Cognitive Behavior Therapy for Insomnia in Those with Depression

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Downloaded by [New York University] at 04:37 12 August 2016 Cognitive Behavior Therapy for Insomnia in Those with Depression

Cognitive Behavior Therapy for Insomnia in Those with Depression is the book for clinicians who recognize that insomnia is more often a comorbid condition that merits separate treatment attention. These clinicians know that two thirds of those who present for depression treatment also complain of significant insomnia and that one third of such patients are already taking sleep medication, and they may be familiar with the research showing that treating insomnia is often important in the management of depression. But what strategies should clinicians use for treating insomnia? How can motivation be enhanced? What about medications? Students and professionals alike will find the pages of Cognitive Behavior Therapy for Insomnia in Those with Depression replete with advanced tools to address the adherence problems often encountered in this group, and they’ll come away from the book with a wealth of techniques for improving both sleep and overall symptom management as well as for treating the insomnia that occurs in comorbid disorders.

Colleen E. Carney, PhD, is an associate professor in the department of psychology at Ryerson University and the director of the Sleep and Depression Laboratory in Toronto, Canada. She was previously on faculty at Duke University Medical Center, where she was awarded the prestigious National Sleep Foundation Pickwick Fellowship and where she also established the Comorbid Insomnia Clinic. She is the president of the Behavioral Sleep Medicine Special Interest Group of the Association for Behavioral and Cognitive Therapies and a fellow of the Canadian Psychological Association. She is also certified in cognitive behavior therapy by the Canadian Association for Cognitive and Behavioral Therapies, and is an active writer, presenter, and workshop trainer. Downloaded by [New York University] at 04:37 12 August 2016 Donn Posner, PhD, is currently working at the Palo Alto VA on clinical research in insomnia. Before this he served as a clinical associate professor of psychiatry at the Warren Alpert Medical School at Brown University and as director of behavioral sleep medicine for the Sleep Disorders Center of Lifespan Hospitals. Dr. Posner is a member of the American Academy of Sleep Medicine and is one of the first certified behavioral sleep medicine specialists recognized by that group. He is also a founding member of the Society of Behavioral Sleep Medicine and was recently awarded the society’s Peter Hauri Career Distinguished Achievement Award. This page intentionally left blank Downloaded by [New York University] at 04:37 12 August 2016 Cognitive Behavior Therapy for Insomnia in Those with Depression A Guide for Clinicians

Colleen E. Carney and Donn Posner Downloaded by [New York University] at 04:37 12 August 2016 First published 2016 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2016 Colleen E. Carney and Donn Posner The right of Colleen E. Carney and Donn Posner to be identified as authors of this work has been asserted by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging in Publication Data Carney, Colleen. Cognitive behavior therapy for insomnia in those with depression: a guide for clinicians/Colleen E. Carney, PhD and Donn Posner, PhD. pages cm Includes bibliographical references and index. 1. Insomnia—Treatment—Popular works. 2. Depression, Mental— Complications—Popular works. 3. Cognitive therapy—Popular works. I. Posner, Donn. II. Title. RC548.C363 2015 616.8′49820651—dc23 2015016125

ISBN: 978-0-415-73837-8 (hbk) ISBN: 978-0-415-73838-5 (pbk) ISBN: 978-1-315-81740-8 (ebk)

Typeset in Minion by Florence Production Ltd, Stoodleigh, Devon, UK Downloaded by [New York University] at 04:37 12 August 2016 I dedicate this book to my family, Shannon, Sydney, and Theo. Their love, support and understanding, allows me to pursue my passion. Colleen E. Carney, PhD

I dedicate this book to my wife Karen and son Max who definitely put the drive into my life each and every day. Thank you for your bottomless reservoir of support. I would also like to thank my co-author Colleen for giving me the opportunity to be part of this thought provoking project. Donn Posner, PhD Downloaded by [New York University] at 04:37 12 August 2016 This page intentionally left blank Downloaded by [New York University] at 04:37 12 August 2016 Contents

Acknowledgment ix

1 Depression and Insomnia: An Overview1

2 Non-psychological Treatments for Those with Insomnia and Depression 14

3 Cognitive Behavior Therapy for Insomnia (CBT-I): Treatment Considerations 26

4 Assessment of Insomnia in Those with Depression 37

5 Behavioral Strategies for Insomnia 60

6 Cognitive Factors and Treatment 79

7 Encouraging Adherence and Troubleshooting Potential Barriers 96

8 Rumination Strategies for Insomnia 120

Downloaded by [New York University] at 04:37 12 August 2016 9 Combining Depression and Insomnia Therapies 134

10 Case Study 157

Appendices A Core Sleep Diary 185 B Expanded Sleep Diary 188 C Daytime Insomnia Symptom Response Scale 194 viii Contents D TRAP or TRAC Worksheet 195 E Daily Activity Monitoring Form 196 F Goal Tracking Form 197 G Blank Pro-Depression and Anti-Depressant Worksheet 198 H Blank Pro-Sleep versus Pro-Insomnia Worksheet 199 I Blank Pro-Energy versus Pro-Fatigue Worksheet 200 J BABIT Continuum Exercise 201 K Behavioral Experiment Monitoring 202

References 203 Index 225 Downloaded by [New York University] at 04:37 12 August 2016 Acknowledgment

We thank Dr. Rachel Manber for her intellectual contributions to this book and her contributions to the field in the area of sleep and depression. Downloaded by [New York University] at 04:37 12 August 2016 This page intentionally left blank Downloaded by [New York University] at 04:37 12 August 2016 1 Depression and Insomnia An Overview

Insomnia is Important Sleep is a significant issue for those with major depressive disorder (MDD). Up to 90 percent of those with MDD complain of insomnia (Kupfer, Reynolds, Ulrich, Shaw, & Coble, 1982; Reynolds & Kupfer, 1987). In community samples, just under half of people with MDD meet criteria for an insomnia diagnosis (Breslau, Roth, Rosenthal, & Andreski, 1996; Stewart et al., 2006). In sleep clinics, the most common insomnia patient seen is one with comorbid MDD (Buysse et al., 1994; Coleman et al., 1982; Edinger et al., 1989; Jacobs, Reynolds, Kupfer, Lovin, & Ehrenpreis, 1988). Additionally, there can be complaints of hypersomnia and sometimes an alternation between hypersomnia and insomnia. Despite the high prevalence, the importance of sleep is under-recognized and as a result undertreated. There are several studies showing that a separate insomnia diagnosis is not considered when MDD is suspected. For example, the best predictor of a MDD diagnosis is the presence of an insomnia complaint (Haponik, Frye, Richards, Wymer, & Hinds, 1996). However, insomnia is not one of the two cardinal symptoms (i.e., depressed mood and/or anhedonia) needed for a MDD diagnosis (American Psychiatric Association, 2013) and thus should not be predictive of this diagnosis. Another potential issue in the underdiagnosis of insomnia is being presumptuous about etiology. Some problems in this area include the presumption that it is important to establish temporal precedence of the insomnia—even in such cases, some presume that the insomnia is merely the first MDD symptom to appear. There are several problems with this view. One is that patients may not be able to remember which symptoms came first, especially given that those with MDD have autobiographical deficits (Lyubormirsky, Caldwell, & Nolen- Hoeksema, 1998). Second, even in sleep specialists, clinicians exhibit poor reliability in Downloaded by [New York University] at 04:37 12 August 2016 determining whether an insomnia diagnosis is present when there are mood symptoms present (Edinger et al., 2011). There are also assumptions that MDD is more serious and therefore clinical attention should be exclusively focused on the MDD. Although MDD is a very serious disorder, on some quality of life indices, chronic insomnia produces greater impairment than MDD (Foley et al., 1995). Insomnia is associated with large societal costs (Carney et al., 2008; Daley, Morin, LeBlanc, Gregoire, & Savard, 2009; Ozminkowski, Wang, & Walsh, 2007). Indeed, the costs associated with MDD increase by an additional $1K annually in those with untreated insomnia and MDD (Asche, Joish, Camacho, & Drake, 2010). Additionally, insomnia is predictive of developing alcohol and substance abuse (Ford & Kamerow, 1989). Lastly, chronic insomnia is associated with 2 Depression and Insomnia increased suicidal ideation (Agargun, Kara, & Solmaz, 1997; Li, Lam, Yu, Zhang, & Wing, 2010; Woznica, Carney, Kuo, & Moss, 2014), and insomnia is an independent predictor of suicide (Bernert, Joiner, Cukrowicz, Schmidt, & Krakow, 2005); that is, even after controlling for depression, there is an increased risk for suicidality. In those with MDD, suicidal ideation is increased when there is insomnia present and insomnia is a significant predictor of suicide completion (Fawcett et al., 1990). Inherent in the assumption that MDD is always more serious is perhaps an implicit assumption that treatment of the MDD will likely resolve the (less serious) insomnia problem. There are many studies to confirm that this is a faulty assumption. Across studies using sleep items from depression inventories, the rate of residual insomnia problems after depressive recovery following antidepressant therapy or psychotherapy is a little less than half (Carney, Segal, Edinger, & Krystal, 2007b; Manber et al., 2003; Nierenberg et al., 1999). It is possible that the rate exceeds 50 percent, as a study that utilized a validated sleep questionnaire in lieu of sleep items from a depression measure found a much higher rate (Carney, Harris, Friedman, & Segal, 2011). Additionally, in the same study, although depression cognitions significantly decreased and were in the nonclinical range after depressive recovery, insomniagenic beliefs did not significantly improve with depression recovery and remained in the pathological range (Carney et al., 2011). Insomnia is also a complicating factor for depression treatment because insomnia predicts poorer response to evidence-based psychotherapy or pharma cotherapy depression treatments (Buysse, 1999; Thase, 1996, 1997). Collectively, the data above confirms what was con - cluded at the National Institutes of Health (NIH) Consensus Conference on Insomnia: Insomnia should be considered a comorbid condition and treated in the presence of MDD. Moreover, after a review of the evidence, the DSM5 Sleep-Wake Disorders Work group concluded that there should be no diagnostic distinction between comorbid insomnia and insomnia alone; the disorder in the fifth edition of the DSM is simply insomnia disorder (American Psychiatric Association, 2013).

Etiological Factors in Insomnia In considering the relationship between insomnia and depression, it may be helpful to first consider causal factors for insomnia. There are many causes of sleep disturbance and there may be as many precipitating or initial causes as there are clients. Although sleep problems initially can be caused by just about anything, there are three main causes or factors that perpetuate a chronic insomnia: problems with the homeostatic, circadian and/or arousal systems. This idea was first presented in Spielman’s Three P Model Downloaded by [New York University] at 04:37 12 August 2016 (Spielman, Caruso, & Glovinsky, 1987a). The model postulates that there are predisposing factors that increase vulnerability to insomnia (e.g., a tendency towards rumination), but having a vulnerability factor does not mean that insomnia is inevitable; it simply provides fertile ground for an insomnia disorder in the presence of a stressor. The stressor is the precipitant in the model. As stated above, there are many precipitants, even positive stressors such as having a baby can precipitate sleep disturbance. MDD can be a stressor in this model. Although insomnia is often a precursor to MDD, in some cases, MDD could lead to more protracted insomnia. Sleep disturbances that are associated with a stressor are expected to resolve with the resolution of the precipitant. Thus in the case of MDD precipitating sleep disruption, we would expect insomnia to Depression and Insomnia 3 resolve when the MDD resolves. Unfortunately we know that insomnia frequently does not remit with the resolution of the depressive episode (Carney, Edinger, Meyer, Lindman, & Istre, 2006). Why? Sleep disturbance becomes a chronic insomnia when there are perpetuating factors present. Perpetuating factors are those factors that often arise from coping with the precipitating factor and initial sleep disturbance. The consequence of these coping behaviors can create disturbances in the homeostatic, circadian and/or arousal systems. Below we discuss each of these factors and then return to the situation of MDD and insomnia.

Perpetuating Factor: Homeostatic System Problems Sleep is regulated by two systems: a homeostatic and a circadian system. We will discuss the circadian system and its role in chronic insomnia in the next section. First, the homeostatic system is a system that balances between wakefulness and sleep. From the moment we are awake and active, we accumulate a chemical in the basal forebrain called adenosine. The build-up of this chemical is associated with increasing sleepiness and pressure for deep sleep; the greater the duration of wakefulness, the greater the build- up of a drive for deep sleep. The greater the amount of time since rising, the greater is the pressure to sleep. This system ensures that we neither sleep too much nor too little. It compensates for sleep loss and lightens sleep if the person was attempting to produce copious, unnecessary amounts of sleep. This means that people needn’t do anything during periods of sleep loss except maintain their schedule, because the body will make up for lost sleep with subsequent deep, restorative sleep. However, attempting to make up for lost sleep by spending increased time in bed or at rest, sends a message to the body that less deep sleep is needed; thus the compensatory mechanism is thwarted. Below we include a sample script for CBT-I psychoeducation. Such an explanation is included in the first treatment session of CBT-I. There are other examples of psychoeducation delivery throughout the book, including in Chapter 5 wherein we describe the behavioral components of CBT-I delivered in the first treatment session.

Therapist: From the moment you get up and are active, you begin to build a drive for deep sleep. You build it all day and into the evening until so much has built up that when you go to sleep, you produce some deep sleep and it keeps you asleep throughout the night. Client: Well, that never happens to me anymore. Therapist: It may well be that you have a problem with this system. Let’s continue and Downloaded by [New York University] at 04:37 12 August 2016 you can tell me what you think. This system determines how much deep sleep you get and it is based on how many hours you have been awake and active. So if you get up later, go to bed earlier, attempt to nap or rest throughout the day or you are less active, less deep sleep drive is accumulated and the result is light, broken sleep and maybe difficulty in falling asleep too. Client: I definitely don’t get deep sleep anymore but it’s not like I am totally inactive . . . Therapist: Let me ask you this, when you feel tired, or you’ve had a poor night’s sleep, or your mood is really low, how much do you feel like keeping up with your regular activities? 4 Depression and Insomnia Client: I’m not sure what you mean. I feel really tired so I try to do my normal activities but I can’t always do what I want. Therapist: Can you tell me more about that? Are you able to get right out of bed when your alarm sounds? Are you always able to go to work? Do you keep up with all your social engagements? Client: Sort of. Not everything. Like I said, I feel exhausted so it’s not always possible. Therapist: This is very common. Most people do an excellent job trying to do all the things they used to but when the fatigue sets in, they find it more and more difficult and they find themselves spending a little more time in bed and a little more time inactive than before they had their sleeping problems . . . Client: I wouldn’t say I spend more time in bed. Therapist: Ok. I was making that assumption based on what you told me was your routine two years ago, before all this trouble started. You had said that you went to bed around 11 PM and got up at 6 AM each morning, you never took naps, you had a weekly card game with friends, lunch on Fridays with coworkers, and you worked out 4 days per week. Client: Well it’s true that I don’t work out anymore, and guess I don’t go to lunch or the card game. I don’t really take naps now because I often can’t sleep. I just try to sleep. I still go to bed at 11 and get up at 6 AM. Therapist: I see. So some of your activities have decreased and you spend more time resting but not always napping? Client: Right. Therapist: Can we take a look at your sleep diary? [See Figure 10.2 in Chapter 10] Client: Sure. See how I go to bed around 11 PM most nights? Except for Tuesday and Wednesday. Therapist: Yes, I see. Most nights were around 11 PM and Tuesday you went to bed an hour earlier and Wednesday you went to bed about 2 hours earlier, around 9ish, right? Client: That’s right. Therapist: And I see that your final awakening during the work week was 6:30 AM and on the weekend it was closer to 8 AM correct? Client: That’s right. Therapist: The item below your final awakening is the time that you actually got out of bed, what do you notice about the time at which you physically get out of bed? Client: It’s later than 6:30 AM. It’s because I am tired. Downloaded by [New York University] at 04:37 12 August 2016 Therapist: Right. Because you are tired, you have difficulty getting up at the time you used to and it is even later on weekends. You used to spend 7 hours in bed each night. How many hours were you in bed on Wednesday? Client: Almost 10 hours. Wow. I never knew that. But I am not sleeping during this time. Therapist: Right, you are not sleeping, but you are also not building a drive for deep sleep. You also told me that you attempted to nap for 90 minutes that afternoon. If you spent 11.5 hours inactive in bed that day, how much time were you building sleep drive? Client: I don’t know [pauses] I think, 12.5 hours? Depression and Insomnia 5 Therapist: Yes. So if there were two people and one spent 7 hours in bed so they had 17 hours of deep sleep drive build-up, and the other had 12.5 hours of build-up, who is more likely to have deep, continuous sleep? Client: Ok, I get it. The person who builds 17 hours has a better chance at better sleep. Therapist: And don’t forget that the person with 17 hours of build-up also has much more activity to add to the build-up. The person with only 12.5 hours also has a lower amount of physical activity to contribute to the build-up. Client: Ok, I get it. Therapist: So we will discuss ways to work with this system to produce more deep sleep for you. But first, I had said there is another system that works with your homeostatic system. I think it’s important to talk about this system too.

Perpetuating Factor: Circadian System Considerations In addition to the homeostatic system that balances sleep and wakefulness, there is a body clock that regulates many systems in the body, including the timing of the sleep and alerting systems. The circadian system is slightly longer than a 24 hour day and thus is highly responsive to cues in the environment, such as the light, for entrainment purposes. The light provides input via the eye into the brain about what time it is. When blue spectrum light is present (i.e., in sunlight) it signals that it is day and this situation is associated with alertness. When red spectrum light is present (i.e., following sunset) it signals night and is associated with melatonin release; a sedative hormone. Improperly timed cues can create sleepiness or alertness at undesirable times. Thus decreased exposure to light can be associated with drift in the circadian system, and ill-timed light (blue light exposure at night) can be associated with ill-timed alertness. Although light is the most powerful cue for the clock, keeping a regular schedule of activities including rise and bedtimes, and perhaps meal times and other activities can help set the clock. Each of these activities is typically associated with light too, i.e., we typically eat under lighted conditions, when we travel to work we are often exposed to daylight etc. In those with insomnia, the regularity of daily activities is diminished relative to good sleepers even when overall levels of activity are the same between those with insomnia and good sleepers (Moss, Carney, Haynes, & Harris, 2014). When there is irregular environmental input (e.g., light or activities) to the clock, the system drifts, because it is more than 24 hours, and symptoms such as difficulty in sleeping, cognitive difficulties, fatigue, and mood disturbance can occur. These are the symptoms experi - enced during jetlag. That’s because jetlag is the result of the mismatch between the Downloaded by [New York University] at 04:37 12 August 2016 internal time and the time in the environment. Even one hour is enough to produce these symptoms; most people can relate to this because daylight savings is only one hour and it typically produces at least mild symptoms. The reason this is important is that if the rise time is varied by an hour or more then the client will experience jetlag symptoms. When people suffer from sleep or mood disturbance they often struggle at getting up at their regular time. They may continue to set the alarm but will remain in bed longer because they feel tired. The circadian system regulates a variety of systems in the body including sleep, alertness, and mood. There are regular predictable patterns for the rise and fall of these activities across a 24 hour period but this system is also largely responsive to 6 Depression and Insomnia environmental output. One way to envisage this system is to visualize a curve that rises in the morning, continues to rise all day, and then begins to fall in the evening and throughout the night (see Figure 1.1). The peak is in the evening and the trough or lowest point is in the early morning. This curve would correspond to the core body temperature curve as this exhibits circadian periodicity. This curve would also help us to understand alertness in a 24 hour period as the clock emits an alerting signal when the curve is ascending; thus increasing as the day goes on and competing with the build- up of sleepiness to keep us awake. Alertness diminishes when the curve is falling (ideally an hour or so before bed) which sets the stage for sleep. Prior to the fall in alerting signals is the release of melatonin in the early evening, coincident with the offset of light (i.e., sunset), which also sets the stage for sleep. Attempting to make up for lost sleep during times at which alertness signals are being sent from the clock, or when melatonin is not present or is present in only small amounts, makes sleep less likely. Thus, trying to sleep during the day is ill-timed given that alertness signals will intrude. For example, those working a night shift will have a strong sleep drive because they stayed up all night building pressure. However, when they attempt to sleep in the morning, they are sleeping in competition with alerting signals from the clock. This is partly why those working night shifts also complain of less restorative sleep or shortened sleep duration. Another consideration is maintaining a schedule that is a poor match for biology, or chronotype. Chronotype refers to the placement of a sleep wake cycle within a 24 hour period. Thus someone who typically becomes sleepy very early (e.g., 9 PM) and typically starts to wake up around 4 AM exhibits morningness or an advance in phase, and someone who typically becomes sleepy very late (e.g., 2 AM) and typically starts to wake up later (e.g., 10 AM) exhibits eveningness or a phase delay. There is some evidence that there is a significant genetic contribution, and there is a developmental pattern (e.g., morningness at the early and late years of life). There is some ability to make shifts using bright light therapy, melatonin, or maintaining a strict schedule but there are individual differences in the ability to maintain the shift. The important consideration is whether someone is keeping a schedule discrepant from their chronotype.

Sleep High opportunity Downloaded by [New York University] at 04:37 12 August 2016

Low Alerting signal from the clock Alerting signal from Morning Afternoon Evening Night Morning Time of day

Figure 1.1 Strength of alerting signals from the clock Depression and Insomnia 7 For example, if a client has a lifelong pattern of going to bed late and rising late, and they are suddenly obliged to rise at 7 AM for work, they will not be able to go to bed early just because they have to wake up early. Also important is that people can have particular beliefs about what it means to be a morning person or a night person. Night owls are associated with a stereotype of laziness so clients can be ambivalent about maintaining a schedule consistent with their chronotype because there is something “wrong” with going to bed late. Likewise, there may be a negative stereotype of being “boring” associated with keeping an early schedule. Below is an example of how to deliver psychoeducation about the clock in an interactive way, using the client’s data and Socratic questioning.

Therapist: We have a clock inside our body that is not quite 24 hours in length. To keep this clock running optimally, we have to set the clock every day with regular habits. Client: What happens if it is not running properly? Therapist: A variety of things can happen. The clock is responsible for mood, alertness, sleep, in addition to other processes, so you could experience insomnia, fatigue, and low or irritable mood and difficulty with performance, for example, it might require more effort to concentrate. Client: Sounds like me. What do you have to do to make it run better? Therapist: We need to set our internal clock with regular habits such as regulating the time at which we get out of bed. Client: What about the time I go to bed? Therapist: It would be ideal if we could regulate bedtime however we are not always sufficiently sleepy at bedtime and we shouldn’t get into bed without feeling sleepy or it will increase the likelihood of lying awake while in bed. Setting the time at which you get out of bed at the same time every morning will regulate your clock and make it more likely that you will begin feeling sleepy around the same time each night. All things being equal, your bedtime would become more regular by getting out of bed at the same time each morning. Client: I already get up at the same time most mornings, so this probably doesn’t apply to me. Therapist: Have you ever taken a flight where you travelled and the time zone changed? Client: Yes. Recently I flew from Colorado to Boston. Why? Therapist: What were the symptoms you had a result of the jetlag? Client: I was tired, I had a headache and I found it hard to eat when everyone else was Downloaded by [New York University] at 04:37 12 August 2016 and couldn’t fall asleep when everyone else was asleep. Therapist: So you essentially had insomnia and other unpleasant related symptoms? Client: Yes, I guess so. Therapist: And how long did it last? Client: Maybe two days? I think I felt tired for longer than that though. Therapist: So there was an immediate effect and then it took a few days before things completely improved? Client: That’s right. What does this have to do with travel? Therapist: Jetlag symptoms are really about this mismatch between the clock in your body and the clock showing local time. The difference between Boston and Denver 8 Depression and Insomnia is only 2 hours but it produced immediate negative effects that lasted a few days. Can you take a look at your sleep log and tell me the difference between the earliest and latest time at which you got out of bed last week? [See Chapter 10 to review specifics of this case, including the Figure 10.2 sleep log] Client: A little over 2 hours. Do you really think it would make that much of a difference? Therapist: Don’t take my word for it. What was your experience when your body expected it to be a particular time and suddenly everything was shifted 2 hours later? How did your body respond? Client: Wow, ok, I get it. The problem is that I am tired so I have to make-up for lost sleep. Therapist: Given what you just learned about building sleep drive, do you think you are making up for the lost sleep? Client: I forgot. No, I guess not. And it looks like I am giving myself jetlag, which sucks. Ok, I get it. Therapist: There is one last consideration for the clock system and that is that there is a window of opportunity for people, specific to them, at which time the best sleep will be produced. Some of this relates to genetics. That is, would you consider yourself to be a night owl or an early bird, or somewhere in between? Client: I used to be a night owl in my early twenties but then I got insomnia and it went away. I would say I am somewhere in between but maybe more of a morning person than not. Therapist: Developmentally, people tend to shift towards being night owls in their teens and early teens and then gradually shift to somewhere in between a morning and night person throughout adulthood. Late in life and also very early in life, older adults and small children tend to be on the earlier side. Even though there are developmental changes, genetics play some role so if you are born with a genetic loading for being a night owl, it means that you will be shifted earlier as a young child but will still be much later than all of your peers. Does that make sense? Client: Yes. My Dad was a night owl and my Mom was an early bird or maybe somewhere in the middle. Therapist: What this all means is that it is important to keep a schedule that makes sense for your body. Since you are somewhere in the middle, we wouldn’t want you to keep a very late bedtime and rise time because that wouldn’t suit you, nor would an extremely early bedtime and rise time. Make sense? Client: Yes. Downloaded by [New York University] at 04:37 12 August 2016

Perpetuating Factor: Arousal System Considerations In sum, two regulatory systems interact to produce quality sleep: the circadian system and the homeostatic system (Borbély, 1982). Even when these two systems are operating optimally; that is, the sleep-wake schedule is regular and well-matched to the person’s chronotype and there is close correspondence to the amount of sleep currently produced and the time spent in bed, these systems can be overridden by the arousal system. This is important, because even when homeostatic pressure is high and the timing of a sleep opportunity is ideal, in emergency situations it is most advantageous to be able to Depression and Insomnia 9 postpone sleep to be able to respond to the emergency. However, sometimes the body becomes more alert in situations that are not emergencies. There is ample evidence of hyperarousal in insomnia across multiple physiological indices (Bonnet & Arand, 1995, 1998; Nofzinger et al., 2004; Vgontzas et al., 2001). Thus, arousal is an important consideration in insomnia and two types of arousal (e.g., conditioned arousal and cognitive arousal) tend to figure prominently as treatment targets. There is evidence of conditioned arousal in many people with insomnia. Conditioned arousal refers to the repeated pairing of wakefulness with the sleep situation (e.g., bed), such that the bed itself begins to acquire alertness-promoting properties. Many people with insomnia report that they are able to feel sleepy and even produce sleep elsewhere (e.g., on the couch) but when they get into bed, they become instantly alert. Such a report is consistent with conditioned arousal. Conditioned arousal is explained to clients during the psychoeducation component of the first treatment session and is easily explained as the body has learned that the bed is no longer associated with sleeping; this has occurred (unintentionally) via repeated pairings of the bed with wakefulness. People with insomnia typically respond to wakefulness in bed by staying in the bed, further pairing the bed with wakefulness and perhaps negative emotions such as anxiety or frustration. Moreover, in an effort to fall asleep or to produce greater amounts of sleep, people with insomnia do activities associated with wakefulness in the bed, such as reading, watching television, gaming, or working on the computer. Performing activities done while awake can create an association with the bed and wakefulness. Thinking about sleep, worries, or anything distressing is predictive of difficulties sleeping (Harvey, 2000; Wicklow & Espie, 2000) and cognitive arousal is seen by insomnia patients as accounting for their insomnia (Lichstein & Rosenthal, 1980). Worrying about sleep and fatigue is characteristic of those with insomnia (Carney & Edinger, 2006) and when in bed and faced with wakefulness, it can perpetuate worries about insomnia and further delay sleep onset. Thus arousal can be a major factor in insomnia that is targeted with CBT-I. For more on how these associations are addressed in CBT-I, see Chapters 5 and 7.

The Sleep of Those With Depression and Insomnia There are several interesting sleep characteristics of those with MDD-I. There are many assumptions, some true and some not, about the sleep of those with MDD. One of the most common assumptions is that MDD-I is characterized by early morning awakenings (EMAs). Although EMAs can occur in depression, when considering all of the Downloaded by [New York University] at 04:37 12 August 2016 insomnia complaints, including increased sleep onset latency and increased wakefulness throughout the night, EMAs have the lowest rate of occurrence (Carney et al., 2007b). Moreover, EMAs may reflect an advancing circadian phase that occurs naturally in aging and can be misdiagnosed as a depression in those with a circadian change only. Because of the sleep changes seen in MDD, there have been many attempts to identify sleep markers that could reliably identify depression. Some of the sleep-related markers include: decreased total sleep time, decreased sleep efficiency (i.e., the proportion of time asleep while in bed), decreased slow wave sleep (SWS), increased REM sleep, and increased wakefulness, including increased sleep onset latency and wakefulness after sleep onset (Benca, Obermeyer, Thisted, & Gillin, 1992). 10 Depression and Insomnia Slow wave sleep is also called delta sleep or N3 because it is stage 3 of non-rapid eye movement sleep (NREM). There may be abnormal proportions of SWS in those with MDD. The number of slow waves in the first NREM period is lower than the waves counted in other NREM periods (Kupfer, Frank, McEachran, & Grochocinski, 1990). This is unusual because normally increased slow waves are seen in the first NREM period and reflect a release of homeostatic pressure. It is possible that people with MDD have decreased homeostatic pressure, given that they tend to have decreased activity and increased time in bed in a 24 hour period, but this can also be seen in insomnia. Another possibility is that rapid eye movement (REM) initially displaces slow waves until later in the sleep period. A decreased slow wave count predicts MDD recurrence and also predicts suboptimal MDD treatment outcomes (Jindal et al., 2002; Kupfer et al., 1990) and one could expect that the consequence of this marker would be less deep sleep, resulting in sleep continuity (e.g., difficulty staying asleep) and sleep quality complaints. Another frequently explored biomarker is rapid eye movement sleep (REMS) related phenomena. There are a collection of findings in MDD of REMS abnormalities including: decreased REMS onset latency (i.e., it appears earlier in the night), as well as increased REMS density. This has been thoroughly reviewed elsewhere (see Benca et al., 1992; Buysse & Kupfer, 1993) so we will review only briefly. Interestingly, markers such as REMS density appear in nondepressed first-degree probands of those with depression and may predict vulnerability to depression (Giles, Biggs, Rush, & Roffwarg, 1988; Giles et al., 1989; Giles, Roffwarg, & Rush, 1987). Increased REMS density is also predictive of negative depression treatment outcomes irrespective of treatment approach (Clark et al., 2000). The fact that several (although not all) antidepressants suppress REMS, as well as the effectiveness of sleep deprivation in the second half of the night where REMS is most pronounced, has been taken by some to mean that REMS must be depressogenic (e.g., Vogel, 1983). REMS deprivation produces immediate antidepres - sant effects although they are reversed on the subsequent recovery night (Vogel, 1975; Vogel, Traub, Ben-Horin, & Meyers, 1968; Vogel, Vogel, McAbee, & Thurmond, 1980). One possible explanation for these phenomena is the internal coincidence model (Wehr & Wirz-Justice, 1980); a model that posits that sleep occurs at a time coincident with circadian vulnerability for mood disturbance. This theory might explain the occurrence of EMAs for some as well as increased REMS. An alternative perspective for the REMS findings, and one that accounts for the finding that insomnia is often prodromal in depression (Baglioni et al., 2011), is the suggestion that the chronic instability of REMS seen in insomnia (Feige et al., 2008) may eventually result in REMS rebound (i.e., a subsequent increase in density) and resultant depression (Riemann et al., 2012). Downloaded by [New York University] at 04:37 12 August 2016 There are also a number of other circadian-related explanations for these phenomena including: 1) The regularity of activities erodes and provides less regular non-photic input into the circadian system (e.g., the social zeitgeber hypothesis (Ehlers, Frank, & Kupfer, 1988)), 2) The sleep phase of those with depression has advanced (Wehr, Wirz- Justice, Goodwin, Duncan, & Gillin, 1979), and 3) There is a problem with the rest- activity ratio (Fulton, Armitage, & Rush, 2000). In humans, with decreasing light, total sleep time and melatonin secretion increases, and activity decreases (Goodwin, Wirz- Justice, & Wehr, 1982), thus the ratio of rest to activity increases. There is some evidence that in teens these effects are mediated by gender (Armitage et al., 2004). If a client is unaware of a phase advance, their bedtime would not change even though sleepiness Depression and Insomnia 11 should occur earlier, there may also be dozing during this period of sleepiness, thus activity would both be increased in this scenario and may actually be less. Most clients with EMAs do not respond to the awakening by getting out of bed for the day, so in this scenario, the rest period is extended, and again, this would increase the ratio of rest to activity. An increase in rest to activity might have a negative impact on interpersonal contact, as people are less likely to socialize when exhausted, and they would be unlikely to have significant social contact in the evening while dozing. Other lines of research have focused on analyzing the EEG data of sleeping patients with MDD with spectral analytic techniques. One line of research has focused on coherence, or the similarity of activity in two areas (Fulton et al., 2000). There is evidence that decreased coherence is associated with MDD and also predicts MDD recurrence (Fulton et al., 2000). One caveat to this finding is that findings are moderated by age and sex (Armitage, Hoffmann, Emslie, Rintelmann, & Robert, 2006). Many of these so- called markers can be characteristic of insomnia with perhaps the exception of REMS abnormalities; thus the specificity of these indices can be somewhat poor. There is a longstanding tradition to view psychiatric disorders as emanating from an imbalance in neurochemicals, and there are purported chemical abnormalities (e.g., cholinergic hypersensitivity (Gillin, Sitaram, & Duncan, 1979) and/or serotonergic or noradrenergic sensitivity (McCarley, 1982)) as key in the sleep disturbances in those with MDD-I. It is unclear which of these can be considered traits versus state-like markers (Berger, Riemann, Höchli, & Spiegel, 1989) moreover some predictions about medications with particular properties (e.g., see Riemann, Berger, & Voderholzer, 2001; Sitaram, 1982) do not always yield data consistent with such theories. Of course, in each of these models, one could posit more depression-specific models as accounting for some of the sleep problems in MDD-I. For example, interpersonal theories could suggest that engaging in less interpersonal activity could decrease stimulation and reinforcers and lead to decreased overall activity, thus increasing the rest to activity ratio. With fewer people around to constrain a schedule towards conventional regularity, there would also be less social zeitgeber input into the clock. Lastly, cognitive etiological models focus on the importance of depressogenic thought leading to avoidance behaviors including less social behaviors. Avoidance would have a negative impact on the circadian system as there would be less exposure to light (perhaps increasing the rest to activity ratio) and less exposure to regular non-photic zeitgebers that provide input into the clock. All theories of depression and MDD-I have mixed evidence or competing explanations; likewise, the failure to discover a universal marker with high sensitivity and specificity is perhaps not surprising given that MDD is a polythetic disorder (for Downloaded by [New York University] at 04:37 12 August 2016 discussion, see Carney & Moss, 2014). A polythetic disorder is a disorder in which there are numerous variations of clinical presentations within the diagnostic criteria. Whereas everyone with Bulimia Nervosa meets the same symptom criteria for the disorder, someone with MDD could have insomnia, hypersomnia, or no sleep complaint at all. Additionally, appetites can be increased, decreased, or unchanged. There may or may not be a disturbance in mood, there may be anhedonia or this may be absent, or one could have both anhedonia and depressed mood. Psychomotor activity may appear significantly sped-up or remarkably slowed down and there may or may not be fatigue. The permutations of presentations become quite large and it is difficult to imagine that all would have the same biological substrates and sleep characteristics. 12 Depression and Insomnia Perhaps a more parsimonious way of conceptualizing etiology in MDD-I clients who present for treatment is to understand that it is not always possible to identify the precipitant cause of the MDD-I so focusing on current perpetuators may be more important.

Etiology in MDD-I As stated previously, Spielman (Spielman et al., 1987a) suggests that there are pre - disposing, precipitating, and perpetuating factors for insomnia, and perpetuating factors are key targets for chronic insomnia treatment. Applying Spielman’s ideas to MDD-I, predisposing factors are factors that increase vulnerability but, in the absence of a stressor, are not associated with an insomnia diagnosis. For example, particular genes, a tendency towards rumination or a particular endogenous chemical environment, may increase the risk for MDD-I, but without a stressor, whether endogenous or environmental, sleep disturbance may be expected to remain at a subclinical level. Broadly speaking, a precipitant is a stressor, which interacts with the predisposing factors to increase sleep disturbance. A strong enough stressor (e.g., a life event) may cause a sleep disturbance severe enough to warrant an insomnia diagnosis, however, the expectation is that when the stressor resolves, so should the insomnia. However, in the clinical histories of clients with MDD-I it is common to hear about the stressor resolving and to the client’s surprise and disappointment, the insomnia does not remit. The answer to why the insomnia does not remit, is that perpetuating factors arise that take over as the main cause of insomnia, and the insomnia becomes chronic. This is often explained to clients during the psychoeducation component of the first CBT-I session because the fact that the insomnia has persisted beyond the resolution of the initial stressor is often taken to mean that the sleep system is broken and the client believes they are powerless to fix it. Explaining that making behavioral corrections to perpetuating behaviors will fix the problem is empowering for clients. Perpetuating factors often originate from coping with the sleep and/or mood symptoms first created by the stressor. For example, when feeling fatigued, people tend to engage in fewer activities in response. When feeling tired, whether it is related to mood or sleep symptoms, people may spend more time at rest and in bed in the 24 hour period. For some, this may relate to how poorly they feel, for others this may relate to a belief that producing more sleep may help to improve their situation, and being in bed for longer periods gives them the best chance to produce more sleep. Some may take sleep aides, whether in the form of alcohol, marijuana, or sedating medications such Downloaded by [New York University] at 04:37 12 August 2016 as diphenhydramine, or sleep medications. A protracted sleep problem can result in a preoccupation about symptoms (Harvey, 2002) and why they are occurring (e.g., symptom-focused rumination) (Carney, Harris, Falco, & Edinger, 2013b; Carney, Harris, Moss, & Edinger, 2010b), and rumination can become a prominent factor in the case. A common perpetuating factor that develops is a belief about sleep effort. Understandably, to “solve” the sleep problem, people with insomnia increase their efforts to sleep and become cognitively inflexible in their belief that one must exert effort to produce and compensate for sleep (Espie, Broomfield, MacMahon, Macphee, & Taylor, 2006). In sum, although insomnia could develop from endogenous factors described above, insomnia may also develop as an acute stress reaction to the onset of Depression and Insomnia 13 depression—additionally, depression could arise from endogenous factors relating to the sleep problem or other sources, or the depression could develop as a stress reaction to chronic insomnia. Now we turn to the three perpetuating factors of chronic insomnia and ask whether those with MDD-I have the same factors—the answer is yes. Those with MDD-I report comparable levels of unhelpful related thinking about sleep (Carney, Edinger, Manber, Garson, & Segal, 2007a), including the belief that sleep requires effort (Kohn & Espie, 2005) as those with insomnia only. Similar to those with insomnia, those with MDD-I also exhibit increased variability in the timing of the sleep period (Kohn & Espie, 2005), as well as other zeitgebers (Szuba, Yager, Guze, Allen, & Baxter, 1992). Again, similar to those with insomnia, those with MDD-I show decreased activity as well as increased time-in-bed (Kohn & Espie, 2005). Lastly, those with insomnia and those with MDD- I similarly show increased arousal (Kohn & Espie, 2005) and symptom-focused rumination (Carney et al., 2013b). Given that: 1) Insomnia is such a prominent, debilitating part of MDD-I, with implications for quality of life and depression outcomes, and 2) MDD-I shares the same perpetuating factors effectively targeted by CBT-I, CBT-I seems particularly well suited for the task of dissemination in this group. Thus the remainder of this book focuses on CBT-I in this group, including, issues related to medication (Chapter 2), treatment delivery issues (Chapter 3), assessment in non- sleep specialty settings (Chapter 4), behavioral and cognitive components of CBT-I (Chapters 5 and 7), as well as how to troubleshoot common CBT-I delivery problems in MDD-I (Chapter 6), rumination strategies (Chapter 8), and combined approaches to MDD-I (Chapter 9). The last chapter follows a case through CBT-I treatment (Chapter 10).

Summary

• Insomnia is costly and important to treat in those with MDD-I. • Although there are innumerous possible precipitants for MDD-I, there are three main causes of chronic insomnia: issues with the circadian or homeostatic systems and/or problems with arousal. – Circadian system problems include schedule variability (e.g., varying rise time) or attempting to sleep during times that conflict with the biological clock. – Homeostatic problems include too little accumulation of sleep drive to sustain deep sleep (e.g., decreased activity or too much time at rest in a 24 hour Downloaded by [New York University] at 04:37 12 August 2016 period). – Arousal problems include conditioned arousal and cognitive and/or physiological hyperarousal. • There are a number of sleep abnormalities in those with MDD-I (e.g., REMS abnormalities) and theories to account for them. Such abnormalities are not characteristic of all clients with MDD-I. • Those with MDD-I share the same perpetuating factors for their insomnia as those with insomnia only, and are thus, good candidates for CBT-I. 2 Non-psychological Treatments for Those with Insomnia and Depression Pharmacological Treatments for Depression

There are a variety of effective pharmacological and other medical treatments for depression; some induce sedation and improve sleep, some increase arousal and interfere with sleep, and others are neutral with respect to sleep. In most cases the effects on sleep are variable, with some individuals experiencing benefits and others experiencing worsening or no effect on their sleep. The American Academy of Sleep Medicine (AASM) has published consensus guidelines for treating insomnia (Schutte- Rodin, Broch, Buysse, Dorsey, & Sateia, 2008). The algorithm from the AASM (see Figure 2.1) suggests to first evaluate cost, and then preference and availability options for Cognitive Behavior Therapy for Insomnia (CBT-I), pharmacologic, and combined treatments. It is of note that NIH consensus guidelines (National Institutes of Health State, 2005) and British Association of Pharmacotherapy guidelines (Wilson et al., 2010) are that CBT-I should be the frontline treatment, and CBT-I is at the top of the AASM algorithm. Once a decision is made to proceed with pharmacotherapy, the algorithm presents a sequence in which the physician begins with a full dose antidepressant and a Food and Drug Administration (FDA)-approved hypnotic such as benzodiazepine receptor agonist (BzRA) or ramelteon. Following a poor sleep response, the second step in the algorithm is to reconsider the diagnosis and consider switching therapy to CBT- I or a combined approach. If there is non-response following this new approach, a different BzRA or ramelteon trial begins. Following a poor response to these approaches, a sedating antidepressant is suggested. Thus, all things considered, the suggestion of a sedating antidepressant is one of the last recommended options because other approaches have better efficacy and safety data available (Riemann et al., 2002; Wilson et al., 2010). Downloaded by [New York University] at 04:37 12 August 2016 One myth about antidepressant therapies is that they improve objective sleep, but patients are unaware of the improvements (Clark, Smith, & Jamieson, 2011). In other words, there are objective improvements but not subjective improvements. There are several problems with this idea. One problem is that it may be unrealistic to expect that clients will continue to adhere to a treatment regimen if they cannot perceive any improvements. Although sedating antidepressants can improve some polysomnographic sleep indices, the results are mixed both in terms of the specific medication and the specific indices of sleep fragmentation and sleep quality. There is also evidence that some antidepressants can worsen or create sleep problems. That said, of greater interest is that the use of objective indices as primary dependent variables in insomnia trials Non-psychological Treatments 15 ignores the essential fact that insomnia is a subjective, not an objective disorder. Diagnosis is based on a subjective patient complaint and there are no quantitative criteria for the disorder, so to emphasize objective indices in insomnia is not appropriate. The goal of therapy is to treat the insomnia complaint, and not a particular index on the PSG. Indeed, ordering PSGs in those with insomnia is not considered within practice parameters for the disorder (Littner et al., 2003). That is, overnight studies are not recommended for routine use in the assessment of insomnia unless there is a suspicion of another disorder such as apnea or periodic limb movements. Incidentally, there is evidence that some of these occult sleep disorders can in fact be caused or made worse by some antidepressants (Rottach et al., 2008). Objective measures of insomnia represent a different, but not a superior construct to prospective subjective ratings. Indeed, this is why sleep diaries are essential in the field of insomnia treatment (Buysse, Ancoli- Israel, Edinger, Lichstein, & Morin, 2006). For more detail on why prospective self-report measures (i.e., the Consensus Sleep Diary) are preferred over objective indices, see Chapter 4. These issues above notwithstanding, below we will briefly review the antidepressant and sleep literature. There are several pharmacologic agents with established efficacy for depression, including monoamine oxidase inhibitors (MAOIs), tricyclics, selective serotonin reuptake inhibitors (SSRIs), Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs), and atypical antidepressant medications. MAOIs are infrequently used because they are difficult medications to utilize given that the patient has to follow particular strict dietary restrictions lest they risk significant and potentially dangerous side effects. Given the uncommon use of MAOIs, we will focus on the other four classes.

Cognitive Behavioral Insomnia Therapy (CBT-I) possible?

No. Yes.

