Overcoming Insomnia

EDITOR-IN-CHIEF

David H. Barlow, PhD

SCIENTIFIC ADVISORY BOARD

Anne Marie Albano, PhD

Gillian Butler, PhD

David M. Clark, PhD

Edna B. Foa, PhD

Paul J. Frick, PhD

Jack M. Gorman, MD

Kirk Heilbrun, PhD

Robert J. McMahon, PhD

Peter E. Nathan, PhD

Christine Maguth Nezu, PhD

Matthew K. Nock, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

Gail Steketee, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

OvercomingInsomniaA COGNITIVE-BEHAVIORAL THERAPY APPROACH

W o r k b o o k

Jack D. Edinger • Colleen E. Carney

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1

About TreatmentsThatWork™

One of the most difficult problems confronting patients with various

disorders and diseases is finding the best help available. Everyone is

aware of friends or family who have sought treatment from a seeming-

ly reputable practitioner, only to find out later from another doctor that

the original diagnosis was wrong or the treatments recommended were

inappropriate or perhaps even harmful. Most patients, or family mem-

bers, address this problem by reading everything they can about their

symptoms, seeking out information on the Internet, or aggressively

“asking around” to tap knowledge from friends and acquaintances.

Governments and health-care policy makers are also aware that people

in need don’t always get the best treatments—something they refer to as

“variability in health-care practices.”

Now health-care systems around the world are attempting to correct

this variability by introducing “evidence-based practice.” This simply

means that it is in everyone’s interest that patients get the most up-to-

date and effective care for a particular problem. Health-care policy

makers have also recognized that it is very useful to give consumers of

health care as much information as possible, so they can make intelli-

gent decisions in a collaborative effort to improve health and mental

health. This series, TreatmentsThatWorkTM, is designed to accomplish

just that. Only the latest and most effective interventions for particular

problems are described in user-friendly language. To be included in this

series, each treatment program must pass the highest standards of

evidence available, as determined by a scientific advisory board. Thus,

when individuals suffering from these problems or their family mem-

bers seek out an expert clinician who is familiar with these interventions

and decides they are appropriate, they will have confidence that they

v

are receiving the best care available. Of course, only your health care

professional can decide on the right mix of treatments for you.

This workbook describes a time-limited treatment for individuals

suffering from insomnia. Insomnia is common, but not easily cured.

The medications that are often prescribed can have significant side

effects and may not improve sleep in the long term. However, there is a

safe and effective approach to sleep management. Cognitive-behavioral

intervention can help you change your behavior and thinking in order

to sleep better. This workbook includes information to educate you

about sleep problems and provides you with helpful recommendations

to improve your sleep. It also outlines strategies for changing unhelp-

ful thinking styles that may be contributing to your insomnia. User-

friendly forms for assessing your sleep and monitoring your thoughts

are also provided. Follow the “sleep rules” in this workbook and chances

are you will soon be on your way to sounder, more restful sleep. You can

use this book on your own or in conjunction with visits to a qualified

health care professional.

David H. Barlow, Editor-in-Chief,

TreatmentsThatWork™

Boston, MA

vi

Contents

Chapter Is This Book Right for Me?

Chapter Sleep Education

Chapter Improving Your Sleep

Chapter Combating Unhelpful Thoughts

Chapter Troubleshooting

Appendix Forms and Worksheets

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Chapter 1 Is This Book Right for Me?

Nearly everyone has occasional sleepless nights. Stress, anxiety, alcohol,

and caffeine are just some of the things than can contribute to problems

with sleep. Certain medical conditions and psychological disorders can

also contribute to irregular sleep patterns. If you are experiencing sleep

problems, and think you may have insomnia, this book can help.

What Is Insomnia?

Insomnia is a common sleep disorder that consists of frequent night-

time sleep difficulties that result in reduced functioning during the

daytime. People with insomnia experience persistent difficulties sleep-

ing despite allowing themselves adequate time to sleep and having a

comfortable bedroom setting. Insomnia is a very common problem

that may be short-lived and temporary, intermittent, or fairly persis-

tent over time. Over one third of the adult population experiences

insomnia at least intermittently, whereas % to % suffer chronic,

unrelenting sleep difficulties.

Common symptoms of insomnia include:

■ Difficulty falling asleep at night

■ Waking up during the night

■ Waking up too early

■ Having sleep that is poor in quality

■ Daytime fatigue or sleepiness

2

■ Concentration, attention, or memory problems

■ Daytime irritability

■ Worries about sleep difficulties or daytime symptoms

Causes of Insomnia

As mentioned, there are numerous causes of insomnia. Stress is a pri-

mary contributor to the development of sleeping problems. Concerns

about work, school, health, or family can keep your mind too active,

making you unable to relax. In the same way, anxiety can often cause dis-

ruptions in sleep. If you are experiencing severe anxiety, you may have an

anxiety disorder that should be dealt with before you try to tackle your

sleep problems. The same is true if you are suffering from depression. In

these cases, you should consult a qualified mental health professional.

Insomnia can also be caused by a variety of medical conditions, particu-

larly those that cause physical pain like fibromyalgia and arthritis. If you

are currently being treated for a medical or psychological condition, your

doctor or therapist may have prescribed medication for you. Prescription

drugs, including some antidepressants, high blood pressure medications,

and corticosteroid medications, can interfere with sleep. Many over-

the-counter (OTC) medications, including some pain medication com-

binations, decongestants, and weight-loss products, contain caffeine and

other stimulants. Talk to your treatment provider about this possibility.

Diagnosing Insomnia

There are several ways to diagnose insomnia. If you are using this work-

book in conjunction with visits to a qualified health care provider,

whether it is your medical doctor or a mental health professional, he or

she may ask you to complete various questionnaires and self-rating

instruments. Your health care provider may also request to interview

your bed partner in order to obtain more detailed information about

your sleep patterns. Depending on your symptoms, you may also be

asked to complete an overnight evaluation at a sleep center. This sort of

evaluation is rarely needed to diagnose insomnia but sometimes is

required to rule out other types of sleep disorders. If you undergo such

an evaluation, a team of people at the center will monitor and record a

variety of your body activities during the night, including brain waves,

breathing, heart rate, and eye and body movements.

If you are planning to use this workbook independently, without the

guidance of a health care provider, you may benefit by first conducting

a brief self-administered assessment of your symptoms. As a first step,

consider the description of insomnia and the list of insomnia symptoms

presented on the previous pages of this workbook. Does that descrip-

tion and list of symptoms fit you? If it does, you very well may have the

type of problem that can be helped by the strategies described in this

workbook. However, it is important to rule out the presence of certain

medical conditions and sleep disorders that would require a different or

additional form of treatment. To do so, we suggest you ask yourself the

following groups of questions:

Group 1

. Have you been told that you snore loudly?

. Do you sometimes awaken gasping for breath?

. Have you been told that you stop breathing during your sleep?

. Are you so sleepy in the daytime that you often tend to fall asleep

when you are seated or become inactive?

. When you wake up in the morning do you still tend to feel tired

and unrested?

. Do you often have a headache or dry mouth when you awaken in

the morning?

Group 2

. Do you often have an urge to move your legs?

. Is the urge to move your legs accompanied by an annoying sensa-

tion such as crawling, tingling, drawing, or general restlessness in

your legs?

3

. Do the symptoms described in questions and go away briefly

if you move your legs or walk?

. Do the symptoms in your legs get worse when you are at rest?

. Do you tend to have the urge to move your legs or restless

sensations more so in the late afternoon or evening hours?

. Do your restless symptoms make it difficult for you to fall asleep

or stay asleep at night?

Group 3

. Do you have a medical condition such as arthritis, fibromyalgia,

or a recent injury that causes you pain?

. Does the pain from this condition make it difficult for you to get

to sleep at night or does it awaken you in the middle of the

night?

. If your pain would go away, do you think that your sleep problem

would be dramatically reduced or perhaps even eliminated?

Group 4

. Do you feel sad, blue, or depressed much of the time?

. Do you seem to have little energy and motivation to do what you

need to do each day?

. Have you lost interest in socializing or engaging in your hobbies?

. Has your appetite changed or have you recently lost weight with-

out trying to do so?

. Do you often have times during which you just want to retreat to

your bed?

. Do you have periods of feeling unusually good or on top of the

world for no reason?

. Do have periods when you seem to have an extremely high

amount of energy such that you lose your interest in or need for

sleep for several days at a time?

4

. Do you seem to worry about many things in addition to your sleep?

. Do you feel uptight, anxious, or stressed much of the time?

. Do you tend to have palpitations, excessive sweating, or shortness of

breath when you are put under pressure or become the center of atten-

tion in a social situation?

