatment recommendations. In doing so, however, it is

particularly useful to point out the relationship between the enactment of treatment

suggestions and improvement noted by sleep diaries and/or self-report. For example,

therapist comments like, “You have done a really good job following the recom-

mendations we discussed last time. It seems as though your efforts have been

rewarded. Your sleep diaries show that you are now sleeping much better. Great job.”

Positive reinforcement of the existing adherence and the relation to sleep improve-

ment can also be used to improve remaining areas of nonadherence. For example,

“Wow, you have really managed to keep to your scheduled rise time, and it seems to

have paid off with improved sleep. I notice that you napped a few times during the

week and these seemed to be followed by your worst sleep nights. You are already

doing such a good job; do you think eliminating these two naps might make the

difference in getting even better sleep?” In providing such comments, it is important

to remain genuine and avoid patronizing the patient. Thus, language that is consis-

tent with the therapist’s usual interpersonal style should be used in reinforcing

adherence.

Trouble-Shooting Problems

Often, an inadequate treatment response results from a misunderstanding of or

not enacting treatment recommendations. The most common of these adherence

problems include not adhering to a standard rise time, not getting out of bed dur-

ing the night during extended periods of wakefulness, and engaging in uninten-

tional sleeping during the daytime. Common sleep hygiene violations include

consumption of caffeine or alcohol too close to bedtime and failure to allow suf-

ficient “wind-down time” prior to bed. A careful review of sleep diaries can

identify deviations from prescribed rising times. Adherence problems such as the

occurrence of daytime dozing episodes, problems with alcohol or caffeine use,

difficulties setting aside time to relax before bed, and extended periods of wake-

fulness spent in bed, should be queried with curiosity not judgment. When such

problems are identified, the relevant treatment recommendations and their ratio-

nale should be reviewed. The therapist should also suggest ways the person

might avoid the identified sleep disruptive practices. When there are difficulties

enacting recommendations, the therapist should encourage problem-solving of

the difficulty and develop plans that will facilitate enactment of that recommen-

dation. The following case examples demonstrate how the therapist may inter-

vene when these problems are identified.

Trouble-Shooting Problems

95

Case 1

Mr. G presented with a complaint of sleep-maintenance insomnia. Initial evaluation

suggested that he showed many of the sleep disruptive practices addressed by the

behavioral treatment discussed herein, so he was provided a course of behavioral

insomnia treatment to address his complaints. After 1 week of this treatment, he

reported little improvement. However, his sleep diaries and a follow-up discussion

revealed that he did not adhere to the instructed standard rise time. On three of the

nights during the first week of treatment, he stayed in bed over 2 h beyond his

prescribed wake-up time reportedly to make up for poor nights of sleep. Also, he

admitted that he did not get out of bed during extended periods of wakefulness

because he hoped that if he would lie in bed long enough, he would eventually go

to sleep. Although he denied daytime napping, he acknowledged some uninten-

tional dozing in the evening while reclining on a couch watching TV.

To address this sleep problem, the therapist invited exploration of the possible

disruptive effect of the noted adherence difficulties would have on his sleep.

Collaboratively, Mr. G and the therapist decide that placing the alarm clock in a

location out of reach from the bed might help force him to get out of bed at the

agreed upon rising time. They also jointly derive a list of activities he might do

instead of lying in bed when he experiences extended nocturnal awakenings. Mr. G

was also encouraged to sit upright while watching TV in the evening and to have

his wife help avoid his usual dozing during the early evening hours. At a follow-up

session 1 week later, he showed markedly improved treatment adherence and an

associated reduction in his sleep maintenance difficulty.

Case 2

Ms. Q was a retired 74-year-old woman who also presented with sleep maintenance

complaints. There were many treatment targets evident from the initial assessment

including unintentional evening napping and spending an excessive amount of time

in bed on most nights. Standard behavioral insomnia treatment was initiated which

included restricting her time in bed to 7 h and enlisting her husband’s help with

dozing in the evening. Less than 1 week after her first appointment, she phoned the

therapist with concerns about her increased daytime sleepiness. She expressed concerns

about driving because of an incident wherein she fell asleep in her car while

stopped for a traffic light. Ms. Q adhered to the time in bed restriction diligently

and she was sleeping very soundly on most nights. However, she continued to feel

sleepy in the daytime and had to constantly fight off naps.

Given the seriousness of the driving accident and Ms. Q’s concerns, the therapist

suggested her to increase her time in bed by 30 min per night to try to reduce this

sleepiness and temporarily ask her husband to assume driving responsibilities.

At her next appointment, she reported reduced daytime sleepiness with the

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6 Behavioral Strategies for Managing Insomnia

increased time in bed. Her diaries showed that she was sleeping well at night with

very few long awakenings. Since she continued to report some mild sleepiness, the

therapist suggested her to add another 15 min to her TIB each night. After trying

this new TIB prescription, she reported elimination of her daytime sleepiness and a

continuation of her improved nighttime sleep.

Case 3

Mr. M was a 52-year-old man with a long history of insomnia and generalized

anxiety disorder. To combat his problem, he developed the habit of consuming 1–2

shots of alcohol in the evening shortly before bedtime. Usually he had little diffi-

culty falling asleep, but he often awakened and could not return to sleep easily.

During his follow-up appointment, it was evident that his sleep had become worse

as he continued to have fragmented sleep but also began to have difficulties falling

asleep. When asked about his experience in trying to follow the treatment recom-

mendations, Mr. M acknowledged that he continued to drink alcohol close to bed-

time several nights each week. He also reported that the idea of giving up the

alcohol and restricting his sleep had made him very anxious. The therapist asked

whether a more lenient amount of time in bed would be more achievable and

whether Mr. M thought he could adhere to this schedule over the next few weeks.

Mr. M said this was less anxiety provoking and he thought that this was something

he could try. The therapist and Mr. M reviewed the sleep diary data to explore the

association between bedtime alcohol consumption and subsequent poor sleep. To

address this problem, the therapist encouraged Mr. M to move his alcohol con-

sumption to an early time such as dinner, so that it did not interfere with his sleep.

Subsequently, he was able to follow the sleep schedule and was generally able to

refrain from alcohol consumption after his evening meal, and his nighttime awak-

ening problem diminished.

These cases demonstrate some strategies that might be used to address

behavioral adherence issues in follow-up sessions. Admittedly, the cases pre-

sented do not illustrate all possible problems patients might present in adhering

and tolerating treatment. Nonetheless, they do illustrate some commonly

encountered problems and provide some demonstration as to how to intervene.

In the end, therapy should be guided by the sleep diary data and by the patient’s

self-appraisal. Sleeping soundly at night and having no daytime symptoms of

insomnia (e.g. fatigue, impaired concentration, distress about sleep) should be

the ultimate goal for each patient. When this is the case, sleep diaries typically

show a regular sleep/wake schedule and little difficulty with sleep initiation or

maintenance. Once the person achieves a sound sleep pattern at night and is