Weigh clinical factors. All things considered, Cognitive Behavior Therapy for sequencing is: Insomnia (CBT-I)

Short-intermediate acting benzodiazepine receptor agonist or ramelteon nonresponse •symptom pattern • treatment goals Downloaded by [New York University] at 04:37 12 August 2016 Switch to other short-intermediate acting • past treatment responses benzodiazepine receptor agonist or ramelteon • patient preference nonresponse • cost • availability of other treatments • comorbid conditions Sedating antidepressant (e.g., TCA, doxepin) • contraindications • medication interactions nonresponse • side effects

Atypical antipsychotic or anti-epilepsy (e.g., gabapentin, olanzepine)

Figure 2.1 American Academy of Sleep Medicine pharmacotherapy treatment algorithm 16 Non-psychological Treatments Tricyclic antidepressants: Although there is good evidence for the use of tricyclic medications in the treatment of depression (Arroll et al., 2005), there are concerns with safety, so the use of these medications requires a cost-benefit analysis. Although tricyclic medications are primarily used to treat depression, they are sometimes used “off-label” for sleep. Off-label is the term applied when a medication is used for a problem for which there is no specific indication. There is one randomized controlled trial (RCT) for tricyclics (i.e., trimipramine) and insomnia (Riemann et al., 2002). In the Riemann and colleagues’ trial (2002) there was evidence for increased sleep efficiency only, as well as some indices of improvement in subjective appraisal of sleep. Whereas some believe that antidepressant effects may be mediated by REM suppression, trimipramine is one of the few drugs not known to suppress REMs. Based on the one RCT, the British Association for Psychopharmacology Consensus Guidelines on Insomnia concluded that evidence for tricyclics for insomnia was “limited” and that there may be safety issues and carry-over effects of concern for daytime driving and safety (Wilson et al., 2010). An additional reason tricyclics are seldom used is the lethality potential in an overdose. Both insomnia and depression are independent predictors of suicide (see Woznica et al., 2014) so overdose must be a heavily weighted clinical factor. Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs are efficacious, commonly prescribed antidepressant medications that inhibit the reuptake of the neurotransmitter serotonin. Commonly prescribed SSRIs for depression are: fluoxetine, citalopram, escitalopram, and sertraline. SSRIs are widely used because of their favorable side effect profiles relative to older medication classes. The effects of SSRIs on sleep are variable. About one third of those treated with SSRIs experience polysomnographic (PSG) verified worsening of sleep, including decreased slow wave sleep and reduced efficiency of sleep (Armitage, 2000). Disruptions in sleep have been reported as long as 30 weeks after SSRI discontinuation (Armitage, Yonkers, Cole, & Rush, 1997; Keck, Hudson, Dorsey, & Campbell, 1991; Minot, Luthringer, & Macher, 1993; Trivedi et al., 1999). Subjective assessment of insomnia using sleep items on depression inventories have revealed modest improvement for some (Asnis et al., 1999; Fava et al., 2006) and worsening in others (Zajecka et al., 1999). Although SSRIs are effective for depression, they are generally not helpful for insomnia, as insomnia is a residual problem after depressive recovery with SSRIs (Carney et al., 2007a; Nierenberg et al., 1999). Thus, because insomnia is sometimes caused by and often unresolved after SSRI treatment, the use of SSRIs alone cannot be considered a sufficient strategy for those with comorbid insomnia and depression. Instead, the independent targeting of both depressed mood and insomnia is a more efficient, comprehensive alternative. A few Downloaded by [New York University] at 04:37 12 August 2016 trials have examined pairing SSRIs with another medication for enhancing overall treatment response. For example, combining a SSRI with trazodone improves insomnia to a greater degree relative to using an SSRI alone, although there is no advantage with respect to depression outcomes (Kaynak, Kaynak, Gözükırmızı, & Guilleminault, 2004; Nierenberg, Adler, Peselow, Zornberg, & Rosenthal, 1994). Despite improvement in insomnia, given the lack of additional antidepressant benefit and the presence of several safety issues (for more see atypical antidepressants below), there are reasons to pause in considering trazodone as an adjunct medication. An alternative is to combine SSRIs with a U.S. FDA approved sleep medication. There are two studies com - bin ing SSRIs with approved hypnotic medications with promising results for both Non-psychological Treatments 17 depression and sleep (Asnis et al., 1999; Fava et al., 2006). Of note, combining fluoxetine and eszopiclone improved sleep to a greater degree than fluoxetine alone, but more importantly, the combined group had greater depression outcomes (Fava et al., 2006). Likewise depression and sleep were improved in the Asnis et al. (1999) study, although there was a worsening of sleep after discontinuation of the hypnotic. In both trials, there were short treatment periods so it is unclear whether this approach is effective in the long run. One additional note is that antidepressant medications can cause or worsen restless leg syndrome (RLS) or periodic limb movement disorder (PLMD) (Hoque & Chesson, 2010) as well as bruxism (Ellison & Stanziani, 1993). Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs): SNRIs are efficacious antidepressant medications that inhibit the reuptake of both serotonin and norepinephrine. Like SSRIs, they are preferentially used because of their relatively safe profile. The three most common SNRIs are: duloxetine, venlafaxine, and desvenlafaxine. SNRIs are comparable to SSRIs with respect to depression efficacy. However, there is some evidence that SNRIs have less of an impact than SSRIs on self-reported sleep improvement in those with depression (Pigott et al., 2007). However, in Pigott et al. (2007) sleep was evaluated using only single item questions from depression question - naires, not insomnia-specific questionnaires, and the differences did not reach statistical significance; so it is unknown as to whether SNRIs yield poorer sleep outcomes than SSRIs. As with SSRIs, insomnia can be a side effect of SNRIs and there is no reason to think that residual insomnia wouldn’t be a significant problem as well. Nonetheless, SNRIs are relatively well tolerated, efficacious, and their impact may be increased by adding an effective hypnotic medication. As with SSRIs, SNRIs can cause or exacerbate RLS and periodic limb movements in sleep (PLMS) (Hoque & Chesson, 2010). Atypical antidepressants: Atypical antidepressants have different pharmacokinetics than the commonly used SSRI and SNRIs. Below we will discuss two atypical anti - depressants: trazodone and mirtazapine and their use in those with MDD-I. At low doses, trazodone will not have much of an antidepressant effect, but can have sedation as a side effect, and thus was tested as a sleep aide for antidepressant-induced insomnia. Indeed, pairing low dose trazodone with a SSRI improves sleep to a greater degree than SSRI only (e.g., Kaynak et al., 2004; Nierenberg et al., 1994; Nierenberg & Keck, 1989; Zornberg & Rosenthal, 1994). Presumably because of its effectiveness as a treatment for the sleep-iatrogenic effects of antidepressant medications, trazodone has been used off-label use as a hypnotic despite the paucity of effectiveness and safety data in insomnia (e.g., Walsh & Uestuen, 1999). Mendelsohn (2005) reviewed the literature and Downloaded by [New York University] at 04:37 12 August 2016 concluded that the risk benefit ratio for selecting trazodone was uncertain. This was because the evidence is limited (e.g., studies available are small and with poor method - ology) and there are safety issues (e.g., sedation, psychomotor changes, and cardiac issues). These sentiments have been echoed by the leaders in sleep psychiatry in many other reviews and in guidelines, sedating antidepressants are low on the options list (Schutte-Rodin et al., 2008). Although there have been no new compelling trazodone studies, this drug frequently continues to be used off-label in those without depression. The British Association for Psychopharmacology Consensus Guidelines on Insomnia concluded that evidence for trazodone was “limited” and there is cause for concern about carry-over effects and safety (Wilson et al., 2010). 18 Non-psychological Treatments Mirtazapine has good efficacy in treating depression and one of its side effects is sedation. There are no studies of mirtazapine in insomnia without depression; therefore the somewhat common practice to treat only insomnia is considered off-label. There are however a number of studies evaluating sleep improvements in depression (Aslan, Isik, & Cosar, 2002; Winokur et al., 2000, 2003). Although total sleep time and sleep efficiency appear to be improved with this medication, these studies are limited by measurement issues (e.g., using only sleep items from depression measures or sleep measures with dubious psychometrics in comorbid groups) (Aslan et al., 2002; Hartmann, Carney, Lachowski, & Edinger, 2015; Winokur et al., 2000, 2003). Of greater concern is that the sedation can be severe enough to be associated with functional and psychomotor impairments, as well as impaired driving (Radhakishun, van den Bos, van der Heijden, Roes, & O’Hanlon, 2000; Wingen, Bothmer, Langer, & Ramaekers, 2005). Another concern with mirtazapine is that, as with many antipsychotic medications, there is risk for significant weight gain, increase in body fat mass, and leptin concentration (Laimer et al., 2006). Weight gain of this sort might be of particular concern in those prone to or with comorbid sleep apnea. Finally as with SSRIs and SNRIs, mirtazapine can cause or exacerbate RLS and PLMS (Hoque & Chesson, 2010). Many antidepressants may also produce daytime sedation and this common side effect has been linked to study participant withdrawals from sedating antidepressant trials (e.g., Metz & Shader, 1990). An additional unfortunate consequence of this side effect is that the increase in daytime sedation may interact with the sleepiness generated by the sleep restriction recommendations in CBT-I, and thus, may create the potential for a dangerous situation. In other words, delivering CBT-I to patients on sedating antidepressants warrants extra caution because of concerns of falling asleep during dangerous situations, such as driving. There may be other reasons (i.e., other than safety) to be concerned with using medication solely because it produces sedation as a side effect. The most common complaint in insomnia is daytime fatigue, and feeling fatigued can trigger rumination in those with insomnia (Carney et al., 2006, 2010b; Carney, Moss, Lachowski, & Atwood, 2013c). Figure 2.2 shows how medication with a side effect of daytime sluggishness can trigger preservative thinking about their sleep problem (i.e., symptom focused rumination). Symptom-focused rumination in insomnia, as well as MDD-I, is characterized by thinking about how badly it feels to be exhausted as well as thinking about the cause of the symptoms. In both insomnia and MDD-I, patients tend to presume that the sole cause of feeling tired or sluggish is the insomnia (Harris & Carney, 2009), so sleep worry, effort, and preoccupation become increased. Indeed, thinking repeatedly about sleep is the best predictor of sleep onset latency problems Downloaded by [New York University] at 04:37 12 August 2016 (Wicklow & Espie, 2000). Thinking repeatedly about exhaustion during the day further increases the tendency towards selective monitoring for feelings of sluggishness, and narrows attention on confirmatory examples that functioning is impaired (Harvey, 2002). Thus, daytime sedation from medication can inadvertently perpetuate insomnia in some, even when sleep itself may look objectively better with CBT-I. In other words, when delivering CBT-I, if daytime sedation remains (i.e., because of the sedating antidepressant), the patient may not appreciate improvements in sleep, even when sleep is verified with objective or self-reported indices such as the sleep diary. It can be difficult for patients to appreciate an improvement in their sleep because the number one complaint in insomnia is often daytime fatigue; thus, daytime sedation can be distressing Non-psychological Treatments 19

Medication Sluggishness

Increased Thoughts anxiety about about mental insomnia cloudiness

Rumination Presume about cause cause is of insomnia sluggishness

Figure 2.2 Putative relationship between sedating medications and rumination

to insomnia sufferers (Harris & Carney, 2009). Thus, there are many reasons sedating antidepressants are one of the last options in the sequence in the list of treatment options presented in insomnia treatment algorithms (see Figure 2.1). St. John’s Wort: St. John’s Wort is not an approved, regulated medication for MDD, but is taken by many patients. The active ingredient in St. John’s Wort is hypericum perforatum. Large, controlled studies in those with moderate to severe MDD do not support hypericum as more effective than placebo (Hypericum Depression Trial Study Group, 2002; Montgomery, Hübner, & Grigoleit, 2000; Shelton et al., 2001). However some studies with mild depression report that hypericum produces comparable effects to standard antidepressant medications, but with a more favorable side effect profile (Linde, Berner, Egger, & Mulrow, 2005). In addition to questionable efficacy in clinically significant depressions, an additional concern with St John’s Wort, is that it may increase Downloaded by [New York University] at 04:37 12 August 2016 photosensitivity (Brockmöller et al., 1997; Lane-Brown, 2000). Photosensitivity may be of concern for sleep in St. John’s Wort users because it could delay melatonin release as well as sleep onset.

Other Non-Psychological Treatments for Depression Electroconvulsive Therapy (ECT): ECT is an effective treatment for depression in which electricity is transmitted through electrodes on the scalp to the brain to induce cortical seizure activity. Effect sizes for ECT are large (The UK ECT Review Group, 2003). Although it is more effective than pharmacotherapy, it is less frequently used because 20 Non-psychological Treatments of the side effects (mainly memory impairments) and because of low patient preference. There are no studies specifically investigating the effects of ECT on sleep, but there appear to be no specific effects, disruptive or restorative, on sleep per se. Some studies on ECT have reported outcome data for various indices of sleep. One study reported that ECT increased core body temperature and increased circadian amplitude, which was taken to mean that circadian rhythm functioning improved (Szuba, Guze, & Baxter, 1997); however this finding has not been replicated. Additionally, in rats ECT did not exert an effect on the circadian pacemaker (Anglès-Pujolràs et al., 2009). There are no studies that have looked at the combination of ECT with hypnotics or CBT-I, or whether this has any advantage over CBT-I alone or combination therapy with medication for MDD-I. Transcranial Magnetic Stimulation (TMS): TMS involves placing a coil on the scalp so that magnetic pulses (similar to those produced in MRI) can change the magnetic field in the prefrontal cortex of the brain and stimulate activity. Meta-analyses suggest this is an effective treatment and that effect sizes are comparable to that of antidepressant medication (e.g., Berlim, Van den Eynde, & Daskalakis, 2013). There appear to be very few side effects; the most common is scalp discomfort, but there are rare reports of seizure or mania. There are no differences in sleep between TMS-treated and sham-treated patients so there does not appear to be a TMS-mediated sleep change (improvement or worsening) (Rosenquist, Krystal, Heart, Demitrack, & McCall, 2013). Vagus Nerve Stimulation (VNS): VNS is a treatment for depression in which a subcutaneous stimulation device is implanted in the chest, and the generator produces intermittent pulses into the vagal nerve. The stimulation of the vagal nerve has mood improving properties. Although it has Federal Drug Administration (FDA) approval for chronic, recurrent depressions (George et al., 2005), it is a costly procedure, with all the risks associated with surgery. Any study evaluating insomnia after VNS has been limited by assessing an insomnia symptom with a single item on an invalidated sleep tool (i.e., an adverse event inventory). One exception is a study of sleep architecture after VNS (Armitage, Husain, Hoffmann, & Rush, 2003). One paper cited this study as showing that VNS improves sleep architecture (Eitan & Lerer, 2006) however, it is important to note that the report of decreased N1 and time awake was not statistically significant and there was an increase in light transition stage of sleep (e.g., N2) (Armitage et al., 2003). One important negative consequence of VNS is a worsening of OSA (Ebben, Sethi, Conte, Pollak, & Labar, 2008); thus, an evaluation of OSA and con - current treatment with positive airway pressure (PAP) devices is needed if considering this treatment. Downloaded by [New York University] at 04:37 12 August 2016

Pharmacological Treatments for Insomnia

Hypnotics Sleep medications approved by Health Canada or the Federal Drug Administration (FDA) are considered an effective treatment option for insomnia. A list of approved medications is contained in Table 2.1 that follows later. Generally, approved medications fall under benzodiazepine or non-benzodiazepine categories. Benzodiazepines are a class of medications that facilitate gamma aminobutyric acid (GABA). GABA is thought to Non-psychological Treatments 21 have a calming effect on the brain and therefore may be important in the onset of sleep. Benzodiazepines work as benzodiazepine receptor agonists that target GABA alpha receptors. Examples include the first five in Table 2.1 (e.g., estazolam, flurazepam, temazepam, triazolam and quazepam). There are also non-benzodiazepine medications that do not have a benzodiazepine structure but operate in similar fashion to benzodiazepines, in that they are GABA agonists that target very specific alpha receptors. Examples include zolpidem or eszoplicone (Z-drugs). Note in Table 2.1 that the binding for traditional benzodiazepines (the first five) is for GABA receptors generally, but this represents nonspecific binding to a receptor. In contrast, the Z-drugs (the next four on the list) bind to very specific GABA receptors in the brain. For example, zolpidem binds to GABA A alpha 1 receptors only. Z-drugs were developed to have a better side effect profile than the benzodiazepines. The thought was that a more specific binding would lead to fewer side effects. This is generally true in that the side effects are less severe for Z-drugs (Buscemi et al., 2007) but there are a variety of potential negative side effects with these medications that limit their attractiveness as an optimal solution for all people with insomnia. These include carry-over daytime sedation, tolerance, rebound insomnia upon discontinuation, or in rare cases, the emergence of parasomnia like behaviors during the night while asleep including sleepwalking, or sleep sex. Further, epidemiological studies show that road accidents are increased in people taking benzodiazepines or zopiclone (Barbone et al., 1998; Neutel, 1995). In contrast, it is important to note that there is no increased risk for auto accidents in those with unmedicated insomnia. There are also issues with a sensation of daytime sedation and cognitive issues, e.g., difficulty in concentrating, remembering, etc. As a result, there are now regulations requiring warnings on these medications about driving and the lowest recommended doses were reduced, especially for woman (United States Food and Drug Administra - tion, 2013, 2014). Additionally, the FDA (e.g., United States Food and Drug Admin- istration, 2007) issued a ruling mandating manufacturers to place warnings about parasomnias and to notify patients about the changes.

Remelteon Perhaps because patients became wary of sleeping pills, there has been increased research and development in the pharmaceutical industry to produce medications different from the benzodiazepine agonists on the market. One new drug that emerged was a melatonin agonist called ramelteon. To gain approval for the labeling as a sleep aid, remelteon had to demonstrate efficacy. There is published evidence for this drug Downloaded by [New York University] at 04:37 12 August 2016 for sleep onset insomnia, but not maintenance insomnia. The side effects include sedation (when taken during the day), and slowing in performance (Mets et al., 2011). There is also a mild increase in prolactin for women taking it for six months (Richardson & Wang-Weigand, 2009).

Doxepin Doxepin is a prescription medication that is a histamine (H1) receptor antagonist, or antihistamine. There is some evidence of improvement in maintenance insomnia although this drug doesn’t appear to be consistently effective by patients’ appraisal (Hajak 22 Non-psychological Treatments

et al., 2001) and there is evidence of rebound insomnia. Side effects of doxepin include: sedation, nausea, upper respiratory tract infection, weight gain, constipation, urinary retention, dry mouth, and blurred vision. Doxepin is highly toxic in an overdose attempt (e.g., (Hawton et al., 2010)) and both MDD (Bertolote, Fleischmann, De Leo, & Wasserman, 2004) and Insomnia Disorder confer risk independently for suicide (Woznica et al., 2014), so this can be a dangerous drug in these populations. Table 2.1 also lists the half-life of each of the medications. The half-life of a medication refers to the time it takes for the concentration of the drug in the body to be metabolized by half and therefore to lose half of its effectiveness (i.e., half of the drug is used up). A very long half-life would be most effective for people with problems staying asleep throughout the night (e.g., dalmane). A long half-life is also associated with increased sedation during the day as the drug remains in the system. A short half-life is most commonly used for those with sleep onset insomnia only. The short half-life would limit the leftover effects of the medication the next day but would be less effective if the patient woke up in the middle of the night. In summary, it should be noted that the hypnotic medications specifically designed to target insomnia have established efficacy for its treatment (Schutte-Rodin et al., 2008), but they also confer some degree of risk with regard to side effects. Moreover, CBT-I has demonstrated effectiveness equal to that of hypnotics in the short run, but a greater durability of effectiveness over time, which is why it is considered the frontline recommended treatment for a chronic insomnia (National Institutes of Health, 2005).

Off-label and Over the Counter Medications There are a number of over-the-counter (OTC) medications designed for insomnia or medications with sedation as a side effect, that are used off-label for insomnia. The most common example of this is the allergy medication diphenhydramine. Diphenhydramine is an antihistamine and histamines are important in maintaining wakefulness. Thus, blocking histamines can produce a side effect of sleepiness or sedation, so it seems intuitive that some people use it for insomnia. However, such medications can also

Table 2.1 FDA-approved sleep medications

Generic name Binding Lowest therapeutic Half-life (hours) dose (mg)

Downloaded by [New York University] at 04:37 12 August 2016 Estazolam Nonspecific 1 10–24 Tiazolam Nonspecific 0.125 2–6 Temazepam Nonspecific 15 8–20 Flurazepam Nonspecific 15 48–120 Quazepam Nonspecific 7.5 39–73 Eszopliclone GABA α 16 Aα1,2,3 Zaleplon GABA A 1 51 Zolpidem GABA α 5 1.5–2.4 Aα1 Zolpidem-ER GABA A 1 6.25 1.6–4.5 Ramelteon MT1, MT2 8 0.8–2 Silenor H1 3 15–31 Source: Adapted from Walsh and Roth (2011); Krystal (2011) Non-psychological Treatments 23 produce a paradoxical side effect of anxiety and restlessness which would clearly worsen or even precipitate insomnia. Other side effects include dizziness, blurred vision, constipation, and urinary retention. Ultimately antihistamines are not recommended in the treatment of chronic insomnia due to the relative lack of efficacy and safety data (National Institutes of Health, 2005).

Melatonin Melatonin is a hormone excreted in the evening after the sunlight goes down that sets the stage for sleep several hours later. Melatonin is subject to environmental input such that exposure to evening light will delay the release of onset and this is associated with taking a longer time to fall asleep. That said, there is no evidence to date of any melatonin problems in insomnia. There is a report that circulating levels of melatonin decrease with advancing age (e.g., Iguchi, Kato, & Ibayashi, 1982) but it is unclear if these results are clinically meaningful (i.e., the significance of “decreased” melatonin is unclear). Oral melatonin supplementation has been demonstrated to be effective in a Circadian Rhythm disorder called Delayed Phase Syndrome. In those with a delayed sleep phase, their entire rhythm is shifted many hours later than most (i.e., they become sleepier many hours later than is conventional and they rise many hours later than is conventional, for more see Chapter 3). For those with this disorder, melatonin release occurs much later and thus, sleep onset is delayed. To correct this problem, melatonin properly timed in the evening can help to shift or advance their cycle earlier. Despite not suffering from a circadian rhythm disorder, some people with insomnia take melatonin before bed as a sleep aide. There are several problems with this practice. First, melatonin takes up to 2 hours to become effective. Second, when taken immediately before getting into bed, endogenous melatonin would have already been present in the brain for several hours and would therefore exert no effect. Taking melatonin before bed does not improve sleep at night because when endogenous melatonin is already present in the brain, there is no additive benefit of introducing exogenous melatonin (i.e., a pill) (Wyatt, Dijk, Cecco, Ronda, & Czeisler, 2006). In contrast, consuming oral melatonin in the early evening, results in sleepiness several hours later (because there was no melatonin present in the brain when the pill was taken) (Wyatt et al., 2006). Thus, it can be said that melatonin is a decent chronobiotic, but not a very good hypnotic. In other words, it can be useful in shifting circadian phase but not so useful in putting people to sleep. In the few supporting studies for melatonin, the effects are so small that it is questionable that the benefits are of any real clinical utility. For example, Downloaded by [New York University] at 04:37 12 August 2016 one meta-analysis examined positive studies and reported a mean increase of sleep efficiency of 2 percent, an increase in total sleep time across the entire night of only 12 minutes, and a decrease in sleep onset latency of only 4 minutes (Brzezinski et al., 2005). Although there may be some statistical significance for some of these findings, these may not be particularly meaningful to the patient. Moreover there are studies reporting negative findings for melatonin (i.e., that sleep worsens). In Buscemi and colleagues’ (2006) meta-analysis, melatonin’s hypnotic effects were negative when given before bed (Buscemi et al., 2007). Therefore although the public at large may be increasingly using melatonin to help with insomnia, there is no real supporting evidence for its efficacy as a hypnotic. 24 Non-psychological Treatments Valerian Root Valerian root purportedly improves anxiety and promotes sedation. It appears to work by facilitating adenosine and amino acids such as GABA. Valerian root has shown some positive effects for sleep in healthy sleepers but not in those with insomnia. NIH’s Complementary Medicine branch has concluded that there is not enough evidence from well-designed studies to confirm efficacy and there is a lack of information about the long-term safety of valerian (National Center for Complementary and Integrative Health, 2012). Valerian can cause mild side effects, such as tiredness the morning after its use, headaches, dizziness, and gastrointestinal symptoms. Additionally there is wide variability in how valerian, and other non-regulated substances are prepared, and the variability in the extraction process and form. This is an important consideration because whether it is dry or aqueous and whether alcohol is used in the process affects the active ingredients. Moreover, some types of valerian involve valepotriates which have been linked to cytotoxicity (cell death) and carcinogenic (i.e., cancer) potential (Houghton, 1999). The bottom line is that because such preparations are not regulated, patients may not know what they are ingesting.

5-Hydroxytryptophan (5-HTP) 5-HTP is an amino acid that is the intermediate step between tryptophan and 5-HT. Because of the role of 5-HT (serotonin) in sleep, it makes sense that one might consider boosting serotonin to help sleep. There is a paucity of rigorous studies testing 5-HTP thus, there is no scientific evidence for the use of 5-HTP in insomnia (Meolie et al., 2005).

Cognitive Behavior Therapy for Insomnia (CBT-I) versus sleep medications CBT-I and approved sleeping medications have comparable efficacy; that is, they both typically produce medium to large effect sizes across a variety of sleep indices (Smith et al., 2002). There are, however, a few ways in which they diverge. For example, unlike pharmacotherapy, the treatment gains achieved with CBT-I endure for years after the end of active therapy (Edinger et al., 1996; Edinger, Hoelscher, Marsh, Lipper, & IonescuPioggia, 1992; Edinger & Sampson, 2003; Edinger, Wohlgemuth, Radtke, Marsh,

Downloaded by [New York University] at 04:37 12 August 2016 & Quillian, 2001; Espie, Inglis, Tessier, & Harvey, 2001; Morin, Colecchi, Stone, Sood, & Brink, 1999a). CBT-I is also rated as more “acceptable” to patients than hypnotic medications (Morin, Gaulier, Barry, & Kowatch, 1992; Vincent & Lionberg, 2001). There is also greater satisfaction with CBT-I than hypnotic medications (Morin et al., 1999a). CBT-I also avoids issues like medication interactions or physiologic side effects. This is why CBT-I is regarded as the frontline recommended treatment for chronic insomnia (National Institutes of Health, 2005). For more on medication issues (i.e., whether hypnotic discontinuation is necessary for CBT-I), see Chapter 3. Non-psychological Treatments 25 Summary

• There are several efficacious pharmacological or other medical treatments for depression, and these treatments can have positive, negative, variable or no effects on sleep. • All antidepressant medications can have insomnia as a potential side effect. • Some antidepressants, antihistaminic agents, antipsychotics, and vagal nerve stimulation can cause or worsen other sleep problems such as periodic limb move - ments, restless leg syndrome, or bruxism. • St. John’s Wort may increase photosensitivity which can create a delay in the circadian phase and cause or worsen sleep onset problems. • CBT-I has comparable efficacy to sleep medications with several advantages over sleep medications for chronic insomnia. • The American Academy of Sleep Medicine recommends 1) CBT-I for chronic insomnia, however, if it is unavailable, 2) consider a short-intermediate benzodiazepine receptor agonist or remelteon, 3) when this agent is ineffective, switch to another intermediate benzodiazepine receptor agonist or remelteon, and if these are ineffective, consider 4) an agent with sedating side effects (e.g., a sedating antidepressant). • Sedating agents warrant caution in combination with the Sleep Restriction portion of CBT-I as there are pre-existing safety concerns with these medications. Sedating agents may have a negative effect on the ability of the patient to appreciate treat - ment improvements, and they could potentially increase rumination. Downloaded by [New York University] at 04:37 12 August 2016 3 Cognitive Behavior Therapy for Insomnia (CBT-I) Treatment Considerations

Cognitive Behavior Therapy for Insomnia is an empirically based treatment focused on addressing research-identified maintaining factors for insomnia. It is a multicomponent treatment made up of techniques that have been empirically validated. One advantage of the CBT model is that it is applicable across a wide array of diagnostic categories. This is because the model is based on the concept, that despite the variety of precipitating events that might have initially caused the insomnia, the factors that tend to maintain the chronicity of the disorder are similar from case to case and are responsive to behavioral and cognitive change strategies. The idea is that in any case, if the maladaptive perpetuating factors are present, then alterations of these factors will lead to reductions in symptoms. Therefore, the debate about biological versus psycho - logical etiologies determining treatment modality is somewhat of a moot point since we know that there are many pathways to disorder and recovery. Even for biological sleep regulatory systems such as the circadian and homeostatic systems, we know that behavioral and environmental input can have profound corrective or disruptive influence. The evidence for CBT-I is strong and the effect sizes are similarly large when compared with pharmacotherapy. CBT-I is the frontline recommended treatment in those with chronic insomnia (Howell et al., 2012; National Institutes of Health, 2005; Wilson et al., 2010) because of the impressive short-term effects and because it is so brief, durable, without polypharmacy risks, patient-preferred (Morin et al., 1992; Vincent & Lionberg, 2001), and an excellent economical choice. Despite criticisms that it is not widely available, there have been excellent gains made in the past few years with respect to training (e.g., Manber et al., 2012), owing in part to an increase in workshop and training opportunities, and a CBT-I training program in the Veteran’s Affairs Administration. Moreover, there are online and telehealth treatment programs Downloaded by [New York University] at 04:37 12 August 2016 with support (Espie et al., 2012; Ritterband et al., 2009; Vincent & Walsh, 2013). Lastly, we have a large number of effectiveness trials demonstrating that non-sleep specialists can effectively deliver this treatment (Buysse et al., 2011; Espie et al., 2007; Jungquist et al., 2010). There has been discussion of utilizing stepped care modes of delivery for CBT-I in which large numbers of patients could be introduced into early steps such as self-help strategies and online programs, and, as needed, funnel through to steps that might include groups run by paraprofessionals, and eventually treatment by a therapist certified in behavioral sleep medicine for the more complex cases (Espie, 2009). Despite the success of CBT-I there are those who do not respond to this treatment. There is a paucity of moderator research investigating the variables that might be Cognitive Behavior Therapy for Insomnia 27 influencing suboptimal response—a necessary step in refining the treatment. Addition- ally, there are currently a number of contraindications for CBT-I. For instance, sleep disorders characterized by excessive sleepiness are a contraindication for CBT-I because in the early stages of treatment the therapy tends to create sleepiness, which potentially makes sleepy clients vulnerable to accidents (e.g., falls, motor vehicle, or occupational accidents). Thus, untreated or suboptimally treated sleep-disordered breathing, narco - lepsy, or periodic limb movement disorder with accompanying excessive daytime sleepiness presents a challenge for CBT-I. Therapists should proceed with extreme caution to plan for daytime sleepiness (i.e. disallow driving until stable) or rule out the treatment entirely. In those with sleep apnea, it is important to determine the level of adherence with their PAP device. Ideally, one would want clients to use their device no greater than 75 percent of nights for a minimum of 4 hours per night at the prescribed pressure in order to consider the apnea as treated. Such devices typically have a feature that allows them to print out their usage, so adherence is easily verified. Another contraindication relates to when there are more important factors worthy of treatment. For example, when a client is in medical or psychiatric crisis, it is not appropriate to begin a highly demanding sleep-focused therapy. Attending to and resolving the crisis is necessary before proceeding with this treatment. For example, in clients who present as actively suicidal, it would be essential to first assure the client’s safety and wait for stability in mood before carrying out CBT-I. In addition to crisis, stability of treatment for the co-occurring psychiatric or medical condition is recommended. If the client has poorly controlled diabetes or thyroid issues, it is recommended to wait until the client is on a stable dose or treatment plan before proceeding with CBT-I. The same could be said for clients with poorly controlled depression. It may be sensible to hold off on CBT-I until a depression medication regimen is established that will allow for more stable mood and a better assessment of the client’s sleep and daytime symptoms on the medication. Similarly, active substance abuse or withdrawal are contraindications for CBT-I. Active substances greatly impact sleep, as does withdrawal. Once stability is established, CBT-I can be initiated, although this is one area where the effect sizes for CBT-I may be diminished in those with extensive abuse histories. Finally, conditions sensitive to sleep deprivation may be a contraindication or an indication to scale back on any part of the treatment associated with sleep deprivation (e.g., sleep restriction). Panic attacks, seizures, mania, and parasomnias can all become exacerbated with increased sleep deprivation so a cost-benefit analysis is necessary to determine if CBT-I is advisable or if the focus of treatment should be on stimulus control and counter arousal rather than sleep restriction therapy. That said, it should be noted that Downloaded by [New York University] at 04:37 12 August 2016 even in the good practice of stimulus control, there may be some sleep deprivation early in treatment as the client remains out of bed for longer periods of time, waiting to become sleepy and not compensating for any lost sleep by sleeping in, napping, or going to bed early. The bottom line is that whenever practicing CBT-I, especially with the disorders discussed above, it is always recommended to monitor for client sleepiness, take necessary precautions, and make adjustments to therapy as needed. In Chapter 2 we reviewed some of the costs and benefits to pharmacotherapy for insomnia. Given these considerations, CBT-I appears to be a particularly viable treat - ment for MDD-I since there is no risk of polypharmacy, it is as effective as hypnotic medication, and it produces superior, durable long-term improvements (Edinger et al., 28 Cognitive Behavior Therapy for Insomnia 1992, 1996; Edinger & Sampson, 2003; Edinger, Wohlgemuth, Radtke, & Marsh, 2004b; Morin et al., 1999; Morin, Kowatch, Barry, & Walton, 1993; Morin, Kowatch, & Wade, 1989; Morin, Stone, McDonald, & Jones 1994b; Perlis et al., 2000). Although there are some variations, at the core of CBT-I treatment are Stimulus Control (Bootzin, 1972) and Sleep Restriction Therapy (Spielman, Saskin, & Thorpy, 1987b), which are empirically validated approaches designed to eliminate conditioned bedtime arousal, increase sleep drive and correct circadian abnormalities. CBT-I also targets the belief that one must engage in compensatory sleep behaviors (i.e., behaviors linked to chron - ically poor sleep; Edinger et al., 1992, 1996, 2001, 2004b; Edinger & Sampson, 2003). Thus far, research has suggested that CBT-I is highly safe and effective with various insomnia patients including those with Primary Insomnia (Edinger et al., 1992, 1996, 2001, 2004b; Edinger & Sampson, 2003; Morin et al., 1994b, 1999a), MDD (Edinger et al., 2009a; Kuo, Manber, & Loewy, 2001; Manber et al., 2008; Morawetz, 2001; Vallieres, Bastien, Ouellet, & Morin, 2000), Periodic Limb Movement Disorder (Edinger et al., 1996), mixed psychiatric or medical disorders (Edinger et al., 2009a; Morin et al., 1994b), cancer (Berger et al., 2002, 2009; Fiorentino et al., 2009; Quesnel, Savard, Simard, Ivers, & Morin 2003; Ritterband et al., 2012; Savard, Simard, Ivers, & Morin, 2005; Spiegelhalder, Espie, Nissen, & Riemann, 2008), and pain-related syndromes (Currie, Wilson, Pontefract, & deLaplante, 2000; Edinger, Wohlgemuth, Krystal, & Rice, 2005; Jungquist et al., 2010; Rybarczyk, Lopez, Benson, Alsten, & Stepanski, 2002; Vitiello et al., 2013). CBT-I also appears to affect the neurophysiology implicated in insomnia, as it results in decreased high frequency activity and increased slow wave activity in the EEG (Cervena et al., 2004). Moreover, contrary to the above-noted findings with hypnotic treatment, the gains achieved during CBT-I appear to endure long after the end of active therapy.

CBT-I in Those with Depression Those with MDD-I manifest the type of treatment targets for which CBT-I has been specifically designed (Kohn & Espie, 2005). For example, those with MDD-I have comparable levels of unhelpful beliefs about sleep, schedule variability, increased time- in-bed, pre-sleep hyperarousal, and sleep effort behaviors to those with insomnia only (Carney et al., 2007a, 2010; Kohn & Espie, 2005). Thus, those with MDD-I would appear to be excellent candidates for CBT-I. Indeed, there are some promising early findings for use of CBT-I in MDD-I patients. Morawetz (2001) found that by treating sleep alone in MDD-I, the vast majority of patients (N = 86) treated with a self-help Downloaded by [New York University] at 04:37 12 August 2016 form of CBT-I reported marked depression improvement in addition to the sleep improvement (Morawetz, 2001). Morin and colleagues (2000) showed CBT-I resulted in an improvement for sleep, and an associated mood improvement among a series of cases with comorbid insomnia and MDD (Vallieres et al., 2000). Several studies have documented the efficacy of CBT-I in patients with complex, multiple comorbidities including MDD and PTSD (Edinger et al., 2009a). A randomized clinical trial combining SSRI medication with CBT-I showed that in comparison to a SSRI alone, there were greater insomnia symptom improvements, and greater depression symptom improve - ments (Carney, Edinger, Krystal, & Shapiro, 2014; Manber et al., 2008). In fact, the addition of CBT-I to an antidepressant medication resulted in greater rates of depression Cognitive Behavior Therapy for Insomnia 29 remission than antidepressant medication alone (Manber et al., 2008). Thus, there is growing support for superior depression symptom outcomes by combining depression treatments with sleep treatments, both pharmacologic and cognitive or behavioral, over depression-only focused treatments.

Brief Delivery for Medical Settings CBT-I is already a brief treatment but it has been adapted to very brief versions for delivery in settings with limited patient contact, such as primary care settings. Because there is evidence for SC and SRT as monotherapies, CBT-I is easily delivered in a session or two. One study used abbreviated behavioral and cognitive therapy (ABCT), which was delivered in two 25-minute sessions two weeks apart with take-home reading materials (Edinger & Sampson, 2003). ABCT was tested using a novice therapist supervised by a behavioral sleep medicine expert. The content of the first therapy session focused on SC, SRT, SH, and psychoeducation. The content closely mirrors the material presented in Chapter 5 including the patient handouts. The psychoeducation is delivered briefly with a more in-depth explanation provided in written materials assigned as homework. The second session is devoted to troubleshooting and making adjustments to the schedule. Another version, brief behavioral insomnia therapy (BBIT) (Buysse et al., 2011) consists of one treatment session and a 30 minute booster two weeks later administered by a nurse practitioner. This treatment has been tested with older adults (Buysse et al., 2011; Germain, Shear, Hall, & Buysse, 2007). The content for this one session treatment was selected rules from SC and SRT: (1) match time in bed to the current average number of hours of sleep (minimum sleep opportunity was set at 6 hours); (2) get up at the same time every day of the week; (3) do not go to bed unless sleepy; and (4) get out of bed when unable to sleep. The second booster session was allocated to troubleshooting and making adjustments, if needed, to the schedule. The results of this study indicated that BBIT fared better than Information Control on both Sleep Diary and actigraph indices of SOL, WASO and SE. Additionally, BBIT-treated participants continued to improve after treatment; at the 6 month follow-up, they were sleeping about 45 minutes more than they were at post-treatment (Buysse et al., 2011). BBIT has also been used to successfully treat treatment-refractory insomnia after depression treatment (Watanabe et al., 2011). A variety of CBT-I effectiveness studies have shown that common disciplines in medical settings including nurses, primary care counselors, physicians assistants, social work, nurse practitioners, can effectively deliver CBT-I to patients Downloaded by [New York University] at 04:37 12 August 2016 (Espie, 2009; Espie et al., 2001, 2007). Given that both insomnia and depression, and certainly MDD-I commonly report to primary care first, implementing CBT-I into these settings is an important frontline priority.

Medication Issues: Is Discontinuation Necessary? Clinicians are often faced with the apparent dilemma of what to do about medications taken for sleep during treatment. Only treatment providers with prescription privileges should provide advice related to medication. Some medications taken for sleep, depending on dose, frequency of use, and duration of use, require a supervised taper and 30 Cognitive Behavior Therapy for Insomnia stopping them abruptly could result in serious consequences. Not all clients who want to sleep better necessarily want to stop taking their sleeping medications. It is important to have an open conversation about the client’s treatment goals as this may or may not include the need for cessation of sleep medication. CBT-I has been found to work with or without sleep medications. In some trials, there are no differences between those with CBT-I alone versus CBT-I plus sleep medications (Jacobs, Pace-Schott, Stickgold, & Otto, 2004); so sleep medications may not hamper the response except in those who are hypnotic dependent. The best long-term benefits appear to be related to withdrawing the sleep medication after the acute treatment phase of CBT-I, and before treatment has ended. During the medication withdrawal period, clients should continue with extra CBT-I sessions to manage the sleep disruptive process of withdrawal (Morin et al., 2009). It is not uncommon in CBT-I treatment that clients often simply stop taking their medications during treatment once they see that they can improve their sleep on their own. These clients should always be made aware that they should make no changes on their own before consulting with their physician. Others remain skeptical that CBT-I would work without their medication and remain on the medications. Ultimately the pros and cons of such a decision should be discussed between the therapist and client, and if there is a decision to discontinue medication, a collaboration should take place between the client, therapist, and the prescribing physician. There is some evidence that those who are hypnotic dependent have somewhat diminished CBT-I treatment outcomes relative to non-hypnotic dependent clients (Verbeek, Schreuder, & Declerck, 1999). This may be due to the decreased self-efficacy and increased unhelpful beliefs about sleep of those who are hypnotic dependent (Carney et al., 2010a). Thus, it is not imperative that clients select hypnotic discon - tinuation as a goal, however when a client decides to remain on medication, the following goals are meritorious of discussion with the client: 1) establish usage within the recommended dose range (ideally the lowest recommended therapeutic dose) and 2) eliminate using the medication as a rescue (i.e., take the medication at the same dose and time each night to eliminate contingent use). Most approved hypnotic medications have tolerance properties (diminishing effectiveness over time), which often prompts an escalation of dose. When increasing doses are used, it is often because the medication is not as effective as the client desires, and the belief is that a higher dose will have the same effect as the previously effective lower dose. This may be true at first, but when the higher dose also loses effectiveness, other medications or substances such as alcohol are often added, or another increase in dose occurs. In many cases, the client may not share these changes with the prescribing treatment provider. This is not only a very Downloaded by [New York University] at 04:37 12 August 2016 dangerous practice, but there is no increased efficacy, and further, it erodes the client’s self-efficacy and increases sleep anxiety. It is important to work with the client so that they understand both the physical dangers of such habits but also the role in perpetuating the insomnia. It is often important to encourage the client to discuss the issues openly with the treating physician. Many clients worry that the prescribing treatment provider will not renew prescriptions if they are made aware of the ways in which the client is using the medication and/or adding other substances. Collaborating with the treating treatment provider on a plan toward safer medication use or a medication discontinuation can help the client to feel more confident about how best to reach their goals. In other words, it is important for the client to understand that Cognitive Behavior Therapy for Insomnia 31 unlike possible past failed attempts to deal with medication dosing they may have attempted on their own, this time they are not alone and that with your help they can learn strategies that will make success much more likely. There is good evidence for the use of CBT-I as part of the discontinuation process (Morin et al., 2004, 2009; Morin, Colecchi, Ling, & Sood, 1995). Below is a description, adapted from Morin’s (Baillargeon et al., 2003) discontinuation protocol, for hypnotic discontinuation. The first step is an assessment of treatment goals. Proceeding with action phase interventions (i.e., a taper) makes little sense if the client is in a stage of contemplating change rather than preparedness for change (Prochaska & Velicer, 1997). If discontinuation is a goal and the prescribing treatment provider (if applicable) has provided a safe taper schedule, CBT-I can begin. As stated, in those with or without a discontinuation goal, it is important for the client to set a goal of taking the same, safe amount of medication every night at the same time. Although it is a common practice to prescribe such medications “prn” or as needed, long-term prn use sets up medication use as contingent on a poor (previous night’s) sleep. We would expect the body to produce some compensatory sleep following very poor nights and if the medication is taken under these conditions, the medication is paired with recovery sleep; however, the improved sleep is attributed to the medication, rather than the body’s natural compensation for poor sleep. Additionally, in those taking sleep medications long-term, there are inevitable but unsuccessful attempts to stop the medication. The typical scenario is that the client decides not to take the medication on a given night and they experience withdrawal from the medication. The withdrawal symptoms include increased insomnia. Clients typically do not know that this is a side effect and they attribute the severe insomnia symptoms as evidence that the medication must have been working more than they thought, and they quickly resume taking the medication either later that night or the next night, and their confidence in their sleep system is further compromised. Moreover, if non- contingent sleep medication use is not established, the sleep improvements associated with CBT-I will be attributed to the medication. By making the dose and timing of medication stable every night, then any changes to the baseline sleep after that will be attributable to the behavioral changes associated with CBT-I, which will be the only variables that were allowed to change. Thus, clients starting CBT-I on sleep medication need not have a discontinuation goal, but ideally, their use is kept predictable and safe throughout treatment. Likewise if the client has just switched or begun an antidepressant medication, it is best to wait until the drug is at steady-state so that CBT-I related improvements are not attributed to the antidepressant medication. Those with chronic hypnotic use have greater levels of unhelpful beliefs about sleep Downloaded by [New York University] at 04:37 12 August 2016 than those who are not on medication or not dependent on medication (Carney et al., 2010a); so it may be important to spend more time modifying beliefs that may get in the way. For example, it is helpful for clients to explore the consequences of thinking that their body can no longer produce sleep without medication. If clients attribute improvements to the medication, the client is encouraged to look at the evidence (e.g., the medication was associated with poor sleep at pre-treatment and the medication remained unchanged throughout treatment, thus the only change was in sleep habits). These techniques are covered in Chapter 6. They are also part of the cognitive therapy component of CBT for depression so unhelpful thoughts about medication and self- efficacy can be explicitly targeted within the context of comorbid treatment. 32 Cognitive Behavior Therapy for Insomnia Once non-contingent sleep medication use is established, and there is only one steady medication used (e.g., rather than a benzodiazepine one night, melatonin a second night, and diphenhydramine on another night) at a stable dose, CBT-I can be initiated. As CBT-I is delivered with an emphasis on increasing sleep self-efficacy and observing how the body compensates for sleep loss naturally when sleep effort is removed, the clients who initially felt they would not attempt medication discontinuation, may now be more amenable to such a goal. At that point, it can be desirable for the treatment team to proceed with the discontinuation component. The first step is to provide psycho - education regarding rebound insomnia and psychological dependence. This was detailed above (i.e., that contingent use of sleep medications creates a situation in which the medication appears to be a rescue from a faulty sleep system). Instead, by providing education regarding normal sleep regulation, the therapist can focus on the idea that the body would be expected to compensate for poor sleep anyway (with or without the medication) and that stopping the medication creates a worsening of insomnia symptoms. It is important that clients understand that the worsening is a side effect of the medication withdrawal and not indicative of an underlying insomnia that the medication was successfully treating. This will be true even for clients that are dependent on nightly medication. They can be made aware that, as with any withdrawal symptoms, they are expected to fade with time, and if properly harnessed, the processes of sleep regulation can then help them back to more normal sleep if they stay the course. After psychoeducation, a taper schedule is constructed in consultation with the prescribing treatment provider. In this scenario it should be noted that the client has already been taught the techniques of CBT-I to help make sleep better while on a steady dose of hypnotic. In some cases, the client is sleeping well with the medication so there may be little sleep restriction in the initial CBT-I; in other cases, sleep remains poor even on medication. Even if sleep is poor on medication, it is important to remain cautious about safety in those taking sleep medications. The goal during a taper is to reduce the weekly dose of medication by 25 percent per week, or whatever the pre scribing physician sees as appropriate. The therapist explains the protocol and rationale for non- contingent use and gradual reduction and solicits feedback on the plan. The client and therapist review the relapse prevention plan for what to do after a poor night (i.e., after rebound insomnia) as well as a coping with fatigue plan. Sometimes clients feel confident early and want to go completely drug-free. Likewise, some physicians may feel that a quicker taper would be suitable for their patient. For many medications at low doses this can be an acceptable way to engage in the CBT-I + taper treatment. However, in cases wherein withdrawal can have dangerous consequences (e.g., benzo- Downloaded by [New York University] at 04:37 12 August 2016 diazepine dependence, abnormally high doses), it is important to go slowly under medical supervision.

Group Therapy CBT-I There is evidence that group therapy is an effective modality for CBT-I (Bastien, Morin, Ouellet, Blasi, & Bouchard, 2004; Verbeek, Konings, Aldenkamp, Declerck, & Klip, 2006). In some ways CBT-I is a perfect candidate for group therapy because psychoeducation, Stimulus Control rules, sleep hygiene rules, Cognitive Therapy as well as counter arousal strategies fit nicely with a group format. However, the sleep scheduling aspect of SRT Cognitive Behavior Therapy for Insomnia 33

Table 3.1 Sample schedule and topics in individual versus group delivery

Week Group Individual 1 Psychoeducation, SC and Sleep Hygiene Psychoeducation, SC, SRT, Sleep Hygiene 2 Troubleshoot adherence, SRT 3 Troubleshoot adherence, determine if Troubleshoot adherence, determine if changes necessary to schedule, add changes necessary to schedule, add counter arousal counter arousal and cognitive therapy 4 Troubleshoot adherence, determine if changes necessary to schedule, add cognitive therapy 5 Troubleshoot adherence, determine if Troubleshoot adherence, determine if changes necessary to schedule, continue changes necessary to schedule, continue with cognitive therapy, introduce with cognitive therapy, introduce termination issues, relapse prevention termination issues, relapse prevention homework homework 6 No meeting No meeting 7 Troubleshoot adherence, determine if Troubleshoot adherence, determine if changes necessary to schedule, cognitive changes necessary to schedule, cognitive therapy, termination issues and relapse therapy, termination issues and relapse prevention prevention

is very challenging in a group format. The idea of scheduling is very personal to clients and linked to their particular presentation. “Scheduling” can have different meaning to different clients; for some it equates to conformity, having a boring lifestyle, or it activates memories of hurt experiences with an autocratic parent. Some clients hear recommendations to change habits as an accusation that they “caused” their insomnia, or they are in some way to blame. Additionally, deriving a schedule must take into account current sleep time production, chronotype, individual life demands, and relationship dynamics, so managing these issues in a group of 6 or more people, can become challenging. One possible way to achieve this is to devote an entire group session to deriving a schedule in which the group members exchange sleep diaries with a partner in the group, and together they calculate the total sleep time, total time in bed and total wake time of their partner’s diary. Together, the group calculates the time-in- bed prescription of their partner’s sleep diary and then they collaborate on a schedule in dyads. The group shares any possible difficulties encountered during the derivation of the schedule and together they engage in trouble-shooting. The facilitator uses questioning to help group members arrive at solutions for the other group members. Downloaded by [New York University] at 04:37 12 August 2016 There are very few resources available for learning group delivered CBT-I, so a template is provided below and contrasts it with an individual therapy schedule. For an example of a schedule and topics, see Table 3.1.