If you answered yes to one or more of the questions in any of these groups

of questions, you may have a condition that would benefit by a medical

or medication treatment instead of or in addition to the form of treat-

ment provided in this manual. Those questions in Group pertain to a

sleep disorder known as sleep apnea, a disorder categorized by repeated

pauses in breathing during sleep. If you answered “Yes” to several of those

questions you likely will benefit by consulting your health care provider

and requesting a consultation with a sleep disorders specialist. Those

questions in Group pertain to a disorder know as restless legs syndrome,

a neurological condition that is characterized by the irresistible urge to

move the legs, which usually requires certain forms of medication as treat-

ment. Those questions in Group are obviously designed to help you

determine if you have a painful medical condition that disrupts your

sleep. The presence of such a painful condition does not necessarily indi-

cate that you won’t benefit by the strategies outlined in this workbook.

However, your results are likely to be much better if you and your physi-

cian work together to ascertain treatments that most effectively reduce or

relieve your pain. Finally, those questions in Group are designed to help

you determine if you have a mental or emotional health problem that

would benefit from separate treatment attention. You should probably

consult a mental health provider if you have positive answers to these

questions, particularly if you answer yes to more than one.

The list of questions presented is designed to assess some of the more com-

monly encountered causes of sleep disturbance that benefit from treat-

ments other than, or in addition to, those described in this workbook.

Admittedly this question list is not exhaustive. Menopausal symptoms in

women and prostate problems in men also commonly cause sleep

difficulties and benefit from medical attention. In addition, many medica-

tions given for other medical problems may have insomnia as a side effect.

If you are taking any medications, you may want to ask your physician

5

about these, particularly if your insomnia symptoms developed or wors-

ened after you began taking the medication(s) in question. Finally,

dependence or abuse of alcohol and many forms of illicit drugs can disrupt

sleep as well. Individuals with such problems may benefit from enrolling

in a formal substance abuse treatment program.

If you do not have any of the types of problems mentioned and generally

answered “no” to the questions presented here, you are probably ready to

begin an additional self-assessment specifically designed to help you better

describe and quantify your sleep difficulty. Perhaps one of the best and

most commonly used methods to assess and describe your sleep difficulty

is by keeping records of your sleeping habits over an extended period of

time. Such records not only help your health care provider in assessing

your sleep difficulties, but also may make you aware of important aspects

of your sleep pattern that you have ignored. The following section provides

more information on how to keep records of your sleep using sleep logs

provided later in this workbook.

Sleep Logs

Before starting any type of program to improve your sleep habits (either

on your own or with the help of a qualified professional), you should

track your sleep pattern for a period of at least weeks. Use the blank

sleep logs provided at the end of this chapter to record detailed informa-

tion about your sleep each night. Place the log at some convenient loca-

tion and complete it each morning within the first minutes or so after

arising. The sleep log tracks the following information:

■ whether you took any naps the previous day

■ whether you used medication and/or alcohol to facilitate sleep

■ the time you entered bed

■ the time the lights were turned off and you attempted to fall asleep

■ the number of minutes it took for you to fall asleep

■ the number and length of awakenings during the night

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■ the time of the final morning awakening

■ the time you actually got out of bed

■ the quality of the previous night’s sleep

■ your level of restfulness upon awakening

Since many of the questions contained in the sleep log pertain to your sleep

and wake time at night, you may be tempted to take special note of your

alarm clock each time you awaken or even to keep some records on your

nightstand during the night. However, since such practices will likely alter

or even worsen your insomnia problem, you should avoid giving in to such

temptations. People with insomnia usually do surprisingly well in estimat-

ing their sleep and wakefulness on the morning following each night’s sleep.

Thus, extra efforts to monitor your sleep during the night are not needed

to produce a useful sleep log record.

The information obtained from self-monitoring will give you (or your

health care provider) more insight into your sleep problems. For exam-

ple, after reviewing your sleep logs, it may become clear that you very

rarely go to bed or wake up at the same time each day, and this obser-

vation indicates you have an erratic sleep schedule. Or, your sleep log

may show that you often rely on medications or alcohol to help you fall

asleep. Also, you may notice that you are spending far more time in bed

than you usually sleep. We will discuss this in more detail in Chapter .

Overview of the Program

The program outlined in this book is based on the principles of

Cognitive-Behavioral Therapy (CBT). You may work through this

book on your own or in conjunction with visits to a qualified health

care provider. If you decide to enroll in formal treatment with a clini-

cian or therapist, he or she will want you to bring this workbook to each

session. On average, it takes approximately to weeks for this pro-

gram to produce noticeable effects. You will do much of the work on

your own while your therapist guides you and answers any questions

you may have.

7

Figure . shows the -P model of insomnia, which provides a frame-

work for understanding the evolution of chronic insomnia and the role

of CBT in managing this condition.

According to this model, predisposing factors, precipitating events, and per-

petuating mechanisms all contribute to the development of chronic primary

sleep difficulties. Some individuals may be particularly vulnerable to sleep

difficulties, either because they have a “weak” or “highly sensitive” biolog-

ical sleep system or they may have personality traits that dispose them to

poor sleep when confronted with stress. When such individuals are con-

fronted with the proper precipitating circumstances (e.g., a stressful life

event, sudden unexpected change in their sleep schedule), they tend to

develop an acute sleep disturbance. This sleep problem, in turn, may then

be perpetuated by a host of psychological and behavioral factors that

emerge in reaction to such sleep difficulty. Specifically, how people think

about their sleep problem and the strategies they use to deal with it often

make the insomnia problem persist over time. This program is designed to

target the thoughts and beliefs you have about sleep and the sleep habits

you developed that keep your insomnia going. You will learn to change

your behavior, as well as how to manage any negative thoughts that may

contribute to your disrupted sleep.

Before you begin practicing the techniques in this book, however, you

need to learn about sleep and how your body’s sleep system works. Sleep

education is provided in Chapter .

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100

0Premorbid

Predisposing Precipitating Perpetuating

Acute Sub-Acute Chronic

InsomniaThreshold

Figure 1.1Spielman’s model describing the evolution of chronic primary insomnia

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Day of the Week

Calendar Date

. Yesterday I napped from _____ to _____ (note time of all naps).

. Last night I took _____ mg of _____ or _____ of alcohol as a sleep aid(include all prescription and over-the-counter sleep aids).

. Last night I got in my bed at _____ (AM or PM?).

. Last night I turned off the lights and attempted to fall asleep at _____ (AM or PM?).

. After turning off the lights it took me about _____ minutes to fallasleep.

. I woke from sleep _____ times. (Do not count your final awakeninghere.)

. My awakenings lasted _____ minutes. (List each awakeningseparately.)

. Today I woke up at _____ (AM or PM?). (NOTE: this is your finalawakening.)

. Today I got out of bed for the day at ____ (AM or PM?).

. I would rate the quality of last night’s sleep as: Very Poor Fair Excellent

. How well rested did you feel upon arising today?Not at All Somewhat Well Rested

Sleep Log

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Day of the Week

Calendar Date

. Yesterday I napped from _____ to _____ (note time of all naps).

. Last night I took _____ mg of _____ or _____ of alcohol as a sleep aid(include all prescription and over-the-counter sleep aids).

. Last night I got in my bed at _____ (AM or PM?).

. Last night I turned off the lights and attempted to fall asleep at _____ (AM or PM?).

. After turning off the lights it took me about _____ minutes to fallasleep.

. I woke from sleep _____ times. (Do not count your final awakeninghere.)

. My awakenings lasted _____ minutes. (List each awakening separate-ly.)

. Today I woke up at _____ (AM or PM?). (NOTE: this is your finalawakening.)

. Today I got out of bed for the day at ____ (AM or PM?).

. I would rate the quality of last night’s sleep as: Very Poor Fair Excellent

. How well rested did you feel upon arising today?Not at All Somewhat Well Rested

Sleep Log

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Chapter 2 Sleep Education

Before you take any steps to correct your sleeping habits, you need to

determine how much sleep you need each night. Generally speaking,

there is no one amount of sleep that “fits” everyone. Most normal adults

sleep to hours per night. However, some people need only or

hours of sleep each night, whereas others require to hours of sleep

on a nightly basis. At this point, it is important to set aside any previous

notions or beliefs you might have about your sleep needs. These beliefs

may be wrong and may hinder your progress.

In addition to getting rid of any old ideas you have about your sleep

needs, it is important that you learn some things about how your body’s

sleep system works. People, like many animals, have powerful internal

“clocks” that affect their behavior and bodily functioning. The “body

clock” works in roughly a -hour period and produces -hour cycles

in such things as digestion, body temperature, and the sleep-wake pat-

tern. For example, if we record a person’s body temperature for several

days in a row, we will see a consistent up and down pattern or rhythm

in temperature across each -hour day. The temperature will be at its

lowest point around or AM, will rise throughout the morning and

early afternoon, and will hit its peak around or PM. Then, once

again the temperature will begin to fall until it hits its low point in the

early morning hours.

