Insomnia and Anxiety (Series in Anxiety and Related Disorders) (28 page)

Maintaining the Status Quo

This attentional bias for confirmatory information also makes it more likely that

such information will be perceived. Thus, a latent belief such as, “I need 8 h to sleep

or I cannot cope,” will result in distressing thoughts if there is a delay in falling

asleep. This may drive thoughts such as, “I am
never
going to sleep,” as well as

ongoing anxiety. The attentional bias toward sleep threat-related material will make

it more likely that the person will perceive the distress and anxiety symptoms and

view them as evidence that he/she will sleep poorly. This will reinforce worries

106

7 Sleep-Related Cognitive Processes

about a future consequence of not sleeping (i.e., that they will not be able to cope

with the daytime symptoms of insomnia). This may drive a safety behavior such as

drinking alcohol to hasten sleep or leaving a message on the boss’ voicemail that

they are sick and cannot come to work. Such safety behaviors will lessen the

pressure to sleep and may quell the arousal/anxiety in the short term; unfortunately,

they also reinforce the original belief that one is helpless to cope with less than 8 h

of sleep. Indeed, unhelpful/rigid beliefs about sleep predict reported usage of safety

behaviors (Woodley & Smith, 2006). The result is a system that is set up to main-

tain the status quo of insomnia.

Teasdale (1997) describes a process in depression whereby, once cognitive

structures are activated, it is as if a wholly different state of mind is adopted. The

content of this “mind-in-place” is negative and self-referent, and the process that

perpetuates this type of thinking is automatic and operates on a relatively closed

circuit. As a consequence, disconfirming information has little opportunity to get in.

The repetitive thoughts revolve around a negative view of the self, and are reinforced

by feedback loops involving the effects of depression on other cognitive systems

(e.g., attention and memory processes) and on the body (e.g., symptoms of fatigue)

(Teasdale, Taylor, Cooper, Hayhurst, & Paykel, 1995).This description would seem

applicable to insomnia as well. As applied to insomnia, Teasdale’s theory would

suggest that a person with insomnia is of a
different
insomnia-focused mind when

experiencing sleep disturbance. Attentional resources are directed at perceiving

threatening sleep-specific information that confirms unhelpful beliefs about sleep.

The repetitive thought process (i.e., worry or rumination) is similar, but the cognitive

thought content may be more related to a fixation on bodily symptoms and their

implication for poor functioning (Carney et al., 2006). Indeed, self-focused rumina-

tion (as described in depression) is not a factor in insomnia, but symptom-focused

rumination discriminated between poor and good sleepers (Carney et al., 2006). As

a result of this perpetuating cognitive process, people with insomnia often feel help-

less; that is, helpless to cope with sleep loss and helpless to produce sleep naturally.

Many people with insomnia think that their sleep system is
broken,
and they worry

about frightening, future catastrophic consequences. The collection of cognitive

strategies described in the next chapter is focused on remediating these processes.

There has been considerable evidence for a cognitive perspective in insomnia.

Sleep threat-based information processing and resultant sleep-interfering behaviors

of those with insomnia tend to set up a psychological status quo, such that it is

difficult for such individuals to break free of those factors perpetuating their diffi-

culties. This may explain the success of CBT for insomnia, a treatment that targets

unhelpful beliefs and behaviors.

References

Ansfield, M. E., Wegner, D. M., & Bowser, R. (1996). Ironic effects of sleep urgency.
Behaviour

Research and Therapy, 34
, 523–531.

Ascher, L. M., & Turner, R. M. (1979). Paradoxical intention and insomnia: An experimental

investigation.
Behaviour Research and Therapy, 17
, 408–411.

References

107

Beck, A. T. (1999). Psychoevolutionary view of personality and axis I disorders. In R. C.

Cloninger (Ed.),
Personality and psychopathology
(pp. 721–730). Washington: American

Psychiatric Press.

Beck, A. T. (1976).
Cognitive therapy and the emotional disorders
. New York: International

Universities Press.

Borkovec, T. D. (1982). Insomnia.
Journal of Consulting and Clinical Psychology, 50
, 880–895.

Broomfield, N. M., & Espie, C. A. (2003). Initial insomnia and paradoxical intention: An experi-

mental investigation of putative mechanisms using subjective and actigraphic measurement of

sleep. [References].
Behavioural and Cognitive Psychotherapy, 31
(3), 313–324.