Applications (apps) and Alternative Modes of Delivery

Smart Phone Applications Smart phone applications that provide sleep estimates are very popular and widely available. Such apps are not used clinically because of their inferior reliability and in 34 Cognitive Behavior Therapy for Insomnia some cases dubious validity. For example, some apps purport to track and sense the “right” time to wake up clients. The websites associated with these apps give no detail as to how they work but the phone is placed on the bed and there is reference to the phone tracking movement so presumably, the application is collecting data with an accelerometer. There are no particular movements associated with optimal waking. The best time to wakeup may be arguably during REMs but the only way to determine the presence of REMs is to measure brain wave activity via electrodes on the scalp, not movement. Other apps provide an “objective” estimate of total sleep time via the accelerometer, similar to a clinical device called an actigraph. The method of placing the accelerometer on the bed has not been tested and is presumably less reliable than wearing an accelerometer (e.g., it can be subject to false input via pets, kids, and other bed partners). There are, of course, wearable accelerometers, and one such popular device was tested and compared with clinically validated actigraphs as well as poly somnography (Montgomery-Downs, Insana, & Bond, 2012). The popular device overestimated total sleep time by over an hour when compared with PSG and over 24 minutes compared to the actigraph. Both the actigraph and the device were particularly poor (i.e., showed greater error) in those with poor sleep; arguably the people most drawn to such devices. Some apps are treatment specific, such as CBT-I COACH. This app accompanies CBT- I treatment and was developed from the CBT-I materials for the VA training rollout. Such apps typically provide sleep diaries, help with calculating sleep prescriptions, psychoeducation materials, and capability for reminder messages with tips, motivation, and alarms to change sleep habits. These are essentially the same as the materials provided with treatment but the delivery mode is different and there may be some advantages to using an app on a Smartphone. For example, it is more readily accessible and discreet to complete forms such as a thought record using a phone than carrying a paper form and completing it in public. Additionally, calculating sleep diary indices can be daunting for some clients, so these apps can make it far easier.

Self-Help Books Self-help books (i.e., bibliotherapy) are a popular mode of delivery for people. Therapy is expensive and many people cannot take time off from work or family each week to attend sessions, while others, particularly in rural areas, may not have ready access to live therapists. Some also may feel uncomfortable talking to a professional about their problems. Bibliotherapy has the potential to increase access to empirically supported Downloaded by [New York University] at 04:37 12 August 2016 treatments in written format. The main drawback to this approach is that for the most part these products are not significantly vetted and so anyone can publish a self-help book and there is no guarantee about the strength of the material presented. In other words, all bibliotherapies are not equal and may not be empirically supported. However, there are books written by experts and voted on by other experts to recommend, e.g., the VA CBT-I training rollout selected a self-help book (Carney & Manber, 2009) available commercially for their training. In addition, there may be no opportunity to receive individual advice when there are issues not covered in the book and the client runs into problems. This has been shown to be important because in tests of bibliotherapy, there is evidence that it is effective (Mimeault, 1999), however the effect Cognitive Behavior Therapy for Insomnia 35 was enhanced when telephone consultation was added. Other studies have similarly reported that bibliotherapy with telephone consultation was equally effective as individual, traditional psychotherapy (Bastien et al., 2004; Currie, Clark, Hodgins, & El-Guebaly, 2004). Thus, although there is support for bibliotherapy, the best support is when there is individual follow-up as well. For those with MDD-I there are few books available, with one exception (Carney & Manber, 2009), written with clients with complex comorbidities like depression, pain, or anxiety in mind.

Internet Delivered CBT There is evidence for successful CBT-I treatment using sophisticated interactive software programs at home or delivered over the internet (Espie et al., 2012; Ritterband et al., 2009; Strom, Pettersson, & Andersson, 2004; Vincent & Lewycky, 2009). This may be a particularly helpful mode for those with poor access to CBT-I or those in remote areas. Such interactive programs may be an important way to increase access to CBT-I although there is some concern about high attrition (24–33 percent) (Strom et al., 2004; Vincent & Lewycky, 2009) so it is important to conduct moderator studies to understand who benefits most from this modality. Perhaps they may be best utilized as an initial step in a stepped-care model of delivery. As such, those that do not do well nor drop out might be encouraged to move on to the next step in care. To avoid “inoculation” against more intense levels of treatment, it may be important to alert clients to the concept of stepped care from the start so that there is understanding and buy in that if earlier steps do not succeed that other levels of treatment are available. In this way clients may be less likely to simply give up if the initial steps do not work.

Resources The Anxiety and Depression Association of America is a resource for those with depression and/or anxiety. There is information and resources for finding therapists, self-help materials, and applications. Website: www.adaa.org/ The Mood Disorders Society of Canada is an organization devoted to support and advocacy for those with Mood Disorders, including MDD. Website: www.mooddis orderscanada.ca The Canadian Association for Cognitive and Behavioral Therapies (CACBT) has a list

Downloaded by [New York University] at 04:37 12 August 2016 of Canadian practitioners who have been certified in Cognitive Behavior Therapy. Website: www.cacbt.ca The Association for Behavioral and Cognitive Therapy (ABCT) has a find-a-therapist listing as well as a listing of self-help resources, and information about disorders. Website: www.abct.org/home/ The National Sleep Foundation is a site devoted to providing information and advocacy about sleep. Website: www.sleepfoundation.org The American Academy of Sleep Medicine (website: www.aasm.net): There is an accred - itation process in the United States for medical sleep specialties. More information, 36 Cognitive Behavior Therapy for Insomnia including a list of providers and sleep centers accredited by the American Academy of Sleep Medicine can be found on at www.aasmnet.org/accreditation.aspx The Depression and Bipolar Support Alliance provides support for those with depres - sion. Website: www.dbsalliance.org

Summary

• CBT-I is a highly efficacious and effective treatment, shown to be effective in those with depression, and to enhance the treatment of depression. • Contraindications for CBT-I include: untreated or suboptimally treated sleep- disordered breathing, narcolepsy, or periodic limb movement disorder with accom - panying excessive daytime sleepiness, unstable condition, substance abuse. CBT-I should be used with caution in those sensitive to sleep deprivation such as those with bipolar disorder, panic disorder, epilepsy, and parasomnias. • CBT-I has been shown to be effective in very brief formats (one to two sessions) and as delivered by non-sleep and non-mental health treatment providers. • There is evidence for other modalities of delivery including group therapy, some internet delivery, telephone delivery and bibliotherapy. It would be useful to have moderator data on alternative modes so that we could determine for whom these modes work best. • It is unnecessary to discontinue sleep medications before starting CBT-I but it is important to establish non contingent use at a stable dose and time each night before proceeding with CBT-I. • Although there are many dubious sources of information on the internet, there are also reputable internet sites available to locate treatment providers certified in CBT-I, and to learn more about sleep or depression, and/or for clients to obtain support. Downloaded by [New York University] at 04:37 12 August 2016 4 Assessment of Insomnia in Those with Depression

Assessment should be regarded as an ongoing activity throughout CBT-I, rather than a single event at the beginning of treatment. It is essential to continuously assess for changes in sleep patterns, varying levels of sleepiness, and client adherence, and remain open to emerging evidence. Consider the following example: at the sleep assessment session, you meet a 41 year old female with average body habitus, no knowledge of whether she snores, no hypertension, and a normal, albeit elevated score on sleepiness scale. Such findings are not particularly suggestive of sleep apnea. If, however, over the course of treatment, there is high adherence to treatment, a very quick sleep onset latency, even when the time spent in bed has been lengthened, there are complaints of subjective sleepiness and a report of many very brief wake-ups in the second half of the night, one should reconsider whether there may be an occult sleep disorder, such as sleep apnea. The goals of the initial assessment session are to establish a diagnosis of insomnia and initial conceptualization of the case, rule out other sleep disorders or conditions contraindicated for CBT-I, assess for comorbidities, substances and medications, establish treatment goals, and obtain family, medical, sleep, and previous treatment histories. That said, new information about any of these factors may emerge throughout treatment and should be revisited.

History of the Insomnia All assessments begin with a discussion of consent and limits to confidentiality followed by a history of the sleep problem. Of course, it is important in psychotherapy to get a history of other issues, including current and past interpersonal, occupational, and health details, but since these remain the same for all problems, we will not go into these general Downloaded by [New York University] at 04:37 12 August 2016 psychotherapy issues here. Instead, we will remain focused on sleep and mood related details. Later we provide a general guide for assessment that we find helpful clinically. The first order of business is typically a question such as, “What brings you here?” or “Please tell me about your sleep problem.” The goal of this question is manifold. What is the nature of the current problem? Is the primary complaint about nighttime or daytime difficulties? When did it start? Is it a lifelong problem, i.e., are there family stories about difficulties as a baby, through childhood, teenage years right up until the present? In some cases, there will be a report of a lifelong insomnia but after beginning work together, it will become apparent that this is not the case. Such is the case with Kelly, a case example presented in Chapter 10 and throughout the book. In such cases, 38 Assessment of Insomnia this can reflect an all or none way of viewing oneself as a “bad sleeper.” Such beliefs likely will be targeted for modification at some point in therapy. How did the problem start (i.e., is the client aware of a contiguous stressor or did it occur unexpectedly)? What is the client’s explanation for what is going on (i.e., to what do they attribute the insomnia)? When providing psychoeducation (see Chapter 5), it will be important to emphasize a case-specific explanation. For example,

I recall that you had said that initially the insomnia began in the weeks before your wedding, and you were puzzled by the fact that it continued even after the stress of the wedding subsided. I would like to talk about some possibilities for why the insomnia persisted even after the wedding . . .

Continue querying about whether the problem changed over time, how long the problem has persisted and the reason for seeking treatment now. It is important to understand how they have tried to fix the situation (i.e., what has been tried with respect to medication or a change in habits), as this is the information the therapist needs to assess sleep effort and to help debunk other possible failed attempts. For example, if the client ceased caffeine in an attempt to fix the situation, it is important to address why this did not work and what other measures are necessary to manage the insomnia. Otherwise, any mention of caffeine will be met with skepticism because it was already tried. In addition, such debunking should help to raise hope for the client that this time their efforts may be more likely to succeed. Lastly, it is important to have agreement on the goals for treatment. Unrealistic goals (e.g., “I want to sleep like I did as a teenager,”) are helpful to uncover because it permits cognitive modification of unrealistic beliefs about sleep. It also serves to demonstrate that the way clients view sleep can have an important effect on both how well they sleep and how they feel during the day. The treatment goals discussion at the end of the assessment session is often the start of the intervention. That is, once realistic expectations are stated (i.e., “I would like to spend less time awake during the night,”), the therapist and client can easily agree on such goals and the therapist can discuss a conceptualization and treatment plan for moving forward with the client.

Diagnosis of Insomnia The diagnostic criteria for an Insomnia Disorder require a complaint of difficulty initiating or maintaining sleep or non-restorative sleep for a minimum of three months Downloaded by [New York University] at 04:37 12 August 2016 (American Psychiatric Association, 2013). There is no guidance as to what numeric value would constitute difficulty initiating or maintaining sleep for a number of reasons. First, it is important to note that insomnia is a subjective disorder. Certainly, “non-restorative sleep” is a subjective term that would be difficult to quantify except perhaps on an EEG. Whereas a cutoff of sleep disruption greater than or equal to 31 minutes is a reasonable proposal (Lichstein, Durrence, Taylor, Bush, & Riedel, 2003), this proposal lacks evidence for optimal sensitivity and specificity (Lineberger, Carney, Edinger, & Means, 2006). Another important factor in this diagnosis is the presence of one or more of the daytime symptoms of insomnia listed in the Research Diagnostic Criteria for Insomnia (Edinger et al., 2004), including fatigue or malaise, attention or concentration problems, negative Assessment of Insomnia 39 mood, social or vocational dysfunction, or poor school performance, somatic symptoms such as tension headaches and gastrointestinal symptoms in response to sleep loss, motivation or energy or initiative reduction, daytime sleepiness, and worry about sleep. Without the presence of these daytime sequelae, the disruption in sleep alone would have to be seen as a consequence of different problems such as short sleep (i.e., someone who requires less sleep than the average) or perhaps mania. However, with both the sleep disruption and daytime sequelae present, it is no longer relevant to consider if the disorder is “related” to another Axis I disorder, as there is poor evidence of validity for the distinctness of these types of insomnia (i.e., secondary insomnia) (Edinger et al., 2011).

Diagnostic and Measurement Pitfalls The most recent DSM update (DSM5) (American Psychiatric Association, 2013) was characterized by significant changes, including a renaming of the Sleep Disorders section to Sleep-Wake Disorders. The renaming of the section denotes an acknowledg - ment that insomnia and other sleep disorders are a 24-hour phenomenon; that is, they have both nighttime and daytime sequelae. In a chart review study, the best predictor of whether a patient was diagnosed with depression was whether they complained of insomnia (Krupinski & Tiller, 2001). The best predictor of a depression diagnosis should be the presence of one of the MDD criteria in section A (i.e., depressed mood or anhedonia). Indeed, these are the discriminating symptoms for differentiating those with insomnia only from those with MDD-I; insomnia and fatigue are not discriminating items (Carney, Ulmer, Edinger, Krystal, & Knauss, 2009). When the patients in the chart review study diagnosed with MDD were followed-up with diagnostic interviews, just over one quarter actually met diagnostic criteria for MDD; the 72 percent incorrectly diagnosed with MDD had undiagnosed insomnia (Krupinski & Tiller, 2001). As noted above, the DSM5 eliminated the distinction between an insomnia related to a mental disorder versus an insomnia that was considered primary, mainly because this distinc - tion lacks reliability and validity (Edinger et al., 2011). In addition, when patients suffer from a comorbid mental disorder, studies suggest that treatment providers are less likely to consider conditioning, beliefs or poor sleep habits as treatment targets or maintaining factors (Nowell et al., 1997), even when the evidence suggests that these are primary factors for such patients (Carney et al., 2010a; Kohn & Espie, 2005). Historically, insomnia has been under diagnosed and consequentially, undertreated, and the changes to the DSM will hopefully improve this problem. With regard to depression and insomnia, perhaps part of the issue relates to the degree Downloaded by [New York University] at 04:37 12 August 2016 of overlap between the two conditions. Daytime symptoms for insomnia include: fatigue, cognitive complaints, mood disturbance (including dysphoria), and impaired functioning (American Psychiatric Association, 2013; Edinger et al., 2004). Indeed, there are very few discriminating items for these disorders (Carney et al., 2009). In a comparison of those with MDD and those with ID only, the only items that discrim - inated the two groups were: depressed mood, anhedonia, guilt, pessimism, thinking about past failures, self-dislike, crying, agitation, hypersomnia, and decreased appetite. Clinical cutoffs for mild and moderate depression on the second edition of the Beck Depression Inventory (BDI-II) (Beck, Steer, & Brown, 1996) have slightly less support when insomnia is present (i.e., specificity is decreased). Thus, the concern is that some 40 Assessment of Insomnia depression measures, and perhaps the diagnostic criteria for MDD itself, may subsume ID within the items. The overlap also becomes a problem in studies in which those with insomnia are included. One way that researchers have dealt with this issue is to remove the sleep items from depression measures. This is an unacceptable remedy because sleep is only one of many overlapping symptoms (e.g., fatigue, cognitive complaints). There is no greater empirical reason to take away the sleep item over any other non- discriminating ID daytime symptom (e.g., fatigue). Another remedy for this conundrum is to covary depressed mood on a depression measure in those with insomnia or to covary sleep on an insomnia measure in those with depression. The use of analysis of covariance in such situations is fraught with statistical problems reviewed elsewhere (Miller & Chapman, 2001). Essentially, when two variables naturally covary, removal of the variance of the other covarying variable results in a third variable that does not exist. Thus, investigating the properties of the nosological categories of sleep and depression and finding measures with improved specificity, but with acceptable sensitivity is still needed.

Assessment and Intervention Strategies Insomnia is assessed with several methods. The clinical interview is a critical piece of the assessment and can be supplemented with a semi-structured interview, such as the Insomnia Interview Schedule (IIS) (Morin, 1993) or the Duke Structured Interview for Sleep Disorders (DSISD) (Edinger et al., 2009b). These instruments can be used to help evaluate diagnostic criteria for insomnia as well as other sleep disorders. Structured interviews may be particularly helpful for the novice therapist in sleep disorder treat - ment. Such interviews help by providing critical questions regarding sleep and medical histories (e.g., the history, nature, and severity of the current complaint, current habits, medical history, treatment history, substance use, and environmental factors such as noise), as well as questions to assess signs and symptoms of other intrinsic sleep disorders. The DSISD is particularly helpful because diagnostic criteria are mapped across DSM, International Classification of Sleep Disorders (ICSD-3; American Academy of Sleep Medicine, 2014), as well as Research Diagnostic Criteria (RDC) (Edinger et al., 2004a) nosologies. In other words, the questions in the DSISD follow directly from the specific diagnostic criteria in these manuals. For example, the following questions are used to query the presence of ID: “Do you have a problem such as difficulty getting to sleep, OR difficulty staying asleep, OR waking up too early?” If the client reports yes to any of the insomnia symptoms, there is a follow-up question that queries whether Downloaded by [New York University] at 04:37 12 August 2016 there are any daytime symptoms:

Does this sleep difficulty cause you any problems in the daytime such as: fatigue or malaise? Impaired concentration, attention or memory? Impaired social or vocational functioning or poor school performance? Mood problems or irritability? Daytime sleepiness? Decreased motivation, energy, or initiative? Increased errors or accidents at work or while driving? Tension, headaches, or stomach upset in response to sleep loss? OR excessive sleep concerns or worries?

In cases in which the client does not endorse a daytime symptom, the DSISD queries, “How would things be better if your sleep problem were eliminated?” If the response Assessment of Insomnia 41 refers to a daytime problem, the criteria are met. The remaining DSISD questions query if the insomnia occurs at least three times per week for at least three months and whether the sleep problem occurs in the context of an adequate opportunity for sleep, e.g., “Do you have this sleep difficulty even if you give yourself enough time to sleep?” Lastly, the DSISD queries whether the insomnia is related to an inadequate or unsafe sleep environment, a substance or medical condition. Asking these questions ensures the therapist covers all of the criteria relevant to making the diagnosis of insomnia disorder. An essential component of insomnia assessment is the daily sleep diary. Sleep diaries are the gold-standard in assessing insomnia because insomnia is a subjective disorder and the prospective reporting method increases accuracy of the subjective ratings (Buysse et al., 2006). For further discussion of the merits of using subjective sleep diary data in the assessment of insomnia, see Chapter 7. Sleep diaries provide details about the severity of sleep onset and maintenance difficulties, habits that disrupt the circadian system (e.g., variability of bedtimes and rise times), or the homeostatic drive for deep sleep (e.g., napping, extended time in bed), as well as calculated indices such as total sleep time or sleep efficiency. There are many versions of sleep diaries that measure various aspects of the insomnia problem, but the variability among diaries limits that ability to make comparisons across studies. To resolve this issue, a consensus diary was derived. This diary was constructed by soliciting a large sample of diaries used by experts working the field of behavioral sleep medicine and then a panel of insomnia experts extracted key items to form a diary draft that was subjected to a larger pool of experts for rating. After that revision, the tool was subjected to lexical analyses and tested with focus groups. The result was the Consensus Sleep Diary (CSD) (Carney et al., 2012) which is the recommended tool for the prospective monitoring of sleep. Copies of a brief, core version and an expanded version with optional items are provided in the Appendix (Appendices A and B). Permission is granted for clinical use only (contact the first author of this book, C. E. Carney, for research related permission). Table 4.1 provides instructions about using the CSD (i.e., how to score indices for both assessment and use throughout treatment). Items that do not require scoring and are self-explanatory are not included in the table (for example, item 12, 13, and 14 query alcohol, caffeine, and medication use, respectively and are simply inspected to determine what substances are consumed and the timing or proximity to bedtime). Sleep diaries are extremely important for assessing the client’s baseline sleep, but are also essential for tracking outcomes throughout treatment. Treatment tracking is readily accomplished with sleep diaries but a retrospective global rating of insomnia symptoms is useful as well. The most validated measure for this purpose is the Insomnia Severity Downloaded by [New York University] at 04:37 12 August 2016 Index (ISI) (Morin, 1993). Another commonly used measure for this purpose is the Pittsburgh Sleep Quality Index (PSQI) (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) however, the PSQI has dubious psychometric properties in those with comorbid Axis I disorders (Hartmann et al., 2015). The ISI is a very brief measure that allows clients to retrospectively rate the severity of their insomnia symptoms (Bastien,Vallieres, & Morin, 2001; Morin, Belleville, Belanger, & Ivers, 2011). One reason for supplementing a gold standard tool (i.e., the sleep diary) is that it can reveal the client’s perception of their sleep problem. For example, a client may present for an assessment with an ISI score and clinical interview results (e.g., “I barely sleep at all”) suggestive of a severe insomnia, while the sleep diary may reveal indices in the mild insomnia to normal range. Downloaded by [New York University] at 04:37 12 August 2016

Table 4.1 How to Use a Sleep Diary

Essential Item # Computations Interpretations/Significance clinical index Sleep onset Item 3: How An average SOL is calculated by adding the An average SOL greater than 30 minutes is conventionally latency (SOL) long did it SOL values for each night (after converting considered an indication of clinically meaningful problem take you to to the same metric, minutes OR hours) and with sleep initiation, as is presence of SOL values greater than fall asleep? dividing the sum by the number of nights 30 minutes on three or more nights a week. Although there are with available data in the recording period. no quantitative criteria for insomnia.

A low average SOL (<10 minutes) suggests sleep duration might be too short for optimal wellbeing.

If the client’s chronotype is delayed and SOL problems occur exclusively with an early bedtime (item 1), it may suggest a Circadian Rhythm Disorder rather than ID. Number of Item 4: How An average NWAK is calculated by adding Three or more awakenings is considered an indication of awakenings many times did the NWAK value for each night and dividing clinically meaningful problem with sleep fragmentation. (NWAK) you wake up, the sum by the number of nights with not counting available data in the recording period. Multiple brief awakenings may suggest the presence of sleep your final apnea or other occult sleep problems. awakening? Wakefulness Item 5: In total, An average WASO is calculated by adding An average WASO greater than 30 minutes is conventionally after sleep how long did the WASO values for each night (after considered an indication of clinically meaningful problem onset these awakenings converting to the same metric, minutes with sleep maintenance, as is presence of WASO values greater (WASO) last? OR hours) and dividing the sum by the than 30 minutes on three or more nights a week. Although number of nights with available data there are no quantitative criteria for insomnia. in the recording period. Early Item 6d: How If 6c is ‘No,’ set 6d to zero. An average An average EMA greater than 30 minutes is considered an morning much earlier EMA is calculated by adding the EMA indication of clinically meaningful problem with early awakening [than planned]? values for each morning (including the morning awakening, as is presence of EMA values greater than (EMA) zero values from the previous step) 30 minutes on three or more nights a week. and dividing the sum by the number Downloaded by [New York University] at 04:37 12 August 2016

of nights with available data in the Clinical judgment is needed when a client does not have a recording period. planned wake up time. In such cases the client can be asked to rate how much earlier than acceptable, or desired did they wake up. Lingering Computed The daily value is the difference between Some of the time spent in lingering in the morning may be in the from items 6a item 6a and item 7. An average index of spent trying to get more sleep (Item 6b) and some of the time morning (What time lingering is calculated by adding the may be staying in bed without necessarily trying to sleep. was your final lingering value for each day and dividing Query about how the time lingering in the morning is spent. awakening?) the sum by the number of nights with The longer the time spent lingering, the more of an and 7 (What available data in the recording period. opportunity for conditioned arousal. This may reflect sleep time did you effort or avoidance or beliefs about what time is reasonable get out of bed to rise. for the day?). Total Wake Computed Nightly TWT=SOL + WASO + EMA, This is an index of overall unwanted wakefulness. For people Time (TWT) from SOL, making sure they all are in the same without insomnia TWT is usually less than 45-60 minutes. WASO and metric (hours or minutes). An average Although there is not a set cutoff of which we are aware, Item 6c TWT is calculated by adding the nightly however it is typical in clinical trials to set TWT>60 minutes TWT values and dividing the sum by the as suggestive of moderately severe insomnia. number of nights with available data in the recording period.

If any one of SOL, WASO, or EMA is missing then TWT is considered missing. Time-in- Computed The difference between item 1 and item 7. When TIB is far greater than TST, query why. Some bed (TIB) from item 1 considerations include: 1) high sleep effort (i.e., trying to sleep (What time An average TIB is calculated by adding the by spending more time in bed), 2) using the bed for escape, did you get TIB values for each night and dividing the 3) sedentary life style (i.e., low levels of activity), and 4) feeling into bed?) sum by the number of nights with available sedated due to medications with long sedative half-life. and item 7 data in the recording period. (What time did you get out of bed for the day?). continued . . . Downloaded by [New York University] at 04:37 12 August 2016

Table 4.1 Continued

Essential Item # Computations Interpretations/Significance clinical index Intended Computed The difference between item 2 and item 7. The ISP is the time allotted for sleep. Its duration is shorter sleep period from Item 2 than TIB when a client spends time engaged in wake activities (ISP) (What time An average ISP is calculated by adding the in bed, such as reading and watching television. did you try ISP values for each night and dividing the to go to sleep?) sum by the number of nights with available Some clinician and sleep researchers compute SE as the ratio and Item 7 data in the recording period. between TST and ISP. This alternative is a better (What time approximation of how SE is computed when sleep is did you get measured objectively by actigraphy or polysomnography. out of bed for the day?) Computed Computed TST= ISP – TWT The computed TST does not always agree with the client’s Total Sleep from ISP estimated sleep duration (i.e., response to Item 8: In total, Time (TST) and TWT Average TST is calculated by adding the how long did you sleep?). Discrepancies between computed TST values for each night and dividing TST and the client estimated sleep duration (Item 8) could be the sum by the number of nights with due to a variety of factors that should be explored. Examples available data in the recording period. include: 1) reporting bias (e.g., the client might have not included light sleep as sleep); 2) a systematic error in one or Alternatively, average TST can also be more diary entries (e.g., considering including EMA in determined by subtracting average response to Item 5, in which case the computed TST TWT from average ISP. underestimates actual TST). Sleep Computed SE = TST/TIB SE values range between 0 and 1, wherein 1 means that the Efficiency from TST client slept 100% of the time spent in bed and 0 means the (SE) and TIB An average SE is calculated by adding the client has not slept at all. The average SE in population studies SE values for each night and dividing the is around 85%. A SE above 95% suggests the possibility of sum by the number of nights with available insufficient sleep, possibly because the sleep opportunity data in the recording period. window might be too short. Downloaded by [New York University] at 04:37 12 August 2016

Nap duration Item 11b If 11a is ‘No,’ set 11b to zero. An average Provides a total amount of nap duration for the day. In clients (In total, how daily nap duration is calculated by adding reporting dozing (i.e., unintentional naps), it is useful to long did you the nap durations for each day (including encourage them to capture dozing with this item too. nap or doze?) the zero values from the previous step) and dividing the sum by the number of days with available data in the recording period.

Total sleep Computed TST + Nap duration (item 11b) In most individuals with insomnia TST24 is almost identical time in from TST to TST because most are not able to nap. A difference that is 24 hours and item 11b An average TST24 is calculated by adding more than half an hour might indicate circadian rhythm (TST24) (In total, how the TST24 values for each 24 hour period abnormality or the presence of a comorbid disorder associated long did you and dividing the sum by the number of with daytime sleepiness. In the latter case, it is possible that nap or doze?) 24 hour periods with available data in the daytime sleep interferes with nocturnal sleep. recording period. Lingering Computed The difference between item 1 and item 2. Query about average values greater than half an hour. This in bed in from item 1 Equivalently, this is also the difference could be due to boredom, anhedonia, habit, spending time the evening (What time between TIB and ISP. with a bed partner, or it could imply sleep effort, that is, an did you get attempt to produce sleepiness in the bed in order to fall asleep. into bed?) An average daily lingering in the evening and item 2 is calculated by adding the values for each (What time evening and dividing the sum by the did you try number of days with available data in the to go to sleep?) recording period. Bedtime Derived Identify the earliest and latest bedtimes This provides an estimate of poor input into the clock. In the variability from item 2. (item 2) for the reporting period (typically absence of low activity or other habits that would reduce sleep (BEDVAR) a two-week period). One index of variability drive, regular bed and rise times create a strong drive to is the difference between the earliest and become sleepy around the same time each night and wake up latest bedtimes. For example, if the latest naturally around the same time each morning. In the adjacent bedtime over two weeks was 1AM and the example, 4 hours of variability is the biological equivalent to earliest bedtime was 9 PM, the variability taking a trip from Manhattan to Los Angeles. is 4 hours. continued . . . Downloaded by [New York University] at 04:37 12 August 2016

Table 4.1 Continued

Essential Item # Computations Interpretations/Significance clinical index Therapists should be curious about reasons for values greater than one hour. For example, is the difference due to having an environmental constraint? Is it due to a belief that one has to “make-up” sleep on the weekends? Is it due to the person’s chronotype? Rise time Take the latest rise time (item 7) for the This provides an index of poor input into the clock. Regular variability reporting period (typically a two-week bed and rise times create a strong drive to become sleepy (RISEVAR) period) and subtract the earliest rise time around the same time each night and wake up naturally (item 7). For example, if the latest rise around the same time each morning. In the adjacent example, time over two weeks was 11 AM and the 6 hours of variability is the biological equivalent to taking a earliest rise time was 5 AM, the variability trip from Manhattan to Europe. Most people have a fixed rise is 6 hours. time several times per week because of work or family obligations, so this is often used as a point at which rise time is fixed for the week. Rise times that vary an hour or more may have circadian consequences that mimic jetlag (e.g., fatigue, concentration and mood problems etc.) For an explanation of jetlag symptoms in insomnia and fixing a standard rise time, see chapter 5. TIB Take the prescribed TIB (e.g., 7 hours) Negative values reflect non-adherence to the TIB prescription, prescription and subtract the average TIB value for i.e., increased TIB. In the adjacent example, the TIB variation the recording period (e.g., 8.25 hours). prescription variation is -1.25, in other words, there is an extra (TIBVAR) hour and 15 minutes spent in bed. Explore non-adherence issues using suggestions in Chapter 7. Zero or positive values are reflective of adherence to the prescription. Assessment of Insomnia 47 In such cases, the discrepancy between the diary and the client’s self-rating and report should be the focus of further inquiry and assessment. It will be useful to discover the reason for the discrepancy since one’s perception of being a poor sleeper or a per - fectionistic style or all-or-none thinking, may reflect unhelpful thinking worthy of further discussion in therapy. Similarly, objective (e.g., actigraph) and subjective (e.g., sleep diary) improvements with treatment without corresponding improvements on global ratings scales (e.g., ISI) warrant exploration with the client. It is important to understand what the client is capturing in a high rating of sleep disturbance on the ISI, in the presence of little corroborating evidence on other measures. In some cases, this may be a misattribution about daytime symptoms, for example, the fatigue may relate to inactivity, anxiety, or depression, rather than poor sleep. Maintaining the belief that the fatigue is solely the product of poor sleep can lead to more discouragement and sleep effort on the part of the client, which in turn can ultimately undermine treatment gains. In this case, remediating sedentary habits or revisiting whether the client’s mood or anxiety is adequately treated, may improve sleep ratings. The ISI is typically respons - ive to changes in self-reported sleep problems across treatment and is thus useful for tracking treatment progress (Bastien et al., 2001). A summed score of 14 or greater (10 or greater in community samples) is suggestive of clinically significant insomnia; scores less than 8 are suggestive of a healthy sleeper (Bastien et al., 2001).

Objective Measurement of Insomnia

Polysomnograms (PSG) So-called “objective” measures of sleep are not commonplace in the clinical assessment of insomnia. PSGs are scored using consensus (i.e., arbitrary) criteria and there are many reasons to question the validity or utility of these criteria for insomnia. For example, some individuals with insomnia have subjective complaints that may not be supported by the standard “objective” sleep indices of PSG. By relying solely on visual scoring of the sleep record we might miss more subtle features of the record that standard scoring does not detect and therefore dismiss the subjective complaints of the client. In lieu of the visually scored approach used in objective analysis, if we analyze the PSG data through spectral analysis; a more sophisticated and less arbitrary approach, the brain wave activity of these insomnia clients tends to show increased high frequency activity (i.e., a frequency associated with light sleep or wakefulness). Moreover, the amount of high frequency activity correlates with their subjective complaint (Krystal, Edinger, Downloaded by [New York University] at 04:37 12 August 2016 Wohlgemuth, & Marsh, 2002). Thus there are serious limits to using visually scored criteria for assessing insomnia. Another problem with PSG for insomnia is the issue of the environment itself. That is, when people with insomnia sleep in an unfamiliar environment, it is not uncommon on the first night for them to experience worse sleep than usual. Conversely some individuals with insomnia will have a very good first night. This may be because there is conditioned arousal associated with their specific bed, or perhaps because some will hope that poor sleep is seen by the clinician on the PSG record and thus the client completely let’s go of sleep effort and therefore paradoxically sleeps much better than usual. In either case, it is difficult to make too much of an inference about the sleep continuity data found on a first night of PSG. 48 Assessment of Insomnia Actigraphy Actigraphy is another possible “objective” measure of sleep. An actigraph is a wearable device, most commonly worn on the wrist that measures movement with an accelerometer. Movements are sampled at a sampling rate that is set by the user and stored for future downloads with the accompanying software. The downloaded data is subject to automated scoring via an algorithm that estimates whether a pattern of movement is most typical of sleep or wakefulness. Such units are generally only as good as the scoring algorithm so it is important to purchase one that has many validation studies associated with it. Actiwatches most often provide estimates of sleep onset latency, wakefulness during the night, total sleep time, and sleep efficiency (Lichstein et al., 2006). Depending on the device, actigraphs have acceptable psychometric properties, albeit somewhat reduced in those with insomnia (Blood, Sack, Percy, & Pen, 1997; Chambers, 1994; Hauri & Wisbey, 1992). That is, when actigraphs are used in insomnia there tends to be an overestimation of sleep. Depending on the algorithm being used, actigraphs may at times mistake lying awake as sleep. That said, those who wish to see sleep disordered clients on a regular basis may opt to purchase a few actigraph units for specific purposes. These devices are more frequently used during Circadian Rhythm Disorder assessment in sleep disorder centers because the assessor can view pattern across the 24-hour period more readily. Additionally, they can be useful in behavioral experiments in those clients with gross underestimation of sleep, that is, those clients who report little to no sleep consistently. For example, allowing clients to examine their actigraph estimates of sleep in comparison to their sleep diary estimates, reduces the degree of misperception and also decreases sleep-related anxiety (Tang & Harvey, 2004). Thus, although there is some utility to actigraphs, they are not a routine tool in the assessment of insomnia unless there is suspicion of a Circadian Rhythm Disorder or gross underestimation of sleep (Buysse et al., 2006; Lichstein et al., 2006; Littner et al., 2003; Standards of Practice Committee of the American Academy of Sleep Medicine, 2003). For a discussion of commercially available apps utilizing accelerometers versus validated actigraphs, see Chapter 7.

Fatigue Fatigue is important to assess in insomnia. It is often the chief complaint (Bishop et al., 2004) when the client is presenting for treatment; that is, many will complain more about the impact of their insomnia on how they feel during the day than the distress Downloaded by [New York University] at 04:37 12 August 2016 of being awake during the night. Fatigue is a common issue among those with a variety of other health conditions. Fatigue is also often the trigger for rumination in those with insomnia (Carney et al., 2006, 2010b, 2013b). There are a number of valid fatigue measures available but two of the most researched and frequently used self-report questionnaires are the Fatigue Severity Scale (FSS) (Krupp, LaRocca, Muir-Nash, & Sternberg, 1989) and the Multidimensional Fatigue Inventory (MFI) (Smets, Garssen, Bonke, & De Haes, 1995). These two measures are recommended as standard scales in the assessment of fatigue in insomnia (see Buysse et al., 2006). The FSS has only nine items (as compared to 20 items in the MFI), thus it is very brief and easy to use. The construct measured is the degree of self-reported severity (Likert scale rating) of fatigue Assessment of Insomnia 49 symptoms over the past week. The MFI is also a rating of fatigue in the past week but focuses on the impact of fatigue across five dimensions, including general fatigue, physical fatigue, mental fatigue, reduced motivation, and reduced activity. Of interest is that fatigue reporting appears to relate to cognitive factors in those with MDD-I (Carney et al., 2013). In other words, the best predictors of physical or mental fatigue in those with both ID and MDD are: a tendency to ruminate in response to feeling tired, believing that one cannot function without a specific amount of sleep, and believing that one needs to avoid activities after a poor night’s sleep. Thus, in addition to targeting sleep, specific fatigue interventions such as activation and cognitive techniques to test maladaptive beliefs about sleep may be needed in those reporting high fatigue. It is noteworthy that behavioral activation (BA) may be a key intervention in both those with depression and insomnia. With regard to mood, increased activation is essential in that it expands a person’s contact with reinforcers, and with regard to insomnia increased activity helps to build a healthier drive for deep sleep as well as helping the client to debunk catastrophic fears about the consequences of poor sleep.

Cognitive Factors There are a variety of cognitive scales available. In this book we have highlighted two. The Daytime Insomnia Symptom Rumination Scale (DISRS) (Carney et al., 2013b) is a 20-item scale that assesses the tendency to ruminate in response to daytime insomnia symptoms. This measure discriminates good sleepers from poor sleepers and has good reliability (Cronbach’s alpha = 0.93) (Harris, Carney, & Moss, 2010). The DISRS is included in Appendix C and permission is granted for clinical use only. The Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) (Morin, Vallières, & Ivers, 2007) is a questionnaire to assess the level of dysfunctional beliefs theorized to contribute to the maintenance (and possibly, the development) of insomnia. The DBAS16 is the most widely used measure of dysfunctional sleep beliefs; scores above 3.7 discriminate those with insomnia and those without (Carney & Edinger, 2006). The DBAS16 is sensitive to clinical change and is correlated with several indices of clinical improvement (Carney & Edinger, 2006).

Sleepiness In addition to fatigue, it is important to assess for sleepiness. Clients commonly use the terms sleepiness and fatigue interchangeably but they differ in important ways. Unlike Downloaded by [New York University] at 04:37 12 August 2016 fatigue, sleepiness is a relatively uncommon symptom in insomnia because sleepiness is the propensity to sleep; that is, when sleepy, if given the opportunity to sleep, one would fall asleep (and quickly). Excessive daytime sleepiness, that is a tendency to fall asleep involuntarily during the day without efforts to prevent it, is a characteristic of many sleep disorders, but not insomnia. Unfortunately many people are not always aware of the extent of their sleepiness, which puts them at risk for mishaps, including motor vehicle accidents (Ward et al., 2013). For example, sleepiness is associated with extended blinks and slow eye rolling movements and these eye movements are associated with accidents in driving simulators (Åkerstedt, Folkard, & Portin, 2004). It is important to understand that in the early phases, CBT-I will likely increase sleepiness, even in those 50 Assessment of Insomnia who do not initially report this symptom, and this can pose a potential safety risk if not addressed. Moreover, in the clients with insomnia who do report sleepiness at base line, the potential for significantly increased excessive somnolence is high and the risks are multiplied. Therefore it should be a high priority to assess for sleepiness both at the beginning and throughout the treatment. To this end, the first step is to make sure that the client understands the definition of fatigue and sleepiness and the distinction between them. Whereas fatigue is the subjective feeling of weariness or tiredness and the desire to rest or sleep; sleep is the propensity to sleep. For instance, many clients with insomnia will report lying in bed awake, utterly exhausted but unable to sleep. This is a good example of fatigue. The same client may also report that there are times when they are sitting on the sofa watching TV, and find themselves unable to keep their eyes open. This is a good example of sleepiness. Understanding and monitoring for this difference is not only a safety issue but becomes an important piece of the treatment especially in Stimulus Control instructions that ask the client not to go to bed until sleepy. Once the client seems to understand and can differentiate between the two, the therapist can then assess for sleepiness independent of fatigue. During the initial interview and throughout treatment, the therapist should discover the situations in which the client is most likely to doze. The therapist can ask about missing plots while watching TV, needing to re-read pages of a book, having to rewind a movie, others telling the client they had dozed off, or especially near misses of falling asleep at the wheel. There are instruments that can help to assess for sleepiness and also help novice therapists to frame the questions. The DSISD contains the following query regarding hypersomnia: “Do you often fall asleep or do you have to struggle to stay awake when you are in any of the following situations: Talking with others, driving, talking on the phone, standing, performing your work, or any other situations?” The Epworth Sleepiness Scale (Johns, 1994) is an 8-item scale in which clients rate the likelihood of dozing on a 4-point Likert scale across a variety of circumstances (e.g., watching TV). Scores above 10 are suggestive of clinically significant sleepiness (Johns, 1994). The scale can be found at www.epworthsleepinessscale.com.

Other Sleep Disorders There are a variety of sleep problems that can present like insomnia (e.g., sleep disordered breathing) (Cuellar, Strumpf, & Ratcliffe, 2007) but are actually not insomnia at all. However, these problems can also be co-occurring disorders that complicate or undermine treatment, so assessment in MDD-I must be comprehensive. Any properly Downloaded by [New York University] at 04:37 12 August 2016 trained therapist can screen for the signs and symptoms of most of these sleep disorders in the context of a good assessment interview; but often, establishing the actual sleep disorder diagnosis requires referral to a sleep center for PSG. Therefore the job of the therapist working with MDD-I clients is to know when to refer their client to the sleep center and when referral is unnecessary.

Sleep Disordered Breathing There are a variety of breathing-related conditions during sleep; the most common of which in MDD-I is obstructive sleep apnea (OSA) (Harris, Glozier, Ratnavadivel, & Assessment of Insomnia 51 Grunstein, 2009b). OSA is a disorder in which there are repeated breathing pauses or reduced oxygen flow due to obstruction or narrowing of the airway during sleep. OSA is associated with significant morbidity including excessive daytime sleepiness, cognitive impairments, and worsened mood (Borak, Cieślicki, Koziej, Matuszewski, & Zieliński, 1996; Cheshire, Engleman, Deary, Shapiro, & Douglas, 1992; Sivertsen et al., 2008). The presence of OSA may convey risk for the development of insomnia as well (Vandeputte & de Weerd, 2003; Wahner-Roedler et al., 2007). The links between OSA and MDD include: 1) fragmented sleep (Schroder & O’Hara, 2005; Sforza, de Saint Hilaire, Pelissolo, Rochat, & Ibanez, 2002; Sharafkhaneh, Giray, Richardson, Young, & Hirshkowitz, 2005), 2) hypoxemia (Kamba et al., 2001; McGown et al., 2003; Pizza, Biallas, Wolf, Werth, & Bassetti, 2010), 3) serotoninergic system abnormalities (Adrien, 2002), and 4) shared common risk factors (e.g., obesity, cardiovascular disease, diabetes, etc.) (Schroder & O’Hara, 2005). The most important consideration for CBT-I treatment in those with comorbid OSA and MDD-I is to ensure there is adequate treatment of the OSA. CBT-I generates sleep deprivation to harness greater drive for deep sleep (see Chapter 5), and as stated, those with pre-existing daytime sleepiness may be at risk for accidents or falls if their sleepiness related to OSA (or PLMD or whatever other disorders they have) remains undertreated. The gold standard treatment for OSA is a PAP device in which air is delivered via a hose and facemask at a pressure strong enough to keep the airway open. For those adherent with PAP treatment, it is highly effective for addressing excessive daytime sleepiness and improving the overall quality of life (Giles et al., 2006). For those having difficulty with adherence, there are effective behavioral protocols for helping with adherence related PAP issues (Carney & Edinger, 2010). As a safety precaution in delivering CBT-I, it may be advisable to require a minimum of 4 nights per week with usage 75 percent or greater each night to safely proceed with CBT-I. One quick assessment tool for screening OSA in non-sleep specialty settings is to assess for eight factors. These eight factors are part of the STOPBANG instrument (Chung et al., 2012). The first feature, the “S” of the STOPBANG is the presence of loud, persistent (i.e., not occasional) snoring. The “T” is for tiredness, although in this context it actually refers to sleepiness; that is, is there a propensity to fall asleep. It is this propensity and not fatigue that the therapist should be looking for. One of the best ways to assess sleepiness is by administering an Epworth Sleepiness Scale, which can help in this assessment. The “O” of the STOPBANG is whether there are any observed apneas, that is, whether anyone has ever seen the client exhibit breathing pauses while asleep. The “P” is for elevated blood pressure, which can be obtained in the medical history. The “B” refers to whether Downloaded by [New York University] at 04:37 12 August 2016 the body mass index [weight in kilograms/(height in meters)2] of the client is greater than 35. The “A” refers to whether the client’s age is 50 years or more. The “N” refers to whether the neck size or circumference of the client is larger than 40 centimeters or 15 inches. Finally, “G” refers to gender, that is, whether the client is a man, since men are more likely to suffer from sleep apnea than women. For every answer in the affirmative, the item is scored as a 1, and a summed score of 3 or greater warrants at least a strong consideration of referral to a sleep disorders center for further assessment. That said, not all of these signs should be considered as equivalent and so it should be said that elevated excessive daytime sleepiness even in isolation, whether by self-report or by an elevated Epworth Sleepiness Scale (ESS) score (ESS>10), should be a strong 52 Assessment of Insomnia indication to instigate the referral process to a sleep center. Additionally, do not be fooled that the absence of any one of these factors, for example, being female, very young, or small in stature, should be taken as a sign to bypass an apnea assessment. All clients should be assessed for co-occurring sleep disorders, especially OSA.

Restless Leg Syndrome (RLS) RLS is a neurological disorder characterized by a compelling urge to move the legs especially during rest or inactivity; thus, symptoms most often appear in the evening and especially when getting into bed. The urge is often accompanied by unpleasant tingling sensations in the legs and the sensations are typically at least partially alleviated by moving the legs and walking. RLS can range from a mild nuisance to a disorder that significantly delays the onset of sleep and adversely impacts quality of life (Allen et al., 2005; Happe et al., 2009). The cause of RLS is not fully understood—the most commonly implicated etiologies involve dopamine dysfunction (Hornyak, 2010; Trenkwalder & Paulus, 2010), genetics (Schormair et al., 2008; Stefansson et al., 2007; Winkelmann et al., 2007) and poorly controlled anemia (Allen, Auerbach, Bahrain, Auerbach, & Earley, 2013). It is particularly important to assess for RLS in those with MDD-I because those with RLS typically report symptoms with substantial overlap with MDD, such as fatigue, disturbed sleep, poor concentration, and psychomotor agitation (Allen et al., 2003; Sevim et al., 2004). Indeed, there is a relationship between RLS and MDD (Cuellar et al., 2007; Sevim et al., 2004; Winkelman, Finn, & Young, 2006). The treatment of RLS may, in some cases, simply involve treating iron deficiencies. However, in most cases, if such deficiencies are not present or iron supplementation fails, treatment involves the prescription of a dopamine receptor agonist (Trenkwalder, Högl, Benes, & Kohnen, 2008). The following questions (contained in the DSISD) are useful in determining whether someone should be referred for evaluation and treatment of RLS:

Do you ever have a very strong urge to move your legs? Is this urge accompanied by an unpleasant sensation in your legs such as crawling, tingling, drawing, restlessness, or ‘electric’ sensations? Does the urge to move and/or unpleasant sensations begin or worsen during periods of rest or inactivity? Are these sensations temporarily relieved by moving your legs or walking? At what time of day do these symptoms occur?