The influence of the internal circadian clock on the sleep-wake cycle is

apparent if one studies the relationship between the body’s -hour tem-

perature rhythm and the timing of the sleep period. Suppose a person is

placed in a place like a cave, away from daylight, external clocks, and all

other time-of-day indicators. In this situation, the person will continue

to show a consistent temperature rhythm and sleep-wake pattern that

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complete a full cycle about every hours. In most people, there is a close

relationship between the temperature cycle and the sleep-wake pattern

they show. This relationship is illustrated by the graph shown on page .

As shown by this graph, the main sleep period begins when the body tem-

perature is falling and later ends after the body temperature begins rising

again. Hence, although the -hour temperature cycle shown does not

control the human sleep-wake pattern, the temperature rhythm reflects

the working of the body clock and can be used to predict when sleep is

likely to occur in the -hour day.

In the real world, work schedules, meal times, and other activities work

together with our body clocks to help us keep a stable sleep-wake pat-

tern. However, significant changes in our sleep-wake schedule can inter-

fere with our ability to sleep normally. This may be caused by what is

often called “jet lag.” If, for example, a man who lives in New York flies

to Los Angeles, he initially is likely to have some difficulty with his sleep

and to experience some daytime fatigue once he arrives in California.

This occurs because the -hour time zone change places his new desired

sleep-wake schedule at odds with his “body clock” that is “stuck” in his

old time zone. This situation is shown in Figure .. on page .The

man’s body clock remains on New York time and initially lags behind

the real world clock time in California.

This traveler is likely to become sleepy hours earlier than he wishes

and to wake up hours before he prefers on the initial days of his trip.

Fortunately, with repeated exposure to the light-dark pattern in the new

time zone, the body clock resets and allows the traveler to “get in sync”

with the new time zone. However, this traveler is again likely to experi-

ence temporary problems with his sleep and daytime fatigue when he

first returns to New York.

In addition to our body clock, getting older usually leads to changes in

our sleep. As we age, we tend to spend more time awake in bed and less

time in the deepest parts of sleep. Because sleep becomes more “shal-

low” and broken as we age, we may notice a decrease in the quality of

our sleep as we grow older. Although these changes set the stage for the

development of sleep problems, they do not guarantee such problems.

However, because of these changes, it is probably unrealistic to expect

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12:0

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Biological Wake Time

Biological Bedtime

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Sleep Sleep

Figure 2.1Circadian Temperature Rhythm

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Circadian Temperature Rhythm Desired Sleep/Wake Schedule

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Figure 2.2Effects of Jet Lag

that you will again have the type of sleep you enjoyed at a much

younger age than you are now.

Finally, before attempting to change your sleep habits, it is important

that you understand the effects of sleep loss on you. This understand-

ing is important because many who have sleep problems make these

problems worse by what they do to make up for lost sleep. For exam-

ple, people may take daytime naps, go to bed too early, or “sleep in”

following a poor night’s sleep in order to avoid or recover lost sleep.

Although these habits seem logical and sensible, they all may serve to

continue the sleep problems. In fact, these habits are usually the oppo-

site of what needs to be done to improve sleep.

In some respects, losing sleep one night may lead to getting more or bet-

ter sleep the following night. In fact, the drive to sleep gets stronger the

longer one is awake before attempting to sleep again. For example, a

person is much more likely to sleep for a long time after being awake

for hours in a row than after being awake for only hours. It is

important to remain awake through each day in order to build up

enough sleep drive to produce a full night’s sleep.

Extended periods of sleep loss, of course, may have some bad effects as

well. If people are totally deprived of a night’s sleep, they usually

become very sleepy, have some trouble concentrating, and generally feel

somewhat irritable. However, they typically can continue most normal

daytime activities even after a night without any sleep at all. When

allowed to sleep after a longer than normal period of being awake, most

people will tend to sleep longer and more deeply than they typically do

on a normal night. Although people tend not to recover all of the sleep

time they lost, they do typically recover the deep sleep they lost during

longer than usual periods without sleep. Hence, your body’s sleep

system has some ability to make up for times when you don’t get the

amount of sleep you need.

Since you have kept a sleep log for a couple of weeks, you have proba-

bly noticed that you occasionally had a relatively good night’s sleep after

one or several nights of poor sleep. Such a pattern suggests that your

body’s sleep system has an ability to make up for some of the sleep loss

you experience over time. Although your sleep is not normal, you can

15

take some comfort in this observation. The important point to remem-

ber is that you do not need to worry a great deal about lost sleep nor

should you actively try to recover lost sleep. Needless worry and

attempts to recover lost sleep will only worsen your sleep problem.

This information is not intended to “make light” of your sleep problem.

You do indeed have a sleep problem that needs to be treated and the

strategies in this book can help. The next chapter provides important

information about how to change your behavior in order to improve

sleep.

16

17

Chapter 3 Improving Your Sleep

Persistent insomnia is a bothersome and often disruptive condition that

reduces quality of life and one’s sense of well-being. It also can adversely

affect mood, reduce performance at work, and increase risk for injury

during routine tasks (e.g., driving) that require normal alertness. Given

these considerations, it is no wonder that many, if not most, individuals

who suffer from persistent insomnia develop some sorts of strategies to

cope with sleep difficulties and minimize their impact on their daily rou-

tines. Since insomnia usually results in erratic and unpredictable sleep,

people with insomnia often assume they should try to sleep whenever

they have the opportunity to do so. For example, insomnia sufferers may

“sleep in” following a poor night’s sleep, or they may nap in the daytime

to recover sleep they feel they lost after a bad night. Some individuals

may even schedule extended times in bed at night so they have sufficient

time remaining for the sleep even if they spend a good portion of

the night awake in bed. Others may lie in bed awake for hours

trying hard to sleep only to become increasingly frustrated as the hours

pass by.

Whereas these strategies may appear sensible, reasonable, or under-

standable for someone suffering from insomnia, all of these practices

may play an active role in sustaining ongoing sleep problems. In fact,

your sleep habits as well as your general attitude and approach toward

sleep play crucial and deciding roles in determining how well or poorly

you sleep most nights. As noted in the previous chapter, consistent,

good quality sleep occurs when there is a strong sleep drive and a

consistent sleep-wake schedule in place. Habits that reduce sleep drive

(e.g., daytime napping) or lead to variation in one’s sleep schedule (e.g.,

sleeping in on weekends) lead to disrupted sleep. Also, practices like

18

going to bed when you are still feeling stimulated and alert or lying in

bed for extended periods trying to “force sleep” only cause frustration

and arousal that make sleep difficult, if not impossible. Thus, your sleep

habits and approach toward sleep will be a central and initial focus of

this treatment program.

In order to conquer your insomnia, you need to follow a regimen

designed to reduce bedtime arousal, increase your sleep drive, and

stabilize your sleep schedule so that your body’s sleep system can work

at its best without inference from you. As a first step toward achieving

this goal, you need to make sure that you are sufficiently relaxed and

ready for bed when you choose to retire each night. To enhance the

chances of being ready for sleep when you enter bed, you should try to

build in some time to relax in some way prior to bed so that you estab-

lish a “buffer” between your active day and your more passive sleep

process. For example, it is a good idea to engage in activities such as

light, recreational reading, listening to soothing music, or watching

TV that you find enjoyable and relaxing during the hour or two just

prior to bed. During this buffer time, avoid mentally or physically

stimulating activities that could increase your alertness. Activities such

as intense studying for an exam, trying to solve a perplexing problem,

or engaging in physical exercise just prior to bed usually make sleep

much more difficult to initiate. Hence, activities such as these should

be avoided just before bed so you have the opportunity to wind-down

sufficiently from your day and prepare properly for sleeping.

In addition to preparing for bed in a proper manner, it will likely be

helpful, if not crucial, that you follow a set of well-tested guidelines that

have proven highly effective in treating chronic insomnia problems. The

following discussion describes the sleep improvement strategies you

should implement and explains why each of these strategies is impor-

tant for improving your sleep.

Sleep Improvement Guidelines

. Select a standard rising timeIt is important that you choose a standard rising time and stick to

it every day regardless of how much sleep you actually get on any

given night. This practice will help you develop a more stable sleep

pattern. As discussed in the previous chapter, changes in your

sleep-wake schedule can disturb your sleep. In fact, you can create

the type of sleep problem that occurs in jet lag by varying

your wake-up time from day to day. If you set your alarm for a

standard wake-up time, you will soon notice that you usually will

become sleepy at about the right time each evening to allow you to

get the sleep you need.