Broomfield, N. M., & Espie, C. A. (2005). Towards a valid, reliable measure of sleep effort.

Journal of Sleep Research, 14
(4), 401–407.

Carney, C., Edinger, J., Meyer, B., Lindman, L., & Istre, T. (2006). Symptom-focused rumination

and sleep disturbance.
Behavioral Sleep Medicine, 4
(4), 228–241.

Carney, C. E., & Edinger, J. D. (2006). Identifying critical dysfunctional beliefs about sleep in

primary insomnia.
Sleep, 29
(4), 440–453.

Carney, C. E., & Waters, W. F. (2006). Effects of a structured problem-solving procedure on pre-sleep

cognitive arousal in college students with insomnia.
Behavioral Sleep Medicine, 4
(1), 13–28.

Carskadon, M. A., Dement, W. C., Mitler, M., Guilleminault, C., Zarcone, V. P., & Spiegel, R.

(1976). Self-reports versus sleep laboratory findings in 122 drug-free subjects with complaints

of chronic insomnia.
The American Journal of Psychiatry, 133
, 1382–1388.

Coursey, R. D. (1975). Personality measures and evoked responses in chronic insomniacs.
Journal

of Abnormal Psychology, 84
(3), 239–249.

Davison, G. C., Tsujimoto, R. N., & Glaros, A. G. (1973). Attribution and the maintenance of

behavior change in falling asleep.
Journal of Abnormal Psychology, 82
, 124–133.

Edinger, J. D., & Carney, C. E. (2008).
Overcoming insomnia: A cognitive behavior therapy

approach therapist guide
. New York: Oxford University Press.

Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001a).

Cognitive behavioral therapy for treatment of chronic primary insomnia: A randomized con-

trolled trial.
JAMA: The Journal of the American Medical Association, 285
, 1856–1864.

Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001b). Does

cognitive–behavioral insomnia therapy alter dysfunctional beliefs about sleep?
Sleep, 24
,

591–599.

Espie, C., Broomfield, N., MacMahon, K., Macphee, L., & Taylor, L. M. (2006). The attention-

intention-effort pathway in the development of psychophysiologic insomnia: A theoretical

review.
Sleep Medicine Reviews, 10
(4), 215–245.

Espie, C. A., & Lindsay, W. R. (1987). Cognitive strategies for the management of severe sleep

maintenance insomnia: A preliminary investigation.
Behavioral Psychotherapy, 15
, 388–395.

Fichten, C. S., Libman, E., Creti, L., Amsel, R., Tagalakis, V., & Brender, W. (1998). Thoughts

during awake times in older good and poor sleepers – The self-statement test: 60+.
Cognitive

Therapy and Research, 22
(1), 1–20.

Gross, R., & Borkovec, T. (1982). Effects of cognitive intrusion manipulation on the sleep onset

latency of good sleepers.
Behaviour Therapy, 13
, 112–116.

Harvey, A. G. (2000). Pre-sleep cognitive activity: A comparison of sleep-onset insomniacs and

good sleepers.
The British Journal of Clinical Psychology, 39
, 275–286.

Harvey, A. G. (2002). A cognitive model of insomnia.
Behaviour Research and Therapy, 40
,

869–893.

Harvey, A. G., & Farrell, C. (2003). The efficacy of a Pennebaker-like writing intervention for

poor sleepers.
Behavioral Sleep Medicine, 1
(2), 115–123.

Harvey, A. G., Tang, N. K. Y., & Browning, L. (2005). Cognitive approaches to insomnia.
Clinical

Psychology Review, 25
, 593–611.

Hauri, P. J. (1991). Sleep hygiene, relaxation therapy, and cognitive interventions. In P. J. Hauri

(Ed.),
Case studies in insomnia
(pp. 65–84). New York: Plenum.

Jones, B. T., Macphee, L. M., Broomfield, N. M., Jones, B. C., & Espie, C. A. (2005). Sleep-

related attentional bias in good, moderate, and poor (primary insomnia) sleepers.
Journal of

Abnormal Psychology, 114
(2), 249–258.

108

7 Sleep-Related Cognitive Processes

Kales, A., Caldwell, A. B., Preston, T. A., Healey, S., & Kales, J. D. (1976). Personality patterns

in insomnia.
Archives of General Psychiatry, 33
, 1128–1134.