The last question is assessing whether the symptoms occur or worsen in the evening or Downloaded by [New York University] at 04:37 12 August 2016 at night. Those with RLS experience creepy crawly sensations in their legs and typically have a strong urge to move their legs in the evening, particularly when at rest. The sensations are lessened when permitted to move the legs. Lastly, in assessing for RLS, it is important to pay careful attention to the medical history. Query if there has ever been a problem with iron levels, the date of the last physical examination and whether blood work assessed iron levels. As well, determine if the timing of the RLS symptoms were contiguous with the start of a new medication. Some antidepressants, including antihistaminergic agents and antipsychotics, can cause or worsen RLS (Allen, Lesage, & Earley, 2005a; Kim et al., 2008), and thus, medication use is part of a thorough assessment. Assessment of Insomnia 53 Periodic Limb Movement Disorder Periodic Limb Movement Disorder is a neurological disorder in which there are multiple brief (0.5 to 5.0 second) lower extremity twitches during sleep (Aurora et al., 2012). This is not merely moving frequently during sleep, tossing and turning, or restlessness, but rather these are stereotyped, sometimes subtle twitches which happen at such a high rate as to potentially cause brief arousals that will fragment sleep, much like OSA can do. It should be noted, that most clients with PLMD are unaware of the movements or the arousals because of their brevity. There is a very high comorbidity between RLS and PLMD, such many with PLMD also have RLS (Allen et al., 2003). That said, one can have PLMD and not have any symptoms of RLS. As with RLS, PLMD is linked to dopaminergic dysfunction (Picchietti & Winkelman, 2005) and treatment involves dopaminergic agonist medications (Boeve et al., 2007). There are also increased rates of MDD in those with PLMD (Picchietti & Winkelman, 2005). In addition, there are reports of increased PLMs with antidepressant medications such as clomipramine, imipramine (Hornyak, 2010), and some SSRIs (Dorsey, Lukas, & Cunningham, 1996) which underscores the importance of a complete medical and medication history. In the DSISD, the PLMD section queries whether a bedpartner has noticed the client’s leg jerking or twitching repeatedly during sleep and prompts the assessor to ensure the client’s description sounds like PLMs. That is, the movements should be described as repetitive, stereotyped extensions of the big toe in combination with partial flexion of the ankle, knee, and in some cases, the hip. Clinically relevant PLMD is often associated with excessive daytime sleepiness, and as noted above, EDS of unknown etiology should result in a sleep disorder center referral for an overnight study to rule-out PLMD and other occult sleep disorders.

Narcolepsy Narcolepsy is a neurological sleep disorder which can be associated with hallucinations upon waking up or falling asleep, sleep disturbance, daytime sleepiness, and/or muscle weakness during waking hours. The presence of excessive daytime sleepiness necessi - tates a follow-up query about narcolepsy; a significant sleep disorder that can also be associated with increased rates of MDD (Ohayon, 2013). The DSISD contains the following query:

Have you had any of the following symptoms: 1) inability to move while in bed

Downloaded by [New York University] at 04:37 12 August 2016 (i.e., temporary sleep paralysis), 2) seeing frightening images or visions while in bed, 3) carrying out some activity without being fully aware of what you are doing; or 4) a broken or disrupted sleep pattern at night?

Any of these symptoms along with excessive daytime sleepiness and/or unintentional sleep during the day warrant a referral to a sleep center to assess for narcolepsy. Additionally, a report of cataplexy (i.e., sudden but brief, bilateral muscle weakness or paralysis associated with the experience of emotion) is suggestive of narcolepsy and warrants referral. Narcolepsy is treated with pharmacotherapy for the specific symptoms of the disorder (e.g., stimulants for daytime sleepiness, SSRIs for cataplexy etc.) (Morgenthaler et al., 2007). 54 Assessment of Insomnia Circadian Rhythm Disorders Circadian Rhythm Disorders are disorders in which there are abnormalities in the timing of the client’s preferred sleep-wake schedule. In other words, the client’s preferred circadian phase is out of sync with the demands of their social and work schedules. Depending on the relation of intrinsic phase to the client’s preferred schedule, a person can experience a variety of problems with sleep initiation and maintenance, but this should not be confused with insomnia and should be assessed and ruled out before beginning CBT-I. In the DSISD, this is queried with the following lead question: “Have you ever had a sleep schedule that was unusual or undesirable to you, OR different from the sleep-wake patterns of most other people you know (for example, working at night and sleeping in the daytime)?” An affirmative response to this question is followed-up with questions about eveningness (e.g., Delayed Sleep Phase Type) and morningness (e.g., Advanced Sleep Phase Type), shift work (e.g., Shift Work Type), cross time zone travel (e.g., Jet Lag Type), multiple short sleeps or naps totaling an approximately normal total sleep time in 24 hours (e.g., Irregular Sleep-Wake Type), or a circadian system longer than conventional, such that sleep-wake times are delayed each night or day, resulting in sleep-wake times that are not entrained to the environment (e.g., Free-Running or Non-Entrained Type). Again, Circadian Rhythm Disorders are not the same as Insomnia Disorder even though many individuals with a circadian dysrhythmia will present to a sleep therapist thinking they have insomnia. Making this differential diagnosis is important because Circadian Rhythm Disorders are not treated with CBT-I, but rather they are best assessed and treated in Sleep Disorder Centers using light therapy, medications, or chronotherapy. Despite the fact that full Circadian Rhythm Disorders are not amenable to change from CBT-I, it should be noted that, delayed sleep phase and advanced sleep phase are part of a continuum of eveningness and morningness respectively, and milder forms can occur in ID and normal sleepers. That is, there are night owls and larks in the normal population and in those with ID, and who differ from those with full Circadian Rhythm Disorders both in the severity of the delay or advance as well as the amount of interference or distress the pattern causes. Such individuals can and should be treated using CBT-I. In those who have a night owl tendency with comorbid insomnia (e.g., see Client #1 in Table 4.2a), late nights do not produce a consistent sleep improvement. For example, the latest bedtime on Saturday is associated with taking an hour to fall asleep but one of the earliest bedtimes (i.e., 11 PM on Thursday) is associated with taking the shortest amount of time to fall asleep (i.e., less than 35 minutes). Additionally, Downloaded by [New York University] at 04:37 12 August 2016 although there are later rise times on the weekend, the client can wake up conventionally early, but this does not consistently resolve their sleep onset problem. For such clients with insomnia and phase delays or phase advances in the absence of a full Circadian Rhythm Disorder, CBT-I can be used but there are a variety of adjustments that may be needed (see Chapter 7). On the other hand, for those who have full Delayed Sleep Phase Type and Advanced Sleep Phase Type, following their ideal schedule resolves any problems (i.e., going to bed late and waking late or going to bed early or waking early). That is, if the individual follows their preferred internal clock, they will have no trouble either initiating or maintaining sleep. As an example, client #2 (see Table 4.2b) consistently falls asleep Downloaded by [New York University] at 04:37 12 August 2016

Table 4.2a Sleep Diary for Client #1

Monday Tuesday Wednesday Thursday Friday Saturday Sunday Bedtime 11:00 PM 1:30 AM 12:30 AM 11:00 PM 1:00 AM 2:00 AM 11:15 PM

Time to fall 120 min 90 min 50 min 35 min 60 min 60 min 120 min asleep

Time awake 10 min 15 min 5 min 15 min 5 min 5 min 15 min during night

Wake time 6 AM 6:15 AM 6:10 AM 6 AM 6:05 AM 8:00 AM 7:50 AM

Rise time 7:50 AM 8:30 AM 7:45 AM 6:15 AM 7:45 AM 10:45 AM 10:30 AM

Table 4.2b Sleep Diary for Client #2

Monday Tuesday Wednesday Thursday Friday Saturday Sunday Bedtime 12:00 AM 1:30 AM 12:30 AM 12:00 AM 2:30 AM 3:00 AM 12:30 AM

Time to fall 180 min 90 min 150 min 170 min 35 min 5 min 120 min asleep

Time awake 10 min 15 min 5 min 10 min 5 min 5 min 15 min during night

Wake time 8 AM 8 AM 8 AM 8 AM 8 AM 2 PM 2:30 PM

Rise time 8:30 AM 8:45 AM 8:30 AM 9 AM 8:45 AM 2:15 PM 2:40 PM 56 Assessment of Insomnia around 3 AM (falling asleep very quickly at 3 AM) with a late wake-up time on the weekend followed by an almost immediate rising. This client will require phase shifting which is beyond the scope of this book and will require a referral to a sleep center.

Psychiatric Comorbidities It is important to assess for psychiatric comorbidities as these will be an important part of the case formulation and depending on their severity and nature may affect the tailoring of treatment. There are some disorders that may make participation in a structured therapy such as CBT-I challenging, for example, psychotic disorders. There are no randomized controlled trials of which we are aware in which CBT-I was tested in those with psychotic disorders. However, one pilot study in those with persistent persecutory delusions found that CBT-I produced sleep improvements associated with large effect sizes as well as reductions in persecutory delusions (Myers et al., 2011). The presence of mania or perhaps even hypomania warrants caution in using techniques such as Sleep Restriction, as sleep deprivation can trigger mania or hypomania. Likewise, the presence of Panic Disorder or Seizure Disorders may warrant the same degree of caution as both panic attacks and seizures can be precipitated by sleep deprivation. On the other hand, insomnia is a very common problem in Post-Traumatic Stress Disorder (PTSD), and CBT-I is highly effective for those with comorbid insomnia, MDD and PTSD (Edinger et al., 2009a; Lichstein, Wilson, & Johnson, 2000). Nightmares are a frequent problem in PTSD and it is important to assess the frequency and intensity of nightmares, and whether the nightmares play a key role in the insomnia. When nightmares are a problem, one could consider additional medication such as prazosin (Raskind et al., 2003, 2007) or adjunctive therapies such as Imagery Rehearsal Training (Krakow et al., 2001). If there is a comorbid Obsessive Compulsive Disorder, it is helpful to know if there are any pre-sleep rituals that account for the delayed sleep onset. In other words, if the client is complaining about feeling tired and it taking a long time to fall asleep, but it is discovered that the sleep initiation attempts are delayed by the client’s need to engage in rituals, the compulsions become an important treatment target. For all comorbid conditions, it is important to ascertain whether the client views that there is a relationship between the condition and the insomnia. That is, did the sleeping problem start, change, or worsen with the onset of the other condition, or did the sleeping problem precede the comorbid condition? Even if the client is not an accurate historian with the timeline, such questions provide insight to how the client views the relation between sleep and other existing conditions. Ultimately, for but a few of the Downloaded by [New York University] at 04:37 12 August 2016 contra indicated comorbidities listed above, insomnia can and should be targeted for treatment within the context of the comorbidity; this is particularly true for MDD. Finally, there are several semi-structured interviews available that can be used to assess for psychiatric disorders including the Structured Clinical Interview for DSM5 Axis I Disorders (First, Williams, & Spitzer, 2015).

Medications or Substances It is important to assess for past and present over-the-counter, prescription, and herbal medications as well as illicit substances and alcohol. The medication list should include Assessment of Insomnia 57 sleep-related medications or medications taken to affect sleep, in addition to medications not taken for sleep. The list of medications that affect sleep is too large to reproduce in a book. Suffice it to say that almost any substance can potentially affect sleep. The following medications are only a partial list that can exert negative effects on sleep: central nervous system stimulants, antihypertensives, respiratory medications (e.g., steroid inhalers), chemotherapy, decongestants, and some antidepressants. It is important to take note of all medications, timing, dose, and duration of use. For all medications or substances it is important to ascertain if there is any relationship between the substances and sleep. That is, did the sleeping problem start, change, or worsen with the start of the medication or substance? It is also important to assess for common substances such as caffeine, alcohol, marijuana, and nicotine. It is important to know the timing, frequency and dose of the active ingredients in these substances. At the time of this printing, The Mayo Clinic website has a useful guide to estimating caffeine content: www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/caffeine/art- 20049372. Active substance abuse or dependence may be a contraindication or a limiting factor for CBT-I because there will be sleep disturbance related to the active properties of the substance as well as the withdrawal that can produce increased alertness or increased sleepiness at undesirable times. In general, it is not advisable for clients who are not stable medically or psychologically to engage in a rigorous treatment such as CBT-I. Instability of sleep is an expected reaction to extreme stress and CBT-I will not override the physical symptoms associated with an acute emergency so it is advisable to wait for medication, medical and psychological stability before embarking on this treatment. For any medications and substances, it is important to consider how the substance may be affecting sleep. Many people presenting for CBT-I treatment will be taking sleeping medications so it is important to assess for hypnotic dependence. The first thing to establish for dependence is nightly use of the medication, and the second thing to establish is their anxiety or willingness to discontinue the medications. Nightly users who are unwilling to discontinue medications and/or those who respond to these queries with extreme anxiety may have hypnotic dependence. Hypnotic dependence is not a contraindication for CBT-I but it is useful to know, as treatment will have to improve sleep self-efficacy, and because many clients who are dependent on such medications have beliefs that interfere with adherence to CBT-I. That is, if the belief is that their sleep system is broken, then attempts to correct the problem with a shift in behavior may be met with low confidence and resistance. See Chapter 3 for an in-depth discussion of hypnotic Downloaded by [New York University] at 04:37 12 August 2016 medications, treatment decision making regarding such medications, and tapering schedules.

Past Treatment History or Experiences It is important to query what treatments, both pharmacological and non-pharmacological, the client has tried in the past and what were the end results. Such information provides detail about what has worked, what has failed, and beliefs about treatments and medications. With regard to past behavioral treatments, sleep hygiene information is the most readily available online and it is the most frequently used treatment 58 Assessment of Insomnia component for insomnia (Moss, Lachowski, & Carney, 2013), therefore most clients have been exposed to and tried some form of this sleep education. Given that sleep hygiene is an insufficient treatment for insomnia when used as a monotherapy (Morin et al., 1999, 2006) most clients will not report success with this treatment. However, many may have confused sleep hygiene with a full course of multi-component cognitive behavioral therapy and thus may have some tempered expectations for CBT-I. Openly exploring the client’s experience of what has been helpful and not helpful is important for building rapport and gaining insight into their struggle with sleep effort and their beliefs about your work together. It is important to assess the client’s memory and understanding of the rationale for the strategies they used. Additionally, it is important to assess the specific detailed behaviors the client implemented in the past that did not work, as many will say that they have tried CBT-I when in actuality they may have only set their alarm during weekdays and decreased caffeine use. Such changes in isolation would not be expected to be effective, but pointing out the reasons for previous failure and the treatment components, that can be added, can debunk the previous experiences and generate new hope for the client. Lastly, it is important to query what substances or medications they have tried. Be sure to ask about timing, dose, course, and if there are any contingencies, e.g., “I only take trazodone following a really bad previous night.” Assess for both positive and negative beliefs about medication. Some clients believe medication is “bad” and refrain from taking prescribed medications for their depression, pain, or other conditions. Sometimes clients substitute other substances that are ineffective or unsafe to avoid prescribed, effective sleep medications.

Treatment Targets Perhaps the biggest goal for assessment is to collect data for determining treatment targets. For example, poor sleep drive habits (e.g., naps, increased time-in-bed, or high caffeine consumption on a sleep diary), circadian rhythm dysregulatory habits (e.g., irregular rise times on a sleep diary or a schedule that is a poor match for the client’s chronotype, such as early bedtimes and rise times in a night owl), sleep effort behaviors (e.g., going to bed early without any ability to sleep early on the sleep diary), and poor sleep hygiene (e.g., smoking, alcohol and/or marijuana before bed). Understanding these factors is ultimately what helps the therapist to adequately conceptualize the client’s insomnia and set up techniques and protocols that can address these problems and help the client achieve much better sleep. See Table 4.1 for a list of treatment targets and how to calculate them from a sleep diary. Treatment targets are described in Chapters Downloaded by [New York University] at 04:37 12 August 2016 5, 6, and 8.

Summary • Essential tools for assessment of insomnia include a clinical interview as well as sleep diaries. • It is important to help the client differentiate fatigue for sleepiness and to assess for excessive daytime sleepiness and refer to a sleep clinic for assessment of disorders that require further follow-up such as OSA, PLMD, Circadian Rhythm Disorders, and narcolepsy. Assessment of Insomnia 59 • Assess medical and psychiatric conditions, as well as a substance or medication history and past treatment history. • Data from the initial assessment is used to formulate the case, but assessment should continue throughout treatment.

Notes 1. Permission for the DSISD can be obtained by contacting the first author (J.D. Edinger). 2. Research permission can be obtained by contacting the first author (C.E. Carney). Downloaded by [New York University] at 04:37 12 August 2016 5 Behavioral Strategies for Insomnia

The evidence for CBT-I is strong (Morin et al., 1999, 2006). Cognitive behavioral therapies are empirically driven therapies so they are developed and refined using data derived from research. The sleep index improvements with CBT-I are associated with large effect sizes in sleep continuity similar to the effect sizes for treatment with hypnotic medication in the short term (Morin, Culbert, & Schwartz, 1994a; Murtagh & Greenwood, 1995; Smith et al., 2002). Unlike hypnotic treatment, with CBT-I once therapy is discontinued, treatment gains are maintained into follow up periods for as long as two years post-therapy (Edinger et al., 1992, 1996, 2001; Edinger & Sampson, 2003; Morin et al., 1999a). Although CBT-I is a multicomponent therapy that can vary with regard to the components used, there are some common core elements (i.e., Stimulus Control and Sleep Restriction) that tend to be incorporated across all the treatment versions. These behavioral strategies form the backbone of the treatment. There is even evidence (see Morin et al., 1999b, 2006) for Stimulus Control and Sleep Restriction to be used successfully as monotherapies but in clinical practice, and in clinical trials, it is most common to combine these highly effective approaches into a multicomponent treatment package. Therefore the clinician has a menu of techniques from which to choose and can decide the appropriate sequence, emphasis, and combination of elements to use depending on the conceptualization of the relevant factors impacting the client’s sleep. The most frequently utilized components of CBT- I (Edinger & Carney, 2014) include:

1. Stimulus Control (Bootzin, 1972): a set of sleep rules to address conditioned arousal. 2. Sleep Restriction (Spielman et al., 1987b): a technique to increase sleep drive by matching the time spent in bed with current sleep production time. Downloaded by [New York University] at 04:37 12 August 2016 3. Cognitive Therapy: a set of techniques to modify catastrophizing beliefs about sleep and fatigue that cause or exacerbate insomnia (discussed in Chapter 7). 4. Counter arousal strategies: a set of techniques to address hyper arousal, including establishing a wind-down period before bed, pre-sleep structured information processing, and relaxation therapy. 5. Sleep Hygiene: a set of rules designed to address sleep-interfering habits, substances, or environmental factors.

The goal of the assessment session is to diagnose the nature of the sleep disruption, discover the factors that are maintaining the problem, assess for any complicating Behavioral Strategies for Insomnia 61 comorbid disorders, and determine whether there are any issues that would contra - indicate the use of CBT-I (see Chapter 4). Once it is established that there is a diagnosis of insomnia and that CBT-I is an indicated treatment, the process of deriving goals for treatment can ensue and the first treatment session can be set (i.e., Treatment Session 1). Essential to the cognitive behavioral treatment of insomnia is that from the outset and throughout treatment, the client will need to fill out sleep diaries to monitor sleep continuity variables. Ideally, it can be helpful to have already supplied the client with diaries and written diary instructions along with other clinic materials (e.g., directions to the clinic etc.) in the mail and have the client bring the diaries to the assessment session, so that some sleep continuity information is already available to the clinician. In any event the clinician should allow some time at the end of the assessment session to either review the accuracy of diaries that have already been filled out, or to teach the client for the first time how to monitor their sleep. What follows is an example of a diary review dialogue (see Chapter 10 for more on this case):

Therapist: First of all I want to thank you for filling out the sleep diaries that we sent to you. These diaries are going to be a very important part of assessing how you are sleeping now but also throughout therapy it will help us to track your progress as we make changes to improve your sleep. I do see that there are some spaces that you left blank and others where you put question marks. Can you tell me what is happening there? Client: Well it said in the instructions that I wasn’t supposed to look at the clock, but that was making me nervous because sometimes I’m not sure how long I have been lying awake. Therapist: That is a very common concern but one that you really do not need to worry about. The truth is that I am much more interested in what it felt like to you, instead of the exact number of minutes that you were awake. So what I really need is your “guesstimate.” Anyway it turns out that people are consistent in the way they report their sleep. If you are off by a few minutes here and there, any so-called errors will be consistent throughout the treatment. Meaning if you tend to under- or overestimate how much sleep you produce, you will do this consistently, so it will be ok for our purposes. Does that make sense? Client: I guess so, but what if I really am off by a lot? Therapist: How about if we do a night together and see how it goes? Client: Okay. Downloaded by [New York University] at 04:37 12 August 2016 Therapist: First of all, let’s do last night because it’s much more likely that you will make a better guesstimate from the most recent night of sleep as opposed to any night earlier this week. So tell me how long did it take you to fall asleep last night? Client: It’s really hard to say and hard to put a number on it. Therapist: Just give it a shot. Give me the first number that comes to mind. Client: I think about 30 minutes. Therapist: Great! It’s just that simple. You say 30 minutes and we both know that that is probably not right to the minute but nevertheless it is close. That is, you know that it probably wasn’t anything like five minutes and you also know it wasn’t 2 hours. Am I correct? 62 Behavioral Strategies for Insomnia Client: Yes I guess that’s right. Therapist: So although it might have been 25 minutes or 35 minutes or even 40 minutes we know we are in the ballpark, which is what we need. All the other columns in the diary can be filled out in the same way. That is, by giving your best ballpark guesstimate. Now, is that something that you think you can do? Client: Yes I think so. If that’s all you need, I can do that. Therapist: Great! From here on that is how I want you to fill out your diaries.

It is important to emphasize that the diaries are essential because they will give a sense of the fluctuations in the client’s sleep and the treatment decisions will be based on them. Therapists should explain that at the beginning of each session the therapist will review and analyze the diary alongside the client so that in the future, the client will be able to analyze it without the help of the therapist and make needed adjustments on their own. As can be seen from the dialogue, it is important to emphasize that clients need not worry about the accuracy of their estimates. It is also important to note that the best time for filling out diaries is first thing in the morning when the memory of how the night proceeded is fresh in the client’s mind. Once the client is clear on how to fill out the diary, they can be provided with two weeks of diaries to assess their baseline sleep. Two weeks is ideal because it does not require too long a period of time between the end of assessment and the first treatment session and yet gives enough data to account for the variability of the clients sleep.

Treatment Session 1 As in all cognitive behavior therapy treatments, the client is oriented towards what to expect. For those clients who have participated in insight or support-oriented therapies in the past, the didactic nature of the sessions as well as the intense between-session work can be surprising, and may not suit all clients. As early as the assessment session the client may need to be oriented to the nature of a more focused cognitive behavioral therapy so that they are prepared for what is to follow. This message will then continue to be reinforced in treatment Session 1 as psychoeducation begins and homework assignments are developed. Once expectations are set, the client is free to choose whether this is a therapy in which they would like to engage. Of course the degree to which the client is ready to make the needed changes to their behavior will play out in the coming sessions and resistance will become part of the focus of the therapy. Downloaded by [New York University] at 04:37 12 August 2016 There are two main approaches to setting up CBT-I treatments: one is a set session- by-session manual driven approach seen most commonly in clinical trials (see Edinger & Carney, 2014) and in training settings. In Chapters 5, 6, 7, 8, and 10, we have used a set approach. The second approach is a more flexible, client-derived case formulation approach (see Manber & Carney, 2015). Across both approaches, the most important techniques will target the most salient problems, but in fixed session approaches there may be extra, potentially superfluous techniques as well. A case formulation approach is more advanced, so we refer the reader to Manber and Carney (2015) for more details. An example of this approach the BA and Behavioral Insomnia Therapy (BIT) treatment is described in Chapter 9 in which elements of BA and BIT are flexibly combined across Behavioral Strategies for Insomnia 63 three modules. For the purposes of this book, we will use the more basic fixed approach (e.g., Carney, Edinger, Krystal, & Shapiro, 2014) with adaptations relevant to depression described in (Carney & Manber, 2009; Manber & Carney, 2015). For most versions of fixed CBT-I, there is an attempt to present Stimulus Control, Sleep Restriction, and to some extent, Sleep Hygiene, in the first session. As a result, it is important to practice a succinct delivery of the rationale (i.e., psycho education) to be able to deliver it with efficiency. If at all possible, it is preferable to practice with a peer rather than alone, because psychoeducation is best delivered interactively using Socratic questioning (see Chapter 7 for more on Socratic questioning). One may want to anticipate a number of possible client reactions and questions that will arise while delivering the psycho - education and practice how to respond to each in turn. Such Socratic delivery may be particularly important in those with comorbid depression because the cognitive impair - ments in depression make it difficult to remember the rationale between sessions and clients may not follow the treatment prescriptions without buy-in. An interactive delivery will be demonstrated below under Stimulus Control.

Stimulus Control Stimulus Control is a treatment for insomnia that can be delivered with good results on its own (Morin et al., 1999b, 2006); however it is most commonly delivered in the context of a cognitive-behavioral package. One common problem that arises in chronic insomnia is the development of conditioned arousal. Conditioned arousal is a situation in which a client has inadvertently learned to associate the bed or sleep situation with alertness or wakefulness. This occurs with the repeated pairing of the bed and sleep situation with being awake, thinking, ruminating, emotional arousal, and/or a variety of sleep incompatible behaviors (e.g. watching TV, reading, etc.). That conditioned arousal if present reveals itself in the assessment as a story in which the client readily is able to sleep under particular circumstances, for example, when on the couch reading, however, when getting into their own bed, sleepiness dissipates, and alertness increases—such is a prime example of conditioned arousal. Fortunately, clients can unlearn this association by being in bed only when sleepy, or very close to it. To counteract conditioned arousal there are five rules for re-establishing the stimulus value of the bed for sleep, they are:

1. Go to bed only when sleepy. Downloaded by [New York University] at 04:37 12 August 2016 2. Get out of bed when unable to sleep and only go back to bed when sleepiness returns. 3. Get out of bed at a consistent time each morning regardless of the amount of obtained sleep. 4. Use the bed and bedroom only for sleep. 5. Do not take daytime naps.

Sample Delivery for Stimulus Control Rationale

Therapist: You said that you are often feeling very sleepy in the evening? Client: Yes, in fact sometimes I even fall asleep while watching TV. 64 Behavioral Strategies for Insomnia Therapist: So you go to bed and what happens? Client: That’s the odd thing, Nothing happens except that I wake right up. I can’t sleep. I’m not sleepy once I get into bed. Therapist: I see. Do you become alert then? Client: Yes, very alert. Therapist: I would say that this is one of the most common problems people with insomnia experience. Any theories as to why this happens? Client: No. It doesn’t make sense to me. Sometimes I think maybe I moved too fast to the bed so I walk slower, but this doesn’t work either. Therapist: People with insomnia have one common experience: they have repeated experiences of being awake in bed. When we repeatedly pair experiences like feeling wide awake, with an object (like a bed), this creates an association in our brain even though we are not aware of it. The association is that the bed is the place in which I am wide awake . . . Client: Wide awake and frustrated. Therapist: Yes, wide awake and frustrated, or worried, or experiencing racing thoughts. Good point because it is one thing to be awake but it becomes even more intense when there is a negative emotion such as frustration that becomes paired with the bed. Does this make sense to you? Client: My bed is the place where I am wide awake? Yes, I definitely think that’s true. Therapist: It’s as if your bed has now become a trigger for waking up rather than sleeping. The good news is that our brain can “unlearn” this pattern. We can create a new association of sleep with the bed by following some rules throughout this treatment. The rules are essentially to be out of bed when you are awake and in bed during a particular time at night and only when you are sleepy. If you are only in bed when you are sleepy, it increases the chances that you will fall asleep. If something changes and you are suddenly awake again, you are no longer sleepy so you need to get out of bed again. Client: That doesn’t make sense. My problem is that I become awake every time I get into bed. So this means I will always be getting out of bed and I will never sleep again. Therapist: So your theory is that you will never sleep again, ever? Client: Yeah, EVERY time I get into bed I am awake so if I have to get out of bed each time, I will never be able to sleep. Therapist: You don’t think that some sleep deprivation will build-up and eventually Downloaded by [New York University] at 04:37 12 August 2016 put you to sleep? Client: Maybe for normal people, not for me. Therapist: Let me tell you about an experiment with people with insomnia and then let’s revisit this issue, ok? Client: Ok. Therapist: In one study, they had someone with insomnia sleep in the laboratory and they of course had poor sleep that night. The next day they asked them to nap. Do you think they were able to fall asleep after having such a poor night of sleep? Client: I don’t know. I know that I wouldn’t be able to fall asleep during a nap even though I am absolutely exhausted. Behavioral Strategies for Insomnia 65 Therapist: And neither could the people in the study. People with insomnia develop something called hyper arousal. All of their bodily systems become hyperactive to help them function, so although they are tired, they are also “wired.” Ultimately this is how people with insomnia still manage to function but it also makes sleeping very difficult because you cannot sleep when alert. In the same research study, they had people with no sleeping difficulties stay in the laboratory bedroom next to the person with insomnia and every time the person with insomnia was awake, they woke up the healthy sleeper. By the morning, both the person with insomnia and the healthy sleeper were awake the same amount and slept the same amount. They asked the healthy sleeper, whose sleep they disrupted, to try to nap. What do you think happened? Client: They probably fell asleep right away and slept the whole time. Therapist: But why? They both had the exact same sleep. Client: There is something different about insomnia. Therapist: That’s correct. There is something different about insomnia—hyper arousal. Now to the third part of our study. In a third bedroom in the sleep laboratory they had another person with insomnia, and every time our first person with insomnia was awake, they woke up the other person with insomnia. So, some of the time, that person was awake because they have insomnia but other times they were awake because they were awoken to match the other person with insomnia’s sleep disruption. The next morning, every 2 hours, they asked the person with insomnia, whose sleep they disrupted, to try to nap. What do you think happened? Client: I don’t know. Therapist: The person with insomnia who was woken up when the other person with insomnia was awake became systematically sleep deprived, and suddenly, they were able to nap. The hyper arousal was over-ridden by the systematic sleep deprivation that was created by keeping them awake an amount more than they were already used to. If you were to stay out of bed when you were not sleepy and really wait until you were sleepy again as opposed to just tired or frustrated with being awake, and as a result sleep deprivation was building, what do you think would happen? Client: I’m worried I would stay awake forever but I guess that’s pretty unlikely. You think that I would eventually become sleepy? Therapist: It’s not about what I think, it’s about how the body works. There have been many people throughout history who have invested billions of dollars to try and discover a way for people like soldiers or astronauts to be able to resist sleep and Downloaded by [New York University] at 04:37 12 August 2016 stay awake for long periods of time—no one has been able to do it, because the body always finds a way to override it. Client: That makes sense. So I just stay out of bed permanently until I am sleepy? Therapist: (Smiles) What I can say is that such relearning will not happen in just one night. It may take some time for the new message to sink in. The new message being your bed is a place for sleep. So how about I give you a set of less extreme guidelines that use what we know about the body that can help us re-associate your bed with sleep, and get rid of the feeling that an awake switch goes off when you get into bed? Client: Ok. 66 Behavioral Strategies for Insomnia Below are the specific Stimulus Control Rules and rationale for their use:

1. Go to bed only when sleepy: Sleepiness, unlike fatigue, is a sensation experienced just before the transition into sleep. Sleep naturally unfolds when a person is sleepy and when given an opportunity for sleep such as a comfortable bed somewhere free from noise and light. Getting into bed because it is a particular time (e.g., “I have always gone to bed at 11 PM” or “I want to sleep,” or “. . . my spouse goes to bed at 11 PM so I go to sleep then too”) rather than because of sleepiness, can result in increased wakefulness, and consequent frustration while in bed. The bed should become associated with sleepiness, and therefore, rapid sleep onset. Therefore, clients are instructed to get into bed in the presence of this cue exclusively. 2. Get out of bed when unable to sleep (and only go back to bed when sleepiness returns): Conditioned arousal occurs because there are repeated pairings of the bed and wakefulness. It is a common experience for people with insomnia to lie in bed for long periods of time, frustrated with their inability to sleep. Most people do not leave the bed because they are exhausted and believe that staying in bed gives them their best odds for eventually falling asleep. However, conditioned arousal prolongs the time that it takes to fall asleep and further pairs the bed with worry and frustration so this strategy tends to backfire. Getting out of bed when unable to sleep prevents the pairing of wakefulness and the bed. Moreover, giving up the effort to sleep makes it more likely that arousal will decrease and that the client will be more likely to be ready to return to the bed. Once out of bed the client should engage in quiet relaxing activities and again return to bed only when sleepy as opposed to out of a feeling of need or desperation. If still unable to sleep the client should repeat this step as much as necessary. 3. Get out of bed at a consistent time each morning (regardless of the amount of obtained sleep): Ideally bedtime would be set every night but because of the first rule (i.e., only go to bed when sleepy) the bedtime cannot be fixed. However, clients can control when they rise by setting an alarm. Setting an alarm sets a window of opportunity so that the body can learn that this window is the only chance it has to sleep. Stimulus control is a technique in which the stimulus value of the bed at night for sleep is increased. However, this rule has other benefits including setting of the biological clock and therefore limiting the possibility of social jetlag symptoms. Further by not allowing oneself to attempt to sleep in longer in the morning, there is no dissipation of the extra sleep drive that was built from being awake longer that night. This starts an earlier build of pressure for deep sleep the Downloaded by [New York University] at 04:37 12 August 2016 following night, whereas lingering in bed reduces the amount of drive for the subsequent night. 4. Use the bed and bedroom only for sleep: If the goal is to increase the stimulus value of the bed for sleep only, then clients should avoid doing anything in the bed that they do when awake. Wakeful activities, when done in bed, can train the body to be awake in the bed. A careful assessment can uncover whether clients eat, read, watch TV, do work or homework, use the computer, phone or other devices in the bed. Then the client can be instructed to move these activities to someplace other than bed and preferably outside the bedroom entirely. Sex may be an exception to this rule under particular circumstances. For some people, sex Behavioral Strategies for Insomnia 67 is relaxing and so may be conducive to good sleep. For those individuals for which sex is alerting and possibly disruptive to sleep they may need to make a choice about when this is worth it to them. In our experience, good sleep can usually be restored by eliminating all the other waking activities and by especially eliminating sleep effort in bed. 5. Do not take daytime naps: If the goal is to strengthen the stimulus value of the bed to be associated with sleep only, during a particular window at night, then sleeping outside of this opportunity will undermine the process. This is one of the reasons why naps are prohibited. There are other reasons to object to naps. For example: (a) Naps reduce the drive for deep sleep at night by reducing Process S. Naps, especially long naps, produce a small amount of sleep and an exponential amount of stage 3 sleep (N3) is lost the subsequent night (Feinberg et al., 1985). (b) Naps are sleep effort and sleep should be effortless. Naps reinforce the idea that because one cannot sleep well during the night, one must engage in effort to compensate, even if it is during the day. (c) Naps reinforce beliefs about low sleep self-efficacy. In other words, napping reinforces the idea that one cannot cope with fatigue. By napping the client misses an opportunity to see how they would do trying to make it through the day without the nap, thus allowing them to maintain catastrophic beliefs about their ability to function without good sleep. (d) Naps decrease daytime activity in a group (i.e., MDD-I) known for decreased activity. (e) Naps disengage people from goal pursuits during the day and decrease exposure to positive reinforcers. (f) Naps are often a prime example of following a feeling rather than a plan. Napping is a depressogenic and insomniagenic behavior; that is it makes both conditions worse rather than better. However, many people with depression and insomnia feel “compelled” to take naps because of the fatigue. When people feel compelled to act in a way that inadvertently maintains the negative state (i.e., fatigue) behavioral conceptualizations would target this behavior for change. Please see Chapter 9 for a description of integrated BA plus Behavioral Insomnia Therapy (BABIT). (g) Naps may be an avoidant behavior—a way to escape emotional stress and/or the experience of fatigue. Avoidance reinforces negative mood and negative

Downloaded by [New York University] at 04:37 12 August 2016 beliefs about one’s self efficacy to cope. (h) Naps decrease exposure to social and photic zeitgebers (stimuli that provide circadian cues for entrainment of our clock) that can help mood and sleep. From a circadian entrainment point of view when one naps they are also training their brains that there are times in the middle of the day that are sleep times, thus in essence training themselves to need the nap.

By following all the stimulus control rules, the paired association of the bed with wakefulness is undone or unlearned, and a new association of the bed with sleep is produced. Eliminating conditioned arousal and sleep effort in bed is a key target for addressing insomnia. 68 Behavioral Strategies for Insomnia Sleep Restriction Just like Stimulus Control, Sleep Restriction is a treatment for insomnia that has been shown effective as a monotherapy (e.g., Morin et al., 2006) but it is most commonly delivered in the context of CBT-I as part of a treatment package. The main target for sleep restriction is to increase sleep drive so that sleep at night becomes more consolidated. As such, sleep restriction is often thought of as targeting mostly sleep maintenance problems, but it has been shown to work with problems of sleep onset and mixed insomnias as well. Many clinicians do not use the term sleep restriction with clients because it increases anxiety. Sleep restriction is an inaccurate description as sleep is often not restricted; only the time spent in bed is restricted. Alternatives for this term are time-in-bed restriction, sleep efficiency training, or sleep quality training. Below is a sample delivery of the Sleep Restriction or Time-in-bed Restriction rationale (for more on this case, see Chapter 10).

Therapist: You told me that your main problem is that you cannot stay asleep throughout the night and the sleep you produce seems light? Client: Yes, I can’t take it anymore. Therapist: Any thoughts as to why this is happening? Client: Hormones? Therapist: I wonder if there may be a simpler answer, especially since you have had insomnia throughout your life so although hormonal changes are co-occurring now, they were likely not a factor earlier in your life. Client: I guess that’s true. Therapist: Let’s talk about a different possibility. We have a system in our body that regulates how much deep sleep we get, so if we understand this system, we can use it to give us more deep sleep. Does that sound like this may be worth exploring for you? Client: Of course. I feel like I get no deep sleep at all. Therapist: We call the system that determines how much deep sleep we get Process S. It operates by accumulating a drive for deep sleep for every moment that we are awake. It is actually the result of building up a chemical associated with our cells working. So what builds the drive for sleep is being awake, but being out of bed and active builds an even stronger healthier sleep drive. This is because if we have been out of bed and active, our cells have been working hard and we have built up a store of the chemical needed for deep sleep. When we go to sleep, we eliminate this built-up chemical and the result is deep sleep. Producing deep sleep is good Downloaded by [New York University] at 04:37 12 August 2016 because, we are less prone to waking up and our bodies feel more restored and refreshed when we wake. In essence getting deep sleep and a more continuous sleep is equivalent to saying that you are getting a better quality sleep. Make sense so far? Client: I think so. You need a chemical to build-up by being active? If you are awake but not active, does it still build? Therapist: To some degree, but there is an association between low levels of activity and light sleep, so being active, rather than lying in bed, is probably an important part of building the strongest sleep drive that you can. Client: But the reason why I am not that active is that I am exhausted. I’m not lying down on the couch for any reason other than the fact that I am so tired. Behavioral Strategies for Insomnia 69 Therapist: That makes sense. Fatigue is one of the more debilitating symptoms of both depression and insomnia. However, one cause of the fatigue may relate to fragmented, light sleep, so in truth one way to help with the fatigue in the long run may be to increase the drive for deep sleep. Do you think it’s worth trying to test that idea? Client: Maybe. I think it’s possible that I wouldn’t feel as tired if I could stay asleep or get some deep sleep. Therapist: That may be true. If deep sleep is determined by staying out of bed and being active an adequate number of hours each day, what do you think happens when you try to nap? Client: Well, I’m not building up the deep sleep chemical? Therapist: True. Also you are spending some of the sleep drive that has been built up for the day so that it is not available to you at night. So by napping you suspend build-up of sleep drive and will have less drive for deep sleep that night. In addition, even during very brief naps, you can produce some deep sleep and even the loss of only a little deep sleep during the day can result in an exponential loss of deep sleep that night. It also means that you have to start building the sleep drive from whatever time you wake up from your nap, but then you won’t have enough time to rebuild sufficient sleep drive by the time you go to bed. What happens if you sleep-in in the morning? Client: I don’t actually “sleep”-in, I am just lying there exhausted. Therapist: I see. But if you are lying there, what does that mean for the build-up of deep sleep drive? Client: Not much I guess. I’m awake but not physically active. I guess I wouldn’t build it up. Therapist: That’s right. Even if you are really awake all of that time you are lying in bed, since you are not active if you do build any drive it is likely to be weak. There is another problem. Remember I said that when we go to sleep we release the chemical that was built-up and this is associated with deep sleep production? The release happens rather quickly so there is very little deep sleep in the second half of the night and essentially no deep sleep in the morning hours. So by staying in bed in the morning you prevent the build-up of healthy strong deep sleep for the next night and even if you were to drift off and get a little bit of sleep that morning it will not be deep sleep but more likely fragmented shallow sleep, whether you experience it this way or not. In this way you are doing what many people with Downloaded by [New York University] at 04:37 12 August 2016 insomnia do; that is, you are trying for as much quantity of sleep as you can get but in the process you are sacrificing good quality sleep. Does that sound like a good trade? Client: No, not really. I am always trying to get any little scrap of sleep that I can but now that I think of it, it never really feels like very good sleep. Therapist: OK. So at least in the short run, does it seem reasonable to go for a better quality sleep rather than quantity? Client: I think that makes a lot of sense. Therapist: Good. Let’s talk about some strategies you can try to get your quality sleep back on track? 70 Behavioral Strategies for Insomnia In sum, spending an increased time in bed relative to current sleep production ultimately will result in a decreased amount of sleep drive that is likely to result in a continued cycle of difficulty sleeping. Thus reduced sleep drive can result in a variety of clinical presentations including: an increased time to fall asleep (i.e., delayed sleep onset latency), waking up more frequently during the night, greater difficulty returning to sleep, a sense of lightened sleep, and every combination of these complaints. In other words, all the problems that constitute insomnia. To address these impairments in sleep drive we use Sleep Restriction; a straightforward technique with two steps:

Step One: Set the time-in-bed to equal the client’s baseline average total sleep time. Step Two: Gradually increase time-in-bed once quality sleep is achieved and sleepiness is evident.

To increase sleep drive, we create systematic sleep deprivation by restricting the time spent in bed to match the amount of average sleep produced as measured by baseline sleep diaries. Some variants in the application of sleep restriction allow for a normal amount of wakefulness in bed (i.e., 30 minutes); thus the time-in-bed prescription could be the average total sleep time plus an added 30 minutes. Then, once sleep deprivation increases and we see sleepiness and improved sleep, clients can start to spend more time in bed. This may seem counterintuitive. Many people think that people with insomnia are already sleep deprived; however there are a few things to consider. One is that often people with insomnia have great variability in their sleep pattern over the course of several days. That is, they can have very horrible nights but then they typically have a few recovery nights; thus their overall average total sleep time may be close to or within normal adult limits (i.e., at least 6 hours). Second, people with insomnia report increased levels of fatigue but not significantly increased levels of sleepiness, suggesting that they are “tired but wired.” Also when they have a bad night they typically respond by increasing their time in bed and/or cutting back on activity, thus weakening or reducing their sleep drive. However the fact that they cannot actually sleep well even during the day suggests that their level of hyper arousal often overcomes their level of sleep deprivation. They need to find a way to send a message to the homeostatic system to produce more pressure for deep sleep, to overcome hyper arousal. Lastly, the explanation provided to our case example Kelly (see also Chapter 10) above (in the Stimulus Control section) about the study in which the person with insomnia was sleep deprived to match the sleep of another person with insomnia is based on a series of Downloaded by [New York University] at 04:37 12 August 2016 studies by Bonnet and Arand (Bonnet & Arand, 1997). In these studies, introducing systematic sleep deprivation overrode hyper arousal and allowed the sleep deprived person to sleep during the day—something they were previously unable to do. These studies demonstrate that people with insomnia are not as sleep deprived as it may seem, or at least not sleep deprived enough to overcome their hyper arousal. Thus introducing sleep deprivation in the short run may be just what is needed to cause therapeutic changes to the insomnia that allows for easier sleep. When someone has a stomach virus that causes vomiting, as soon as they stop vomiting and start to feel hungry, the natural tendency is to eat. There is nothing pathological about eating when hungry, but while ill, this behavior will likely have a Behavioral Strategies for Insomnia 71 negative effect, namely, more vomiting. A different approach to this illness is what is called for to produce a different response—“stomach-rest.” Stomach-rest is a fasting period to allow the stomach to recuperate. When hungry this approach seems as counterintuitive as the idea to restrict the time spent in bed, but both time-limited remedies are highly effective in the long-term. When sleeping poorly, resting or increasing sleep attempts with increased time in bed seems to make good sense, while limiting time in bed further does not make intuitive sense. However, since this is a homeostatic system that automatically recovers deep sleep, the system needs less time in bed to trigger compensation; that is, more deep sleep. It is important to note that good application of sleep restriction requires sleep diary monitoring. Most often, problems with this very effective treatment relate to a novice therapist attempting to sleep restrict using a client’s retrospective report of their sleep in order to make the prescription. This is a notoriously much poorer estimate than can be obtained by the prospective estimates on sleep diaries. It is imperative to assign two weeks of prospective sleep diaries directly before the prescription is made in order to derive an accurate “dose” of sleep restriction. The first step for sleep restriction is to calculate the client’s average total sleep time, which is best accomplished by working backwards. To more easily fit on a page, in the example provided in Chapter 10 (Figure 10.2), we present seven days of data only. To begin, calculate the time-in-bed each night. The time in bed is the difference between getting into bed and getting out of the bed in the morning. Examine item 1 and item 7. On the first day (1/15/14), the intervening time between 11:15 PM and 7:10 AM is almost 8 hours. If you do this for each day and add all of these time-in-bed values together and divide them by the number of days (7), you will get approximately 9 hours and 25 minutes. Next, calculate the total time spent awake while in bed. To do this, add item 3 and 5 together, as well as calculate the amount of time the client was awake from the time they woke up (item 6) and the time they got out of bed for the day (item 7). For example, on the first day (1/15/14), the time to fall asleep is 40 minutes, the time awake during the night is 80 minutes, and the time between the final awakening (i.e., 6:30 AM) and the rise time (i.e., 7:10 AM) is 40 minutes; thus, 40 + 80 + 40 = 160 minutes. Calculate the rest of the days the same way. The result is the following for total wake time: 160, 170, 220, 190, 290, 180, and 290 minutes = 60 + 65 + 55 + 120 + 70 + 190 + 390. Subtract the total time awake during the night from the time spent in bed to calculate the average total sleep time. For example, the first night (1/15/14) is 475 – 160 = 315 minutes of total wake time, or approximately 5.25 hours. To calculate the average total sleep time, add all of the total sleep time up and divide by the number of days monitored: Downloaded by [New York University] at 04:37 12 August 2016 (5.25 + 6.33 + 6.25 + 5.33 + 3.33 + 7.25 + 6)/7 = 5.6 hours. The next step is to use this amount (i.e., average total sleep time is about 5.6 hours) to match with the client’s prescribed time in bed. However, keep in mind that, although not essential, 30 minutes can be added to allow for a normal amount of time to fall asleep. The decision to add time or not is at the discretion of the therapist and can depend on a number of different factors such as age of the client, level of sleepiness the client is experiencing at baseline, and assessed impact of other comorbid disorders. In other words, the decision to add 30 minutes to average total sleep time may depend on how much the therapist judges the client’s overall functioning and resources to be compromised by other factors. For the purpose of this book, since clients with depression generally could be considered to 72 Behavioral Strategies for Insomnia already be compromised by their mood disorder we will assume that 30 minutes will be added. Therefore, this client will be asked to spend a maximum of about 6 hours in bed during the initial restriction phase. The next step is to determine WHEN the client should get into and out of bed for their time-in-bed prescription. This is done collaboratively. The window must be the same every night in order to optimize the circadian system (that is, the biological clock). Remember that one way to entrain the clock is to get up and get light exposure at the same time each morning. In the example above, the prescription is to spend no more than 6 hours in bed, and currently, it appears from the diary as though they have to be awake around 6:30 AM 5 days a week. Thus, the client may want to set 6:30 AM as their standard rise time, but this should be confirmed with the client. Keeping the rise time at 6:30 AM every morning, that is, 7 days per week, will optimize the clock’s functioning as well as being consistent with Stimulus Control’s rule of setting a standard rise time. Counting back 7 hours, the earliest bedtime would be 12:30 AM. This is called the “earliest possible bedtime” because remember that Stimulus Control has a rule that stipulates to refrain from getting into bed until sleepy; so 12:30 AM would be the earliest bedtime. If the client finds themselves not feeling sleepy at 12:30 AM, then they stay up until they become sleepy. This minimizes the amount of time they spend awake while in bed and simultaneously increases the drive for deep sleep. It should be noted that as the client carries out this plan then it can be anticipated that in the first few days the client may become more sleepy than usual. Therefore, session time needs to spend discussing strategies that can be used to help the client stay awake during the day. In addition, there is a safety issue to be considered. The client should be alerted to the possibility of becoming significantly sleepier during the day and as such could be at more risk for such things as falling asleep while driving. Although it has been emphasized that it is not ideal for the client to nap, in the case of safety the client can be instructed that they may need to nap for a short time before engaging in driving or other dangerous activities or they should refrain from such activities altogether during the first days of treatment. Finally, once the client’s sleep is improved and they show signs of sleepiness, the time in bed is increased by 15 minutes per week until the sleepiness resolves or their sleep worsens. Alternatively, the time spent in bed can be increased by 30 minutes every two weeks. This decision is again at the discretion of the therapist and should be discussed with the client. Generally the more sleepiness the client complains of, the more likely it is that they would be able to tolerate a 30 minute increase to time in bed without it disrupting their sleep. Downloaded by [New York University] at 04:37 12 August 2016 Again the process of sleep restriction sends a message to the homeostatic system to increase the depth of sleep in response to systematic nightly deprivation. If the client does not immediately increase their time-in-bed following a poor night’s sleep, there will be an increased pressure to sleep deeply the next night or subsequent nights, and this system can naturally compensate for lost sleep over time.