. Use the bed only for sleepingWhile in bed, you should avoid doing things that you do when you

are awake. Do not read, watch TV, eat, study, use the phone, or do

other things that require you to be awake while you are in bed. If

you frequently use your bed for activities other than sleep, you are

unintentionally training yourself to stay awake in bed. If you avoid

these activities while in bed, your bed will eventually become a

place where it is easy to go to sleep and stay asleep. Sexual activity

is the only exception to this rule.

. Get out of bed when you can’t sleepNever stay in bed, either at the beginning of the night or during the

middle of the night, for extended periods without being asleep. Long

periods of being awake in bed usually lead to tossing and turning,

becoming frustrated, or worrying about not sleeping. These reactions,

in turn, make it more difficult to fall asleep. Also, if you lie in bed

awake for long periods, you are training yourself to be awake in bed.

When sleep does not come on or return quickly, it is best to get up, go

to another room, and only return to bed when you feel sleepy enough

to fall asleep quickly. Generally speaking, you should get up if you find

yourself awake for minutes or so and you do not feel as though you

are about to go to sleep.

. Don’t worry, plan, or problem solve in bedDo not worry, mull over your problems, plan future events, or do

other thinking while in bed. These activities are bad mental habits.

If your mind seems to be racing or you can’t seem to shut off your

thoughts, get up and go to another room until you can return to bed

without this thinking interrupting your sleep. If this disruptive

thinking occurs frequently, you may find it helpful to routinely set

19

aside a time early each evening to do the thinking, problem solving,

and planning you need to do. If you start this practice you probably

will have fewer intrusive thoughts while you are in bed.

. Avoid daytime nappingYou should avoid all daytime napping. Sleeping during the day par-

tially satisfies your sleep needs and, thus, will weaken your sleep

drive at night.

. Avoid excessive time in bedIn general, you should go to bed when you feel sleepy. However, you

should not go to bed so early that you find yourself spending far

more time in bed each night than you need for sleep. Spending too

much time in bed results in a very broken night’s sleep. If you spend

too much time in bed, you may actually make your sleep problem

worse. The following discussion will help you 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.

Determining Time in Bed (TIB)

It is important that you allot enough time for sleep each night but not too

much time. The amount of time you schedule for yourself in bed each

night should fit your own individual sleep needs. As noted in the previ-

ous chapter, sleep needs vary considerably from one individual to the

next. Some people are very long sleepers whereas others need relatively

little sleep to function effectively each day. In that sense, sleep needs are

very much like shoe sizes in that no one size fits everyone. As a result,

there is no single amount of time that should be allotted for each night’s

sleep. However, as a general rule the amount of time you schedule in bed

each night should be fashioned to fit your individual sleep needs.

In order to determine how much time you should stay in bed, you will

need to review your completed sleep logs from the last two weeks (see

Chapter ). If you are working with a therapist or clinician, he or she

will help you with this process. If you are working through your sleep

problems on your own, you will find the following instructions helpful.

20

First, calculate your average total sleep time (ATST) by checking your

sleep logs and figuring out how much time you actually spend asleep each

night. Do not take into account the many minutes you spend tossing and

turning or staring at the ceiling. We are talking about actual time spent

asleep here. Then, use the following formula to determine the ideal

amount of time you should remain in bed each night.

21

Time in Bed (TIB) � Average Total Sleep Time (ATST) � minutes

Look at the sample sleep log shown in Figure .. on page . In this

example, the person slept minutes per night, on average, but had an

average time in bed of minutes or hours per night. This person’s

ATST falls between ⁄ and hours, which at first glance seems normal

for an adult. However, there is a big difference between this average total

sleep time (⁄– hours) and average time in bed ( hours). Using the

TIB formula, this person’s ideal time in bed is minutes or hours and

minutes. Of course, depending on preference, this individual could

adjust the TIB down to hours or up to ⁄.

Once you have calculated your ideal TIB, use it to choose a standard

wake-up time and earliest bedtime. For example, if you decide that you

want to get up each morning at AM, but your recommended TIB

equals hours, this means that your earliest bedtime would be AM.

For some people a sleep schedule with a AM bedtime and AM ris-

ing time may seem ideal. Others may decide it is probably not a good

idea to go to bed this late. There is room for flexibility, however. Earlier

schedules that include an PM bedtime and AM rising time or a

AM bedtime and AM rising time could be considered instead.

Whatever the exact TIB you derive from your sleep log calculations, use

your discretion when selecting the bed and rising times that fit with this

amount of TIB. Once you have identified the schedule that seems most

acceptable to you, record it in the spaces provided on page . It is very

important that you try to stick to these times as closely and as consis-

tently as possible. This is an important step toward overcoming your

insomnia.

Day of the Week Mon Tue Wed Thurs Fri SatCalendar Date 3/5 3/6 3/7 3/8 3/9 3/10. Yesterday I napped from _____ to _____ (note time

of all naps).None None None None None None

. Last night I took _____ mg of _____ or _____ of alcohol asa sleep aid (include all prescription and over-the-countersleep aids).

None None None None None None

. Last night I got in my bed at _____ (AM or PM?). 11:00 PM 11:30 PM 11:15 PM 10:30 PM 11:15 PM 10:30 PM. Last night I turned off the lights and attempted

to fall asleep at _____ (AM or PM?).11:30 PM 11:30 PM 11:15 PM 11:00 PM 11:15 PM 10:50 PM

. After turning off the lights it took me about _____ minutes to fall asleep.

20 min 35 min 75 min 45 min 15 min 20 min

. I woke from sleep _____ times. (Do not count your finalawakening here.)

2 1 3 2 1 2

. My awakenings lasted _____ minutes. (List each awakeningseparately.) 25 min

15 min 60 min

10 min25 min30 min

60 min40 min 90 min

30 min45 min

. Today I woke up at _____ (AM or PM?). (NOTE: this isyour final awakening.)

6:30 AM 7:00 AM 7:15 AM 7:30 AM 7:00 AM 7:15 AM

. Today I got out of bed for the day at ____ (AM or PM?). 7:00 AM 7:30 AM 7:30 AM 7:45 AM 7:15 AM 7:30 AM. I would rate the quality of last night’s sleep as:

Very Poor Fair Excellent

2 3 2 3 2 3

. How well rested did you feel upon arising today?Not at All Somewhat Well Rested

1 4 2 5 1 3

AVERAGE

Total Sleep Time 360 min 415 min 400 min 425 min 390 min 410 min 400 min

Time in Bed 480 min 540 min 555 min 615 min 510 min 540 min 540 min

Figure 3.1Calculating a Time in Bed (TIB) Prescription

22

23

My standard rising time is_________________

My standard bedtime is_________________

You should try this sleep-wake schedule for at least weeks while you

follow the rest of the sleep improvement strategies discussed. Once

you have done so for a minimum of weeks, you should examine

how well you are sleeping at night and how tired or alert you are feel-

ing in the daytime. If you are sleeping well most nights and are as

alert as you would like to be in the daytime, then you probably don’t

need to make changes to your TIB. However, if you find you are

sleeping well at night, but feeling tired most days, you should try

increasing your time in bed (TIB) at night by minutes. For exam-

ple, if you begin with hours in bed per night the first weeks and

find that you are tired in the daytime despite sleeping soundly at

night, you should try spending hours and minutes in bed each

night during the subsequent weeks. If you continue to sleep sound-

ly at night but still feel tired in the daytime, you can add another

minutes to the time in bed during the third -week period and so

on. However, when you notice an increase in the amount of time you

are awake in bed each night, you will know that you have increased

your time in bed at night too much. If this occurs, you should

decrease your time in bed by minutes per week until you find the

amount of time that enables you to sleep soundly through the night

and feel reasonably alert in the daytime. You should also decrease

your time in bed after the first weeks if the initial amount of time

in bed chosen does not reduce your time awake in bed each night.

To help you make decisions about changing your time in bed, it may be

helpful to consider some simple guidelines. If you routinely take more

than minutes to fall asleep or you are routinely awake for more than

minutes during the night, you probably should reduce the amount

of time you spend in bed each night. You also should consider decreas-

ing your time in bed if you find that you routinely awaken more than

minutes before you plan to. Of course, the key word here is, “routine-

ly.” Occasional nights during which you have a somewhat delayed start

to your sleep or you have more wakefulness than usual once you get to

sleep should not be viewed as reasons for changing your sleep schedule.

Only when such occurrences are frequent or routine should you try a

somewhat shorter time in bed. In the end, the best guideline to use is

how you feel each day. If you are satisfied with how you generally feel

in the daytime, you can assume that the sleep you are obtaining at night

is sufficient.