Kuisk, L. A., Bertelson, A. D., & Walsh, J. K. (1989). Presleep cognitive hyperarousal and affect as

factors in objective and subjective insomnia.
Perceptual and Motor Skills, 69
(3), 1219–1225.

Levey, A. B., Aldaz, J. A., Watts, F. N., & Coyle, K. (1991). Articulatory suppression and the

treatment of insomnia.
Behaviour Research and Therapy, 29
(1), 85–89.

Lichstein, K. L., & Rosenthal, T. L. (1980). Insomniacs’ perceptions of cognitive versus somatic

determinants of sleep disturbance.
Journal of Abnormal Psychology, 89
, 105–107.

Mathews, A., & MacLeod, C. (1994). Cognitive approaches to emotion and emotional disorders.

Annual Review of Psychology, 45
, 25–50.

Mogg, K., Mathews, A., Bird, C., & MacGregor-Morris, R. (1990). Effects of stress and anxiety on

processing of threat stimuli.
Journal of Personality and Social Psychology, 59
, 1230–1237.

Monroe, L. J. (1967). Psychological and physiological differences between good and poor sleepers.

Journal of Abnormal Psychology, 72
, 255–264.

Morin, C. M. (1993).
Insomnia: Psychological assessment and management
. New York: Guilford Press.

Morin, C. M., Blais, F., & Savard, J. (2002). Are changes in beliefs and attitudes related to sleep

improvements in the treatment of insomnia?
Behaviour Research and Therapy, 40
, 741–752.

Morin, C. M., Vallières, A., & Ivers, H. (2007). Dysfunctional Beliefs and Attitudes About Sleep

(DBAS): Validation of a Brief Version (DBAS-16).
Sleep, 30
(11), 1547–1554.

Ree, M. J., Harvey, A. G., Blake, R., Tang, N. K. Y., & Shawe-Taylor, M. (2005). Attempts to

control unwanted thoughts in the night: Development of the thought control questionnaire-

insomnia revised (TCQI-R).
Behaviour Research and Therapy, 43
, 985–998.

Segerstrom, S. C., Tsao, J. C. I., Alden, L. E., & Craske, M. G. (2000). Worry and rumination:

Repetitive thought as a concomitant and predictor of negative mood.
Cognitive Therapy and

Research, 24
, 671–688.

Semler, C. N., & Harvey, A. G. (2004). Monitoring for sleep-related threat: A pilot study of the

sleep associated monitoring index.
Psychosomatic Medicine, 66
, 242–250.

Storms, M. D., & Nisbett, R. E. (1970). Insomnia and the attribution process.
Journal of

Personality and Social Psychology, 16
, 319–328.

Tang, N. K. Y., & Harvey, A. G. (2004). Effects of cognitive arousal and physiological arousal on

sleep perception.
Sleep, 27
(1), 69–78.

Tang, N. K. Y., Schmidt, D. A., & Harvey, A. G. (2006). Sleeping with the enemy: Clock monitoring

in the maintenance of insomnia.
Journal of Behavior Therapy and Experimental Psychiatry,

38
(1), 40–55.

Taylor, L. M., Espie, C. A., & White, C. A. (2003). A comparative experimental investigation of

attentional bias in people with acute versus persistent insomnia secondary to cancer.
Behavioral

Sleep Medicine, 1
, 200–212.

Teasdale, J. D. (1997). The relation between cognition and emotion: The mind-in-place in mood

disorders. In D. M. Clark & C. G. Fairburn (Eds.),
Science and practice of cognitive behavior

therapy
(pp. 67–93). Oxford: Oxford University Press.

Teasdale, J. D., Taylor, M. J., Cooper, Z., Hayhurst, H., & Paykel, E. S. (1995). Depressive thinking:

Shifts in construct accessibility or in schematic mental models?
Journal of Abnormal

Psychology, 104
(3), 500–507.

Thoresen, C. E., Coates, T. J., Kirmil-Gray, K., & Rosekind, M. R. (1981). Behavioural self-

management in treating sleep maintenance insomnia.
Journal of Behavioral Medicine, 4
, 41–52.

Waters, W. F., Adams, S. G., Binks, P., & Varnado, P. (1993). Attention, stress and negative emotion

in persistent sleep-onset and sleep-maintenance insomnia.
Sleep, 16
(2), 128–136.

Watts, F. N., Coyle, K., & East, M. P. (1994). The contribution of worry to insomnia.
British