Sleep Hygiene Sleep Hygiene is the treatment that most treatment providers outside of sleep know about and use (Moss et al., 2013) but it is not an effective treatment as a monotherapy Behavioral Strategies for Insomnia 73 (Morin et al., 1999b). In one study, 106 non-sleep specialty healthcare providers were surveyed about how they treat insomnia. Of all of the interventions listed for insomnia (including Stimulus Control, Sleep Restriction, sleep medications), the most commonly used intervention for insomnia was Sleep Hygiene (88 percent reported using sleep hygiene as a tool in their practice). A similarly high number believed that it was an effective treatment for insomnia (80 percent). When quizzed about efficacious treatments such as stimulus control, they mistakenly thought that SC included: caffeine, alcohol, bedtime snack and temperature or light recommendations even though these recommendations are actually sleep hygiene. In the same study, sleep hygiene was the most common technique provided in a google search of insomnia treatment on the internet, so clients are able to access this information for themselves as well. Sleep hygiene is categorized as NOT empirically supported according to American Psychological Association criteria (Morin et al., 1999b, 2006). It is not that these practices are unimportant for sleep health; however the data shows that making changes in sleep hygiene behaviors will not by itself eliminate insomnia. In other words, they are necessary, but rarely sufficient to treat insomnia. One can assume that many clients with insomnia have already been exposed to some form of sleep hygiene instruction, either on the Internet, on TV, or through their primary care physician. It is also safe to assume that most of these clients have not experi - enced much benefit from making changes to these behaviors especially considering that they are in your office still seeking help for a chronic insomnia. Therefore, before discussing sleep hygiene with the client, it may be useful to have a brief discussion about why these changes may have not been successful in the past but how they may be able to have a greater impact in the context of the multicomponent therapy that is being provided. For example, it may be useful to question the client about how these behaviors were put in place in the past and for how long. Many clients may only change one or two behaviors at a time which might not have been enough to fix their insomnia especially in the context of hyper arousal, conditioned arousal, and poor circadian entrainment. Likewise if a client only changes caffeine or alcohol consumption for a few days, it may not have been enough to draw any real conclusions about the effect that these substances have on their insomnia. In this way the therapist may be able to generate greater motivation on the part of the client to engage in more consistent and thorough sleep hygiene changes. Another concept that can be discussed is that although sleep hygiene by itself may not have caused or will fix the client’s problem, it may be said that poor sleep hygiene creates at least a vulnerability to having worse sleep. For example, drinking too much liquid in the evening may produce at least a semi-full bladder which may lead to a greater Downloaded by [New York University] at 04:37 12 August 2016 propensity to wake up during the course of the night. In a client who is prone to waking with frustration and worry, decreasing liquid in the evening may help but not enough to fix the problem. That said, during sleep restriction, one of the steps is to gradually extend time in bed to help the client achieve optimal sleep. If the client continues to have a full bladder this may affect how much the client can extend their total time in bed. In other words with a full bladder at night the client might only be able to extend to a total of 6.5 hours in bed while a client with an empty bladder might be able to extend to seven hours. Discussion of all of these issues can serve as good motivation for clients to reengage in healthy sleep practices again even though this has not led to success in the past. 74 Behavioral Strategies for Insomnia Once this debunking of past experience and provision of rationale for reengagement of good sleep practices has taken place, you are now ready to present the actual rules to the client.

Sleep Hygiene Rules (In No Particular Order): 1. Caffeine: Reduce the intake of caffeine, preferably to one cup (200 mg) per day, early in the day. If more is consumed, consumption should be discontinued at least in the afternoon so that it is not too close to bedtime. Caffeine blocks adenosine build-up so theoretically it could limit the drive for deep sleep. Further it is a stimulant that can increase arousal. Caffeine also produces an increase in fatigue during the withdrawal phase which can be misattributed to the sleeping problem, tempt the client into napping or decreasing activity, and produce increased distress or anxiety about the sleep problem. There are likely individual differences in the sensitivity to caffeine and the efficiency with which one eliminates caffeine for the body, so more specific recommendations for timing and consumption are very difficult. Thus, there are likely multiple reasons to manage caffeine use. 2. Nicotine: Eliminate or reduce consumption of tobacco products. Tobacco has stimulant properties and thus interferes with the depth of sleep. Moreover, once nicotine is eliminated, withdrawal symptoms are produced and clients can wake up with a craving for a cigarette. One note to the therapist is that in the addicted client, giving up nicotine entirely is clearly a very difficult process and may not be advisable simultaneous with the already difficult protocol of CBT-I. For those clients that are on nicotine it may be advisable simply to educate the client about the insomnogenic properties of nicotine and to perhaps shift the timing of nicotine consumption so that it does not occur shortly before bedtime. 3. Prescribed exercise: Be sure to be active and exercise if possible. Exercise and increased activity should have a positive impact on building healthy sleep drive. Some recommendations suggest refraining from exercise that is too close to bedtime for fear that it can be too alerting. 4. Consume a light bedtime snack, preferably one that contains tryptophan (e.g., milk, peanut butter). Tryptophan is a building block for producing serotonin (a neurotransmitter implicated in sleep) so the thought is that tryptophan-rich foods would improve sleep. There is no real evidence for this recommendation in those with insomnia. That said, it can be said that having some light food in your stomach during the night might decrease the possibility of arousal at night due to hunger. Downloaded by [New York University] at 04:37 12 August 2016 Also, consistently having a snack at the same time can begin to serve as a circadian cue for the coming of bedtime. 5. Avoid middle of the night eating: There are a few reasons for avoiding eating in the middle of the night. First, gastrointestinal upset is associated with sleep prob - lems (Shaheen et al., 2008). Second, eating upon awakening can create conditioned arousals to eat at the same time each night. 6. Avoid heavy liquid consumption in the evening: As stated, having a full bladder in the middle of the night can lead to increased arousal and number of awakenings. Cutting down overall liquid consumption over the last 4–6 hours of the evening before bedtime can be helpful. Behavioral Strategies for Insomnia 75 7. Reduce alcohol and other substances: Alcohol and substances such as marijuana lighten sleep. Both substances can decrease arousal initially and may even help with sleep onset; however the body must then work to break them down and eliminate them. While the body works to eliminate these toxins, REM sleep is suppressed. Once most of the substance (e.g., marijuana or alcohol) is broken down, REM sleep rebounds and lightens sleep in the latter part of the night. Therefore, while it can be said that consuming alcohol or marijuana may help one to get to sleep, it is also certainly true that it will disrupt sleep maintenance. Thus the net result from a sleep perspective is negative. One other note is that, as stated, in the early phases of CBT- I there is a tendency for an increase in sleep deprivation and consequent daytime sleepiness. This can be especially problematic in the evening when the client is having trouble staying awake until their prescribed later bedtime. It may be helpful to point out to such clients that consuming substances that can be hypnotic may only serve to exacerbate their struggle. As such it may be advisable to cut down or eliminate these products as much as possible to aid in the early stages of treatment. 8. Optimize environment to minimize light, noise, or extremes in temperature. It is difficult to sleep when too hot or too cold but it should be noted that it is generally easier to get warm in a cool environment than it is to get cool in a warm environment. Therefore, it is generally better to keep bedrooms at cool temperatures. Likewise, minimizing noise is conducive to better sleep. Finally, a lit bedroom (e.g., leaving lights on or the television) can be alerting and interfere with restorative sleep.

Counter Arousal Techniques Counter arousal is an umbrella term that incorporates techniques aimed at general arousal reduction. There are several different techniques for counter arousal, but included below are the most frequently used. The first of these is creating the buffer zone. The buffer zone is simply a one hour wind-down period before bed. During this period, it is preferable to cease goal-directed activities. That is, it should be a period of time devoted to leisure and relaxation (e.g., baths, listening to music, watching movies, hobbies, yoga), and/or a release from responsibilities and stress (e.g., refraining from checking e-mails or engaging in work catch-up, doing housework). The body needs to de-activate in order to allow sleep to unfold. Goal-directed activities require a certain degree of physical and mental arousal, which is counter to good sleep. Another counter arousal strategy is to engage in pre-sleep structured information Downloaded by [New York University] at 04:37 12 August 2016 processing. If clients don’t have a chance to process information during the day, they will tend to do it once they get into bed or by waking in the middle of the night. Thus shifting the timing of this needed information processing may be useful. There are several different versions of these strategies none of which have been compared head-to-head. So it is difficult to say which will have the best result for your client but may require some experimentation during the course of therapy. The first of these approaches is early evening problem-solving (Carney, Edinger, & Segal, 2005; Espie & Lindsay, 1987). The instructions are very simple: clients set aside some time in the early evening, when at their problem-solving best, to work through a problem constructively. To do this, ask the client to divide a page in half and label the first column concerns and the second 76 Behavioral Strategies for Insomnia column solutions. In the evening, typically just after dinner, they write down a concern that is on their mind, and then generate the “next” step in solving the problem. Writing down the ultimate end-solution can be overwhelming because there may be many steps before the solution is effective. For example, if the concern is holiday shopping for the child’s daycare, the ultimate solution is to buy the gift, but the next step may be to set a budget for the gift. The client then puts away the form at the end of the problem solving session, reminding themselves that they worked on this problem when at their problem- solving best and that they can return to this task again tomorrow at the appointed time. For this to work best it is useful to have the client commit to regular practice each evening so that it can become a habit. There is no set amount of time to set aside for this task, most often it takes about 20–30 minutes. It may be especially effective to have the client select not only a time but also a special place. In this way, with repeated practice, this time and place may take on a stimulus function and operate as the “worry time and space” such that once the client leaves there it is as if they can pin their concerns there and leave them behind. Another processing strategy is done in the pre-sleep period: the Pennebaker technique (Harvey & Farrell, 2003; Smyth & Pennebaker, 2008). In a Pennebaker exercise, clients write about their experiences, concerns, and emotions in an attempt to process them before bed. The rationale is that if clients have something on their minds, when there is no stimulation (i.e., in the dark, without sound), clients will naturally start to process the material, and it is better to do this outside of the bed. These techniques are most helpful for decreasing pre-sleep arousal rather than improving sleep per se (Carney et al., 2005; Mooney, Espie, & Broomfield, 2009) so they should be incorporated as part of a package with Stimulus Control and/or Sleep Restriction Therapy. Again, setting up a special place and time for this emotional processing can work well in conjunction with the behavioral techniques in that the client is both conditioning themselves to have designated sleep space and time distinct from the worry or processing space and time. Finally the most widely studied counter arousal approaches are relaxation therapies. Relaxation therapy has evidence for use as a monotherapy; however, the effect sizes are more modest than the other two monotherapies SC and SRT (Morin et al., 1999b, 2006). There are no reasons to favor one relaxation strategy over another (e.g., progressive muscle relaxation versus autogenic versus diaphragmatic breathing) so it may be helpful to ask clients whether they found any particular relaxation strategy to be useful or not useful in the past and proceed from there. This way, if a client has had a negative experience in the past, they can try a different one from the list. The therapist may also decide to choose one strategy over another if it is felt that it particularly targets a specific Downloaded by [New York University] at 04:37 12 August 2016 problem. For example, all things being equal, if a client is assessed to be particularly physically tense, the therapist might choose to start with progressive muscle relaxation, etc. It is important to advise the client not to use relaxation strategies as sleep effort. In other words, if the client uses the relaxation strategy like a sleeping pill by applying it upon getting into bed and trying at that point to relax as a way of making themselves sleep, such effort is only likely to lead to more arousal and frustration and is therefore doomed to backfire and fail. Rather relaxation strategies should be approached as a method for reducing basal levels of arousal overall throughout the 24 hour period. Clients need to be taught that it takes consistent practice to be able to “relax” on command. With sufficient practice, eventually, people will be able to access those skills in the Behavioral Strategies for Insomnia 77

pre-sleep period so that they can be generally relaxed as they get into bed. However, attempting to use these strategies while in a highly tense situation like getting into bed while anxious will likely have poor results, and the client may terminate the use of this strategy prematurely.

Implementation If possible, Stimulus Control, Sleep Restriction, and Sleep Hygiene are most commonly presented in the first treatment session. That said, there may be circumstances when there is not enough time for all three and some of the content will have to wait until treatment Session 2. SC and SRT are still considered among the most potent elements of CBT-I and so all efforts should be made to cover at least those techniques in Session 1 in order to get the client started on the right foot. Regardless, there is always a lot of information for the client to consume and remember. Given that those with insomnia and depression may suffer from increased concentration difficulties, it is advisable to always provide a take-home summary of the recommendations that have been made in the session. An example of such a handout is provided in Figure 5.1. There are reminders

My plan for better sleep Over the next two weeks, I will do the following: 1. I will use a standard get-up-out-of-bed time, seven days per week, regardless of the sleep I obtain on any particular night. My latest time out of bed is: ______. 2. I will go to bed only when I am sleepy, but never before my earliest possible bedtime. My earliest bedtime is: ______. 3. I will get up out of bed when I can’t sleep. I will give up the effort to sleep, and go to another room until I feel sleepy enough to fall asleep quickly before returning to bed. 4. If I still cannot fall asleep when I return to bed, repeat step 3. 5. I will avoid doing wakeful things while in bed. In other words, I will use the bed for sleeping only. If sexual activity is not alerting, this can be an exception to the rule. 6. If I ﬁnd myself worrying, problem-solving, ruminating, planning in bed, or engaging in sleep effort, I will get up and stay out of bed until this thinking dissipates and I feel sleepy enough to return to bed.

Downloaded by [New York University] at 04:37 12 August 2016 7. I will avoid daytime napping or spending time lying down throughout the day except in the case of safety. 8. I will ﬁll out my sleep diary each morning, preferably within an hour of rising, so that I can track the impact of this plan on my sleep. 9. I will set aside the hour before bed as a wind-down period. Other helpful hints: I will limit caffeine to one drink as far away from bedtime as possible. I will attempt to exercise, although not right before bed.

Figure 5.1 Client summary of sleep rules 78 Behavioral Strategies for Insomnia

of the elements that have been discussed and what is expected as “homework” in between sessions. There is also space for the client to write down the earliest possible bedtime and latest possible rise time. One could also provide space to write down strategies that have been discussed to help the client stay awake before their prescribed bedtime. Although counter arousal strategies may become part of the treatment package, other than the buffer zone, which is almost always discussed in Session 1, formal relaxation therapy is not likely to be covered until the second or third treatment session and can be added at that time. Aside from covering any additional information that was not covered in Session 1, much of the time in the other sessions is spent on troubleshooting any possible nonadherence to the sleep schedule or stimulus control instruc tions and using cognitive strategies to help restructure over valued ideation (for troubleshooting see Chapter 6). Finally, the last session should be devoted to going over what treatment gains have been attained and how to manage any recurring acute insomnia so that relapse is prevented in the future.

Summary

• CBT-I is a highly efficacious treatment for insomnia with durable effects. • CBT-I is comprised of: Stimulus Control, Sleep Restriction, Sleep Hygiene, Counter arousal strategies and Cognitive Therapy (Chapter 7). – Stimulus Control helps to disassociate the bed with wakefulness (i.e., condi - tioned arousal) – Sleep restriction increases the drive for deep sleep – Cognitive therapy modifies sleep-interfering beliefs – Sleep hygiene is sometimes necessary but rarely sufficient to address insomnia – Counter arousal strategies encourage pre-sleep processing or problem-solving to decrease the likelihood of processing while in bed Downloaded by [New York University] at 04:37 12 August 2016 6 Cognitive Factors and Treatment The Cognitive Model

Cognitive-behavioral models share one main idea, which is that mood, behavior, and thoughts are linked in such a way as to be mutually influential on one another. Thus making positive changes in cognition can have a positive impact on behavior and mood. Cognitive treatments that target the negative thinking implicated in maintaining health issues are expected to spur positive behavior and mood change. Practically speaking, cognitive therapy (CT) also may be an important tool to be used in behavior therapy in cases in which over valued beliefs get in the way of following behavioral recom - mendations (Carney & Edinger, 2006). For example, if one believes that 8 hours of sleep is necessary to function well during the day, the recommendation to limit the time spent in bed to less than 8 hours may be met with poor adherence because it is in opposition to the client’s beliefs. Modifying sleep need beliefs to favor sleep quality over quantity is more likely to yield adherence with an instruction to limit time in bed. We would expect less anxiety and arousal and therefore less resistance in someone whose beliefs were modified to value quality over quantity, relative to someone who valued sleep duration exclusively. Thus, although the goal of CT is to modify negative thinking linked to disorder, CT also may have an added positive impact on adherence to behavioral or even pharmaceutical adjuncts to treatment.

Depression-Specific Versus Sleep-Specific Cognitions and Overlapping Processes

Depression-Specific Cognitive Factors Downloaded by [New York University] at 04:37 12 August 2016 The neuropsychological literature suggests that cognitive impairments in MDD appear most reliably across the following domains: processing speed, selective and sustained attention, autobiographical and explicit memory, inhibition of goal-irrelevant stimuli, and effortful processing. To elaborate, those with MDD do more poorly on timed tasks (e.g., Knott, Lapierre, Griffiths, De Lugt, & Bakish, 1991) while those who recover from MDD show post-treatment improvements in processing speed (Seppälä, Linnoila, & Mattila, 1978). Those with MDD also show sustained attention deficits (Hart, Wade, Calabrese, & Colenda, 1998; Zakzanis, Leach, & Kaplan, 1998) perhaps owing to preferential allocation of attention resources to negative, self-referent material (Gotlib & McCabe, 1992). These attention issues appear to resolve with treatment, as responders 80 Cognitive Factors and Treatment to CBT show less interference for negative self-relevant material on the primed emotional Stroop task but non-responders continue to experience interference on the Stroop (Segal & Gemar, 1997). Further, depressed individuals have difficulties on tasks that involve explicit memory (Bazin, Perruchet, De Bonis, & Feline, 1994), but they remember negatively valenced material preferentially (Dalgleish & Watts, 1990). They also exhibit autobiographical memory deficits; that is, those with MDD preferentially remember negatively valenced and vague personal memories (Williams et al., 1996a; Williams, Mathews, & MacLeod, 1996b). Similarly, those with depression have issues with inhibition; that is, they have trouble ignoring goal-irrelevant stimuli (e.g., negative, self-referent stimuli) in favor of goal-relevant stimuli (Hasher & Zacks, 1988; Lau, Christensen, Gemar, Segal, & Hawley, 1999). Lastly, those with MDD show the greatest deficits on effortful, not automatic tasks (Hartlage, Alloy, Vázquez, & Dykman, 1993), in other words performance is worse for tasks requiring volitional effort. These neuropsychological findings are largely in support of prevailing Cognitive Theories of Depression (e.g., Beck, 1967). A shared component across cognitive theories of depression is an information processing bias. More specifically, depressed individuals specifically monitor for and attend to negative, self-referent stimuli (e.g., Gotlib & McCabe, 1992; Segal, Gemar, Truchon, Guirguis, & Horowitz, 1995; Williams et al., 1996b). These findings are consistent with Beck’s schema activation hypothesis (Beck, 1967), a theory that posits increased activation for negative, self-referent schemas when dysphoric mood is present. This may account for autobiographical memory deficit findings (Dalgleish & Watts, 1990; Williams et al., 1996a, 1996b.), in that recollection of personal memories during an MDD episode is biased towards negative mood- congruent content (Teasdale & Barnard, 1995). Beck has also argued that negative thinking is automatic and reflexive, rather than effortful and deliberate (also argued in Hartlage et al., 1993). This may account for the consistent finding that those with MDD show deficits on effortful processing tasks but not automatic tasks, and perhaps why information processing is slow (e.g., Knott et al., 1991). Deficits in effortful processing are also consistent with Response Style Theory (RST) (Nolen-Hoeksema, 1991), which posits that rumination is defined by both a negative processing bias and the automaticity of this process. Whereas effortful processing is difficult, rumination is automatic. Possibly because those with depression have a preferential bias for depression-related and self- referent material, rumination appears to be something that occurs quite naturally. When those high in depression symptoms are instructed to ruminate on their feelings, they Downloaded by [New York University] at 04:37 12 August 2016 show problem solving deficits, but those who are instructed to distract themselves from such content show problem solving capabilities comparable to those of their non- dysphoric cohorts (Lyubomirsky & Nolen-Hoeksema, 1995). When asked to think repetitively on concrete aspects of the problem (the “what”), problem solving is more effective than when one is instructed to think repetitively about the “why” and the consequences of the situation (Watkins, Moberly, & Moulds, 2008). For a clinical demonstration, see Chapter 8. Thus, the experimental, theoretical and psychopathology literatures converge on several themes of cognitive deficits in those with MDD; namely, 1) a negative information processing bias, that is (2) experienced as an automatic process, and (3) is activated in the presence of depressed mood. Cognitive Factors and Treatment 81 Sleep-Specific Cognitive Factors The neuropsychological literature suggests some equivocal results in insomnia, particularly when sleep duration is in the normal range. There is evidence to suggest some shared neuropsychological deficits between insomnia and MDD, namely, 1) an information bias which in insomnia is sleep-related and 2) some slowing in effortful (Orff, Drummond, Nowakowski, & Perlis, 2007), sustained processing (Edinger, Means, Carney, & Krystal, 2008b). Although the evidence is somewhat mixed, the findings become more consistent with respect to these deficits when the mean total sleep time is below normative values (< 6 hours). At these levels of total sleep time the neuro - psychological deficits are more reliably produced, and pronounced (Fernandez- Mendoza et al., 2010). Studies with positive findings, suggest those with insomnia have slower processing speed (Orff et al., 2007), difficulties with selective and sustained attention (Edinger et al., 2008), and difficulties inhibiting goal-irrelevant stimuli (i.e., effortful processing) (Jones, Macphee, Broomfield, Jones, & Espie, 2005; MacMahon, Broomfield, MacPhee, & Espie, 2006). These studies of neuropsychological deficits provide some support for cognitive theories of insomnia. The first Cognitive Model of insomnia was articulated by Charles Morin (1993), as he applied the Cognitive Model of Depression (Beck, 1967) to sleep continuity disturbance. The idea is that people with insomnia have dysfunctional beliefs about their sleep that can perpetuate insomnia. These beliefs about sleep include unrealistic expectations about sleep need, catastrophic thoughts about the negative consequences of insomnia on functioning and health, fears of losing control of sleep ability, and the conviction that sleep is unpredictable (Morin, 1993). There has since been considerable evidence to support Morin’s earlier (1993) theories (e.g., Carney & Edinger, 2006; Carney et al., 2006, 2010a). There are also several other cognitive models that draw from and expand on Morin’s work (Espie, Broomfield, MacMahon, Macphee, & Taylor, 2006; Lundh & Broman, 2000; Perlis, Giles, Mendelson, Bootzin, & Wyatt, 1997) including Allison Harvey’s (2002) Cognitive Model. Harvey’s model is heavily influ - enced by existing models of anxiety. The central idea is that overvalued beliefs (about sleep and daytime functioning) lead to negative thoughts when in a triggering situation. The trigger may be lying awake at night or it may be feeling low energy during the day; in either scenario, negative thoughts that are driven by dysfunctional beliefs about sleep and/or fatigue lead to states like anxiety, depression, and distress. When a negative state and negative thoughts about sleep or functioning are triggered, this instigates increased monitoring of the internal or external environment for confirmation that the situation Downloaded by [New York University] at 04:37 12 August 2016 is in fact threatening. For example, noticing fatigue while at work and thinking, “I am never going to get my work done if I can’t perk up,” leads to a focusing of attention on further signs of fatigue or evidence that one cannot properly concentrate on work. This can set up a vicious cycle of focusing on symptoms of impairment and a belief that the impairment will result in negative outcomes can yield greater perceived impairments despite no evidence of any objective impairments on tests (Semler & Harvey, 2006). When such selective attention is directed away from disconfirmatory evidence, it increases the likelihood of discovering confirmatory, albeit weak, evidence, and results in a worsening perception of the feared symptoms such as fatigue. This further reinforces the original belief (e.g., that one cannot cope with the consequences of sleep 82 Cognitive Factors and Treatment loss) and increases the likelihood that the clients will engage in what Harvey calls “safety behaviors” (e.g., caffeination) to avoid the undesirable experience (e.g., in this case, fatigue). The problem is that when one engages in safety behaviors (i.e., to avoid an anticipated undesired outcome such as nocturnal wakefulness or daytime fatigue), this can result in the unintended perpetuation of insomnia as a consequence. Some examples of safety behaviors related to fatigue may include consuming a stimulant like coffee, cancelling social engagements, avoidance of difficult mental work, decreasing or eliminating exercise, and/or napping. Some examples of safety behaviors related to nocturnal wakefulness may include using a sedating medication, going to bed early or sleeping in, or attempts at thought suppression while in bed. All of these behaviors can be said to be perpetuating factors of insomnia. Perhaps of greatest concern is that all of these behaviors could be considered evidence of sleep effort. (Espie et al., 2006). Sleep effort refers to behavior aimed at fixing the problem of insomnia, albeit in a way that is more likely to exacerbate rather than relieve the situation. It stands to reason that if one is engaged in any kind of behavioral or mental effort this should result in increased arousal. Therefore, by definition sleep effort runs in opposition to and undermines the body’s natural compensatory mechanism for sleep loss. In addition, the inevitable failure of sleep effort to produce good sleep also reinforces low sleep self-efficacy. That is that the person will quickly lose any sense that they have control over their sleep, and there are few things as anxiety provoking as believing that one has lost the ability to sleep despite all their best efforts.

Overlapping Cognitive Factors for Insomnia and Depression There are some obvious information processing characteristics shared across depression and insomnia. The classic Beckian model of mood-thought-activation (which emanate from latent beliefs) is at the core of both of these disorders. We know that those with depression and insomnia (MDD-I) have the similar types of unhelpful beliefs about sleep as those with insomnia but without depression (Carney et al., 2010a). General negative thinking is not characteristic of people with insomnia alone, but we see such negative thinking in those with MDD-I. We see attentional biases in both disorders; that is we see increased attention to sleep threatening information (Broomfield, Gumley, & Espie, 2005; Semler & Harvey, 2004) in those with insomnia and we see increased attention to general threats to the self in those with depression (Hasher & Zacks, 1988; Lau et al., 1999). Further, rumination or repetitive thought are evident in both disorders. Downloaded by [New York University] at 04:37 12 August 2016 In those with depression we see that ruminative content tends to be negative and self- focused while there can also be repetitive thinking about symptoms (Bagby & Parker, 2001). In those with insomnia, the content is not self-focused; rather, the content tends to be focused on symptoms such as fatigue (Carney et al., 2006, 2010b). Moreover, in those with MDD-I, insomnia symptom rumination is associated with poor sleep even after controlling for depression, while general depression-related rumination does not predict insomnia (Carney et al., 2013b). Similarly, although depressive thinking resolves and becomes subclinical with depressive recovery, insomnia beliefs, and therefore insomnia, do not tend to remit without insomnia-focused treatment (Carney et al., 2011) Finally, in depressed individuals with insomnia, even after controlling for depressive Cognitive Factors and Treatment 83 mood, unhelpful beliefs about sleep remain at the same level of those with insomnia only (Carney et al., 2010a). Thus, while there are some interesting overlaps in the cognitive styles and types of thinking of both individuals with depression and individuals with insomnia, it seems that there are beliefs that are particular to insomnia, which do not have their roots in depressive cognition and which require specific and directed treatment in order for them to change. We will focus on rumination and strategies to address rumination in Chapter 8. Now that we have reviewed the highlights of cognitive features of insomnia, depression, and the combined condition of MDD-I, we turn our attention to cognitive treatment strategies.

Cognitive-Focused Treatment for Insomnia Despite evidence for cognitive factors in the etiology of insomnia, unlike CT for depression, the evidence for CT for insomnia is not well-established. Core behavioral strategies in CBT-I such as Stimulus Control or Sleep Restriction, are so effective that they enjoy guideline status as monotherapies, but the evidence for CT as a monotherapy does not currently meet American Psychological Association (APA) criteria for an effective therapy (Morin et al., 2006). In a recent randomized clinical trial comparing BT, CBT-I, and CT, it found that CT was similar to BT and CBT-I, although CBT-I produced more rapid response than CT (Harvey et al., 2014). Nonetheless, a change in the way one thinks about sleep and fatigue is predictive of treatment response and belief change is linked to adherence (Edinger, Carney, & Wohlgemuth, 2008a). Thus, even if CT lacks evidence as a monotherapy, it is included in CBT-I for a variety of reasons, not the least of which is to enhance adherence to follow the behavioral instructions. For those familiar with cognitive therapy for depression, you will find that the specific cognitive techniques therein translate very nicely into CBT for insomnia. Cognitive therapy is a therapy based on the idea that solutions to difficult behavioral problems can be found by changing the way one thinks. In this model how people think will affect what they do and how they feel, so making changes in thinking can affect powerful change. There are a number of counterproductive and overvalued beliefs that are associated with insomnia. One example is that people with insomnia often believe that there is a particular amount of sleep needed in order to “function” adequately. In particular, most people believe that 8 hours of sleep is needed in order to have energy, perform well, and stay healthy. In truth, there is no magic number. Sleep is highly variable from night to night and person to person, and overall functioning is not tied to the absolute amount of sleep one obtains (Harris, 2014). Sleep need for any given person Downloaded by [New York University] at 04:37 12 August 2016 is sometimes difficult to determine, but in general one can be thought to be getting the “right amount” if they feel well rested and alert for most of their day. It is only when one is consistently obtaining less than what they specifically need that a condition of sleep deprivation exists, but people with insomnia generally tend to obtain what is considered low-normal amounts of sleep on average. The consequence of maintaining the belief that one must obtain 8 hours is that when sleep is less than that magic number it increases anxiety about the ability to cope, and it can become a self-fulfilling prophesy in the maintenance of insomnia chronically. There are numerous maladaptive beliefs that crop up in insomnia and serve to perpetuate the condition indefinitely. In CT the therapist encourages the client to examine whether such beliefs might be unhelpful, and 84 Cognitive Factors and Treatment encourages them to explore other alternative beliefs that may be less anxiety provoking. Belief change can be approached using several techniques. The most widely used of these techniques are as follows:

• Cognitive Restructuring using Thought Records • Cognitive Restructuring Using Socratic Questioning • Cognitive Restructuring Using Behavioral Experiments • Coping Cards: Encouraging Negative Thought-Incongruent Behavior • Shifting Information Processing Using Stimulus Control

The remainder of this Chapter will describe each of these approaches.

Cognitive Restructuring Using Thought Records One of the most common techniques in CT to change beliefs is the use of a worksheet known as a Thought Record (TR). The TR is a monitoring tool for negative thoughts that teaches clients how to examine the evidence for their thoughts associated with distress and to use this examination to generate possible alternative and more balanced thoughts and to consider if this helps to improve mood. Most TRs start with a column to record the situation in which the client experiences an activating thought. Just recording the situation may be helpful in and of itself because if the client records the same circumstance across multiple TRs, this can help them to recognize common triggers for negative thinking. For example, in insomnia, a common trigger might be trying to engage in focused performance at work. Situations such as these that are high in perceived resource demand could trigger thoughts about the sleep problem and worries about how lack of sleep may hinder performance and result in negative outcomes. The second column in TRs typically records mood, and often the client is asked to give a mood intensity rating, (i.e., if the mood is “anxious,” anxiety intensity is rated from 0–100). The third column is generally where clients are asked to record their specific thoughts. Clients are encouraged to record any thoughts occurring in the situation. The therapist encourages the client to explore any and all the related thoughts that occur to the client in the situation as a way to identify the thought that is most connected to the negative mood state recorded in the second column. Thoughts that are strongly connected to the negative emotion are labeled “hot thoughts” and are circled so that the client can focus attention on examining the evidence for and against this particular thought in columns four and five. Downloaded by [New York University] at 04:37 12 August 2016 It should be noted at this point that when the client is first learning how to complete the TR, it is advisable that the therapist helps the client to practice this in session. Before moving to columns four and five, a good deal of work can go into just having the client get good at filling out the first three columns of the TR (i.e. situation, mood, and thoughts). At first they are not always going to be readily able to generate their automatic and catastrophic thoughts. For example, a client can write thoughts descriptive of how they feel such as, “I am so tired,” but it may take some Socratic questioning to get the client to discover hot thoughts that are related to the most intense emotion, such as, “I won’t be able to function today.” It is essential that cognitive work eventually identify core beliefs since these may be the drivers of anxiety, sleep effort, and ultimately chronic Cognitive Factors and Treatment 85 insomnia. In addition, to practice in session, for some clients it may be advisable to have them work on only the first three columns for homework until they have the task fairly well in hand. Once the therapist is satisfied that that client can identify “hot thoughts,” the client can move on to practicing columns four and five and examining the evidence. Whereas some versions of the TR focus solely on amassing evidence against the thought, we prefer versions that encourage the client also to write down the evidence that supports the thought. This is because the intention in this work is not to suggest that the client’s thinking is necessarily erroneous. All thoughts will be based on some degree of truth. That is, there might very well be some evidence supporting the fact that when the client is tired, they won’t be performing as well as they might if they were feeling completely well rested. To ignore such evidence will eventually seem ingenuous and invalidating. By looking at both the positive and negative evidence we can validate the client’s concerns while still showing that things are not as severe and catastrophic as they may seem, and calling into question whether the thought is helpful. This is really the key to cognitive restructuring; that is, it is not to have the client wholly discard their thought, but rather to have them temper the thought to something more reasonable and workable. As with uncovering core catastrophic beliefs, recording information against the thought can be difficult for some clients. This is because some clients will have a cognitive style of automatic thinking and a well-developed mechanism for ignoring disconfirming information. For example, if the thought is related to a concern that sleep will never happen again, the client may not be able to acknowledge the fallacy in this, because of the strength of the emotion accompanying that thought. In other words, it “feels” as though it is true so disconfirming information is ignored. This type of thinking is called emotional reasoning. In CT for depression, emotional reasoning is highlighted as a cognitive error that should be challenged directly (Beck, Rush, Shaw, & Emery, 1979). It is somewhat common for clients to record examples of emotional reasoning in the evidence column. Through careful questioning, the therapist can help the client to discover how feeling as though something is true, is not the same as it actually being true; moreover this cognitive style is unhelpful for their sleep and daytime functioning. In this same way, the therapist will have opportunities to also explain other overvalued or unhelpful beliefs and how they can create problems. For example, a self- fulfilling prophesy is a belief in which the client assumes that something negative will happen, and the strength of this belief and the resulting behavioral accommodations makes it more likely that something bad will indeed happen. For instance, waking up Downloaded by [New York University] at 04:37 12 August 2016 and believing that feeling groggy upon awakening is evidence that one had a poor night’s sleep and that it will therefore be a bad day, may result in increased monitoring for signs of fatigue throughout the day and a greater likelihood of feeling more tired. Likewise, such a person might decide to engage in less challenging activity which can lead to boredom and poor mood. Thus the belief and resulting adjustments to perception and behavior in order to accommodate the belief make the “bad day” prediction more likely. Upon seeing this kind of situation detailed in the TR a therapist can begin to have the client see the inherent problems in this type of thinking. The therapist can ask clients to imagine that there are two people and one woke up thinking, “Ugh what a horrible night, I am never going to be able to do my work today,” and the 86 Cognitive Factors and Treatment other thought, “Ugh, what a horrible night, but I have had other nights like this and I know it will turn out ok,” Then the therapist can ask the client to predict which one is more likely to have a better day. Most clients can begin to see the vicious cycle when it is presented to them in this way. In one experiment, people with sleep problems were randomly assigned to a positive feedback condition upon awakening (i.e., they were told in the morning that their sleep was of good quality) or negative feedback condition (i.e., they were told that their sleep was of poor quality) (Harvey, Schmidt, Scarna, Semler, & Goodwin, 2005). Even though objective sleep was no different across the groups, the negative feedback group reported more negative thoughts, more daytime fatigue, and more sleep-interfering behaviors during the day. Such studies make clear that the way sleep is appraised can have a powerful impact on daytime experiences. Once evidence against and in support of the thought are listed in the appropriate columns, clients are encouraged to derive alternative thoughts that are more balanced with respect to evidence (column six). In other words, clients learn to write more adaptive, helpful thoughts such as, “even though I am tired, I usually am able to get my work done if I take a walk in the afternoon.” Once more balanced thoughts are generated and recorded, clients are asked to reflect on their mood again and re-rate the intensity (column seven). If mood ratings do not improve, the TR is re-reviewed. Common TR problems include that the circled thought is not truly the hot thought, in which case the therapist can probe with further questions to uncover the relevant core negative thought that is most highly emotionally charged. Once the new information is added, the mood can be re-rated. Another problem is that the more balanced, adaptive thought may not be particularly believable or compelling at first, in which case the session can focus on what evidence the client holds against the thought, and care can be taken to provide psychoeducation about cognitive errors. In addition, if the client is somewhat dubious about the newly generated alternative, this can provide an opportunity for a behavioral experiment (see below) to test the validity of the new thought. It is hoped that eventually the client will begin to consider alternative, more helpful thoughts, which in turn should have positive impact on mood and behavior. In Figure 6.1 we provide a sample completed TR.

Cognitive Restructuring Using Socratic Questioning Socratic questioning is a process intended to help the client uncover for themselves more adaptive viewpoints and to challenge their own unhelpful thinking. This technique is not mutually exclusive of other techniques and, in fact, Socratic questioning is also often Downloaded by [New York University] at 04:37 12 August 2016 used when completing a TR. This line of questioning can be used to uncover key thoughts as well as encouraging the client to identify evidence against the thought. Below is an example of Socratic questioning to help the client discover unhelpful thinking in their thinking and how unhelpful this type of thinking is in implementing behavior change. The example is meant to depict the depressive-specific issues that can arise in delivering sleep treatment in someone who is depressed. In the example below, the therapist is trying to troubleshoot difficulty the client is having with following a prescribed rise time. In doing so, the Socratic questioning brings up issues about self- efficacy and self-confidence. The therapist and client discover a pattern of dichotomous thinking in which things need to be done perfectly or the client is defective in some Cognitive Factors and Treatment 87

Situation Mood Thoughts Evidence Evidence Balanced Re-rate (rating for the against the thought mood 0–100) thought thought (0–100) Watching Exhausted What if I I have had I eventually Thinking Exhausted television in 80% can’t sleep this problem sleep, just about how 60% the evening again for a while. not well. tense I am Anxious tonight? may make it Anxious 90% I feel tense Sometimes I more likely 45% I can’t right now so am tense an to fall believe how I am hour before asleep. tense I feel. probably bed but going to somehow I may or I am never have some manage to may not going to be trouble fall asleep. have trouble able to falling falling sleep asleep. I was out of asleep without a town and later— pill. forgot my thinking pill and still about it may This is fell asleep. make it ridiculous. worse. The pill doesn’t Even if I work that have trouble great all the falling time. asleep, it doesn’t mean I will never fall asleep without a pill—I have slept without a pill before

Figure 6.1 Thought Record example Downloaded by [New York University] at 04:37 12 August 2016

way. The client in the interchange below is Kelly, described fully in Chapter 10. In the example that follows, the questioning exploring negative self-talk is similar to that seen in CBT-D, but the therapist is also able to bring the discussion back to the topic of sleep.

Client: You are going to be angry at me. I didn’t get up at the time we set. Therapist: I’m going to be mad at you? Client: Yah, I’ve always had trouble following through with things. I screw up opportunities like this all the time. Therapist: Can you tell me a little more about this? 88 Cognitive Factors and Treatment Client: Well, I never finished medical school . . . Therapist: You never finished medical school, so this means. . . . ? Client: Well that I’m a screw-up. Therapist: I see. What was the reason you switched out of medical school? Client: Well, I switched out of that track because I had always wanted to teach kids. But my Mom was disappointed . . . Therapist: Does this mean that once you start a program you should finish it even if you discover it is not your passion? Client: Well, yes. Therapist: I wonder if this is 100 percent true? You told me about your daughter Barb switching programs one month ago and how proud you were that she “had the guts to pursue what she really wanted.” Can you help me reconcile this? Client: I don’t know. But she definitely made the right choice. Therapist: Yes, it certainly sounds like she did. But did you make the right choice? Don’t you love teaching? Client: Yes, I do. Very much so. Therapist: Then are you saying that following a passion is OK for your daughter, but not for you? Client: Yes. I guess it just felt like I screwed up but I’m probably not being fair with myself now that I think about it that way. Therapist: I wonder how it makes you feel when you have thoughts such as, “I screw things up?” Client: Crappy. I feel bad about myself and wonder why I can’t do anything right. Therapist: And what happens when you are having thoughts like, “I screw things up,” and you are feeling badly? Client: It’s hard to turn it off then. I don’t feel like doing anything and I feel horrible, sometimes for days. Therapist: So, having the thought, “I’m a screw up,” makes you feel badly and you think about this over and over again, and then you lose motivation to do anything at all? Client: Yah. Therapist: Sounds like having that thought makes you stuck even more? Client: I guess so. But I am not intentionally telling myself that I am a screw-up. Therapist: Of course, but when you do have that thought, you feel so horrible that you cannot move forward with a plan? Client: I guess so, yes. Downloaded by [New York University] at 04:37 12 August 2016 Therapist: If you were able to interrupt this type of negative thinking, like we just did by talking about your daughter, could this have a different outcome? Client: Maybe. Therapist: OK so let’s look at what got in the way of getting up the prescribed time in the morning? Client: Well, I got out of bed at the right time during the week but not on the weekends . . . Therapist: So 5 out of 7 times you got out of bed at the prescribed time, but you told me that you didn’t get out of bed at the right time? Client: Well, not all the time. Cognitive Factors and Treatment 89 Therapist: Do you see a possible problem with seeing things as all or none? In other words, you either do it 100 percent of the time or you have “screwed up” completely in some way? Client: I’m not sure I know what you mean? Therapist: If you got up at the agreed upon time 5 of 7 nights, does that mean you would say that you “screwed up” completely? Client: No, I guess not. Therapist: Is there a consequence for you to be seeing things as all correct or all terrible? Client: I guess it’s sort of negative, is that what you mean? Therapist: If you can never take credit for something you accomplish unless it is 100 percent perfect, seems like there might be very few opportunities to feel good about what you have done. Seems like a recipe for feeling bad about yourself no matter what happens, which probably doesn’t do much for your confidence. What do you think this type of thinking does for the belief that you are a screw-up? Client: I see what you mean. I’m not really a screw-up but it frustrates me when I can’t follow through on something. Therapist: You already did it over 70 percent of the time, we just need to think about what got in the way the other two days. What was different about the two days you struggled to get out of bed? Client: It seemed weird to set an alarm on a weekend day and thought I might just get up naturally around the time. Therapist: That makes sense. Can you think of a way we can solve this problem? Client: This week I can just make sure to set the alarm. Therapist: Sounds reasonable. Can you think of anything that could get in the way? Client: No, I think I can do this.

Cognitive Restructuring Using Behavioral Experiments Whereas TRs have been the most traditionally used tool, in recent years, contemporary CT has focused more heavily on behavioral experiments (BE). That said, none of the strategies laid out thus far need to be thought of as mutually exclusive. A therapist can use TR’s and Socratic questioning to unearth catastrophic thinking and then use a BE to assess the validity of the belief. A BE is a test the client designs with the therapist to gather data about their beliefs. In essence, many of the techniques that are used in CBT-I can be considered as forms of BE. Clients are often leery about recommendations to get out of bed at the same time every morning irrespective of their previous night’s Downloaded by [New York University] at 04:37 12 August 2016 sleep, but some are willing to suspend their disbelief and test it out for two weeks. It is often helpful to frame all of the behavioral recommendations as experiments that are short term in nature. Following SC rules serves as a behavioral experiment that can modify many sleep- related beliefs that are unhelpful. For example, if a client is fixated on needing a particular number of hours for a sleep opportunity each night, following stimulus control instructions will typically vary the amount of sleep one obtains. By accepting that sleep duration will vary a bit initially, it helps the client face their fears about needing a particular magical number of hours of sleep. Challenging these fears, as well as discovering that better sleep quality even without the desired quantity yields better than 90 Cognitive Factors and Treatment expected functioning, will reduce anxiety about sleep. Also implicit in SC instructions is the idea of acceptance when sleep is not forthcoming. In other words, clients who practice good SC learn to behave, and eventually think like a person who is not preoccupied with sleep. Clients who practice this rule increase the drive for deep sleep and unlearn conditioned arousal but they also covertly challenge the idea that one MUST sleep simply because one wants to or because it is a particular time. In essence, clients are learning not to engage in sleep effort. Many clients are unaware that they are challenging these beliefs, but if a client is adhering to this rule, they are inadvertently building their confidence as someone who can cope with sleep loss, and someone who need not exert effort to sleep because they trust their body to produce sleep when it is truly needed. The following is a sample dialogue with Kelly, a case example from Chapter 10, for setting up standard wake times as a behavioral experiment:

Therapist: Given all you just learned about how your sleep system works, I wonder if you are willing to try a few strategies to get your sleep system back on track. Client: I can give it a try. Therapist: If we know that getting up at the same time every morning helps to set the clock and also ensures that you start building enough sleep drive for deep sleep the next night, then can we experiment over the next two weeks with a set time to get out of bed and keep track of the results? Client: [Smiles]. I might be able to do it for two weeks. I’m not sure if it will work for me. I already get up at the same time five times a week. Therapist: [Picks up sleep diary for them to look at together]. I see that your alarm is set for the same time five times a week, but are the rise times and final awakening times the same on this diary? Client: Well no, sometimes I just keep hitting the snooze button and stay in bed longer, but it’s because I am really tired. Therapist: Yes, of course. And what about the weekend? Client: Again, I am really tired so that’s why I stay in bed. Therapist: Understandable. But we know that the habits reported on this sleep diary, however good they feel in the moment, are the habits associated with recurring insomnia week after week—this is why you are here. So I wonder what happens if you test out a standard get out of bed time and we compare the two diaries in two weeks’ time. Client: You think my sleep could get better in two weeks? Therapist: We won’t know unless we try. We can keep track of the experiment with Downloaded by [New York University] at 04:37 12 August 2016 your sleep diaries. This way, you don’t have to take my word for it. You will be able to see your sleep system in action and how this simple change will help it to improve your sleep. Are you willing to do this over the next two weeks? Client: I’m skeptical, but willing to try it out.