Sleep Hygiene

The sleep improvement guidelines discussed thus far are essential for cor-

recting the sleep problems of many insomnia sufferers. For a sizable sub-

group of insomnia sufferers, these strategies are the only behavioral

changes required to produce an improved sleep pattern. However, it

sometimes is important to make changes in one’s general lifestyle and

sleep environment to fully correct an insomnia problem. This is true

since the sorts of daytime activities in which you engage, the foods and

beverages you consume, and the surroundings in which you sleep may

also all influence how well you sleep at night and how you feel in the

daytime. In addition to making the specific changes to your sleep habits

just discussed previously, you also may benefit from implementing the

following lifestyle changes and alterations to your bedroom to promote

a more normal sleep-wake pattern.

. Limit caffeineCaffeine is a stimulant that may make it harder for you to sleep

well at night. You should also know that caffeine stays in your sys-

tem for several hours after you consume it. Limit your caffeine to

24

the equivalent of no more than three cups of coffee per day and

do not consume caffeine in the late afternoon or evening hours.

. Limit alcoholAlcoholic 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. Try to avoid drinking

alcohol in the evening or using it as a sleep aid.

. Exercise regularly but not close to bedtimeTry some regular moderate exercise such as walking, swimming, or

bike riding. Such exercise performed in the late afternoon or early

evening may lead to deeper sleep at night. Also improving your

fitness level, no matter when you choose to exercise will likely

improve the quality of your sleep. However, as noted previously,

avoid exercise right before bed because it may make it harder to get

to sleep quickly.

. Try a light bedtime snack such as milk, peanut butter, or cheeseThese foods contain chemicals that your body uses to produce

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

drowsiness.

. Keep your bedroom quiet and darkNoise and even dim light may interrupt or shorten your sleep. You

can block out unwanted noise by wearing earplugs, running a fan,

or using a so-called “white noise” machine that is specifically

designed to screen sleep-disruptive sounds. Also, if possible, elimi-

nate the use of night-lights and consider using dark shades in your

bedroom so that unwanted light does not awaken you too early in

the morning.

. Keep your bedroom coolMake sure the temperature in your bedroom is comfortable.

Generally speaking, temperatures much above degrees Fahrenheit

cause unwanted wake-ups from sleep. During hot weather, use an air

conditioner to control the temperature in your bedroom.

25

Summary

This portion of the workbook reviewed important changes you can

make in your sleep habits, sleep schedule, lifestyle, and bedroom to

enhance your sleep pattern. It is important to understand that you

should adhere to the strategies discussed consistently to get the best

results. If you are able to do so, you should see some notable improve-

ments in your sleep within a relatively short period of time—usually

within – weeks. Moreover, if you are able to adopt the recommenda-

tions provided in this chapter as your general approach to sleep, you are

likely to appreciate improvements that persist over time. In addition,

you should be better equipped to address any future bouts of insomnia

you may have. However, changes in sleep habits and lifestyle, while

beneficial, may not fully address insomnia problems in everyone. For

many insomnia sufferers, sleep worries and unhelpful sleep-related

beliefs contribute significantly to insomnia. The following chapter

discusses strategies especially designed to address these additional

important contributors to daytime and nighttime insomnia symptoms.

26

27

Chapter 4 Combating Unhelpful Thoughts

Chapter described the many ways you can alter your behavior in order

to combat insomnia. This chapter talks about your thoughts and the

role they may play in maintaining your sleep problems. It outlines

strategies for managing these unhelpful thoughts so they no longer keep

you awake at night.

The Insomnia Brain

Some people don’t even consider that how we think and how we feel can

have a huge impact on how we sleep. It turns out that what and how we

think affects how we sleep, how we feel, and how we deal with periods of

sleep loss. Lots of research and conversations with insomnia patients have

led us to conclude that there is a particular way of thinking associated

with insomnia. We call it the “Insomnia Brain” because most people tell

us that this way of thinking is not typical of how they normally think, but

since they have had insomnia, their type of thinking has changed and the

way they view sleep has changed too. The Insomnia Brain tends to be very

“noisy” and very focused on the effects of not sleeping.

Negative thoughts in the Insomnia Brain spread like wildfire. You may

find that although you don’t consider yourself to be a worrier, once you

get into bed all you can do is worry. When this happens, it is likely that

all your thoughts are negative and related to one another. For example,

you may find yourself in bed on a Sunday night, worrying about work

and a project you have due. This can lead you to worry that if you don’t

get the project done, then you will lose your job. If you lose your job,

you will get evicted from your apartment because you won’t be able to

28

pay the rent, and so on. All of this negative thinking keeps your brain

awake, making it virtually impossible for you to fall asleep. The more

this happens in your bed on a nightly basis, the more likely it is to con-

tinue to happen. This is because it becomes an unintentional and

unwanted habit. The good news is that all habits can be broken if you

have a good strategy.

Do you tend to get upset about not sleeping or worry about whether or

not you will be able to manage during the day? Many people with

insomnia will say, “I wasn’t worried at all today but as soon as my head

hit the pillow, it was like a switch went off.” Does this ever happen to

you? It means that your bed has become a signal for worry and upset.

There are ways to change this signal.

Refer back to Chapter and the recommendation to get out of bed and

leave the room when you cannot sleep. One of the most effective strate-

gies for quieting an active mind is to leave the bedroom when you start

to experience troubling thoughts. This will break the habit. It may take

several attempts at first, but your brain will eventually get the picture

that your bed is not the place for it to be active. This practice may have

other benefits too. Taking the Insomnia Brain out of bed results in

becoming more clear-headed and being better able to switch off your

troublesome thinking. You can return to the bed when you are no

longer worrying or problem solving. Some people are concerned that

getting out of bed will limit their opportunity for sleep, but the chance

of sleeping while your brain is active is limited. Getting this type of

mental activity under control by spending a few minutes out of bed will

increase your chances of being able to sleep.

Constructive Worry

While most people find that getting out of the bed is enough to address

their nighttime worry problem, some continue to worry. Some bedtime

worries are a result of keeping so busy during the day that no time is

available to deal with the worries. Sleep is the first opportunity that is

quiet enough for your brain to try and complete its unfinished business.

Could this be you?

Constructive Worry Instructions

When we have problems, we tend to use our problem-solving skills to

make our lives better and to relieve ourselves of anxiety. It is not surpris-

ing that some of us may use our problem-solving skills at the wrong time

and place, namely bedtime. We may think about a problem, trying to

solve it, but unfortunately, the anxiety caused by the problem will keep us

awake. Constructive worry is a method for managing the tendency to

worry during that quiet time when sleep is supposed to be taking over.

Do this exercise during the early evening (at least hours before bed). It

should take you only about minutes to complete. Here’s how it is done:

. Write down a problem(s) facing you that has the greatest chance of

keeping you awake at bedtime, and list them in the “Concerns”

column of the Constructive Worry Worksheet on page .

. Then, think of the next step that might help fix it. Write it down

in the “Solutions” column. This need not be the final solution to

the problem, since most problems have to be solved by taking

steps anyhow, and you will be doing this again tomorrow night

and the night after until you finally get to the best solution.

■ If you know how to fix the problem completely, then write

that down.

■ If you decide that this is not really a big problem, and you will

just deal with it when the time comes, then write that down.

■ If you decide that you simply do not know what to do about

it, and need to ask someone to help you, write that down.

■ If you decide that it is a problem, but there seems to be no

good solution at all, and that you will just have to live with it,

write that down, with a note to yourself that maybe sometime

soon you or someone you speak with will give you a clue that

will lead you to a solution.

. Repeat this for any other concerns you may have.

. Fold the Constructive Worry Worksheet in half and place it on

the nightstand next to your bed and forget about it until bedtime.

29

(You may wish to photocopy the worksheet and then fill it out so

you do not need to tear the page out of the book.)

. At bedtime, if you begin to worry actually tell yourself that you

have dealt with your problems already in the best way you know

how, and when you were at your problem-solving best. Remind

yourself that you will be working on them again tomorrow

evening and that nothing you can do while you are so tired can

help you any more than what you have already done; more effort

will only make matters worse.

. An additional benefit of the constructive worry technique may be

less anxiety during the daytime.

Use the sample Constructive Worry Worksheet shown in Figure . as

a guide when filling out your own. Additional blank copies of the work-

sheet can be found in the appendix at the back of the book.

30

CONCERNS SOLUTIONS

1. The air conditioning isn’t working in the car 1. Could ask my wife if she has time to takeit in

2. Could call tomorrow for a Saturdayappointment

2. Money! 1. Will make an appointment with our financialplanner tomorrow

2. Will agree to that project for extra income

3. Will cut out my latte over the next month

4. I will wait until my credit card is dueto pay it

Figure 4.1Example of completed Constructive Worry Worksheet

31

CONCERNS SOLUTIONS

. _________________________________ . _________________________________

. _________________________________

. _________________________________

. _________________________________ . _________________________________

. _________________________________

. _________________________________

. _________________________________ . _________________________________

. _________________________________

. _________________________________

Constructive Worry Worksheet

32

Thought Records

In addition to nighttime worry, sometimes we have thoughts or beliefs

about sleep that can actually make sleep worse. Most beliefs about sleep

boil down to a fear about whether we will be able to cope with the

insomnia. It is common for people with insomnia to worry about

whether they will lose control over their abilities to sleep, whether they

will become sick as a result of the insomnia, and even whether they may

“go crazy” if their insomnia persists. These worries can be very frighten-

ing, so it is often helpful to take a more critical look at the types of beliefs

that lead to such distress.