As stated, it is often helpful for clients to see these recommendations as time limited so framing the steps of various protocols as BEs encourages willingness. For example, see Figure 6.2. This client is testing out the belief: “I’m tired and need to save my energy so that I have enough resources to deal with things.” This belief is very common in people with insomnia. Fatigue is a key feature of both insomnia and depression and BA Cognitive Factors and Treatment 91 is an effective strategy for improving mood but beliefs about needing to rest in order to manage fatigue, often get in the way of activation. Resting is a common sense strategy for improving fatigue so by the therapist merely saying that resting increases fatigue is often not particularly compelling. It may be more effective for clients to achieve belief change through an experiential learning process. While resting when tired can truly feel good in the short run, excessive rest can have a negative effect on motivation. The adage that an object at rest, stays at rest, is particularly poignant in this circumstance. Spending long periods on the couch watching television or on the computer tends to lead to further time on the computer or television. In addition, it tends to produce boredom and lethargy. Conversely, engaging in goal directed activities can have positive effects on motivation and energy, as there is momentum in such a strategy. Further, moving around increases blood flow and oxygenation, whereas staying at rest can create deconditioning and muscle shortening which can lead to aches and pains. Lying down activates the parasympathetic nervous system, but being upright activates the sympathetic branch. Excessive rest can also have a negative effect on sleep because it may lead to dozing or napping, and mitigate the build-up of drive for deep sleep. Excessive rest can have negative mood consequences as well because people can become anxious or feel badly about themselves if they have a low rate of goal-directed activity. For example, if a client has a to-do list of 5 items for the week and at the end of the week, little on the list was accomplished, it can inspire self-focused rumination about what is wrong with them that they are unable to meet goals or worry about the consequences of not getting the needed tasks completed. Worry and rumination can lead to increased sleep effort and further worry (e.g., the person may go to bed with the thought, “I had better get some sleep tonight or else I will not be able to get the items on my list accomplished”). Lastly, rest can have negative effects on mood because without movement and leaving the house, the possibilities for positive reinforcement are diminished. Rest is often done in solitude or with little active social engagement, which leads to a less rewarding life, and fewer exposures to situations that could provide regulatory input into the circadian system. Thus, when a client is encouraged to engage in a BE like the one presented in Figure 6.2, generally, contrary to their beliefs, they will notice an improvement in either fatigue, mood and/or sleep with activation, and/or a worsening of fatigue, mood and/or sleep with conservation. In addition to the standard protocol instructions of CBT-I, there are other behavioral experiments that specifically target belief changes. Given that each client can present with their own unique set of beliefs and concerns, theoretically there can be as many different types of experiments as there are clients. That said, there are several common Downloaded by [New York University] at 04:37 12 August 2016 experiments we test in those with insomnia and depression fairly consistently. Another common belief is that: “I need to scan my body to figure out if I have enough energy and resources to [do a task].” Such body scanning is what Harvey (2002) refers to as monitoring. The belief that body monitoring is helpful can be tested with an instruction to focus intensely (for 15 minutes) on fatigue symptoms followed by 15 minutes of focus on the present environment, e.g., sounds, smells, sights, and tactile information in the environment. In each case the client can rate mood and fatigue and compare the differences. Generally, solely to be searching for signs of fatigue will most certainly yield evidence of fatigue and perception of greater intensity. Conversely, when one is focused outward on the here and now they will tend to feel better. 92 Cognitive Factors and Treatment

Belief to test: I’m tired and need to save my energy so that I have enough resources to deal with things. Week One Experiment: Spend one week conserving energy as much as possible. Track sleep efﬁciency (SE) on sleep diary, mood and fatigue. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Felt nice to Bored and Achy and Too boring Ruminating Depressed Depressed do nothing depressed bored; in house 6/10 9/10 ☺ achy 8/10 depressed (went Depressed Couldn’t 8/10 shopping) 9/10 take it-- Fatigue SE was SE = 62% shower and 9/10 64%--sleep Fatigue Fatigue Aches and go for a was crappy Overall 9/10 6/10 very tired walk SE = 62% fatigue = 9/10 Fatigue 9/10 SE = 64% SE = 69% SE = 65% 8/10 SE = 64% Depression Fatigue = 6/10 6/10 Week Two Experiment: Plan activities to expend energy. Track sleep efﬁciency (SE) on sleep diary, mood and fatigue. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Laundry, Showered, Showered, Out with a Visited Depressed Brunch, showered, read, walk, paid bills, friend Mom, went 5/10 skating, walk and cleaned walk, made to store to grocery dinner with closet dinner Fatigue switch out Showered, shopping, friend Depressed Depressed 2/10 phone walk, out for clean house 6/10 2/10 (felt coffee, SE was good today) SE = 69% Depressed bought gifts Depressed 81% SE = 82% 3/10 3/10 Fatigue Depression SE = 85% Fatigue Fatigue 4/10 2/10 Fatigue Fatigue 5/10 5/10 5/10 Fatigue = 3/10 SE = 84% 6/10 Depressed SE = 84% SE = 82% 5/10 Downloaded by [New York University] at 04:37 12 August 2016

Figure 6.2 Behavioral experiment tracking example

Another testable belief is, “I need to fix my depression and feel more motivated before I can do [any task, including the behavioral recommendations in CBT].” A belief that motivation needs to come first to perform tasks can be tested by asking the client to do one task without the sensation of motivation and monitor the results. The essential point is that behaving and experiencing the outcome is often superior to verbal delivery of information, and is less vulnerable to resistance and often self-perpetuating in a positive Cognitive Factors and Treatment 93 direction, thus less prone to relapse. Readers are encouraged to read Ree & Harvey (2004) for more on insomnia-focused behavioral experiments.

Coping Cards: Encouraging Negative Thought-Incongruent Behavior Often, in-session, the client can begin to see a range of alternative possibilities and is able to process the information that disconfirms their long held negative beliefs about sleep. Clients may feel ready to make a behavior change in session, but then when they get home, they may find themselves overcome by old automatic thinking and emotions and therefore unable to implement new strategies. Coping Cards are “notes to the self” to be read at times when information processing may undermine the commitment to the behavioral goals. Once a particular type of information processing is activated, information that is congruous with the negative mood and thoughts is over attended to at the expense of disconfirming information. If the client writes a message to themselves at a time when information processing is more open to a range of information, and then reads this alternative when they feel more stuck, it may prompt them to engage in a more adaptive behavior. A note to the self on a smart phone, cue card, note pad, or post-it note can be an effective lifeline that encourages behavior change and increases self-efficacy. In the example below, we see the therapist establishing the mood-thought-behavior connection in order to encourage the client to make a behavioral change. Rather than buying into the client’s formulation that particular circumstances or moods (e.g., feeling horribly in the morning) determine behavior (e.g., whether or not to set an alarm clock for the morning), the therapist suggests an alternative coping behavior (e.g., setting and turning on the alarm clock at a different time, when mood is less negative). While the therapist is making the thought-mood-behavior connection, the client spontaneously suggests a method akin to the Coping Card. In most circumstances, the therapist will introduce the idea.

Therapist: How did things go last night? Were you able to set the alarm? Client: No. Therapist: What got in the way? Client: I don’t know. Therapist: Did you have the thought, “I should set my alarm” last night? Client: Yes, but I felt so horribly last night because I’m so tired that I knew I wasn’t going to be able to do it. The idea of setting the alarm was not at all appealing. Downloaded by [New York University] at 04:37 12 August 2016 Therapist: I get it. And how did you feel the next morning? Client: Well, horrible—even worse. I was exhausted. Therapist: You responded to feeling horribly by doing something that made you feel even more horrible. Sounds a bit like a trap. Maybe the way to get out of this trap is to respond to this situation in a different way. If not setting an alarm makes you feel horrible the next morning, could we experiment with setting the alarm and gathering information on whether your mornings could be less horrible? Client: Well, that was my plan. Therapist: Right, but you followed your feeling rather than your plan. This resulted in feeling more horrible and you started to criticize yourself for not following the 94 Cognitive Factors and Treatment plan, which also worsened your mood. Instead of tying the “on” button of your alarm clock to how you feel—what if your alarm was turned on during the day when you feel better? Your alarm clock can be turned on at any time, right? Client: I never thought about this. I could turn it on when I got home—take the decision out of it. Therapist: Can you think of anything that could get in the way? Client: I wonder if I would turn it off before bed if I was feeling really bad. Therapist: Well, we could wait and see if this is a problem or we could try something to minimize the likelihood of this happening. Client: I could put a post-it note on the clock like: “DO NOT TURN OFF, NO MATTER WHAT!” Therapist: Do you think this would help? Client: I do. The idea of the note kind of makes me laugh. I think if I saw the note it would change my mood a little. I think this may work. I am going to start turning on my clock when I get back from work, before my mood plummets, and I will stick a funny note on it to remind me not to turn it off.

It is often most helpful to have the client write the coping card in session. We keep a small stack of post-it notes and index cards for this purpose. It is often helpful to have several reminders on the card including a reminder of the desired behavior. Some choose to put reminders on their smart phones.

Shifting Information Processing Using Stimulus Control The Stimulus Control instruction to get out of bed when unable to sleep is important for giving up sleep effort and addressing conditioned arousal but there may be other benefits as well. When people are lying in bed attempting to sleep, they unknowingly go in and out of a very light stage of sleep but are often unaware of any sleep at all. The reason why they misperceive or underestimate sleep has many possible explanations

Stay up until 11 PM

If you fall asleep, you will be awake later.

Downloaded by [New York University] at 04:37 12 August 2016 This will fix your sleep problem. Turn on the lights. Don’t lay down. Invite a friend over. I would rather sleep than nap. Go out and visit Louie.

Figure 6.3 Coping card example Cognitive Factors and Treatment 95 (Harvey, 2002; Lundh & Broman, 2000; Perlis et al., 1997). Most theories suggest a role for arousal (Bonnet & Arand, 1996, 1997; Perlis et al., 1997, 2000; Tang & Harvey, 2004). For example, high frequency brain activity intrudes into the onset of sleep and is perceived as wakefulness rather than sleep. The consequence is that staying in bed trying to sleep could result in a confusional state between wakefulness and sleep. In addition, information processing, problem solving and emotion regulation are less than optimal while in this transitional stage between wake and sleep. Ever heard of the saying, “things will look better in the morning?” That may well be true in part because looking at things when half asleep is not likely to feel positive. Getting out of bed creates a shift into full wakefulness, ends the light stage of sleep, and as a result, increases lucidity. While lucid, information processing, problem solving and emotion regulation is more optimal so that the client has a better chance to become calm and ready to return to bed.

Summary

• A cognitive model for insomnia (Harvey, 2002; Morin, 1993) emphasizes the role of beliefs about sleep self-efficacy and fatigue in activating negative thoughts about sleep or fatigue. These thoughts lead to increased monitoring in the environment for sleep or fatigue threats as well as increased safety and avoidance behaviors that interfere with sleep. There are similarities across cognitive theories of sleep and depression; namely attentional bias towards negative information (depression) and sleep or fatigue threats (insomnia). • Cognitive therapy attempts to address cognitive causal factors and may also act by addressing cognitive barriers to adherence. • Cognitive Therapy does not have APA level evidence as a monotherapy but nonetheless is a common element in CBT packages for insomnia. • There are a variety of cognitive techniques used in insomnia treatment including Thought Records, Socratic Questioning, Behavioral Experiments, and Coping Cards. These can all be used simultaneously to discover alternative thoughts and enhance outcomes. Downloaded by [New York University] at 04:37 12 August 2016 7 Encouraging Adherence and Troubleshooting Potential Barriers

There are many successful trials of CBT-I in those with MDD-I (Edinger et al., 2009b; Kuo et al., 2001; Lichstein et al., 2000; Manber et al., 2008; Morawetz, 2001; Watanabe et al., 2011). In each of these trials CBT-I was delivered unaltered. Nonetheless, CBT-I is a demanding treatment and MDD-I clients can present with specific barriers that can interfere with tolerating the rigors of the protocols, and make following the treatment more challenging. In this chapter, we provide some troubleshooting strategies for the more common problems. Cognitive therapy, as stated in Chapter 6, is an important tool for increasing adherence. We have included in this chapter some cognitive strategies that can be utilized for troubleshooting resistance, but the reader is directed to Chapter 6 to understand the theoretical underpinnings of such techniques. Most problems of non-response or suboptimal response to CBT-I in those with or without a comorbid condition, amount to difficulties following all of the strategies. It is important to check in every session with the client’s experience with following the recommendations. The first step in addressing non-adherence is a troubleshooting assessment. Throughout this assessment, it is important to gather as much information as possible about the factors that may be interfering with adherence. In addition, the assessment affords an opportunity to intervene as well. It is important not to assume the reason behind nonadherence. Query for the antecedents, the presumed barrier to adherence and the consequences. There are many reasons why someone has difficulty following an instruction such as getting out of bed at a same time. These rules are not easy to follow, especially when one is experiencing fatigue and low mood, so it is always important to validate these experiences and acknowledge that it is difficult but not impossible to focus on behavior change to improve sleep. Approach the situation Downloaded by [New York University] at 04:37 12 August 2016 empathetically and openly, and foster a spirit of curiosity. What follows is a series of common troubleshooting scenarios with Kelly, a case study from Chapter 10.

Troubleshooting Difficulties with the Morning

Discomfort Therapist: So, the last time we met, we discussed quite a long list of recommended changes to your sleep routine and I wanted to check in with how things went over the last two weeks. Adherence and Troubleshooting Barriers 97 Client: It was ok but I really couldn’t get up at 5:30 AM—I just couldn’t. Therapist: I see. I would like to get some more information so that we can understand what got in the way if that’s ok? [Client nods yes]. There was so much to remember from last week, can we start by checking in with what you remember about why we are setting a rise time each morning? Client: To build sleep drive? Therapist: Excellent. That’s right, to build enough drive for deep sleep the next night and the nights to come. Can you remember any other reasons? Client: I’m not sure. . . . Therapist: There was another reason that related to the clock, does this sound familiar? Client: Sort of . . . I need to set my clock each morning around the same time? Therapist: That’s true. You sound like you are referring to your alarm clock. I was alluding to your biological clock. Getting up at the same time every morning can help to set your biological clock so that over time your brain learns when to go to sleep and when to wake. But you are correct that setting the alarm clock can help you to wake at the same time each morning. So, can you tell me more about what happened in the morning? Were you able to set the alarm and get out of bed at 5:30 on any morning? Client: The first morning, but then no. Therapist: [looking at the sleep diaries] I love that you started off right away with the recommendation, what happened this first morning that you were able to do it? Client: I think I was pretty eager for the treatment to work, but I didn’t notice sleeping any better the next night so I may have lost my drive? Therapist: So by the second morning you felt unmotivated or perhaps discouraged? Client: Maybe. I don’t know. I was so tired. I just couldn’t get up. I would think I’ll just lie here for a few minutes but then an hour would go by . . . I don’t know. Therapist: Were you sleeping during this time? Client: No. Therapist: So you would notice that you felt tired and you would have the thought, “I can’t get up.” Client: I guess. Therapist: Did you have any other thoughts? Client: I’m not sure. . . . that it was too cold to get up? Therapist: You mean you noticed that you were cold? Client: Not that I was cold, but that if I get up I will be cold. I’m so comfortable and warm in the morning and I can’t imagine getting up. I hate the feeling of getting Downloaded by [New York University] at 04:37 12 August 2016 up and feeling cold. In fact, it’s not so much I’m too tired to get up—I’m used to feeling tired when I get up. I just can’t face the idea of the shock of feeling cold. It feels so awful to suddenly be cold. It makes me feel achy and it seems like it takes an hour before I feel comfortable. Therapist: I can see why this would be unpleasant and make it more difficult to stick to your plan. If we were to find a solution to this problem, would you be able to get out of bed at 5:30 AM, or do you think there is something else? Client: No. I think that would help. Therapist: I notice that after three days the final awakening is past 5:30 AM. Did you continue to set an alarm? 98 Adherence and Troubleshooting Barriers Client: No. I knew I couldn’t do it so I figured what is the point? Therapist: So on one hand, getting out of bed at the same time would probably fix your sleep problem, which is important to you, but on the other hand, getting out of bed and feeling cold would feel unpleasant. If this is an issue of physical discomfort, can you think of a way to help with the discomfort of transitioning from a warm bed to a cold room? Client: I tried programming the thermostat to warm up the room in the morning but it didn’t work because I felt even toastier in the morning and I didn’t want to get up [smiles]. Therapist: I guess that’s off the list, even though it sounded like a good idea. Any other ideas? Client: No. If I could just get my bed to hover downstairs maybe that would work [smiles]. Therapist: [laughs] maybe that’s a good idea . . . I don’t know of a way to get your bed to hover, but what if you were to wrap yourself in your blanket and leave the room? Client: So that I stay warm? Therapist: What do you think? Is it worth a try? Client: That might work. I’ll try it. I could sit on the couch for a bit. Therapist: Anything else that would make it easier? Client: I could have some nice warm socks next to the bed to put on before my feet hit that cold floor. Therapist: That’s brilliant! And you could still combine this with the blanket idea? Client: Ok. I can do all of that. Therapist: What about the alarm? This was a secondary problem with sticking to the plan. Are you willing to set it now that you have this strategy for physical comfort in place? Client: Yes, I think so. Therapist: Any other possible problems? Client: No I actually think this might work. Therapist: Great. Let’s write down the blanket, warm socks, and alarm ideas on the bottom of your recommendations sheet.

In this case, the nonadherence was related to thoughts about how uncomfortable and cold it is out of the bed in the morning. Devising a plan in which one transitions with some warmth to a seated position in another room, can be a helpful way to make following the rule of getting out of bed at the same time every morning less aversive. Downloaded by [New York University] at 04:37 12 August 2016

Sleep Inertia For some, the feeling of grogginess in the morning is aversive and is taken as a sign to stay in bed. There are many ways to help with this issue. First, attributing sluggishness exclusively to a poor night’s sleep is unhelpful and most often inaccurate. It is not unusual to experience temporary sleepiness upon waking up. This state is called sleep inertia; a transitional state which often relates to the stage of sleep out of which the person is roused (e.g., Tassi & Muzet, 2000). Waking from deep sleep will produce more sleep inertia than waking from N1 sleep. Although sleep inertia can also result from sleep Adherence and Troubleshooting Barriers 99 deprivation, this is not typically the case in insomnia and assuming that how one feels in the morning relates only to poor sleep will increase sleep anxiety and likely sleep effort as well. Similarly, assuming that sleep inertia is predictive of a poor day of functioning can lead to behavior that would confirm this belief (i.e., it can become a self-fulfilling prophesy for a bad day). The therapist can begin to shift these attributions by providing psychoeducation that sleep inertia is experienced universally by good sleepers and those with insomnia alike, most often lasts less than 30 minutes, and is simply a product of the stage of sleep occurring just prior to waking-up. Therefore, sleep inertia is not thought to have much bearing on how one will feel the rest of the day. Such challenging of unhelpful thinking about the significance of this state is one way to address problematic outcomes that result from more negative attributions. Another way to help with this problem is to encourage the client to devise a behavioral experiment. If the belief is, “Sleep inertia is related to how poorly I slept, so it means I will feel badly all day,” this can be tested by an experiment wherein the client uses techniques that can minimize the time spent in sleep inertia and then monitor what happens during the rest of the day. This can be compared to a week in which the client applies no coping strategies. Some coping techniques to enhance alertness and diminish sleep inertia are to encourage movement (physical activity such as taking the dog for a walk, showering, and turning on lights or going outside to enhance exposure to bright light). Another possible experiment would be to have the client rate the severity and duration of the sleep inertia each morning and then perhaps have a phone alarm set for several time points in the day to cue the client to rate their level of fatigue at each time point. Most clients will discover that morning sleep inertia does not correlate well with their daytime fatigue and function. This will tend to diminish the significance of the inertia for the client.

Eveningness or Night Owl Tendencies There are many other reasons people have for having difficulty adhering to a set wake time. One important reason relates to being a night owl, or an eveningness chronotype. Those who have a delayed sleep phase sometimes are faced with waking close to the nadir of their circadian rhythm, so melatonin has not switched off and the alerting signals from the clock have not yet begun. Getting up at such a time can be challenging. There are many possible solutions to this problem. One way is to set-up the environment to encourage a slight shift away from eveningness, towards an earlier bed and rise time. Setting an earlier rise time and sticking to it every single day will expose the client to Downloaded by [New York University] at 04:37 12 August 2016 light earlier in the day and should result in at least a slight advance of their natural tendency. That is, the nadir of their rhythm will move to an earlier hour. This should eventually allow the client to wake more easily at these times. Emphasizing that such a shift can take place and that difficulty rising will only be temporary may be helpful in increasing adherence. Nevertheless, for some the night owl tendencies may feel too overwhelming to adhere to this recommendation, and so more help is needed. Solutions to difficulties rising at a standard time tend to focus on implementing strategies either in the morning, evening, or both. Morning strategies target ways to get out of bed and to increase alertness. The first goal in trying to shift someone earlier is to get them out of bed. In most cases this will 100 Adherence and Troubleshooting Barriers be accomplished with an alarm clock. Setting an alarm does not guarantee that someone will hear the alarm or get out of bed, but without the alarm there is almost no chance that the person will wake spontaneously. So it is an essential first step in solving the problem. The therapist should attempt to determine what the client’s history has been when the alarm sounds. If the client reports being unaware of the alarm sounding, he will need a louder alarm. There are a variety of very loud alarms available including ones with very high decibels, ones that vibrate in addition to sounding, and ones that employ flashing strobe lights. Most clients use a more conventional clock and these may be inadequate. Some clients will report that they are in the habit of pressing the snooze button, often unaware that they have done so. One solution for this may be multiple staggered alarms across the room that may be just annoying enough to force the sleepiest individuals to get out of bed to shut the alarm off. Additionally, some find it helpful to use the alarm as a cue to at least slide their legs over the side of the bed. When legs dangle over the edge of the bed, it creates discomfort in the lower back and can increase arousal until the person can get out of bed entirely. When someone else lives with the client, another solution may be to ask this person to be the backup plan to the alarm. Whatever the method(s), once awake, it may be helpful to use some of the sleep inertia strategies discussed above, including movement or physical activity, and/or light (either going outside, turning on bright lights, or using a bright light box). For some clients, scheduling enjoyable morning activities such as going out for a coffee and/or meeting a friend, can be helpful in looking forward to the morning and motivating to getting out of bed on time. Another possibility for helping night owls to begin to rise earlier is to focus on interventions in the evening. There are a few possibilities for evening management, including decreasing the level of light exposure in the evening and/or limiting the amount of late evening activity. It may be particularly important to decrease evening light exposure in clients taking St. John’s Wort as there is some evidence that this compound increases light sensitivity (Schey et al., 2000). Curtailing light exposure can be achieved by minimizing the overall number of lights in the room and using soft lighting, or lighting high in red or amber wavelengths (i.e., the part of the light spectrum associated with melatonin release) and low in alerting (blue wavelength) light. Use of blue spectrum blocking sunglasses if outside or free downloadable programs for com - puter screens, (e.g., f.luxTM) can minimize the degree of blue light absorption (i.e., light in the 440–460 nm wavelength range). With regard to activity level, those who are night owls often become most alert in the evening hours so it may take longer for them to disengage from tasks in the evening. Activity begets more arousal and more activity, so Downloaded by [New York University] at 04:37 12 August 2016 clients should be encouraged to create a buffer zone of quiet relaxing activities about 1–2 hours before bed time, which may be a helpful way to start winding down.

Early Morning Awakenings Early morning awakenings (EMAs), or waking up an hour or so earlier than desired, may be an indication of “morningness,” or a side effect of depression, or both. Differentiating these conditions can be accomplished during the assessment by asking the client if the EMAs were present prior to depression onset. A positive response suggests an advanced chronotype which means that the nadir of the circadian rhythm Adherence and Troubleshooting Barriers 101 comes earlier than average, implying that melatonin has switched off earlier and the alerting signals from the clock are already fairly high well before the client’s desired wake time. Such an individual may also feel sleepy long before their desired bed time. Such a tendency may need to be taken into consideration when determining the bed time and rise time for SRT and SC. In other words, for such morning-types, learning to sleep beyond their habitual rise time may prove too difficult and it may turn out to be easier to align the prescribed schedule with their inherent tendency. Depressed individuals with a more neutral chronotype may eventually be able to be trained to sleep later, but for morning-types who may not know that they are more of an early bird the rise time may need to be earlier than initially desired. It should be noted that some clients may express ambivalence about morningness. There are those that see an advanced chronotype as negative. Common stereotypes exist that early birds are boring and cannot have an active social life because they go to bed early. Many clients are unaware that chronotype is largely genetic so some psychoeducation is important. Additionally, it is helpful to use cognitive techniques such as TRs, Socratic questioning or BEs to modify beliefs about an earlier chronotype. In truth, early birds are not prohibited from having an active, satisfying social life. They can certainly stay up later for special events especially if they are physically active during the event. In addition, after their insomnia abates, they can take a brief nap prior to going out to manage their level of sleepiness. They may find some friends in their circle who enjoy morning activities. Clients can make a list of the possible benefits of getting up early in the morning, such as having increased time for goals such as exercise, alone time, or a chance to beat the traffic on a morning commute. On that same list, they can make another column in which they list the things they worry they will lose by shifting their schedule earlier. In a final column, clients can troubleshoot ways they could continue doing the activities listed in the second column (i.e., moving some activities to different times or use time gained by waking early). Once the list is complete, BE’s can test the belief that “life is unsatisfactory with an earlier schedule.” In most cases the results of the BEs demonstrate that the clients sleep better, feel better during the day, and are more productive, by implementing some of the strategies on the final column of their list. Another strategy to foster greater acceptance of shifting one’s schedule earlier is to use analogies. This is a technique most commonly associated with Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, & Wilson, 1999), discussed in Chapter 8. One analogy is a story in which a child always wanted to be a center in basketball. Center is the position in basketball generally held by one of the tallest members of the team. The child dreamed of being a star center but grew-up to be a short young man. Downloaded by [New York University] at 04:37 12 August 2016 Despite being short he continued to try out for center and every year he did not make it to the team. Finally a coach said he could join the team but only if he was willing to try the guard position [this is typically reserved for the shortest members on the team]. The boy steadfastly insisted that he was a center and would not like to be a guard. The coach told him that it was his choice but reminded him he was playing outside of his strengths, and encouraged him to try something new. The young man relented and became a star guard for his team. He found that he had skills that suited being a guard and he found that he quite enjoyed playing the position. He also knew the center position so well that he had a talent for getting the ball to the center to score. By shifting his perspective and playing within his game, he was able to combine the best of both 102 Adherence and Troubleshooting Barriers worlds, with amazing results. The purpose of the analogy is to present scenarios that clients can relate to as a way of helping them to understand the general concept and more easily shift their perspective. The key, of course, is to find the right analogies that fit the client’s experience and help them to easily relate it to the behaviors that they are trying to change.

Troubleshooting Difficulties with Bedtime

Staying Awake Until the Prescribed Bedtime A ubiquitous problem in the practice of CBT-I is when clients return to subsequent treatment sessions and explain, “I can’t stay up until my earliest bedtime. I’m way too sleepy.” If nothing else, if the client is truly sleepy and not just tired, this is ironic since when they first presented they complained of an inability to get sleepy and fall asleep. It can therefore be suggested that this shift is good news and confirms that the client is on the right track and building a healthier sleep drive. That is, if the treatment is working the client should start experiencing increased sleepiness. In essence, in CBT-I we are attempting to shift the client’s focus away from sleep, over which they have little control, to strategies to stay awake, over which they can have much better control. The client should be warned from the outset of therapy that increased sleepiness in the first few weeks is likely and can make it more difficult to continue staying up until the prescribed bedtime. When sleepiness is a problem, if the client is getting close to their prescribed bedtime and sleep is going well, the best solution to the problem is to begin extending time in bed according to SRT protocol. That is, add 15 or 30 minutes depending on how robust the sleep and how sleepy the client. However, there will be numerous occasions in the early going of treatment when the client gives over to sleepiness at variable hours, resulting in dozing or going to bed much earlier than prescribed. There are several things to consider. First, it is always important to help clients understand the distinction between what is meant by sleepy versus fatigued. Those with insomnia have high levels of fatigue but rarely have pre-treatment sleepiness. The following dialogue demonstrates how the therapist can help the client make this distinction and uses this to encourage the client to stay awake longer:

Therapist: I wonder if we are using the word sleepiness to mean the same thing. Although people tend to use the word fatigue and sleepy interchangeably, they actually represent different things. When I say “sleepy,” I mean it as a description Downloaded by [New York University] at 04:37 12 August 2016 of the state right before falling asleep. It is the propensity to fall asleep, or the struggle to stay awake. This means that if given an opportunity to sleep while feeling sleepy, you would fall asleep and fairly quickly. Fatigue on the other hand is exhaustion, whether it is physical, mental, or emotional, and it is associated with a strong desire to sleep, but if given an opportunity, sleep would not necessarily occur (or at least not quickly). Fatigue is the same as feeling tired or run down. So sleepiness is associated with falling asleep, fatigue is not. Therefore, one can be fatigued without necessarily being sleepy. Does this make sense? Client: I think so. Well then I almost never feel sleepy. But I feel fatigued almost every waking minute. Adherence and Troubleshooting Barriers 103 Therapist: That is actually fairly common for people with insomnia. So you felt “too tired,” meaning too fatigued, to follow the recommendations? Client: Yes I felt so tired that I had to go to bed before the time we said. Therapist: I see. So you didn’t feel sleepy but because you felt tired you went to bed. Do I have this right? Client: Yes. Therapist: But it seems from your diaries that when you go to bed tired but not sleepy, you often do not go to sleep or seem unable to stay asleep. Does that seem right? Client: Yes, I guess that’s true. Therapist: Well since you don’t often experience sleepiness currently, we need to create a situation in which you will experience it because when you feel sleepy, sleep will happen more naturally. Going to bed when you are fatigued, doesn’t allow sleepiness to occur. You say that you feel fatigued every waking minute, so what made you go to bed at the time that you did? Client: I just get so tired of feeling tired. There’s nothing to do and I am so desperate to sleep. Therapist: That makes sense. But what if we could find something for you to do until sleepiness sets in and then you could actually fall asleep rather than tossing and turning in bed for hours? Client: I can’t imagine there could be something I could do because I am so tired. Therapist: Fair enough, but is it worth discussing, given that the only way you can get a break from this pattern is to set up a situation wherein you start to experience sleepiness? Client: Sure.

Fatigue and dozing in the evening often can be helped by having the client engage in evening activation. Evening activation simply refers to scheduling activities that are likely to succeed in keeping the client awake. Some examples would be scheduling joint activity with other people, engaging in activities that require one to stay in motion (i.e. folding laundry, sorting photos, baking cookies, etc. or doing more activities to maintain alertness). One thing to note is that eye strain is relatively common in those with fatigue, so briefly holding a cool cloth over the eyes while seated, can help with the temptation to close the eyes for prolonged periods. Particularly in people with depression, there is inadequate build-up of a drive for deep sleep, increased fatigue, greatly reduced activity, especially goal-directed activity in the 24 hour period, and decreased availability of potential reinforcers in the Downloaded by [New York University] at 04:37 12 August 2016 environment. As a result, it’s as if their entire day serves as a wind-down in prepara - tion for bed. This may prematurely stunt deep sleep drive build-up and may reflect a preoccupation with sleep or an avoidance strategy; both of which are potentially sleep- and mood-interfering. For people with MDD-I the therapist will do well to consider BA throughout the day as a way to not only bring the client into contact with positive reinforcers but also to help build healthier sleep drive for the night. That said, it is especially important in such cases, to work on evening scheduling of activities whether inside or outside of the home, with a termination of the activities and a demarcated drop into wind down activities one hour before bed. Another strategy is to make sure that people with MDD-I refrain from putting on nightclothes like pajamas until just 104 Adherence and Troubleshooting Barriers before their prescribed bedtime. For some clients with MDD-I, putting on nightclothes occurs right after work or directly after dinner; some may remain in pajamas all day. This is a change-worthy habit because it increases sleep preoccupation. It is always important to identify instances of over-focusing on sleep during the day or night because it will almost always lead to increased anxiety about sleep and sleep effort.

Delaying Bedtime While some people struggle to stay awake or out of bed before the prescribed bedtime, others have the opposite problem in that they remain engaged in activities well into the morning hours, delaying bedtime significantly. This might be a positive thing for building sleep drive but for some, the delay in bedtime often results in a delay in rise time as well. As a result, their schedule becomes more and more delayed. From the outset it is important for a thorough assessment of the cause of delaying bedtime. For those who are night owls, mood and energy may be best in the evening, and this may be the first time in the day when they feel good. It is thus understandable that a client would feel compelled to take advantage of a time in which they start to feel awake and alert, and avoid going to bed. In such cases it can be helpful to engage the client in a discussion of the consequences of not following their schedule goals, e.g., they will become shifted later, they will have greater difficulty adhering to the scheduled rise time, they are likely to experience increased fatigue, they may wind up missing appointments in the morn - ing, and they may engage in negative self-talk about not following goals. Solutions include starting the wind-down period (i.e., the buffer zone) an hour earlier to encourage greater disengagement, and largely troubleshooting adherence to a standard rise time discussed earlier in this Chapter (i.e., increasing morning activity, manipulating light exposure in the morning and before bed, and use of alarm clocks, etc.). Ultimately, adhering to an earlier standard rise time should have some impact on shifting the person’s circadian clock earlier, which in turn should allow them to get sleepy and disengage earlier.

Troubleshooting Common Problems in Depression Anhedonia Waiting for the feeling of motivation to do something is a common strategy that we may all use from time to time. However, waiting for motivation in a disorder characterized by motivation deficits, often interferes with goal pursuit. It is a faulty assumption Downloaded by [New York University] at 04:37 12 August 2016 that the feeling of motivation must always precede behavior. To demonstrate this truth, ask your client to think about examples of things they do despite not feeling like it. There are many things that people do for which they feel little to no internal motivation. For example, many people will admit that there are days that they may not feel like getting up and going to work, and yet they swing their legs around off the bed, get up, shower, eat breakfast, and go to work; all without feeling like it. Likewise, imagine if you always waited first for motivation. If one were to listen to the thought “I don’t feel like going into work today,” it is easy to see how quickly life might become that much more difficult and unworkable. It is precisely this kind of difficulty that people with depression find themselves in when they wait for motivation to come before action. Waiting for motivation often results in inaction, decreased positive reward, social Adherence and Troubleshooting Barriers 105 isolation, and continual depressed mood and anhedonia. The alternative is to set up a plan for how one would like their day to go and then to follow this to determine if life works better or worse. Such strategies are used in BA (Dimidjian et al., 2006; Lejuez, Hopko, & Hopko, 2001; Martell, Dimidjian, & Herman-Dunn, 2013). Even if not engaged in a full BA protocol, it is helpful to use tenets from BA to help with motivation issues. For more detail, see Chapter 9. Briefly, instead of using an internal state to guide behavior (i.e., behaving from the Inside-Out), clients can use a plan that can eventually lead to different contingencies and thereby change their internal state. In other words, they can follow a plan, not a feeling (i.e., behaving from the Outside-In). By setting up an “Outside-in” instead of an “Inside-out” strategy and by collaborating on a plan with a chain of positive contingencies, the client is more likely to achieve their desired goal. Clients may not at first be able to articulate a full plan to get out of bed that is highly likely to succeed, but they may be able to identify a strategy for: setting an alarm, devising a backup to the alarm, keeping their eyes open, sitting upright in bed, getting out of bed, staying out of bed, and a reward system for being out of bed. It is important to break down all the components of getting up and the identified barriers as well as discuss morning contingences that will increase the likelihood of getting out of bed shortly after the alarm rings. Setting-up the strategy to make behaviors more likely and easier is a prominent focus in BA. There are as many contingency plans and strategies as there are clients for getting out of bed in the morning. Some possibilities include: keeping blinds or curtains open in the bedroom, using a timer for the lights in the morning, using the alarm as a cue to stand up or sit up, setting an alarm clock to loudly broadcast a news channel to provide a transition, using the sound of the alarm as a cue for the feet-on-the-floor technique (i.e., swinging legs over the edge of the bed), setting the coffee on a timer the night before, keeping a coping card with positive thoughts next to the bed, walking directly to the bathroom to take a shower, using multiple and staggered alarm clocks throughout the bedroom, eliciting help from others to help with getting out of bed, taking a blanket and going to a different room to sit until more fully awake as a transition, scheduling morning activities (maybe with other people), and setting up a reward system for mornings in which the goal is met. The key is to explore the idea that behaviors can and do occur in the absence of motivation. Further, it is important to help the client discover that their life often goes better when they set it up in this way. For depressed clients who do not have enough of these examples already in their lives or who can’t remember what that is like, behavioral experiments can again be useful to help the client begin to discover the value of outside-in strategies. Downloaded by [New York University] at 04:37 12 August 2016 Using Sleep or the Bed as an Escape In those with MDD-I, there are some who use the bed as an escape. Such avoidance is a common perpetuating factor in depression (Martell et al., 2013). Avoidance maintains low mood because it limits access to positive reinforcement, i.e., there are few opportunities for positive reinforcement in the bedroom especially if one cannot sleep and lays awake tossing and turning. Moreover, although avoidance initially alleviates tension, the net result is that protracted escape becomes confining, and the world of the client shrinks. Such tendencies can be addressed in a variety of ways. Socratic questioning and/or Thought Records can challenge unhelpful thinking about the role of avoidance. Once a client has had psychoeducation about sleep regulation Socratic 106 Adherence and Troubleshooting Barriers questioning about the consequences of using the bed for escape can serve as a check to see how much the client has retained or understood of the sleep regulation rationale. Clients should be able to explain that increased time in bed decreases drive for deep sleep, decreases regular input into the body clock, increases fatigue, increases condi - tioned arousal, decreases positive reinforcement, thwarts goal pursuit, and maintains negative mood. Another strategy is to create ambivalence as a way of enhancing motivation. The therapist can create such ambivalence by presenting two contradictory arguments side- by-side. The following dialogue demonstrates how exploring the pros and cons (both short term and long term) of self-imposed isolation can create the desired client ambivalence:

Therapist: From what I understand, life seems overwhelming so you believe it is better to remain in your room when you’re home. Have I got that right? Client: Yes. It just feels better to stay tucked away in my room. Therapist: But at the same time you are also tired of feeling tired, you want better sleep and you have said repeatedly that you are lonely. Sounds like you are at an impasse?

Reflecting the two sides of the problem, or “sharing the dilemma” allows the therapist to refrain from arguing for adherence (which can only encourage resistance) and encourages the client to take responsibility for a shift. If the client argues for maintaining avoidance, the choice and consequences are highlighted.

Therapist: So it sounds like at this point, you would prefer not to explore ways to increase your time out of your bed because it is too hard. Would it be a better use of our time to shift our goals away from improving sleep and fatigue, and towards acceptance?

Clarifying how the behavior is contrary to their goals often causes clients to shift and consider behavior change. However, in cases in which the client agrees that sleep should no longer be a treatment target—this becomes their choice and it may be a reasonable decision for that moment in time. Smoking is never a healthy choice and is always change- worthy but people may not be ready to make a change. Likewise, knowing that we can successfully improve someone’s sleep does not mean that they are ready to make the considerable effort needed to make this happen. Clients sometimes come to the conclusion that their sleep isn’t bad enough for them to keep a schedule 7 days per week and get out of bed when unable to sleep. This decision reflects some degree of increased confidence Downloaded by [New York University] at 04:37 12 August 2016 in the ability to cope with the consequences of sleep and might actually bode well for decreases in sleep anxiety and arousal. Treatment can shift towards other therapy goals and/or acceptance when clients no longer consent to sleep-focused treatment.

Troubleshooting Fatigue

The Belief that Fatigue Precludes Following Behavioral Recommendations Some clients will explain, “I am too exhausted to follow any recommendations.” This makes sense because central fatigue is generated when there is a mismatch between Adherence and Troubleshooting Barriers 107 the estimated resources needed to complete a task and the perceived personal resources one has to allocate to the task (Chaudhuri & Behan, 2004). In the case of CBT-I, clients will often estimate the resources needed to complete the task of following sleep schedule recommendations as impossibly high, given that they estimate their personal resources as too low to meet the demands of this task. This is why it is necessary to collaboratively build contingencies to lighten the resource demand of the sleep schedule. The task of rising 2 hours earlier than desired has higher resource demand than being awoken 2 hours earlier by a loved one who has filled the apartment with the smell of coffee, slipping into a warm robe and slippers, and getting into a nice, hot shower. The second part of the equation for central fatigue is an estimation that personal resources are deficient to meet the needs of the task. In those with insomnia, there are beliefs of low self-efficacy (Edinger et al., 2008), a sense one cannot cope with the consequences of fatigue (Morin, 1993), a tendency to selectively scan and focus on evidence that one is fatigued (Harvey, 2002), and a tendency to think repetitively about fatigue (Carney et al., 2010b). Thus, especially those with MDD-I are highly likely to perceive themselves as deficient of resources. Again therefore, it is helpful to break down the task so that it has less of a resource demand (as above), however it is also important to explore the deficiency beliefs. In truth, most people with insomnia, including those who are depressed, are often amazing in their ability to cope long-term with sleep disruption. Insomnia is chronic and often lasts for years and years and despite this, people with insomnia have a disproportionately low level of disability. In many ways they are expert copers. In a ten-year insomnia history, there may be some difficult experiences, but there will be over 3700 days of coping as well. The therapist can use Socratic questioning to help clients discover their own amazing strengths.

The Belief that Fatigue is Dangerous and/or Rest is Essential Some clients believe, “I NEED to rest, I am exhausted.” Behind this belief is the idea that there is a need to compensate for poor sleep and to resist compensating is hazardous to one’s safety or health. It is important to reinforce with the client the rationale for being out of bed when unable to sleep (i.e., to reverse conditioned arousal). They also can be educated that the body has a natural mechanism to compensate for sleep loss (i.e., sleep drive), and with insomnia, the lost sleep creates too great an opportunity for sleep, rather than too little an opportunity. Thus the sleep of those with insomnia tends to be quite variable rather than consistently poor and with the compensatory behaviors in which they tend to engage, their overall total sleep average is usually not much less Downloaded by [New York University] at 04:37 12 August 2016 than normal (i.e., 6 hours). The therapist can use Socratic questioning to uncover the depth of understanding of these very important facts about the sleep system. In addition to difficulties with the rationale, it is important to query catastrophizing about the consequences of fatigue. Outside of the context of insomnia, resting when tired can be an adaptive strategy in moderation, but the sleep system is a homeostatic system (Chaudhuri & Behan, 2004) and while too little resting causes exhaustion, the excessive resting seen in both people with depression and insomnia also maintains fatigue (Kohn & Espie, 2005). Often, clients have heard news stories about links between sleep loss and early deaths, cancer, cardiovascular disease, dementia, diabetes, etc. It is natural to assume that such research applies to insomnia as well, but in actuality these studies 108 Adherence and Troubleshooting Barriers are less likely to apply to people with insomnia with the exception of those with chronically low average total sleep times (less than 4–6 hours per night on average) (Fernandez-Mendoza et al., 2010). Such research often employs epidemiologic methods that assess sleep disruption with one or two broad sleep-related questions. Querying sleep in this way includes people with all kinds of sleep disruption and excessive daytime sleepiness such as those with sleep apnea, periodic limb movement disorder, shift work sleep disorders, circadian rhythm disorders, and/or those with chronic voluntary sleep restriction. The links between sleep and early mortality, cardiovascular disorder, and diabetes have been established in these disorders (e.g., Folkard & Tucker, 2003; Irwin et al., 2008; Spiegel, Tasali, Leproult, & Van Cauter, 2009), but not in insomnia. In cases of catastrophizing, it may be helpful to use either psychoeducation, or Socratic questioning, or a Thought Record to challenge unhelpful thinking that equates the consequences of general sleep disruption with those of insomnia. As has been stated before, most clients with insomnia have had their problem for years rather than days or months by the time they are in your office. It does not take much prompting on a TR or with Socratic questioning to demonstrate that despite hundreds and often thousands of nights of insomnia, the client remains in otherwise reasonable health. Finally, behavioral experiments can also be set up to test the hypothesis that fatigue is dangerous (see Chapter 6 for the energy conservation versus energy expenditure experiment). It is ultimately counterproductive to stay in bed when tired because it reinforces a belief that fatigue can be dangerous, it delays the build-up of sleep drive, it associates the bed with wakefulness, and the consequence of lying in bed for long periods is typically more fatigue and lethargy, not less. Experiments that explore the link between moderate activity and fatigue versus inactivity and fatigue can be helpful. For those combining CBT-I with CBT-D or BA, activity monitoring (see Figure 9.2 in Chapter 9) is an excellent way for a client to make the links between wakeful inactivity and increased fatigue experientially. Explore what contributes to feeling fatigued during the day and create ambivalence about fatigue-producing habits such as inactivity, poor food choices, substances, etc. Many people with insomnia will tend to attribute all negative daytime effects to poor sleep and tend to ignore the variety of factors that can produce fatigue (i.e. boredom, tension, depression, dehydration, extended time on computers, etc.) The following dialogue demonstrates how the therapist can help the client discover new reasons for their fatigue. The dialogue takes place within the context of a con- current BA protocol, such as BABIT (see Chapter 9), however one can assign activity Downloaded by [New York University] at 04:37 12 August 2016 monitoring and schedule activities within the context of CBT-I for clients with decreased activities.

Therapist: So you said you cannot do anything about your sleep because you are too fatigued. Do you think there is anything you could do to help your fatigue? Client: Well, no, because I’m tired because of my sleep. Therapist: What else might account for your fatigue? Client: Nothing. I’m tired because of my sleep. Therapist: I wonder if it is possible that other things cause fatigue too? We talked about jetlag like symptoms occurring with irregular bed and wake times when the body Adherence and Troubleshooting Barriers 109 clock has difficulty adjusting to the variability of the sleep and activity schedule. What are some of the symptoms that occur with this schedule variability? Client: Feeling grouchy, irritable, fuzzy-headed . . . and I guess fatigued. Therapist: That’s right. So could this have a small role in the fatigue you are feeling? Client: Maybe but I can’t keep a schedule because I’m so tired I can’t change it. Therapist: Ok. If we look at your activity log, do you notice any patterns between your highest fatigue ratings and what you are doing? Client: The highest is 8, and it happened 3 times—watching TV on the couch. Therapist: What about the lowest rating? Client: The lowest was 4, which happened once when I went out to see my friend Jake downtown. Therapist: What’s the difference between these two types of activities? Client: I guess sitting on the couch is not really an activity, or may be low activity. Therapist: Do you see a connection between low activity and fatigue and greater activity and feeling less fatigued? Client: Maybe . . . Therapist: I want you to stand up right now and stretch in whatever way feels comfortable to you. [after client stops stretching] How do you feel now? Client: A little better. Feels good to stretch. Therapist: Moving muscles, getting greater circulation and oxygen has a positive effect. Constricting flow and staying in the same position for a long time increases fatigue. Do you think dehydration or nutrition have any impact on fatigue? Client: I guess so. In fact, now that I think of it I feel weak and tired if I haven’t eaten or had anything to drink for long hours. Junk food can also backfire on me. Therapist: Ok. So you have had these experiences. What about coffee—have you ever experienced an energy crash a few hours after you have a coffee? Client: Yes, definitely. I am so tired I usually have another coffee. Therapist: This suggests caffeine withdrawal. As it is eliminated from our system, we get withdrawal symptoms of fatigue. Having another coffee will get rid of the symptoms but then you will face them again later. How about your medication? Do you think this contributes to your level of alertness or fatigue? Client: Unfortunately my sleeping pill makes me feel groggy the day after I take it. So, I guess so yes. Well, I guess the answer is that there are a bunch of things that make me tired. Therapist: And we have many tips to help with fatigue, including being active, eating well, staying hydrated, limiting caffeine, increasing bright light exposure, or taking a shower. Downloaded by [New York University] at 04:37 12 August 2016 When we blame fatigue on sleep exclusively and believe there is nothing we can do to manage it, suddenly there is a lot riding on fixing the sleep problem. Can you see how this belief might get in the way from making changes to improve the situation? Client: Yes, definitely.

Comorbid Pain and Mobility Issues There may be circumstances (e.g., pain, mobility, frailty) in which there are concerns about a client getting out of bed in the middle of the night. When providing SC instructions about getting out of bed it is important to remind all clients, and especially 110 Adherence and Troubleshooting Barriers ones with mobility concerns, about turning on enough light to provide for a safe path to where they are going. Some clients may be reluctant to do so out of fears it will make them more alert and/or concerns about waking up other family members. Given that most light sources in the house will not have high concentrations of blue spectrum light, the chances of the light activating the person is negligible. This may be particularly true as we age (Herljevic, Middleton, Thapan, & Skene, 2005; Verriest & Uvijls, 1977). Research studies on light and alertness often recruit young healthy sleepers rather than people with insomnia across the age spectrum, so it is not known how such factors affect those with insomnia. Giving up the effort to sleep should create enhanced sleepiness while out of bed and do much more to ease arousal than any amount of standard room light can do to boost arousal. Concerns about disturbing family members by turning on a light is understandable but the client can often trouble-shoot including using low level night lights along the floor, or closing bedroom doors so the light from other rooms will not shine into the bedroom. Moreover, it is always helpful to remind clients that the recommendation to get out of bed is only temporary until reconditioning takes place, so most family members are tolerant of these measures knowing they are short term, and especially if they typically sleep through it anyway. These issues aside, there may be valid reasons for safety concerns in some clients. For those who are frail, in pain, and/or have significant mobility issues getting out of bed may be risky or even ill-advised. In such cases, a technique called counter control may be a useful alternative to the standard SC instruction (Hoelscher & Edinger, 1988). Counter control is a technique in which the client still gives up the effort to sleep but does not leave the bedroom or bed (Davies, Lacks, Storandt, & Bertelson, 1986). The instructions are to sit up in bed and engage in an enjoyable restful activity until sleepy. Once the client is sleepy, they can turn off the light, stop the activity, and once again see if they are able to sleep. The crucial element to counter control is that the client does not engage in any sleep effort nor allow themselves to remain in bed feeling frustrated or upset about sleep. Traditional stimulus control is still preferable because with counter control, the client is doing wakeful activities while in bed so there still could be concerns about conditioned arousal, however, given the hope that they are not in bed engaged in sleep effort, it is a reasonable compromise for those who may be unable to get out of bed. The support for counter control suggests that it is best for issues with waking up in the middle of the night (Hoelscher & Edinger, 1988) so the other SC rule about not going to bed until sleepy still applies. One other consideration in those with pain and mobility issues is resting. Rest may be necessary for certain physical conditions; however, excessive resting is associated with Downloaded by [New York University] at 04:37 12 August 2016 increased pain and fatigue as well as lightened sleep. Using the bed or bedroom for rest rather than only for sleep may strengthen the bed as a cue for pain and suffering and weaken the bed as a cue for sleep. Thus for those with physical conditions that neces - sitate resting, it is advised that if possible clients rest in positions other than supine and not in the bed or bedroom. Finding ways to safely and gradually increase activity and provide resting guidelines is an important intervention strategy for such clients.

Relationship Issues Sexual activity is often an exception to the Stimulus Control recommendation to avoid doing wakeful activities in bed. Many individuals may find that following sexual activity, Adherence and Troubleshooting Barriers 111 they are actually more relaxed and prone to sleepiness. However, when sex is alerting for the client we encourage them to consider moving sex to another place and/or time at least during treatment to re-establish the bed as a place solely for sleep. In such cases, it is important to ask clients whether they foresee any difficulties in raising this issue with their partner. Some clients may be uncomfortable discussing with their partner the possibility of moving sex to a place other than their bed or a time other than bedtime during treatment. There are a variety of possible issues that require follow-up inquiry. Especially for clients with depression they may be prone to engaging in “mind-reading” and assuming their partner will say no. In truth, partners of people with insomnia often are quite willing to support treatment recommendations because in addition to wanting to help their partner, their partner’s insomnia often impacts them negatively. If clients are making assumptions about their partners, it is important to work with them about their belief and see if they are willing to test their negative assumption. Some clients may need assertiveness or other communication skills training before tackling sensitive, intimate communication with their partners. Sometimes this assessment reveals significant relationship issues—a common problem for people with insomnia, and this may require additional work. Lastly, both people with insomnia (Carney et al., n.d.) and people with depression report libido problems (Cyranowski, Frank, Cherry, Houck, & Kupfer, 2004; Johnson, Phelps, & Cottler, 2004). This is further complicated by the fact that those with depression may experience sexual dysfunction as a result of their pharmacologic treatment for depression (see Lane, 1997). Thus, this simple assessment of whether there are any barriers to moving sexual activity out of the nocturnal bed and/or to a different time can reveal a range of issues and potential treatment targets, which do not relate to sleep directly but could nonetheless have an impact on well-being and thus, indirectly—sleep. Another common problem in relationships is the fact that many partners do not necessarily share the same circadian tendencies. That is, sometimes owls live with larks or vice versa. Part of the insomnia problem may be due to, for example, an “owl” client who is consistently going to bed with their “lark” partner earlier than when they themselves are sleepy. In the first weeks of treatment, it is not uncommon that clients will complain that their bed partner will be unhappy that they are going to bed later and not coming to bed with the partner. Again, one way to handle this is to remind the client that the initial schedule for time in bed is temporary and may eventually be shaped to work out closer to that of their partner. However, if the client and/or their bed partner are still not persuaded, some troubleshooting discussions will be needed. One possible

Downloaded by [New York University] at 04:37 12 August 2016 solution is to have the client go to bed at the earlier hour with their bed partner to cuddle and spend some quality time, but then to leave the bedroom once their bed partner has fallen asleep. Then the client can return to bed but not before their prescribed bedtime at the earliest. In this way the client is spending some time with their partner in their bed, albeit awake, but again is not engaging in any sleep effort at that time. Similar problem solving can be accomplished for “lark” clients who wake earlier in the morning than their “owl” partners. In the best of all possible worlds the therapist might consider bringing bed partners into CBT-I sessions. From the very first assessment to the last session, including bed partners can help enrich the assessment (especially of intrinsic sleep problems such as apnea, periodic limb movements or parasomnias), help with adherence to protocols, and 112 Adherence and Troubleshooting Barriers provide support and optimize treatment response (for more see Rogojanski, Carney, & Monson, 2013). Further, it should be noted that the instructions for stimulus control and sleep restriction protocols are not necessarily intuitive at first blush. When that client goes home to describe these protocols to a bed partner, without sufficient provision of the rationales, it is possible that bed partners could unwittingly sabotage the clients efforts by encouraging them to do things like gain more rest, go to bed earlier, or sleep in later when they haven’t slept well. Having the bed partner in the office from the first session can eliminate this problem in that the bed partner is instructed in the rationale along with the client. This usually allows for better collaboration between client and partner.

Cognitive Issues People with insomnia and depression can suffer from cognitive issues and the amount of material covered, especially in session 1, can be a lot to retain. One novice mistake is to deliver the psychoeducation material (contained in Chapter 1) like a general lecture. There should be ample information from the assessment that should permit tailoring of the educational material to the specific client presentation. More importantly, psychoeducation should be collaborative and emerge as a two-way conversation. Although the therapist is the expert on sleep, the client is an expert on their own sleep experience. The therapist should use questioning to elicit examples of each sleep regulation concept as well as have the client pick out examples from their sleep logs that could be acting as maintaining factors in their insomnia. Such active two-way engagement is an important therapy technique to enhance retention of the materials. It is important to check in and ask questions about how much the client heard and understood, while normalizing any memory issues the client is having as part of the their disorder. Use repetition and begin every session with a bridge from the last session. This is done by asking the client to recall what they remember from last week and use questions to try and elicit any information missing from their bridging attempt. In clients with memory issues, providing handouts and writing down homework so that they can bring the information home, is a helpful way to ensure that clients follow treatment recom - mendations. Some clients like to make a note on their phone or on a coping card if they have concerns about remembering the material. In clients with traumatic brain injury (TBI) we use a sleep diary with a larger font and only the following key variables: Day; Into Bed; Time to Fall Asleep; Total Time Awake During the Night; Time you Woke Up; and Time Out of Bed. With TBI it is crucial to use handouts for retention. Also it may be necessary to break the information normally covered in session one Downloaded by [New York University] at 04:37 12 August 2016 into two sessions: Stimulus Control during the first week and Sleep Restriction and Sleep Hygiene the following week. The rest of the sessions will tend to look the same as CBT-I in those without TBI. In sum, for some clients, retention, understanding, and accommodation of the material may take longer and require a few more sessions to bring to fruition.

Troubleshooting: Assessing or Modifying Therapist Beliefs Therapists need to be mindful that they bring a set of personal beliefs to the therapeutic relationship. As always, being aware of and ensuring that these beliefs do not intrude Adherence and Troubleshooting Barriers 113 into therapy is essential to good practice. In addition to therapists’ personal beliefs about psychotherapy, therapists also have their own beliefs about sleep. If a therapist believes that people need 8 hours to function or they don’t believe sleep need is controlled by a homeostatic system that produces an adequate amount for health if given an adequate opportunity, they may have greater difficulty implementing CBT-I. Below we discuss common therapist beliefs that can interfere with competent delivery.

Beliefs that Underestimate Clients’ Abilities to Make Change If a client does not adhere to a schedule prescription, it is important to avoid making assumptions about the cause. For example, if the therapist concludes “Of course my client cannot follow a prescription—they have anhedonia, so they can’t follow recom - mendations,” then logically, little can be done until the anhedonia is resolved. This is evidence of the same kind of inside-out thinking that creates a barrier for clients and was tackled earlier in the chapter as problematic. There are many reasons why people have difficulty following prescriptions and spending time discovering the reasons behind this resistance is the key to increasing the likelihood of adherence. A key core belief in depression is hopelessness (Beck, 2008) and it is important not to collude with the client in this unhelpful assumption. An important therapist activity is to use Socratic questioning to help the client to discover instances that disconfirm hopelessness and to help the client design experiments to test the belief of hopelessness. Numerous studies have demonstrated conclusively that CBT-I can be effectively delivered without any modifications in people with insomnia with various comorbid problems including depression, pain, hopelessness, and anhedonia (Kuo et al., 2001; Lichstein et al., 2000; Manber et al., 2008; Morawetz, 2001), so this belief is worthy of testing. For therapists who are just now learning CBT-I for the first time, remember that, as with our clients, when learning anything new there is a tendency at the first sign of discomfort to resist and to return to old, more comfortable patterns of behavior. Hence, when meeting resistance from clients who say that they cannot engage in some instruction because they are too depressed, anxious, worried, etc. there may be a tendency for the therapist to quickly abandon CBT-I in favor of therapies with which they have more familiarity, facility, and history. It is important for therapists to monitor for their own beliefs about insomnia and their clients. Depression symptoms may pose barriers to insomnia treatment implementation but barriers can be assessed and problem-solved within the context of CBT-I and improving sleep is as important for improving Downloaded by [New York University] at 04:37 12 August 2016 depression as is improving depression for sleep (Manber et al., 2008).

Beliefs that Sleep Diaries are Unnecessary It is not uncommon for novice CBT-I therapists to have unhelpful beliefs about sleep diaries. Such unhelpful beliefs include: “Sleep diaries are not accurate, we should use objective measures instead,” “I can’t ask my client to do this, it is too much work,” or “Tracking sleep will worsen my client’s sleep problem.” The belief that “objective” measures of sleep are preferable is unhelpful and inaccurate in a variety of ways. First, it is a myth that objective measures of sleep are somehow “truer” measures of sleep. 114 Adherence and Troubleshooting Barriers Sleep is a construct, defined and measured in a variety of ways. One objective measure of sleep is overnight polysomnography (PSG). During a PSG study, sleep is defined by particular patterns of electrical activity in the brain. This definition of sleep using this method is somewhat arbitrary. The first consensus system was derived by visually examining 30 second periods (because this is what fit on a PSG page) and labeling whether it is sleep or not sleep. Sleep is coded when the brain wave activity is slower than alpha with low voltage amplitude for greater than 50 percent of the 30 second period (Rechtschaffen & Kales, 1968). However, there are many problems with this way of defining sleep. In the example provided above, 14 of the 30 seconds could be characteristic of wakefulness, but we may categorize it as sleep. This may or may not match with the perception of the sleeper, because they are aware that there was substantial wakefulness (i.e., 14 of the 30 seconds) in this period. For example, in some with insomnia, their sleep looks fairly normal using this criteria, but they have large subjective complaints and measuring the degree of high frequency brain wave intrusion (via spectral analysis) reveals poor sleep depth that correlates with the subjective complaint (Krystal et al., 2002). Consensus clinical assessment guidelines do not support the use of the PSG as routine practice in those with insomnia and depression (Kushida et al., 2005). Other problems with relying on PSG include the fact that the sleep lab can either create so much anxiety that the degree of sleeplessness is exaggerated or the sleep lab is such a novel environment that conditioned arousal is reversed and the degree of sleeplessness is under-represented. So PSG is not at all preferable to prospective sleep diaries. Another way to conceptualize sleep is the relative absence of or gross reduction of motor movement. This is the way it is defined in actigraphy. Actigraphs are often worn on the wrist and use accelerometers to sample movement and store the data. The sampled data are analyzed using algorithms for what movement patterns are most typical of rest versus activity. Many apps use accelerometers and profess to measure sleep. There are multiple problems with valuing this particular definition or measure - ment of sleep. Accelorometers that are used clinically are often subject to many validation tests of the algorithm. Even with these many validation studies, we know that this form of measurement can be dubious in insomnia, owing to the fact that sleepless people can lay awake with minimal movement (Blood et al., 1997; Chambers, 1994; Hauri & Wisbey, 1992). Algorithms associated with smart phone apps or wearable devices such as the Fitbit TM are not subjected to the same rigorous validation and have been shown to be even less accurate than clinical actigraphs (Montgomery-Downs et al., 2012). In contrast, sleep diaries reflect a subjective perception of sleep, and Insomnia Downloaded by [New York University] at 04:37 12 August 2016 Disorder is a subjective disorder. The diagnosis is based on the client’s complaint of sleeplessness. Despite some reasonable suggestions (Lichstein et al., 2003) there are no consensus quantitative criteria for insomnia because morbidity cutoffs are not reliable. That is, occasional severe sleep loss can be similar to mild, chronic loss (Lineberger et al., 2006). Although subjective perception is most important in insomnia disorder, not all subjective measures are the same. The best evidence suggests that prospective measurement of subjective data is superior to retrospective measurement (Coates et al., 1982), and sleep diaries are a prospective measure. Subjective retrospective measures such as the PSQI or the ISI have appeal because they are brief and have good psychometric properties. Unfortunately, the psychometric properties of the PSQI may Adherence and Troubleshooting Barriers 115 be somewhat questionable when used in those with comorbid psychiatric disorders because of the confound of the PSQI with anxiety (Hartmann et al., 2015). The question of whether the ISI may be preferable in those with MDD-I has not been investigated to date. Nevertheless only sleep diaries capture the variability of sleep (Wohlgemuth, Edinger, Fins, & Sullivan, 1999) as well as the sleep indices needed for sleep scheduling (Buysse et al., 2006). That is, it is near impossible to carry out effective sleep restriction therapy without sleep diaries. It is true that people with insomnia most often underestimate sleep diary total sleep time, and overestimate sleep onset latency and wakefulness after sleep onset relative to absolute PSG estimates of the same values (Coates et al., 1982; Spielman, 1986). However, the evidence for sleep diary reliability is strong, e.g., the agreement between PSG and diaries is high (kappa = .9), as well the sensitivity (92.3 percent) and specificity (95.7 percent) (Rogers, Caruso, & Aldrich, 1993). Because of the importance of subjective complaints and the reliability of the measure of longer periods (i.e., 2 weeks), and problems with retrospective subjective measures, PSG and actigraphy, the sleep diary is the gold standard measure in the field of insomnia (Carney et al., 2012).

Sleep Diaries with Improbable Values In a small proportion of cases of people with insomnia, there is a phenomena called paradoxical insomnia, or sleep state misperception (SSM). SSM occurs when there are consistently improbably low sleep total values in conjunction with intact functioning. It is not possible to go without any sleep for more than a few days without considerable efforts in place to do so. Moreover, even in cases of low total sleep time, sleep is variable so any consistent report (i.e., every single night) of little to no sleep is likely inaccurate. For example, clients with SSM might report getting 0–2 hours of sleep a night for months or years and yet report surprisingly reasonable daytime functioning. Although sleep diaries have validity as evidence, ultimately the construct they measure is sleep percep - tion so the perception of the client’s sleep may not match what their bed partners report, or what the PSG or actigraphy suggests. The degree of that discrepancy determines the degree to which the perception represents typical or paradoxical insomnia. In the case when the therapist suspects that the diary data may reflect SSM, it is important to consider how, when, or if to raise this issue with a client. There needs to be a strong working alliance before raising this issue or it can be interpreted as evidence that the therapist does not believe that the sleep problem is “serious” or that the therapist believes the client is fabricating the data. Either interpretation can cause a rift in the Downloaded by [New York University] at 04:37 12 August 2016 therapeutic alliance. If raising these issues is not possible given the current relationship, it is important to take time to develop this relationship before raising it. Luckily, the discrepancy fades with time-in-bed restriction; so one possibility is simply to arbitrarily select 5 or 6 hours for the TIB prescription. Below are some possibilities for trouble - shooting this problem in those with an established therapeutic relationship. There are many possible reasons for SSM, including hyperarousal. Hyperarousal often occurs in chronic insomnia and one result of hyperarousal is increased fast wave activity intruding into sleep which can interfere with the amnestic effects that should result during sleep (Perlis et al.). This phenomenon seems particularly severe in SSM. Even good sleepers will have brief arousals during the course of every night, and 116 Adherence and Troubleshooting Barriers during these arousals the person might process information like a sound in the room, the feel of the sheets, or the sight of the clock. These arousals are extremely brief and in normal sleepers there seems to be no memory trace for the experience. So, for the good sleepers it is as if the arousal never occurred. In insomnia, and particularly in SSM, the intrusion of fast brain wave activity is severe enough that it appears to inhibit the amnesia for these small arousals so that the individual with SSM remembers every little sound, sight and sensation. Therefore, although they might be sleeping most of the time, they encode the time passed, as “awake” time. The problem with doing CBT-I in someone with SSM, is that compared to people with more typical insomnia, sleep and wake estimates from those with SSM will be so far off that to match a sleep restriction prescription to the clients total sleep time estimate, would exceed the lower limits of time-in-bed that are safe. In other words, in SRT we recommend that the restriction of TIB match the client’s estimate of TST plus 30 minutes but never drop below 5 hours. In clients with SSM their estimates average total sleep time per day might be anywhere from zero to 4 hours. The problem therefore, is that to do SRT with these clients the TIB prescription will have to be somewhat arbitrary. Although someone reports 0 minutes of total sleep time, we cannot restrict TIB to 0 + 30 minutes. In this case the therapist might simply have to choose 5 hours as the starting point for restriction. A word of caution here is that for clients with SSM there is the possibility that the arbitrary prescription for SRT might be much lower than the client is actually sleeping even though they do not perceive it. This sets up the possibility of creating more extreme sleep deprivation in these clients than is typical early in the treatment. That is, if the client estimates that they are sleeping 15 minutes per night but is actually sleep 7 hours per night, and the therapist restricts this client to 5 hours, this is more sleep deprivation than usually occurs in more typical insomnia where the deprivation set up by SRT is mild. These clients will complain of very little sleep but often will be surprised how well they are functioning. This is because they are actually getting much more sleep than they think. One sign that the dose of restriction is too high is that in the early going of restriction the client may perceive more sleep at night but para doxically may report much worse sleepiness and fatigue during the day because now they are getting significantly fewer hours than when they started. This may force the therapist to reconsider the SRT dose. At the very least these clients should be carefully monitored for sleepiness and warned that they should not engage in any activities where sleepiness would become a danger. The good news is that eventually the misperception tends to minimize when drive for deep sleep builds and overrides hyperarousal as the treatment Downloaded by [New York University] at 04:37 12 August 2016 progresses. In the meantime there are consequences to SSM that can interfere with treatment. Those reporting little to no sleep tend to be quite anxious. They use dichot - omous language such as “I don’t sleep at all” and understandably, they have extremely low sleep self-efficacy. In one study, participants wore actigraphs and then reviewed the actigraph data with the experimenter and compared it to the sleep logs during the same period (Tang & Harvey, 2004). After the actigraph and log review session, the discrepancy between the two modalities diminished, which suggests that it may be possible to modify misperception with an exercise in which the client can see the dis - crepancy. Additionally, by providing an explanation of the hyperarousal phenomena above, clients can understand that the therapist does not believe that the client is Adherence and Troubleshooting Barriers 117 fabricating or exaggerating their sleep complaints, rather, the therapist suggests that hyperarousal may be providing confusing feedback to the client’s perceptual systems. It is important to encourage the client to look for any evidence that they might have been sleeping so that they can try to catch even an extra minute on the sleep diary. Clients can be reassured that as the treatment progresses, the misperception will diminish, which primes them to expect or look for more sleep time. Additionally, it may be helpful to explore with the client the consequence of self- identifying as someone who “doesn’t sleep.” There was a study in which those with insomnia were given fake feedback based on an actigraph they wore (Tang & Harvey, 2004). One group was told that based on their actigraph data, they slept much more than they thought and the other group was told that based on their actigraph data, they slept much less than they thought. The next day, the group who were told they slept better rated their daytime symptoms as less severe than the group who were told that they slept worse; suggesting that perception of sleep is a key variable to assess and modify. SSM can be managed better in treatment once clients have an understanding that: 1) extreme lows in average total sleep, especially “no sleep,” are not possible, 2) misper - ception is a result of a neuropsychological (i.e., extreme cortical hyperarousal) process in insomnia, 3) misperception diminishes with sleep deprivation, and 4) there is a negative, self-fulfilling prophesy consequence to labeling oneself as a non-sleeper.

Troubleshooting What Activities to do During Stimulus Control Many clients have concerns that leaving the bedroom will make them more alert. They may be concerned that they will find activities too interesting and they will not become sleepy. They may have read that light will make them so alert that they will not be able to return to sleep. Perhaps the first best answer to these concerns is to say that the client could potentially be right but that maybe it doesn’t matter. There is lots to explore with this concern. Most light sources in the house will not have the light intensity (e.g., lux) or high concentrations of blue spectrum light, to significantly activate the person; however, even if the light provides some activation, the argument is that staying in bed is more risky and detrimental to sleep than getting out of bed. That is, the rationale for SC is to recondition the bed to become a cue for sleepiness and sleep rather than arousal and anxiety. We know that pairing the bed with wakefulness promotes wakefulness. We don’t know if leaving the room promotes wakefulness. Getting out of bed, unpairs Downloaded by [New York University] at 04:37 12 August 2016 the bed with wakefulness, increases sleep deprivation, which increases sleep pressure, and is counter to sleep effort (in other words, the client is now engaged in efforts to stay awake which will make it more likely that they will become sleepy). It is important for the client to see that none of this relearning is likely to happen in one night. Stimulus control is not magic. Alternatively, staying in bed could potentially shield the client from light that may or may not alert them, but now they are: 1) reinforcing conditioned arousal, 2) engaging in sleep effort, which paradoxically increases the likelihood of wakefulness, 3) staying in an environment with few distractions from excessive mentation, and 4) engaging in the same pro-insomnia behavior that they were unsuccessfully using pre-treatment but hoping for a different result. One way to test 118 Adherence and Troubleshooting Barriers this concern is to use a BE in which two weeks are spent following SC. The therapist can use Socratic questioning to help the client see that even if they are awake longer by getting out of bed, if they don’t compensate for lost sleep and stick to their schedule, there is a hidden benefit to becoming activated out of bed—this will build healthier sleep drive and eventually produce better sleep. In CBT-I time should be spent not only reviewing the numbers on the sleep diary but also the therapist should be asking exactly how the time spent awake was passed. It is also important to note that clients who get out of bed but then try not to do anything as a way of getting bored and sleepier faster, are still engaged in sleep effort and this is not likely to be any more productive than tossing and turning in bed. Learning to get up and read a good book, even if it is engrossing, is much more conducive to acceptance and relaxation. In this way, becoming more awake and getting less sleep in the first nights of treatment can be reframed as a positive sign that the client is learning to let go of sleep effort and the treatment is working well. In essence, clients should learn that they might need to lose a few battles to ultimately win the war. No matter what the therapist should always be checking on the clients understanding and acceptance of the rationale. Any situations in which a client is catastrophizing about the possibility that any particular recommendation will increase sleep deprivation, is an opportunity to ask them about the rationale: “and if it is true, and you are to remain awake longer, what is the benefit with respect to sleep drive?”

Is it Time for a Sleep Specialist Consultation? Troubleshooting mainly consists of two tasks: 1) assessing whether the sleep schedule is correct and 2) addressing partial or total non-adherence. To assess whether the schedule is correct, the therapist assesses: 1) whether the scheduled sleep opportunity is at the right time given the client’s chronotype, 2) whether the TIB is too short (i.e., is there too much sleepiness present?), and 3) whether the TIB prescription is too long of an opportunity (i.e., are the insomnia complaints persisting?) Sleep schedule troubleshooting is contained in Chapter 5, so we will not re-review here; this chapter focused on nonadherence. If the sleep schedule appears correct and there appears to be good adherence but no improvement in insomnia, it may be time to refer to a sleep specialist. Likewise, if insomnia is improved, the client appears to be sleeping well for a reasonable number of hours and time-in-bed has been sufficiently extended, but sleepiness remains, this too may signal the need for a referral. CBT-I is a highly successful treatment in Downloaded by [New York University] at 04:37 12 August 2016 which most clients respond well. However, we know that some people do not have an optimal response, so it is best to refer them on for a second opinion, as well as an assessment of possible occult sleep disorders. Some clients do not appear to have risk factors for sleep disordered breathing or neurological disorders during sleep at intake, but after failing CBT-I, a sleep study may reveal that an occult sleep disorder either accounts for resistant insomnia or hampers treatment response. Sleep disorder centers have multidisciplinary teams that can help the management of complex cases. Thus, when there is a case of non-response especially when there has been good adherence, it is important to refer to a sleep specialist. Adherence and Troubleshooting Barriers 119 Summary

• Rise-time difficulties may relate to issues of comfort, eveningness, or aversion to sleep inertia. • Early morning awakenings can be a sign of phase advance rather than insomnia per se. • Bedtime difficulties may relate to chronotype, as well as too short or too long of a buffer zone. • Motivation, anhedonia, cognitive issues, and hopelessness are common features of depression and are workable in the context of CBT-I. • Modifications may be necessary to Stimulus Control rules in those with pain and mobility issues or medical frailty. • Some instances of non-response may relate to therapist beliefs which results in only partial or under dosed delivery of the treatment. It is important to be aware of our own biases when treating clients. • In cases of non-response despite good adherence, the client should be referred to a sleep specialist for evaluation and further treatment. Downloaded by [New York University] at 04:37 12 August 2016 8 Rumination Strategies for Insomnia

Rumination is a common issue for people with depression (e.g., Nolen-Hoeksema, 1991) and it is also an important issue for people with insomnia (see Carney et al., 2006, 2010, 2013). Rumination is a form of repetitive thinking. The content of the repeated thoughts differs slightly in those with insomnia only versus those with depression; although there is some overlap in content (Carney et al., 2006). In the presence of fatigue, the content tends to focus on somatic symptoms and why (i.e., past-focused thoughts) the symptoms are occurring; inevitably leading to the conclusion that the cause of the fatigue is the previous night’s sleep. Such is the type of rumination we see in insomnia but also MDD-I. In contrast, in MDD but not in insomnia only, the thought content in rumination tends to focus on negative aspects of the self. In the context of anxiety, thoughts tend to be future-oriented and catastrophizing (i.e., worry). That is, if someone with insomnia was lying awake, unable to sleep, the content would focus on the future, e.g., “If I don’t get to sleep, I won’t be able to function tomorrow” (e.g., Carney et al., 2010; Harvey, 2002). In each of these scenarios, the thoughts are repetitive and difficult to escape. Many people with depression and insomnia believe that ruminating helps them to solve problems; that is that rumination is useful. Indeed, repetitive thought may, at times, be helpful to solve problems, as this type of reflection can sometimes lead to insights and the generation of solutions. However, in the presence of negative mood, the types of thought that tend to be generated are mood-congruent and inherently unhelpful. An experiential way to help someone reflect on the process of rumination is to engage in an in-session rumination based on Watkins, Moberly, and Moulds (2008) study (Watkins et al., 2008). In this study, participants either focused on abstract or concrete aspects of an emotional scenario, such as a conflict. Thus, in-session, ask the client for a recent rumination episode; inquire as to how much time was spent on ruminating. Downloaded by [New York University] at 04:37 12 August 2016 Next, ask what solutions were generated and whether any solutions were implemented. The answer to this question, if the client is indeed ruminating, is most often no. Then reflect, for example, “You estimate that you spent 40 minutes ruminating without a solution? Is it possible that the cost-benefit ratio does not work out in your favor?” If the client persists in the belief, the therapist can set up a behavioral experiment and ask the client to test it out.

Therapist: You said that maybe you just didn’t have enough time for rumination to result in a solution? Client: Maybe. Rumination Strategies for Insomnia 121 Therapist: Can we try a little experiment to see whether that is true? That is, can we test if rumination is helpful? Client: OK. Therapist: I would like to set aside 15 minutes right now to try this experiment. Before we do, you said that you didn’t have any solutions to the problem with your neighbor even though you thought about it for 40 minutes this morning causing you to be late. I wanted to confirm that you don’t have a solution yet? Client: That’s right. I’m not sure what I can do and it’s driving me crazy. Therapist: Can I get a mood rating from you right now please? Client: I’m about 65 percent sad, and about 80 percent frustrated. Therapist: Ok, thank you. During the 15 minutes, I will ask you to intensify your thinking about your conflict with your neighbor to generate solutions. I want you to really analyze why and what caused it to happen, as well as analyze the implications of the conflict with your neighbor. Can you do that please? Client: So, why it happened and the implications of it? Therapist: Yes. Does that sound ok? Client: Yes, that’s typically what I am thinking about anyway—why and thinking about how I could prevent it or how I can get rid of the problem. Therapist: Ok, great. I will set our timer. After 15 minutes. Therapist: OK thank you. Can I get another mood rating now please? Client: I sort of feel worse. My neighbor is such a jerk. The more I think about it, the more I realize that he is such a jerk to treat me like that. Therapist: Sounds like this brought up negative thoughts for you. What is your negative mood rating right now after that exercise? Client: Frustration is more like 90 percent and I feel really down, maybe 80 percent. Why do I let people treat me like that? Therapist: So you were thinking about the “whys”—“Why do I let people treat me like that?” and it made you feel pretty lousy. What about any new solutions? Client: [Sighs and shakes head no.] Therapist: Can we try something else? Client: Sure Therapist: Let’s take the same situation, but instead of focusing on the why, start by exclusively focusing on the “what” of the problem. Tell me the concrete, specifics details without thinking about why at all. If you find yourself asking a why question, just take a breath and refocus. Tell me everything in as much vivid detail as possible Downloaded by [New York University] at 04:37 12 August 2016 and in chronological order. I will set the timer again. After 15 minutes. Therapist: OK. Can I get a negative mood rating now please? Client: I’m calmer now. Maybe because time has passed? Feeling down is like 50 percent and frustration is lower too, maybe 60 percent. When I think about it, the main thing he said was that he had some sort of weed killer he could give me. It just made me mad because I thought he was saying my place is a mess. That I’m not taking care of my responsibilities, which made me mad because I’m tired and depressed. I’m doing the best I can. I should take better care of my lawn. I just didn’t appreciate the insinuation. 122 Rumination Strategies for Insomnia Therapist: This is a pretty big shift in both mood and perspective. In the first 15 minutes, we focused on the why and you had no solution and felt worse. We can add this to the 40 minutes this morning that resulted in feeling worse, continuing to feel stuck and being late. You shifted your focus away from trying to figure out the why to just remaining at the level of what took place and what happened? Client: I don’t know. I think I have a few possible solutions. I can take the free weed killer because I sort of know I need to do it or I don’t have to. I don’t really know if he was trying to be snarky. I can see that maybe he wasn’t and IF he was being snarky, that seems a little lame to me and maybe not worth getting upset over. Therapist: When we balance the amount of time rumination takes and the toll on your mood, along with the observation that it rarely leads to a solution, I wonder if it shifts your opinion in some way? Client: It does.

The idea is that rumination, and other repetitive thought processes including worry, can sometimes change simply by examining the process of thought rather than the content and observing its outcomes, perhaps through a behavioral experiment or a log of rumination and its outcomes. In Chapter 9, we discuss that the TRAP and TRAC worksheet (a blank version is included in Appendix D) can be used to identify triggers to the rumination (an avoidance pattern) and to develop alternative coping responses to the rumination. For example, rumination can be addressed behaviorally by using it as a cue to engage in BA, including activation in the form of Stimulus Control, i.e., leaving the bedroom when it occurs in bed. Alternatively, rumination may be addressed via strategies that reflect on the process rather than the content per se. That is, there does not have to be any challenge at all; rather there can be a noticing of thoughts without engagement, acceptance, and through acceptance, paradoxically, comes change. In addition, when one takes an observing and accepting stance to thoughts, even if a change in thoughts does not occur, the experience of rumination itself becomes less disruptive. In other words, the rumination stops generating as much negative emotion. In clients with insomnia, the tendency to ruminate in response to feeling tired is negatively correlated with attending to one’s activities in the moment, whereas adopting a non- evaluative stance toward thoughts and feelings, and allowing them to come and go rather than fighting them, allows one to be more fully engaged in life (Moss Atlin, Atwood, Khou, Ong, & Carney, 2013). Such is the premise of mindfulness and acceptance-based techniques. Indeed, in Mindfulness Based Treatment for Insomnia (MBTI) rumination about insomnia Downloaded by [New York University] at 04:37 12 August 2016 symptoms as measured by the DISR Scale (Carney et al., 2013b) (see Appendix C) decreases with mindfulness treatment.

Metacognitive Approaches Metacognition is, in essence, thinking about thoughts. The mere act of reflecting about thoughts, one’s thought process, and the consequences of such patterns can be a powerful agent of change. In Chapter 6, we reviewed a process for direct challenges as a path to modifying thinking. The process of learning a new way of thinking about thoughts, that is, that thoughts are not facts and can thus be challenged and modified, Rumination Strategies for Insomnia 123 was purported by Beck to be a pathway to establishing a new relationship to thoughts, or “decentering” (Beck et al., 1979). There is some evidence that interrupting troublesome thoughts and re-appraising their veracity or utility via CT may result for some, in decentering (Ingram & Hollon, 1986). However, for many, Socratic questioning and TRs may not result in decentering. This was part of the impetus for the development of Mindfulness Based Cognitive Therapy (MBCT). In recognition that mood-triggered repetitive thought in the form of rumination was the most important predictor of relapse and recurrence in depression (Nolen-Hoeksema, 1991, 2000; Segal et al., 2006), the MacArthur Foundation funded three experts in repetitive thought to develop a preventative strategy for relapse prevention (Segal, Williams, & Teasdale, 2002). Their focus of finding a preventative treatment was on rumination and facilitating decentering. Thus, we will turn our attention to rumination in the context of MDD-I. Metacognitive approaches to the treatment of depression are part of the “third generation” cognitive behavioral therapies and include ACT and MBCT. Before discussing what these interventions are, we briefly review empirical evidence for their efficacy in the context of depression and then, after describing the theoretical foundation and techniques, we discuss the application of these techniques and theoretical constructs to the context of insomnia, concluding with a brief review of emerging evidence for the efficacy of metacognitive approaches in the treatment of insomnia.

Empirical Support for Metacognitive Treatments for Depression There is empirical support for the efficacy of ACT and MBCT for depression treatment, including evidence for their efficacy when delivered as self-help interventions (Zettle, 2015). Hoffman and colleagues conducted meta-analyses of mindfulness based therapy, which included both MBCT and Mindfulness Based Stress Reduction (MBSR) inter - ventions for anxiety and depression (Hofmann, Sawyer, Witt, & Oh, 2010). These investigators identified four studies that included individuals with diagnosis of depres - sion (chronic depression, treatment resistant depression, residual depression, and those with history of depression) and concluded that there is a large pre- to post-treatment effect (Hedges’s g = 0.95) for improving mood symptoms in these four samples (Hofmann et al., 2010). Piet and Hougaard (2011) conducted a systematic review and meta-analysis of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder and reported that MBCT significantly reduced the risk of relapse or recurrence, with a relative risk reduction of 34 percent (Piet & Hougaard, 2011). Two of the six studies reviewed compared MBCT with maintenance Downloaded by [New York University] at 04:37 12 August 2016 antidepressant medication and found no significant differences in depression relapse rates (Ruiz, 2012). A review paper of studies that directly compared ACT to CBT for depression (Ruiz, 2010) reported comparable efficacy (Hedges’s g = 0.25).

Key Concepts and Techniques Used in Metacognitive Treatments for Depression Metacognitive approaches are focused on second-order rather than first-order change. First-order change refers to wholesale alterations in behaviors, for example by changing frequency and/or intensity or eliminating behaviors or by changing thoughts, beliefs or 124 Rumination Strategies for Insomnia schemas, in order to change behaviors. In contrast, second-order change aims to change one’s relationship or the context of one’s thought. ACT and MBCT for depression are focused on promoting psychological flexibility, responding to stressful situations reflectively, rather than reflexively, and increasing commitment to valued-based actions (Bishop et al., 2004). In doing so, these interventions can be viewed as aiming to change individuals’ relationships with their thoughts and experiences rather than to directly address their depressive symptoms through altering depression-related behaviors and thoughts. In the context of these two therapies psychological flexibility refers to expanding one’s options regarding behavior and thought, while including a willingness to tolerate negative experience. With such willingness the hope is that one can consider taking small steps towards a valued goal as a viable course of action. Acceptance is a central construct in both ACT and MBCT. It involves the active and aware embrace of all thoughts and experiences and, when appropriate, not attempting to change them. As opposed to passively tolerating or resigning, acceptance is an active process that involves a deliberate decision to hold negative thoughts and feelings and not to avoid or escape the experience. Acceptance is not always intuitive. It is said in ACT work that minds are programmed to want to find problems and fix them. However it is the rigid application of this stance that often gets individuals stuck in rumination without positive outcome. Taking a fixing stance may be helpful in relation to things over which we have control, but when the same attitude is applied to things over which we have no control (e.g. sleep and/or mood), this often results in spiraling frustration, anxiety, and increased depression. Given that it is difficult for minds to grasp the concept of acceptance, the use of metaphor is often a powerful tool to be employed. Likening acceptance to experiences that the client can relate to, often can help the client gain greater understanding of the concept. For example, one metaphor to convey what it is like to have or hold a thought without engaging the thought (acceptance without fixing) is that it is like watching the TV news with the ticker scrolling at the bottom of the picture. It is hard to concentrate on both the story and read the ticker at the same time, however, one can learn to focus on the story and not read the ticker. The point is that one does so not by making the ticker go away, but rather keeping it in the periphery of vision, knowing that it is there, but at the same time not interacting with it. In addition to metaphor there are several techniques that are used for promoting acceptance, including a) adopting an observing stance, in which a negative thought or experience is watched dispassionately, as one might watch leaves floating by on a stream, b) distancing from a thought by giving it a shape, size, color, or another descriptive quality, such as “interesting,” c) repeating the thought or a key word out loud until only its Downloaded by [New York University] at 04:37 12 August 2016 sound without meaning remains, almost as if it were a tongue twister, d) labeling the thought as merely an event in one’s mind (e.g., “I am having the thought that I am no good”) rather than a reflection of attending to and fusing with its content (e.g., “I AM no good”). Acceptance is promoted not as an end in itself but to increase psychological flexibility by broadening the range of reaction options. This is often accomplished because as one becomes more accepting of thoughts, feelings, and emotions, by definition it allows one, in essence, to put a bit of distance between themselves and these characteristics and therefore to gain a better perspective for what they are as opposed to the more catastrophic interpretations of what they are. For example, by using the technique of distancing one might be able to describe a pounding, racing heart as being Rumination Strategies for Insomnia 125 like a basketball that is being dribbled inside their chest. As such one may then be willing to have the basketball dribbling occur a while longer rather than having to stop it immediately, because when thinking of it that way they see it as not as bad as they first thought. Once a person is willing to allow symptoms to be as they are, they are more able to entertain options for behavioral action. Such acceptance can also be a very important construct in insomnia. Commitment to values-based actions is a second central construct in ACT and is the vehicle for change that complements acceptance of what cannot be changed. It refers to deliberate actions that are congruent with and motivated by values that are important to the individual. Depression is associated with reduction in engagement in appetitive behaviors that were important to the individual in the past. ACT involves helping individuals with depression identify and reconnect with what really matters to them in life (i.e., their values) and commit to actions that are congruent with these values. For example, an individual with depression who valued fitness and health, and therefore was committed to and derived pleasure from going to the gym may have stopped exercising due to anhedonia. If this person identifies health promotion as an important value, then commitment to live in accordance with their values in this example would mean committing to resuming exercising and taking small steps to gradually re-engage in an exercise routine. In this way value-based action supports BA. In Chapter 9 we discuss why BA may have important input into the sleep regulatory system. As discussed above, MBCT was initially developed as an approach to relapse prevention in depression. Whereas in traditional CBT relapse, prevention is focused on identifying automatic dysfunctional depressogenic thought and changing their content, MBCT aims to reduce future risk of relapse and recurrence of depression by focusing on changing the individual’s relationship with such thoughts. Originally, MBCT was called Attentional Control Therapy because of the focus on teaching clients to con- tinually bring their attention to a stated target (e.g., the breath, a part of the body, etc.) (Segal et al., 2002). MBCT teaches clients in remission from depression to become more aware of their thoughts and feelings in response to their experiences and relate to their thoughts and feelings as passing events in the mind. In that way, MBCT helps individuals to decenter, or disengage from habitual ways of interpreting and responding to their experiences, which have historically put them at risk for depression recurrence. Mindfulness mediation is a core technique of MBCT. It involves nonjudgmental awareness of bodily sensations, thoughts, and feelings. MBCT also includes exercises designed to help people apply awareness skills into daily life. The aim is to replace Downloaded by [New York University] at 04:37 12 August 2016 habitual, “automatic” patterns of mindless reacting to cognitive-affective experiences. Rather, individuals are encouraged to observe these experiences and act intentionally and mindfully. The idea is that observance and acceptance of automatic depressogenic thoughts allows for disengagement from the thoughts and increases one’s ability to identify new ways to deal with challenges and stressful situations.

Metacognitive Approaches to Insomnia In an elegant series of experiments, Bonnet and Arand provided support to the idea that insomnia is a disorder of hyperarousal (Bonnet & Arand, 1997). Hyperarousal can 126 Rumination Strategies for Insomnia be experienced physiologically, through body tension and autonomic arousal, emotion - ally, through negative high arousal emotion, such as anxiety, and through cognitive processes, such as racing thoughts, and thoughts that increase arousal. CBT-I sometimes incorporates relaxation methods to address physiological arousal and cognitive therapy to address cognitive arousal. Ong, Ulmer and Manber (2012) have proposed a two-level model of arousal in insomnia, which supports the use of metacognitive techniques in insomnia (Ong et al., 2012). They distinguish between cognitive and metacognitive sleep- related cognitive arousal. Primary cognitive arousal refers to thoughts related to the inability to sleep, such a thought that insufficient sleep will lead to negative and unacceptable daytime consequences. Secondary or metacognitive arousal refers to how one relates to thoughts about sleep in terms of the meaning, emotional valence, and degree of attachment one has to these thoughts. Secondary cognitive arousal is likely to increase primary cognitive arousal because it could create a bias in the attention to and perception of sleep-related threats. For example, the degree to which one accepts the middle of the night thought, “My day is going to be shot unless I fall quickly back to sleep” as fact, rather than an event in one’s mind will likely lead to additional thoughts about negative outcomes of not falling asleep, which, in turn, further escalates hyperarousal. By using metacognitive techniques, without necessarily changing the content of the thought, the person can detach from the threat perception thus reducing the probability of additional thoughts about the threats related to insufficient sleep. In this way the person is more likely to defuse threatening internal experience and decrease hyperarousal. Garland, Gaylord, and Park (2009) posit that de-centering occurs with mindfulness because mindfulness can facilitate the reappraisal of stressful events and distressing thoughts (Garland et al., 2009). Thus, mindfulness allows an individual to “de-center” from initial stress inducing appraisal (e.g., “my day will be shot”), adapt a different perspective, and reappraise the situation, which is likely to attenuate the original activation of the stress response system, thus halting (or at least reducing) further escalation of hyperarousal. Mindfulness meditation helps cultivate adopting an objective stance about sleeplessness. This applies to the middle of the night experience as well as to the experience during the day. For example, an objective nonjudgmental awareness of the tendency to attribute low energy during the day to sleeplessness at night could lead to the insight that being absorbed in the frustration makes it more likely that the state of low energy will continue to interfere with the day’s activities. Another metacognitive technique is the Chinese finger trap analogy, which provides an experiential demonstration of the importance of letting go of efforts in certain situations, including sleep and fatigue. Below is an Downloaded by [New York University] at 04:37 12 August 2016 exchange with a client named Kelly, whose case is presented in Chapter 10.