The Thought Record is a very simple, yet very powerful tool. It’s pow-

erful because it curbs the Insomnia Brain’s tendency to be negative and

consider only the worse-case scenarios of sleep loss. Balanced thoughts

also challenge those beliefs that generate anxiety. Lastly, this tool will

help you see that you are not powerless; that your efforts toward chang-

ing your sleep habits do produce improvements in your sleep, as well as

your mood, and help to reduce daytime fatigue.

Thought Record Instructions

Using the blank Thought Record on page , think of a time, perhaps even

last night when you had strong feelings or upsetting thoughts related to

your insomnia. What were you doing or where were you when you had

these feelings or thoughts? Write them down in the “Situation” column of

the record. What kind of mood or feelings were you experiencing? Write

down your feelings in the “Mood” column. What are you thinking or

what were you thinking when you began to feel this way? Are you con-

cerned about how you will deal with another day with this insomnia? Are

you predicting that you’ll never sleep? Write these thoughts down in the

“Thoughts” column. Even if some of them seem to be untrue or silly, it is

important to write them down. There are no wrong thoughts.

The next step is to look at each of these thoughts and figure out why

they seem to be so true. What is the evidence for these thoughts? Write

this down in the “Evidence for the Thought” column. Most people can

remember a time when they had difficulty dealing with their insomnia.

The Insomnia Brain remembers this as “evidence” that you can’t deal

with insomnia. But this is probably not the whole story.

It is important to look more critically at these beliefs, and one way to do

this is to think about whether this thought is true % of the time. For

example, you may focus on the one instance in which you performed

poorly at work and discount the thousands of times you have performed

well even though it was difficult. Or we overlook that there are small

things that don’t support the thought. For example, we may forget that

there have been times when we have felt good after a poor night’s sleep;

or when we felt poorly after a good night’s sleep; or we jump to conclu-

sions or focus on the worst possible outcome. Write all this evidence

down in the “Evidence against the Thought” column. Examining the

evidence against the belief forces the Insomnia Brain to focus on

thoughts that are less anxiety provoking or less frustrating.

The last step in this process is to consider both the evidence for and

against the belief and think of a thought that lies somewhere in the

middle. This thought should consider that there may be some part

of the evidence for the belief that may be true, but it should take into

consideration that there is plenty of evidence against the belief. For

example, a balanced alternative to the thought, “I’m never going to

make it through tomorrow” is: “I sometimes feel groggy at work after a

poor night’s sleep, but not always, and I always seem to cope pretty well

with it.” Write this new thought down in the “Adaptive/Coping

Statement” column. Most people tend to feel a little better after com-

pleting this exercise. Use the sample Thought Record shown in Figure

. as a guide when filling out your own. Complete Thought Records

on a daily basis or whenever you are bothered by a particular thought

or feeling over the course of the next weeks. Additional blank copies

of the record can be found in the appendix at the back of the book.

When you review your Thought Records you may notice that your

thoughts typically fall into several categories. These thinking styles or

thought patterns are described on pages –.

33

34

SituationMood (Intensity

0–100%) ThoughtsEvidence for the thought

Evidence againstthe thought

Adaptive/Coping statement

Do you feel any differently?

Sitting at my desk thinkinghow sluggish I feel

Down (75%)

Frustrated (100%)

Worried(80%)

Tired(100%)

I’m never goingto get through today

I’m going to mess up

I need to get some sleep

I can’t concentrate

I’m going to get sick if I keep goinglike this

I can’t keepgoing on like this

What’s wrongwith me?

Last week I made a mistake on my report

I’ve already stopped exercising

I’m startingto feel less like doing things

I’ve made mistakes at work when I have had a goodnight’s sleep

I’ve had insomniafor over a yearand haven’t been sick

I notice I feel alittle better after lunch

I always seem tohave an okday despitemy insomnia

I don’t feel my best, but the truth is, I alwaysmake it through (70%)

Just because I don’t feel at my best, doesn’t mean that anything bad is going to happen (75%)

I’ve noticed there are things I can do to cope with the fatigue, so it is not hopeless (80%)

Down (30%)

Frustrated (60%)

Worried (10%)

Tired (70%)

Figure 4.2Example of completed Thought Record

35

SituationMood (Intensity0–100%) Thoughts

Evidence for thethought

Evidence againstthe thought

Adaptive/Copingstatement

Do you feel anydifferently?

Thought Record

36

Common Insomnia Thoughts

Misattribution: Because you have insomnia, you may attribute your

negative thoughts or bad moods to the fact that you have problems

sleeping, while discounting other possible causes. For example, it is nor-

mal to experience some grogginess for the first – minutes upon

awakening. This is called sleep inertia and it does not necessarily mean

that you had a poor night’s sleep that will lead to having a bad day.

Similarly, it is normal to experience an increase in sleepiness and a

decline in mental and emotional functioning in the early afternoon.

This is a normal phenomenon called the “post-lunch dip.” It corre-

sponds to a “dip” in one’s body temperature after lunch. It is not

evidence that you are unable to function.

Emotional reasoning: This is when you view your feelings as facts. Just

because you have some anxious feelings during the day does not mean

that you will be unable to sleep that night. This belief will only lead to

further anxiety when sleep does not come and, in turn, will keep you

awake even longer.

All-or-none thinking: Lots of people with insomnia say, “I didn’t sleep atall last night.” This is highly unlikely. The odds that you were lying

motionless in your bed for hours straight are very small. Otherwise,

you would be completely unable to function. You would be more than

just a little groggy and fatigued the following day. If you find yourself

thinking that you didn’t get any sleep on a particular night, review your

sleep logs in an effort to find “the missing sleep.” For example, did you

miss any parts of the TV show you were watching that night? If so, you

may have dozed off for a few minutes during the program.

Self-fulfilling prophecy: This is when you predict that you will have a terri-

ble day because you had poor sleep the night before, and without know-

ing it, you approach the day in such a way that ensures you will, in fact,

have a terrible day. There is tremendous power in the mind’s ability to

create a reality consistent with its beliefs.

Catastrophizing: Have you ever thought about what you are specifically

worried about when you worry about your sleep? Sometimes people are

surprised to find what they are actually worrying about when they

worry about their sleep. For example, you may be worried that you will

not be able to sleep tonight. Ask yourself, “What if I don’t sleep tonight?

What would be so bad about that?” Actually answer this question. The

answer may be, “I’m worried that I won’t be able to get my job done.”

Again, ask yourself, “What if I won’t be able to get my job done? What

would be so bad about that?” Continue to ask these questions until you

discover the worst case scenario. When exploring the worst possible

outcome, it may look like the following, “I’m worried that I would get

fired and then I wouldn’t be able to pay my mortgage, so I would lose

my house, and then I would be homeless. . . .” Many people with

insomnia worry that they may become nonfunctional and unable to

support themselves, or even that they might “go crazy” because of their

sleep problem. Considering that this is what lurks beneath the surface

worry of not sleeping, it is probably no wonder that it is difficult to

sleep. In other words, there is so much riding on whether you might

sleep (e.g., you might “go crazy” or become homeless) that it increases

the pressure to sleep and makes insomnia almost inevitable. It helps to

understand that this is the fear about not sleeping, and it is important

to examine whether it is unhelpful to have this belief. In other words, it

is important to consider the evidence that you will “go crazy” or will

become homeless.

Mind-reading: Some people with insomnia believe that others are

“noticing” their poor performance. They may worry about this out of a

fear of negative evaluation from others. This belief is often untrue

because most people with insomnia function quite well. What tends to

be different after a poor night’s sleep is the amount of extra effort

required to do regular tasks. If you think that people are noticing that

you are incompetent at work because of your insomnia, it can be help-

ful to explore whether this thought is true. Very likely, it’s not. Or at

least it’s not true % of the time.

Overgeneralization: This is when you put too much emphasis on a sin-

gle event or incident. For example, you may think, “I had trouble com-

pleting my crossword today, so I will be mentally useless at work.” To

combat this type of thinking, you need to see the range of evidence.

People with insomnia tend to cope extraordinarily well % of the

time.

37

Discounting the positive/Focusing exclusively on the negatives: There are

often hundreds of instances of coping and good functioning within the

day that are discounted in lieu of one instance wherein functioning was

lower. You may think your whole day was a waste simply because you

forgot one appointment. Review the rest of your day and you will see

that you accomplished all your tasks and attended to all your other

responsibilities. Don’t focus on the one missed appointment. Instead,

focus on how productive you were overall.

Continued Monitoring

As you continue working to correct your poor sleep habits, it is impor-

tant that you also continue monitoring your sleep using sleep logs. We

have provided additional copies in the appendix at the back of the book.

Also, remember to complete the Constructive Worry Worksheet in the

early evenings and the Thought Record whenever you are bothered by

a particular thought or feeling. Use these tools to monitor your progress

and to combat your unhelpful thinking styles. Seeing the progress you

have made serves to motivate you to continue with the program and

working to change your negative thoughts will help lessen your anxiety,

which will undoubtedly lead to better sleep.

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39

Chapter 5 Troubleshooting

Many who follow the recommendations in this workbook will

experience notable sleep improvements in a relatively short period of time,

usually within to weeks. If you fall in this group you should be sleep-

ing soundly at night and no longer experiencing daytime sleepiness or other

types of daytime impairment. If this describes you, you are well on your

way to overcoming your insomnia. However, for many people with insom-

nia, the treatment program outlined in this workbook involves an entirely

new way of thinking about and reacting to their sleep problems. Among

some individuals with insomnia, old attitudes and habits may persist even

though earnest efforts are being made to follow the types of suggestions

provided in the previous chapters. Other individuals may encounter some

unexpected difficulties when trying to implement certain aspects of the

treatment program described. In either case, the benefits obtained from

these strategies may fall short of what is expected or desired and some addi-

tional corrective strategies are necessary to address these types of problems.

If you have attempted to follow the sleep improvement strategies outlined

in the previous chapters for several weeks and are not satisfied with your

results, you may benefit by troubleshooting your overall approach. This

chapter reviews common difficulties individuals encounter when imple-

menting the treatment program described in previous chapters and pro-

vides troubleshooting advice for addressing such difficulties.

Trouble Getting Up on Time

Since your body clock is very important in regulating your sleep-wake

pattern, it is important that you “train” your clock properly so it works

for you and not against you. Your body clock can work in a predictable

40

and consistent fashion only if you follow a consistent sleep schedule

that is reinforced by your adhering to a standard rising time. If you are

not obtaining the results you desired from this program, perhaps it is

because you continue to have too much day-to-day variability in your

rising time. Take a look at the sleep logs you have been keeping and

examine your rising times across each week. Are those times pretty con-

sistent or do they vary by an hour or more across the week? If so, you

probably will benefit by making extra efforts to be more consistent in

your rising time.

Some people have more difficulties than others establishing and

adhering to a standard rising time. Some individuals report they sleep

through the alarm from time to time, whereas others admit to hitting

the snooze button repeatedly, particularly if they feel they have had a

bad night’s sleep. For many individuals, the idea of having to get up

at the same time on weekends as on workdays seems distasteful and

unreasonable. These adherence difficulties and attitudes will only sus-

tain an insomnia problem. Strategies such as using a loud alarm, plac-

ing it out of reach from your bed, enlisting the assistance of willing

family or friends to make sure you are up at the rising time selected,

and reminding yourself that consistency is what will make a difference

in your sleep are all important strategies to consider to help you make

sure you get up on time and consistently from day to day. If you do,

you should wake up well rested on weekdays and weekends, so delay-

ing your rising time will not seem useful.

Trouble Avoiding Naps

Whereas many insomnia sufferers understand that eliminating daytime

naps will lead to better nighttime sleep, some have great difficulty avoid-

ing such naps. Among some such individuals, such as those who are

retired, it is difficult to avoid daytime napping particularly during the

post-lunch dip occurring in the early PM. Also, it is not unusual for indi-

viduals to experience unintended napping or dozing particularly in the

hours following the evening meal and prior to the target bedtime. Many

who implement the strategies outlined in this workbook find they have

to reduce their time in bed dramatically, usually by delaying their cho-

sen bedtimes. While trying to adhere to their new bedtimes, such indi-

viduals may have great difficulty warding off unintended sleep during the

early evening hours. This is true particularly if these hours are spent read-

ing, watching TV, or engaging in some other sedentary activity. If any

significant amount of sleep occurs during these hours, it will likely

notably detract from the subsequent night’s sleep. If the types of napping

problems described here affect you, strategies to avoid sleep during these

hours are needed.

Fortunately there are some relatively simple and effective methods for

avoiding unintentional evening napping. During the time of year when

daylight persists into the evening, taking a – minute walk outdoors

after your evening meal may help your body clock adjust to the new

delayed bedtime and help you minimize your early evening sleepiness.

Also remember that being mentally and physically active reduces your

level of current sleepiness. As such, avoiding sedentary and relaxing

activities during the post-lunch dip and early evening may help you

fend off unwanted dozing. Finally, if you have a family member or

roommate who can help keep you awake and avoid unintended after-

noon or evening dozing, take advantage of that person’s help.

Staying in Bed When You Can’t Sleep

One of the more difficult recommendations for many people to follow

is that of getting out of bed whenever they are awake for extended peri-

ods. Perhaps it is winter and you have turned down the thermostat in

your home for the night. You know it might be cold in the house so you

avoid getting up even though you find yourself tossing and turning. You

may tell yourself that if you just lie there long enough, you are bound

to go to sleep. Or perhaps you tell yourself that although you are not

sleeping, at least you are “resting.” Of course, you know from your past

experiences these are the thoughts and strategies on which you have

been relying and they have not resolved your insomnia problems.

Remember, the purpose of getting out of bed is to retrain yourself to

sleep more soundly. It is important to avoid long periods of wakefulness

41

in bed wherein you are tossing and turning and finding that the bed is a

tortuous and unpleasant place to be. Keep a robe handy on those nights

that the house is cold so it is easier and less aversive to get out of bed when

you are not sleeping. Also, realize that adhering to this strategy now will

lead to more consolidated and rewarding sleep in the future and fewer

extended awakenings in bed. Reminding yourself of this fact should help

you adhere to this suggestion more consistently so you achieve your over-

all sleep goals.

Trouble Getting Back to Sleep

Some individuals claim that whenever they get out of bed at night, they

have trouble getting sleepy again so they can return to bed and resume

their night’s sleep. Many times this problem is not about the process of

getting out of bed, but relates more to the types of activities in which the

person engages after getting out of bed. Some people engage in physical-

ly (housecleaning) or mentally (balancing the checkbook) stimulating

activities when they get up during nocturnal waking periods. Others

may engage in sedentary yet attention-grabbing activities that lead them

to delay their return to bed. Activities such as watching late-night

provocative talk shows or reading that captivating mystery novel are

common examples of this sort of activity. Generally speaking, activities

that are sedentary, relaxing, and easy to stop when you feel sleepy are the

best choices for occupying your out-of-bed time during unwanted night-

time waking periods.

Lingering Daytime Fatigue

Some people carefully implement the strategies described in the previous

chapters and note they continued to feel tired or fatigued in the daytime

despite having improved sleep at night. For some individuals this occurs

because they are still running a “sleep debt” and could use more sleep

time than they are currently getting. If you find that you are sleeping

much better but you are routinely awakened by your alarm, this is a sign

you could sleep longer in the morning if allowed to do so. If this scenario

42

43

describes you, an upward adjustment in your TIB is needed. In increas-

ing your TIB you are encouraged to follow the instructions presented on

pages – in Chapter . In following these strategies, you should note

that your goal is to achieve a sleep pattern wherein you routinely go to

sleep quickly, sleep soundly through most nights, and routinely awaken

feeling rested just prior to your alarm going off.

Of course some people with insomnia achieve an optimal sleep pattern

yet continue to feel very fatigued in the daytime. It is important to note

that not all symptoms of daytime fatigue are the result of inadequate

nighttime sleep. Often factors such as an overly busy lifestyle, excessive

stress at work, and a lack of sufficient personal time to relax and restore

oneself mentally may all contribute to marked levels of daytime fatigue.

Hence, if your sleep has improved yet you continue to have significant

daytime fatigue, you may need to consider other causes of this daytime

symptom. Try building in some time to relax or engage in more recre-

ation activities or stress-relieving exercises or pastimes to see if these

sorts of activities provide you some benefit. If you generally feel much

less fatigued during holiday periods or vacations, it may be a sign that

stress reduction rather than further sleep improvements are what you

need most.

Changing Your Thoughts

Changing your unhelpful thoughts about sleep requires practice. The

Constructive Worry Worksheet in Chapter is a helpful tool that you can

use on a regular basis to resolve problems before you go to sleep. Problem

solving before bed makes it less likely that your worries will keep you

awake at night. If you are having trouble finding the time to complete this

worksheet, it may be helpful to set aside a -minute block of time

specifically for problem solving. Make this activity a priority. It will stop

you from worrying when you should be sleeping. Practice completing this

form on a nightly basis for a couple of weeks. Working out your issues

before bedtime will decrease your anxiety and worrisome thoughts, which

may be major contributors to your sleep problems.

44

The Thought Record (also from Chapter ) is yet another tool that is

helpful in challenging negative thoughts that may serve to maintain

your insomnia. As suggested for the Constructive Worry Worksheet, try

to set aside a block of time for completing your Thought Record.

Ideally, you should schedule a Thought Record around the same time

each day.

If you are having trouble completing some or all of the columns of the

Thought Record, refer back to the example in Chapter . Use this sam-

ple as a guide when filling out your own record. Practice completing

this form over the next several weeks until you get the hang of it.

Enlisting the Help of a Professional

If your sleep hasn’t improved and you aren’t making the progress you

had hoped for, you may wish to seek the help of a qualified health care

provider. Meeting with a mental health professional like a clinician or

therapist is one option available to you. Scheduling an appointment

with your primary care physician is another. If you have tried these sorts

of consultations and they do not provide the relief you desire, you may

benefit by consulting a sleep specialist. You can find an accredited sleep

specialty center that employs such professionals by reviewing the listings

in your local yellow pages or by consulting the website of the American

Academy of Sleep Medicine (www.aasmnet.org). Within such centers,

individuals who specialize in insomnia treatment or are trained in

behavioral sleep medicine techniques are most likely to be able to assist

you. If you consult such a professional, you may find that you will

benefit from a therapist-guided version of the type of treatment out-

lined in this book. It also may be the case that you have an underlying

and previously undetected sleep disorder such as sleep apnea that

requires an alternate type of therapy. Whatever the case, for some indi-

viduals consulting a professional for assistance is what is needed to

obtain the sleep improvements desired.

Appendix Forms and Worksheets

45

46

Day of the Week

Calendar Date

. Yesterday I napped from _____ to _____ (note time of all naps).

. Last night I took _____ mg of _____ or _____ of alcohol as a sleep aid (include all prescription and over-the-counter sleep aids).

. Last night I got in my bed at _____ (AM or PM?).

. Last night I turned off the lights and attempted to fall asleep at _____ (AM or PM?).

. After turning off the lights it took me about _____ minutes to fall asleep.

. I woke from sleep _____ times. (Do not count your final awakening here.)

. My awakenings lasted _____ minutes. (List each awakening separately.)

. Today I woke up at _____ (AM or PM?). (NOTE: this is your final awakening.)

. Today I got out of bed for the day at ____ (AM or PM?).

. I would rate the quality of last night’s sleep as: Very Poor Fair Excellent

. How well rested did you feel upon arising today?Not at All Somewhat Well Rested

Sleep Log

47

Day of the Week

Calendar Date

. Yesterday I napped from _____ to _____ (note time of all naps).

. Last night I took _____ mg of _____ or _____ of alcohol as a sleep aid(include all prescription and over-the-counter sleep aids).

. Last night I got in my bed at _____ (AM or PM?).

. Last night I turned off the lights and attempted to fall asleep at _____ (AM or PM?).

. After turning off the lights it took me about _____ minutes tofall asleep.

. I woke from sleep _____ times. (Do not count your final awakeninghere.)

. My awakenings lasted _____ minutes. (List each awakeningseparately.)

. Today I woke up at _____ (AM or PM?). (NOTE: this is your final awakening.)

. Today I got out of bed for the day at ____ (AM or PM?).

. I would rate the quality of last night’s sleep as: Very Poor Fair Excellent

. How well rested did you feel upon arising today?Not at All Somewhat Well Rested

Sleep Log

48

Day of the Week

Calendar Date

. Yesterday I napped from _____ to _____ (note time of all naps).

. Last night I took _____ mg of _____ or _____ of alcohol as a sleep aid(include all prescription and over-the-counter sleep aids).

. Last night I got in my bed at _____ (AM or PM?).

. Last night I turned off the lights and attempted to fall asleep at _____ (AM or PM?).

. After turning off the lights it took me about _____ minutes tofall asleep.

. I woke from sleep _____ times. (Do not count your final awakeninghere.)

. My awakenings lasted _____ minutes. (List each awakeningseparately.)

. Today I woke up at _____ (AM or PM?). (NOTE: this is your final awakening.)

. Today I got out of bed for the day at ____ (AM or PM?).

. I would rate the quality of last night’s sleep as: Very Poor Fair Excellent

. How well rested did you feel upon arising today?Not at All Somewhat Well Rested

Sleep Log

49

Day of the Week

Calendar Date

. Yesterday I napped from _____ to _____ (note time of all naps).

. Last night I took _____ mg of _____ or _____ of alcohol as a sleep aid(include all prescription and over-the-counter sleep aids).

. Last night I got in my bed at _____ (AM or PM?).

. Last night I turned off the lights and attempted to fall asleep at _____ (AM or PM?).

. After turning off the lights it took me about _____ minutes tofall asleep.

. I woke from sleep _____ times. (Do not count your final awakeninghere.)

. My awakenings lasted _____ minutes. (List each awakeningseparately.)

. Today I woke up at _____ (AM or PM?). (NOTE: this is your final awakening.)

. Today I got out of bed for the day at ____ (AM or PM?).

. I would rate the quality of last night’s sleep as: Very Poor Fair Excellent

. How well rested did you feel upon arising today?Not at All Somewhat Well Rested

Sleep Log

50

Day of the Week

Calendar Date

. Yesterday I napped from _____ to _____ (note time of all naps).

. Last night I took _____ mg of _____ or _____ of alcohol as a sleep aid(include all prescription and over-the-counter sleep aids).

. Last night I got in my bed at _____ (AM or PM?).

. Last night I turned off the lights and attempted to fall asleep at _____ (AM or PM?).

. After turning off the lights it took me about _____ minutes tofall asleep.

. I woke from sleep _____ times. (Do not count your final awakeninghere.)

. My awakenings lasted _____ minutes. (List each awakeningseparately.)

. Today I woke up at _____ (AM or PM?). (NOTE: this is your final awakening.)

. Today I got out of bed for the day at ____ (AM or PM?).

. I would rate the quality of last night’s sleep as: Very Poor Fair Excellent

. How well rested did you feel upon arising today?Not at All Somewhat Well Rested

Sleep Log

51

Constructive Worry WorksheetConcerns Solutions

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Constructive Worry WorksheetConcerns Solutions

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Constructive Worry WorksheetConcerns Solutions

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Constructive Worry WorksheetConcerns Solutions

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Constructive Worry WorksheetConcerns Solutions

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Constructive Worry WorksheetConcerns Solutions

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Constructive Worry WorksheetConcerns Solutions

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Constructive Worry WorksheetConcerns Solutions

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Constructive Worry WorksheetConcerns Solutions

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Constructive Worry WorksheetConcerns Solutions

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61

SituationMood (Intensity0–100%) Thoughts

Evidence for thethought

Evidence againstthe thought

Adaptive/Copingstatement

Do you feel anydifferently?

Thought Record

62

SituationMood (Intensity0–100%) Thoughts

Evidence for thethought

Evidence againstthe thought

Adaptive/Copingstatement

Do you feel anydifferently?

Thought Record

63

SituationMood (Intensity0–100%) Thoughts

Evidence for thethought

Evidence againstthe thought

Adaptive/Copingstatement

Do you feel anydifferently?

Thought Record

64

SituationMood (Intensity0–100%) Thoughts

Evidence for thethought

Evidence againstthe thought

Adaptive/Copingstatement

Do you feel anydifferently?

Thought Record

65

SituationMood (Intensity0–100%) Thoughts

Evidence for thethought

Evidence againstthe thought

Adaptive/Copingstatement

Do you feel anydifferently?

Thought Record

66

SituationMood (Intensity0–100%) Thoughts

Evidence for thethought

Evidence againstthe thought

Adaptive/Copingstatement

Do you feel anydifferently?

Thought Record

67

SituationMood (Intensity0–100%) Thoughts

Evidence for thethought

Evidence againstthe thought

Adaptive/Copingstatement

Do you feel anydifferently?

Thought Record

68

SituationMood (Intensity0–100%) Thoughts

Evidence for thethought

Evidence againstthe thought

Adaptive/Copingstatement

Do you feel anydifferently?

Thought Record

69

SituationMood (Intensity0–100%) Thoughts

Evidence for thethought

Evidence againstthe thought

Adaptive/Copingstatement

Do you feel anydifferently?

Thought Record

70

SituationMood (Intensity0–100%) Thoughts

Evidence for thethought

Evidence againstthe thought

Adaptive/Copingstatement

Do you feel anydifferently?

Thought Record