Therapist: So tell me about the increased use of energy drinks this week. Client: I really can’t take how tired I feel. I think I’m going to end up in the hospital. Therapist: You worry that you would end up in the hospital because you are tired? Client: You know when you hear that someone was admitted due to exhaustion? Therapist: I see. So does the difficulty following the schedule, the difficulty refraining from napping attempts and the increase in caffeinated drinks all relate to trying to manage or escape feeling tired? Client: Yeah. I really hate it. I can’t take it. Rumination Strategies for Insomnia 127 Therapist: You can’t take it. I see. Do you think the strength of your aversion to feeling tired may play a role in this problem? Client: You mean it’s all in my head somehow? Therapist: Not exactly. What I meant to say was whether the fact that you need to avoid this sensation at all costs, increases your attention to it and may unwittingly increase the likelihood of detecting any sensations of fatigue? Client: Maybe. But I do feel tired. Therapist: I don’t doubt that for a minute. But if all this energy is focused on resisting the experience of fatigue, isn’t a fair amount of attention and energy being devoted to the very experience that you don’t like? Client: Maybe. Therapist: There is a saying, “that what you resist, persists,” what do you think about this? Client: If you are saying I shouldn’t “resist” feeling fatigued, that doesn’t make sense to me. I can’t take feeling tired, so I have to do something about it. Therapist: Have you ever heard of a Chinese Finger trap? Client: I think so. Therapist: I have one right here [hands it to client]. The person places their index fingers in each end and they have to solve how to get their fingers out. Client: [inserts fingers] I can’t. I’m stuck. I can’t pull them out. Therapist: Often the first solution someone tries is to resist, to pull out, to struggle against the puzzle, but what happened when you used this strategy? Client: It starts to squeeze and get tighter and I get stuck. I can’t feel anything to release it either. Therapist: What is the opposite of struggling? Client: Not struggling? Relaxing? That doesn’t seem to be working either. Wait. I did it. Therapist: So what did you do? Client: If you push in, rather than struggle, it works. Therapist: Why do you think I gave you this puzzle to try? Client: I guess you don’t want me to struggle with feeling tired? That you want me to push in? Does that mean you want me to try to feel tired? To induce it? Therapist: You could induce it, I suppose, but I was thinking of something a little different. I want you to imagine that you were having a party and there was someone who you really did not want to come. You didn’t invite them but you were really focused on the idea about whether they might show up uninvited. You Downloaded by [New York University] at 04:37 12 August 2016 worried for weeks before the party and tried to think of ways to keep them out if they showed up. Maybe you even hired security for the door to keep them out. How much fun is the anticipation for the party and how much fun would you have at the party, waiting to see if they showed up? Client: Probably not much fun. Therapist: And what if they got in anyway? Would it ruin things? How much fun would you have at your party now? Client: None. I couldn’t have fun until they were gone. Therapist: And even if you managed to get rid of them, knowing they could return would be distracting again, no? 128 Rumination Strategies for Insomnia Client: OK, I get the finger trap thing and this too, struggling against something NOT happening makes it worse. It takes up all your energy and ruins the party so to speak. But what is the equivalent of pushing your fingers in here? Therapist: You don’t have to like the party guest, in this case fatigue, and you don’t have to necessarily invite or induce it, but what would happen if you were open to its presence? What if you focused your attention on the invited guests and the party at hand instead? Could the shift in attention lessen the negative impact of fatigue? Client: Maybe. That would be hard. Therapist: It’s sort of like your low back pain. You told me that the pain improved after attending the chronic pain group. Given how the pain group did not work on your herniated disks at all—how would you explain why the group was so helpful? Client: I learned that I could turn down the volume on the pain. The pain doesn’t go away but it fades to the background. I focus on other things and the pain decreases. I get it about feeling tired now. I need to turn down the volume.

In the context of CBT-I mindfulness meditation can also help restore the automaticity of the process of falling asleep as awareness of levels of alertness, sleepiness, and fatigue increase and acceptance counteracts sleep effort. The information can be used in a matter of fact way to guide one’s behavior: if feeling sleepy, go to sleep; if fatigued, rest, but not in bed; and if in a state of high arousal, focus on behaviors that reduce arousal. As discussed earlier, individuals who have experienced insomnia for a long time exert much effort in order to control sleeplessness. In some cases this effort compromises engagement in other activities that used to promote their sense of well-being and were consistent with their value system, such as socializing with friends, exercising, etc. For example, having lost sight of some of their life values in the service of symptom management they cancel or do not schedule social activities so that they can go to bed earlier (Carney & Edinger, 2006) or because they do not have the energy, use the time that was previously dedicated to morning exercise for sleeping in. These avoidant, safety behaviors were described in the previous chapter. In insomnia, as in depression, commitment to personal non-sleep-related values can guide deliberate actions that do not involve sleep effort. Such actions may include adherence to treatment recom - mendations that might initially appear counter intuitive, such as limiting the time spent in bed, or not engaging in safety behaviors, such as cancelling social engagement and sleeping in. The steps involved in helping clients develop a plan for value-based commitment to action are: identifying one’s values, and helping clients realize the cost of maladaptive Downloaded by [New York University] at 04:37 12 August 2016 sleep-related behaviors that are not consistent with those values (e.g., canceling a social engagement is not consistent with the value of staying connected with people). The discrepancy can then naturally lead to changes in these maladaptive behaviors. Again, the other side of this equation is that in order to live in congruence with these values, one must be more willing to accept the presence of uncomfortable thoughts, feelings, and emotions (e.g., in the name of valued connection with others, one might have to accept the thought that “I might fall asleep while sitting listening to my friends”). The therapist should keep in mind that when asked to state their values clients often respond with statements about their goals and aspirations rather than their values. However, values provide a direction for attainable actions but are not in themselves attainable Rumination Strategies for Insomnia 129 targets. The Life Compass (Dahl & Lundgren, 2006) is a tool to help clients identify their values. The Life Compass exercise encourages clients to rate the importance of various life domains, such as family, friendships, work, spirituality, etc.

Therapist: You said that your insomnia gets in the way in several areas of your life, specifically you mentioned that you are no longer socializing or working out. I would like us to do an exercise called the Life Compass. I want to ask about aspects of dimensions of your life and I want you to tell me about the importance of these areas of your life. What about your relationship with your daughter? How important is this area? Client: This is one of the most important things in my life. Barb and I have a good relationship. I wish I were more present with her. I used to call her more often and go out for lunch with her. Therapist: I see. So family relationships are a top priority; one of your most import - ant values. Although it sounds as though your current lifestyle may not reflect this? Client: Yes. Plain and simple, I am tired. I feel preoccupied with just trying to survive. Just trying to function, you know? So I try to rest when I can and arranging activities with my daughter, being present is what I value but not something I feel able to do given how crappy I feel. Therapist: I see. What about other relationships, perhaps starting with family relationships? You mentioned you have a brother? Client: Absolutely. This is similar. I feel a little disconnected right now from my brother [starts crying]. It’s the same. I’m tired and I think I am so focused on surviving that I have lost sight of what’s important. Therapist: OK. So feeling tired and focusing energy on resting and conserving energy has disconnected you from living a life in tune with your values? Client: [nods] Therapist: What about friendships? How important are friendships in your life? Client: Yes, very important. Maybe not quite as high as family but pretty close. I have good friendships. Although, now that I am thinking about it, I have good friends but I am not really spending time with them or spending much energy on them. I wish that we went out more and I know that it is me. I don’t say yes so I am letting how crappy I feel affect my relationships. Therapist: OK. I was going to ask you about romantic relationships and then I remembered that you actually told me that while you are feeling depressed and not Downloaded by [New York University] at 04:37 12 August 2016 sleeping well, you feel ambivalent about relationships because you really wish you had someone but your motivation is low for trying to meet someone. Do I have that right? Is this low in importance, or not as valued as other areas of your life? Client: No, it is something I value. It’s sad. I wish I had someone but I never do anything about it. When you feel tired and your sex drive is low, it’s so hard. Therapist: OK. I have written these down in your values or life compass column and you can see how I wrote down the barriers you cited in the last column. These are things getting in the way of living your valued life or living in a way that matches your values. I would like to explore other things you may value like leisure or hobbies, your work, spirituality, health? 130 Rumination Strategies for Insomnia Client: OK. But it is going to be the same. Hobbies are important. I like knitting, but I am not. I want to work out but I don’t. I like yoga and I know it helps my back, but I haven’t gone for two years. There are ideas I have for work—but I am in a rut and doing things that don’t work that well and that I don’t enjoy, instead of trying something that would make me feel more fulfilled. It’s so depressing, but what am I supposed to do? I am exhausted and just trying to get through each day. Therapist: It’s your belief that you have to get rid of the sleeping problem or the depression to live your valued life? Client: Well yes. If you are tired, you can’t do anything. Therapist: In fact you have been doing something, right? You are using a strategy to get by, and that is to conserve your energy and cut back on everything. Has this allowed you to live the life you would like? The life you described in your life compass? Client: It doesn’t really feel like a choice, but no, it doesn’t give me what I want. Therapist: Is it possible that the strategies you are currently using actually block you from your valued life, the life that you want? Client: Yes, although it seems impossible to think of a way in which it could be different. Therapist: I wonder if you could conceive of a life in which living in a way that is more consistent with your valued life would work better for you? That is, I wonder if we could explore a world in which you could be living your valued life alongside your fatigue. Client: What do you mean by: alongside my fatigue? Therapist: Well, right now it sounds like you give up a lot of what you value when you are fatigued. But I wonder, when you are conserving energy does that make you feel less fatigued, or less depressed? Client: I don’t think so. In fact, I know there are many times when I go home to rest but I continue to feel exhausted and sad. Therapist: At the same time you are missing out on valued pieces of your life, correct? Client: Without a doubt. Therapist: So I ask you—which is better, to be fatigued and home alone or fatigued and with your daughter, or friends? Client: Well when you put it that way, I guess the answer is simple. I would rather be with people. Therapist: Even if you are fatigued? Downloaded by [New York University] at 04:37 12 August 2016 Client: Yes I guess I would say that. Therapist: This is what I mean by living a valued life alongside your fatigue. Client: I can see what you mean and would be excited to think about ways that I could get back to some of the things that are important to me. I guess we would need to talk about what that looks like but yes, I am open.

Thus in the example above, the exercise leads the client to re-appraise the strategies they are currently using to cope as blocking themselves from their valued life. The ambivalence this exercise creates can help to facilitate change towards living a life more commensurate with the client’s values. Rumination Strategies for Insomnia 131 Mindfulness-Based Treatment for Insomnia (MBTI) Ong, Shapiro, and Manber (2008) have developed and tested a mindfulness-based intervention for insomnia that they later named MBTI (Ong et al., 2008). Although the treatment was originally developed as a group intervention, there is no reason to believe it cannot be implemented in an individual therapy format. MBTI combines mindfulness meditation and three behavioral components of CBT-I, sleep restriction therapy, stimulus control, and sleep hygiene introduced in a manner consistent with mindfulness principles. For example, the stimulus control instruction to get out of bed when unable to sleep is discussed using the language of awareness and acceptance: “I am not in a state conducive to sleep so I might as well be fully awake.” Similarly the stimulus control instruction to go to bed only when sleepy is discussed using the language of awareness: “I notice that I am not sleepy now; I might as well wait until I become sleepy.” MBTI discourages the therapist from being directive when introducing the behavioral components of CBT-I. For example, concepts central to the rationale for stimulus control (i.e., conditioned arousal) and sleep restriction therapy (i.e. the importance of the sleep drive) are introduced by the therapist who then encourages the clients to discuss how the ideas apply to them. Barriers to adherence with the behavioral components of CBT-I are addressed through discussions of mindfulness principles, such as flexibility and promoting decentering from the immediate distress or re-connecting with commitment to value-based actions. Each session begins with formal mindfulness meditations that include both quiet (e.g., body scan, breathing, or sitting meditation) and movement meditation (e.g., yoga, walking, or stretching meditation). Each week, the mindfulness group facilitator engages the group in inquiry; that is, questions about the experience, e.g., “What do you notice in your body?” Between session work includes implementation of the behavioral components of CBT-I and a 30–45 minute daily meditation practice. The session by session outline is presented in Table 8.1.

Table 8.1 MBTI Session outline

Weekly Topics Therapy Activities Introduction Introduce concept of mindfulness and model of insomnia; lead through first mindfulness practice Stepping out of auto pilot Start with meditation and inquiry; discuss sleep hygiene Paying attention to Start with meditation and inquiry; discuss sleepiness, fatigue sleepiness and wakefulness and wakefulness; introduce sleep restriction

Downloaded by [New York University] at 04:37 12 August 2016 Working with sleeplessness Start with meditation and inquiry; adjust sleep restriction; introduce stimulus control The territory of insomnia Start with meditation and inquiry; troubleshoot Acceptance and letting go Start with meditation and inquiry; relevance of acceptance and letting-go Revisiting the relationship Start with meditation and inquiry; discuss reactions to sleep with sleep (reactions to bad nights); discuss informal meditation Eating, breathing, and Start with meditation and inquiry; relapse prevention for sleeping mindfulness insomnia Source: Adapted from Ong and Scholtes (2010) 132 Rumination Strategies for Insomnia Empirical Support for Metacognitive Treatments for Sleep Research on the efficacy of metacognitive therapies examined the effects of mindfulness meditation and MBSR on sleep quality in non-insomnia samples with or without sleep complains (cancer clients, individuals with depression and insomnia, adolescents with sleep complaints who completed substance abuse program, and adults with anxiety disorders and sleep dissatisfaction) as well as insomnia samples. Controlled and uncon trolled studies of MBSR for individuals with a variety of cancer diagnoses (not selected for insomnia diagnosis) yield some but not definitive evidence for the potential benefits of MBSR on sleep (Carlson & Garland, 2005; Carlson, Speca, Patel, & Goodey, 2004; Shapiro, Bootzin, Figueredo, Lopez, & Schwartz, 2003). For example, Shapiro and colleagues found that the practice of mindfulness techniques was associated with reporting feeling refreshed in the morning but no differences in sleep quality between the MBSR and the control (Shapiro et al., 2003). Britton and colleagues randomized individuals with depression and insomnia to MBCT or a wait-list control (Britton et al., 2010). Participants in both groups reported reductions in subjective sleep onset latency (based on sleep diaries). Within the active treatment group, more time spent in meditation practice was associated with less self-reported time awake after sleep onset. However, objectively measured number of middle of the night awakenings using polysomnography was significantly greater among participants in the MBCT group than control. They also had more wakefulness, in fact, the amount of time spent in mindful - ness meditation practice in that study was positively correlated with these two indices of cortical arousals. These intriguing findings suggest that the observed improvement in subjective sleep is not likely to be related to a reduction in hyperarousal. Bootzin and Stevens (2005) conducted a pilot study that combined a mindfulness component with CBT-I in adolescents with a substance abuse history and sleep complaints (Bootzin & Stevens, 2005). This study, which had high attrition rate, found some improvements in sleep and reductions in relapse of substance abuse among treatment completers. In an open trial, Yook and colleagues (2008) found that among people with anxiety dis - orders, MBCT improved sleep quality and reduced scores on a worry questionnaire and the two effects were related (Yook et al., 2008). Empirical evidence on the efficacy of mindfulness based interventions in samples of individuals with confirmed diagnosis of insomnia disorder is promising. Uncon- trolled small studies of MBSR (Britton, Shapiro, Penn, & Bootzin, 2003) and MBCT (Heidenreich, Tuin, Pflug, Michal, & Michalak, 2006) reported improvements in subjective time awake after sleep onset and total sleep time among individuals with Downloaded by [New York University] at 04:37 12 August 2016 DSM-IV defined primary insomnia. These studies also found reductions in cognitions related to rumination and worry. Ong et al. (2008) evaluated an intervention that combined mindfulness meditation and the behavior components of CBT-I (MBTI) and found that half of the sample experienced at least 50 percent or greater reduction in self-reported total wake time and all but two participants no longer had clinically significant insomnia at the end of the treatment (Ong et al., 2008). This study also found a significant correlation between the number of meditation practice sessions during treatment and reduction in hyperarousal (Ong et al., 2008). A 12-month follow-up of participants supports the long-term benefits of adding mindfulness to behavioral therapy for insomnia, with 61 percent of participants experiencing no relapse (Ong, Rumination Strategies for Insomnia 133 Shapiro, & Manber, 2009). More recently evidence that mindfulness meditation might be a viable treatment option for adults with chronic insomnia comes from a randomized controlled pilot study in which participants with insomnia were randomized to MBCT, MBSR, or a self-monitoring control. The results indicate that those who received a metacogni tive intervention (MBSR or MBTI) had significantly greater reductions in the number of minutes they spent awake after sleep onset, overall insomnia severity, and pre-sleep arousal. Importantly, remission and response rates in MBTI and MBSR were sustained from post-treatment through follow-up and were highest among those who received MBTI at the 6-month follow-up. Gross and colleagues (2011) randomized individuals with chronic primary insomnia to receive either MBSR or eszopiclone. Participants in both groups experienced signifi - cant improvements in subjective and objective (actigraphic) sleep from baseline to post- treatment. Within the MBSR group, there were improvements in subjective and objective latency to sleep onset as well as subjective total sleep time and sleep efficiency. Because the study was not adequately powered to establish non-inferiority (i.e., equiva - lent efficacy), the absence of significant differences between groups is not interpretable. Although we are unaware of a study evaluating ACT as a standalone therapy for improving sleep or insomnia, there is a case report in which ACT was combined with CBT-I (Dalrymple, Fiorentino, Politi, & Posner, 2010). Although not definitive, together these studies suggest that the integration of metacognitive techniques into CBT-I might contribute to improve outcomes.

Summary

• Rumination has been implicated as a key process in both insomnia and depression. In depression, rumination is a key predictor of relapse. • There are a variety of strategies for rumination including experiments that teach clients about the unhelpful outcomes of rumination, and experimenting with alternative coping responses to rumination including stimulus control at night and BA during the day, and metacognitive strategies. • Metacognitive treatments target the process of repetitive thought rather than the content. One of the main agents of change is a process called decentering. • Metacognitive treatments include MBCT, MBTI, MBSR, and ACT. • There is promising support for metacognitive approaches in addressing rumina - tion, as well as improving outcomes for depressive relapse (Segal et al., 2002) and Downloaded by [New York University] at 04:37 12 August 2016 insomnia relapse (Ong et al., 2009). 9 Combining Depression and Insomnia Therapies

Although there may be subjective sleep benefits with effective depression treatment for some, there still often remain objective sleep problems and a high rate of residual subjective sleep problems even after successful depression treatment (Carney et al., 2007b). The issue of residual sleep problems is of great concern because persistent issues with sleep are predictive of depressive relapse (Paykel et al., 1995). Thus, it is essential to target comorbid insomnia along with depression, and fortunately there are several treatment options available. One possibility is to pair a depression treatment such as pharmacotherapy or psychotherapy with a sleep medication. There is evidence that combining sleep and antidepressant medications produces greater depression treatment response (i.e., almost 10 percent higher remission rates), as well as greater sleep improvement, than antidepressants alone (Fava et al., 2006). There also exists evidence for improving sleep by combining antidepressant medications with a low dose of the sedating antidepressant trazodone (e.g., Kaynak et al., 2004), although, unlike sleep medications, there appears to be no additive depression benefit. An alternative is to combine the therapy of choice for chronic insomnia (i.e., CBT-I) with an effective depression treatment. Indeed CBT-I has amassed considerable evidence for treating insomnia in those with depression (Edinger et al., 2009a; Kuo et al., 2001; Lichstein et al., 2000; Morawetz, 2001; Taylor, Lichstein, Weinstock, Sanford, & Temple, 2007; Vallieres et al., 2000) and even has some evidence for improving depression in the absence of depression therapy (Morawetz, 2001). Despite evidence that CBT-I has been shown to produce recovery from depression (e.g., Morawetz, 2001), the current state of the literature would suggest that both conditions Downloaded by [New York University] at 04:37 12 August 2016 receive clinical attention concurrently. One promising option is combining pharmaco - therapy for depression with CBT-I. Adding CBT-I to antidepressant medication produces superior results for both depression and insomnia as opposed to treating depression alone (Carney, Atwood, & Shapiro, 2013a; Manber et al., 2008). Moreover the effect sizes and proportion responding to the combined treatment is superior to combining antidepressant therapy and pharmacotherapy for insomnia (Fava et al., 2006) (i.e., when compared to a hypnotic medication + antidepressant medication, CBT-I + antidepressant medica - tion, it nearly doubles the MDD remission rate) (Manber et al., 2008). Additionally, there may be drawbacks to pharmacotherapy for depression including resistance to medications because of personal beliefs, side effects, or failed past antidepressant trials, Combining Depression and Insomnia Therapies 135 and SSRIs can actually worsen leg movements and disrupt sleep further (Dorsey et al., 1996). Thus, one option is to combine two psychological therapies. Cognitive-behavioral therapeutic approaches have several overlapping features that allow for easy integration, however some parts are so different that one issue that must be considered is whether to administer the two treatments sequentially or concurrently. There are no treatment development studies or sequencing studies to inform such questions. It seems reasonable, and is probably common clinical practice, to use case formulation to decide when, how and what components to introduce for specific clients (for more on case formulation, see Manber & Carney, 2015). Alternatively, by com - bining the treatments concurrently there may be aspects of each treatment that complement the other. In other words, there may be aspects of CBT-I that may help with CBT-D and vice versa. For example, there are both depression-specific and sleep- specific reasons to want someone with depression to get out of the bed in the morning. From a sleep perspective, setting a regular rise time: 1) helps to set the body’s biological clock, 2) it reinforces stimulus control (i.e., that the bed during particular hours is a signal for sleep only), and 3) it helps to build the homeostatic sleep pressure needed for deep sleep on subsequent nights. Likewise, there are also theoretical reasons for an earlier rise time in those with depression. For example, selective REM sleep deprivation helps with mood (Vogel et al., 1980) and REM sleep is more likely to occur in the latter half of the night, thus, setting an early and regular rise time has a good chance to inadvertently restrict some degree of REMS in those with depression. Additionally, one side effect of CBT-I is decreased time in bed (TIB) both during the day (i.e., naps) and in the 24-hour period (i.e., refraining from going to bed until sleepy and getting up at a set rise time each morning). Decreased TIB at night means that there will be increased time out of bed and greater exposure to light cues and the chance for increased activity and increased exposure to reinforcers. In other words, getting out of bed early provides an opportunity for BA. In fact, perhaps some of the depression benefits of CBT-I (e.g., Lachowski, Maich, & Carney, 2014; Manber et al., 2008) may relate to inadvertent BA because of the increased time out of bed in a 24-hour period (Lachowski et al., 2014). BA has been demonstrated to be an efficacious treatment for depression (Chambless et al., 1998; Cuijpers, Van Straten, & Warmerdam, 2007; Dimidjian et al., 2006). In addition to being an effective treatment, the straightforward therapy goals and tasks make it an attractive therapy in training clinics (Sturmey, 2009). There are two prominent versions of BA with considerable overlap but some differences in foci. One version of BA (Lejuez et al., 2001) builds activity scheduling around stated goals that Downloaded by [New York University] at 04:37 12 August 2016 arise during a structured values assessment. The values assessment queries whether there are unmet goals or needs in domains in the client’s life such as hobbies, health, relationships, occupation, etc. For example, a client who is no longer socializing due to depression, but for whom friendships are an important source of enjoyment, social activity scheduling component would be an important part of their treatment. A second version of BA is associated with Neil Jacobson (Dimidjian et al., 2006; Jacobson, Martell, & Dimidjian, 2001) and although the focus is also on scheduling, the primary target is to decrease avoidance. These two BA packages have substantial overlap and the skills and goals of the two approaches have been combined into a single package by others (e.g., Puspitasari, Kanter, Murphy, Crowe, & Koerner, 2013). 136 Combining Depression and Insomnia Therapies Behavioral Activation and Behavioral Insomnia Therapy (BABIT): An Integrated Treatment While conducting a National Institute of Mental Health funded trial combining antidepressant medication with CBT-I, the first author (CEC) encountered an interesting problem. Whereas it made sense that participants would be leery of the placebo antidepressant condition, instead, potential participants declined participation if they were required to take an active antidepressant medication (over 200 people cited this as the reason for not participating). This was a problem for the trial but it also highlighted a problem among some people with both depression and insomnia; negative attitudes towards pharmacologic remedies. There were some who declined because they generally disliked taking medications of any kind, and some who declined because they had previous experiences with medication that they described as negative. We discovered that many of those with anti-medication attitudes had two or more failed antidepressant trials in the past. Indeed, it is worth noting that chronic insomnia is predictive of a poorer response to antidepressant medication therapy (Thase et al., 1997). We communicated to these potential participants that it was important for them to receive depression treatments too and there was a willingness to engage in depression treatment, but a resistance to the intervention if it was pharmacological. Out of this clinical need, arose an integrated treatment called Behavioral Activation and Behavioral Insomnia Therapy, or BABIT. The behavioral components of CBT for insomnia and CBT for depression were selected because the evidence for behavioral components for insomnia is superior to the cognitive components (Morin et al., 1999b, 2006). Moreover, as noted above, BA is a simple treatment to train therapists, it is very brief, and it is effective. We knew that integrating treatments could make the length of therapy longer, so our aim was to create an effective therapy that could be easily disseminated (i.e., easy to train novice therapists) but equally important was the need to keep it relatively brief. There were many possible ways to integrate the treatments including simple sequencing. The first sequence to consider was to deliver the depression treatment first, followed by the insomnia therapy second. This is based on a conventional belief that depression is the more serious of the two disorders and therefore should be treated first, and perhaps, also, is the fact that about half of those who recover from depression appreciate a recovery in their insomnia as well (Carney et al., 2007b). However, this sequence posed a problem in that the participants were presenting to our sleep programs complaining chiefly of their insomnia and were willing to forego depression treatment in order to participate in Downloaded by [New York University] at 04:37 12 August 2016 insomnia-focused treatment. The second sequencing option was to deliver the insomnia treatment first, followed by the depression treatment second. Those who presented for the insomnia and depression treatment were people who identified as having both depression and insomnia, but the chief complaint was most often insomnia. Perhaps of greater importance is that there is an empirical basis for treating insomnia first in that insomnia treatments have been shown to boost depression response (Manber et al., 2008) and even treating insomnia only can lead to depressive remission (e.g., Morawetz, 2001). However, just because clients may view their insomnia as the primary force in their depression does not mean that this will be true. Therefore a third option was to treat depression and insomnia concurrently. Treating insomnia and depression Combining Depression and Insomnia Therapies 137 concurrently is relatively simple because the best evidence for a schedule of CBT-I is four biweekly sessions (e.g., Edinger, Wohlgemuth, Radtke, Coffman, & Carney, 2007). This allows for the BA treatment to start in weeks 1 and 2 while simultaneously collecting the two weeks of baseline sleep diaries, and then to start the behavioral insomnia treatment in week 3. In such a leap frog type model, depression-focused treatment could resume while clients were testing out their insomnia strategies, and then the insomnia strategies could receive troubleshooting attention subsequently on a biweekly schedule. In combining the two therapies one could also consider the mechanisms of the two treatments and integrate them more fully to potentiate the two therapies. For example, as stated, activation helps with fatigue but it also could increase adherence to the prescribed rise time and restriction of napping strategies. A decreased time-bed in the 24 hour period allows for greater opportunities for activation. Decreased time-in-bed also reduces using the bed as an avoidance strategy. Both BA and BIT have repetitive thought strategies to decrease rumination. Thus, we sequenced the treatment based on what we viewed as key effective components of the therapies that when integrated would produce the most synergistic effect. We began with a manual modeled closely on Lejuez and Hopko’s BA treatment (Lejuez et al., 2001), however, in discussing mood and mood-related goals, we integrated discussion of sleep and sleep goals as well. We presented them as having a strong influence on one another and emphasized that strategies that targeted mood often have a pro-sleep and pro-energy effect, and pro-sleep strategies often have a positive mood or antidepressant effect. We formally inserted the insomnia components from (Edinger & Carney, 2008) at session 4, 6, 8, and 10, but often, because of the potentiating effect of the mood components (e.g., scheduling activities) two sessions were enough with check-ins on sleep at the agenda-setting portion of the sessions. We also integrated components of Martell’s (Martell et al., 2013) BA treatment because avoidance and rumination were prominent features of those who we were seeing, and we needed a structured tool for the student therapists to address these target problems. This decision was made after two focus groups with the study therapists. The first author (CEC) attended a workshop on BA with Dr. Martell and proposed the integration of an avoidance model along with the TRAP or TRAC worksheet (see later) and how to use rumination as a cue for activation during the day or stimulus control at night. At the same group of meetings, we determined that adding 2 sessions to the 12 session treatment was permissible if it was not possible to get through all of the material in 12 sessions. At the time of this writing, the session mode and median was 13 and the mean number of sessions was 12.4 (SD = 1.4). The lowest number of sessions in completers Downloaded by [New York University] at 04:37 12 August 2016 was 9 and the highest number of session was 14. To determine if an additional session is needed, we discuss this with participants at session 12 and have them generate pros and cons of adding additional sessions, and also collaborate on an agenda for how the additional sessions are to be used. Even at 13 sessions, this is a very brief therapy. BABIT sessions are conceptualized as occurring across 3 distinct modules of treatment. In Table 9.1, we provide a description of the typical therapy activities across the three modules. Although the rows match up with the number of sessions, this is meant as a guide only because therapists are encouraged to work with the clients’ goals flexibly to drive the focus of the session content. For example, if the Life Area Assessment reveals relationship goals primarily, then this will drive the focus of that 138 Combining Depression and Insomnia Therapies domain of the treatment. Some clients may receive only one CBT-I session (with a SRT and CS focus) and need only one brief check in about the sleep schedule. In such cases, sleep is quickly resolved and we focus on the other aspects of the case that require attention, for example, the case formulation may be driven by avoidance and rumina - tion. Other cases require extensive focus on scheduling activities to address sleep and fatigue. That is, for some, the focus may be decreasing time-in-bed and increasing activity, while increasing goal-directed and pleasurable activities and exposure to light during high fatigue periods during the day. Thus, the modules provide an outline of focus and typical therapy activities but therapists are trained to identify the key perpetuating factors for the case and adjust focus accordingly. In addition, the case form - ulation is shared with the client in the first module and we solicit feedback from the

Table 9.1 Description of module content in BABIT

Module BABIT session activities 1 Introduction to BT; monitor activities Behavior-mood-sleep-energy link; Anti-depressant versus Pro-depression behaviors Life area assessment; setting goals; start sleep diary monitoring 2 Refine and set goals; continue sleep diary Working on sleep-specific goals; Pro-sleep versus Pro-Insomnia behaviors; SRT and SC Prescription; Scheduling activities to help with rise time and scheduling a wind- down period before bed Goal setting; scheduling activities with a focus on how these may facilitate sleep goals (e.g., scheduling evening activities to address evening dozing); avoidance psychoeducation Introduce TRAP or TRAC Adjust TIB if needed and troubleshoot adherence to sleep and activity schedule; add other CBT-I components if needed; use TRAP or TRAC to target fatigue avoidance and add alternative pro-energy coping TRAP or TRAC; scheduling activities; psychoeducation on rumination Adjust TIB if needed; continue with TRAP or TRAC, goal setting

Downloaded by [New York University] at 04:37 12 August 2016 Use rumination as a cue for SC at night and activation during day Continue with TRAP or TRAC, goal setting, rumination strategies Adjust TIB if needed; continue with TRAP or TRAC, goal setting, rumination strategies 3 Planning for termination; continue working on goals, ensure client can calculate sleep diary variables and make time-in-bed prescription adjustments independently Assign Relapse Prevention Letter to Self; discuss what are likely to be future goals post-termination using the Life Area Assessment Termination and relapse prevention Combining Depression and Insomnia Therapies 139 client on whether it matches with their experience. Once there exists some agree ment on the maintaining factors of the case, this allows the client and therapist to collab orate on mutually agreed upon goals for treatment. The sharing of the case formulation and devising initial goals for treatment occurs in module 1—a module focused on orienting to treatment, a life area assessment, establishing a model of depression and insomnia, and beginning activity monitoring and then sleep monitoring. Once module 1 is complete, most often after 2–4 sessions, we proceed to behavior change in the second module of the treatment.

Module 1: Introduction, Setting Goals, and Uncovering Behavior-Mood- Sleep-Energy Link The premise for BABIT is that there are behaviors that perpetuate depressed mood, as well as behaviors that facilitate neutral or positive mood. We expand this idea to include the notion that there are behaviors that perpetuate insomnia and fatigue, and those that lead to quality sleep, and energy, respectively. The rationale for BABIT provided at session 1 is based on Hopko and Lejuez’s ideas about identifying perpetuating factors for depression and behaviors that are antithetical to depressed mood, as well as Spielman’s (1987) ideas about perpetuating factors in insomnia. In BABIT, these ideas are broadened to include insomnia, and fatigue. As noted above, the two BA approaches by Lejuez and colleagues (2001) and Jacobson and colleagues (2001) have different foci but the skills in each package are largely complementary. As a result, the two approaches are easily integrated into BABIT wherein values are assessed and treatment goals are derived across domains. In the same assessment, avoidance patterns and behaviors are identified that are associated with negative mood, poor sleep and low energy. Avoidance behaviors are also identified in the activity monitoring that begins in week 1, and throughout treatment, including when there are instances of non-adherence with homework. Once these targets are identified, treatment focuses on increased activation, goal pursuit and replacement of avoidance behaviors with mood-, sleep- and energy- congruent behaviors. Mood and energy targets impact sleep positively because of the greater regularity of activities, which can positively impact the biological clock and increased activity can generate greater sleep drive. Additionally, there is greater activity to combat fatigue and the negative arousal associated with negative mood; thus fatigue and rumination are attenuated. All sessions begin with a presentation of the agenda for that session and an invitation for the client to add to the agenda. All sessions also include an assessment of mood, Downloaded by [New York University] at 04:37 12 August 2016 suicidal ideation, and sleep for the week; we compare this with separate sleep and mood measures (in our clinic, this is the BDI-II and ISI) and take note of elevations on suicide items and follow-up with a risk assessment as needed. Following this, as therapy begins, but before explaining the rationale to the client, we provide a sheet with two visual analog scales (based on Lejuez et al., 2001) one for depression and one for insomnia (see Figure 9.1a and b). We explain that depression encompasses a range of symptoms that can include insomnia and fatigue and they vary day to day and from person to person. We further explain that at one point or another when these symptoms are of a particular severity and occur chronically for most of the day for a minimum of 2 weeks, we arbitrarily call this Major Depressive Disorder and 140 Combining Depression and Insomnia Therapies make a diagnosis. All clients undergo a pre-treatment Hamilton Rating Scale for Depression (Hamilton, 1960) and we use this data to encourage clients to talk about their prominent symptoms. We then ask them to place an X at the place at which best describes their current depression (i.e., today). We provide the same explanation of insomnia and insomnia symptoms, which can include depressed mood, and talk about the point at which we consider an (arbitrary) diagnosis. We ask them to make an X at the spot on the line that characterizes the severity of their insomnia currently. The placement of the X allows us to assess how distressing and/or severe their sleep and mood problems are currently. When someone places the X at the extreme right of the line, this suggests that this is the most severe depression or insomnia imaginable for the client. In cases in which this is highly discrepant from the therapist’s assessment of functioning rating, this provides helpful information for the formulation. For example, a client insomnia rating at the most severe range, when their functioning is assessed to be good and their symptoms are not particularly severe, (e.g., the average sleep efficiency is just below the morbidity cutoff of 79 percent; insomnia is not present every night), may be experiencing considerable anxiety about sleep. The second step is to ask the client to consider where they would like to be at the end of treatment. That is, we ask them to consider their treatment goals with respect to symptom severity. We do this with Figure 9.1b. On this worksheet we ask them to place an X at the place at which they would like to be post-treatment. If the response is at the extreme left pole (see Figure 9.1b) this suggests that the client has some unrealistic expectations for therapy, and serves as good information for the case formulation. We provide an explanation that it is normal and functional to feel sadness occasionally, as well as normal and functional to have occasional sleeplessness, and ask whether absolutely no sad mood and no fluctuations in sleep quality is a realistic goal. We also ask them to consider whether setting a reasonable goal is important, and ask them about what could happen if goals were set too low, too high, or if the plan to pursue the goal wasn’t adequate to meet the goal? Asking such questions sets up the rationale for the goal pursuit focus. Lastly, we ask clients to talk about some of the strategies they

X No Depression Severe depression diagnosis depression Downloaded by [New York University] at 04:37 12 August 2016

X No Insomnia Severe insomnia diagnosis insomnia

Figure 9.1a Establishing insomnia and depression as static conditions with a continuum of symptoms Combining Depression and Insomnia Therapies 141

X X No Depression Severe depression diagnosis depression

X X No Insomnia Severe insomnia diagnosis insomnia

Figure 9.1b Establishing (achievable) treatment goals

have used to “solve” their depression and sleep problems. This uncovers both strengths (some effective, adaptive strategies that can be incorporated into the treatment plan) as well as unhelpful strategies such as trying to repeatedly think about “why people don’t like me” (i.e., rumination) or “I lay in bed watching TV and wait to fall asleep, and I have a glass of wine before bed” (i.e., sleep effort). Such a discussion about goal pursuit uncovers a plethora of useful information for the case formulation. After agreeing upon realistic treatment goals we provide an introduction to behavioral therapies (including a disclosure about the importance of between-session homework and monitoring) and a basic behavioral conceptualization (i.e., behavior affects and is affected by what we think and how we feel, and changing behavior has a powerful therapeutic effect on sleep, energy, and mood). To demonstrate this principle we begin working on a worksheet completed over several sessions of module 1. We present a divided worksheet (or in our lab we use a white board) with one column labeled Pro- Depression behaviors and the other column labeled Anti-Depressant Behaviors (Table 9.2). Later, when we discuss avoidance, and introduce the TRAP or TRAC worksheet, clients easily see the connection between Pro-Depression behaviors as avoidance patterns and Anti-Depressant Behaviors as Alternative Coping strategies (see Figure 9.4). We complete a similar sheet for Pro-Fatigue versus Pro-Energy as well as Pro-Sleep versus Pro-Insomnia if these emerge as priorities in this session, but typically we start Downloaded by [New York University] at 04:37 12 August 2016 with the depression worksheet and highlight ones that may also worsen sleep or energy levels. Blank copies of each of these worksheets are provided in the Appendices. Most often, we return to sleep-specific or fatigue-specific areas when they emerge in subsequent sessions. The key, however, is to be responsive and flexible about clients’ needs and priorities. At the end of the module, the worksheets may not be complete, but there are enough entries that clients can begin to see how anti-depressant behaviors, pro-energy, and pro-sleep behaviors have many similarities; thus they can accomplish their goal of feeling better by making relatively few changes. That is, changes in one domain are likely to have a positive impact on the other two. For example, reducing the time spent inactive in a 24 hour period should increase vigor, set the clock, increase 142 Combining Depression and Insomnia Therapies

Table 9.2 Anti-depressant behaviors and pro-depression behaviors example

Pro-depression behaviors Anti-depressant behaviors Don’t go out Fresh air Hanging out with Joe Hanging out with other friends Drinking Going fishing Thinking about my problems with my Mom Go with friend to a movie Skipping meals or eating chips instead of meals Eat regular meals Staying in my pajamas Shower and get dressed

a build for deep sleep, and expose the clients to increased opportunities for positive reinforcement. Following the discussion of pro-depression and anti-depressant behaviors, the therapist can introduce the first piece of homework for the client, which is to monitor their activities across the week on The Activity Monitoring form (Figure 9.2). This homework is typically accepted but occasionally, this exercise can be met with resistance. Clients may anticipate shame, e.g., “I would be too embarrassed for you to see how little I do.” This gives an opportunity to the therapist to normalize the presence of avoidance in depression. It also helps the client to see connections between avoidance and feeling poorly, and allows both the therapist and client to devise ways to alter avoidance and obtain a new result. Below is an example of working through this issue. Please note that the client in this chapter is a fictional client named Blake who differs from the CBT-I client Kelly presented in Chapter 10 and throughout the rest of the book.

Therapist: It sounds like you are saying that you think you do very little throughout the week is that right? Client: Yes. It’s embarrassing. Therapist: You feel embarrassed? Client: Normal people DO things and its embarrassing that I don’t. Therapist: People with depression are often less active than people without depression precisely because of how poorly they feel, so, in truth, this is not unusual. I find that we can learn quite a lot about patterns by examining what you do throughout the week, and this can really help when we are looking for things that might be helpful to change. Do you suspect that being less active helps the depression or makes it feel worse? Client: I know it makes me feel worse, but I feel too badly to do anything about it. Downloaded by [New York University] at 04:37 12 August 2016 Therapist: I see. So this is a pro-depression behavior that we will probably need to target, but we would need to come up with a pretty powerful strategy to address the fact that you feel unable to increase your activity? Client: Well. . . . yeah. Therapist: OK. If I have a big obstacle to overcome, I find that I need all the information possible in order to come up with a good plan. Does that make sense? Client: Makes sense, yes. Therapist: I find that these monitoring forms uncover the information we need in order to come up with a good plan. Are you willing to do this? Client: OK. Combining Depression and Insomnia Therapies 143 Clients’ may have other negative predictions that can also create resistance. That is, they could resist out of hopelessness, such as, “What’s the point? I already know I need to do something. This won’t help.” The therapist can adopt an open stance to the possibility that monitoring may not be helpful but ask that the client test out this notion. For example, the therapist can say,

It is certainly possible that this would not be helpful. But thus far what you have already been doing does not seem to be working. Would you be willing to test out the idea at least for this week? We often find at least one thing, one pattern from activity monitoring that we can use to devise a strategy. So do you see any downside to testing it?

Progress is slowed when clients come into sessions having not done their homework. Common reasons have to do with forgetting to do the assignment or forgetting to bring the paperwork in. Some clients may simply state that they became confused and did not know what to write on the form. When assigning homework, it may help to determine ahead of time if there will be any foreseeable barriers to completing the monitoring. There are a variety of ways to troubleshoot monitoring including having the client do the monitoring on the calendar of their smart phone, setting smart phone alarms to serve as reminders to fill out the form, keeping the form in their pocket etc. It can also save valuable session time later to practice with the form in session a few times to make sure that the client is clear how to fill it out. In all sessions, after checking on how the week went (i.e., mood and sleep) the therapist should ask if there were any problems with the homework. Homework must be reinforced every session. Failing to ask about homework sends the message that homework is not important, which in turn will likely lead to less homework getting done. However it is important not to badger clients over missed homework as this can create shame and anticipatory anxiety the next time that the homework is not completed. Beginning with an invitation to learn about struggles the client may have had with the homework ensures a safe environment. Additionally, a functional behavior analysis of homework “stuckness” is incredibly useful. Often, the barrier to homework is a Pro- Depression behavior that can be or has been listed on the form and the client can be oriented towards troubleshooting by focusing on the Anti-Depressant behaviors that will “unstick” them. The homework from week 1 is the Activity Monitoring Form (see Appendix E for a blank form). If someone has not done any of the form it is important to explore what got in the way. Did they almost do it and got overwhelmed? Did they Downloaded by [New York University] at 04:37 12 August 2016 ever take the form out of their bag throughout the week? Did they complete the form and not bring it? Did they complete it but missed a day or two and perfectionism precluded them from bringing it in? After assessing the nature of the problem, you can complete a form together based on the previous day, so there is something in-session to work with. Whatever is finally produced on the activity monitoring form, the goal of going over the form is to help the client link low mood and low energy with particular activities and improved mood and alertness with other activities.

Therapist: You did a great job with this form. I can tell you put a lot of work into it. What did you get out of doing it? Rate low mood 0 (absent)–100 (severe) Daily Activity Record BABIT

Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday in bed 6–7 AM in bed in bed in bed in bed in bed in bed awake 85 in bed 7–8 AM in bed in bed in bed in bed in bed in bed awake 80 8–9 AM in bed in bed in bed in bed in bed in bed in bed 9–10 in bed in bed in bed in bed in bed in bed in bed AM 10–11 in bed in bed in bed in bed in bed internet in bed AM awake 80 awake 90 awake 95 awake 55 awake 95 80 awake 90 11–12 internet 85 bath 60 Internet 80 shower 30 internet 85 Internet 80 internet 85 AM 12–1 internet internet groceries Internet reading back to internet PM 85 85 70 25 75 bed 70 90 internet, internet breakfast pay bills back to 1–2 PM coffee 65 resting 80 read 85 85 70 55 bed 95 2–3 PM shower 65 TV 80 TV 85 TV 75 TV 90 TV 85 TV 85 reading internet Internet computer 3–4 PM in bed 80 nap shower 70 70 80 80 85 reading phone Internet 4–5 PM TV 80 lunch 65 shower 65 lunch 60 75 (bed) 85 80 reading reading visit mom 5–6 PM TV 80 Internet 80 lunch 70 cook 50 85 75 45 visit Mom 6–7 PM TV 80 TV 80 TV 80 TV 75 TV 90 dinner 55 50 reading Internet internet computer 7–8 PM in bed 80 nap dinner 65 80 85 85 75 Internet computer 8–9 PM dinner 75 TV 85 in bed 85 dinner 65 TV 75 85 80 9–10 TV 85 TV 85 TV 85 TV 80 TV 85 TV 90 TV 80 PM 10–11 Internet internet in bed in bed in bed 85 in bed in bed PM 80 85 awake 85 11–12 phone internet in bed in bed 85 in bed in bed in bed AM (bed) 85 95 12–1 in bed in bed Internet 80 in bed in bed in bed In bed Downloaded by [New York University] at 04:37 12 August 2016 AM in bed 1–2 AM in bed in bed in bed in bed in bed in bed awake 90 in bed 2–3 AM in bed in bed in bed in bed in bed in bed awake 90 3–4 AM in bed in bed in bed in bed in bed in bed in bed 4–5 AM in bed in bed in bed in bed in bed in bed in bed 5–6 AM in bed in bed in bed in bed in bed in bed in bed

Figure 9.2 Daily Activity Record Combining Depression and Insomnia Therapies 145 Client: I learned I don’t do anything. Therapist: I see a full page here. Can you clarify what you mean by saying that you didn’t do anything? Client: I didn’t do anything productive. I watched TV all day and I can’t believe how much time I spent in bed. I had no idea I stayed in bed so much. It’s depressing. Therapist: I noticed your mood is pretty low when you are lying in bed. Is that what you mean by depressing? Client: Yes. And I also meant that normal people don’t spend that much time in bed. Therapist: I see. So would you say that lying in bed is a pro-depression behavior? Certainly your mood ratings would suggest that you are right about that. Sounds like we might need to target the extra time in bed, given that your mood and energy is lowest when you do that and you see it as a depressing or pro-depression behavior? Client: Yes, but when I’m out of bed, I’m just lying on the couch, so that’s not that much better. Therapist: What do you mean by that? What are your mood ratings when lying on the couch in comparison to lying in bed? Client: They are about the same. But I wouldn’t know what else to do. Therapist: You said earlier that you did absolutely nothing productive but I wonder if that’s true. I see some instances of goal-directed behavior here, do you? Client: Taking a shower? I should have done it every day. Therapist: What do you notice about your mood when you took a shower? Client: It’s one of the highest mood ratings—still low though. Therapist: Yes, but your mood did improve. What was the activity when your mood was highest? Client: When I saw my Mom. Yes, that was nice. It was also a beautiful day so I liked the walk over there. Therapist: So you left the house, went outside, and visited someone, and your mood was the best it was all week? Client: This always works to lift my mood but I don’t always have the energy to do it. Therapist: Well we can talk about ways around this later, but it sounds as though we have found some antidepressant behaviors to add to your list? Client: Yes. Downloaded by [New York University] at 04:37 12 August 2016 In addition to the idea that activation is an antidepressant behavior, the therapist can introduce the idea that activity is a pro-energy and pro-sleep behavior. This is accomplished by helping the client calculate time in bed each day. In Figure 9.2 we see that the client got into bed on Monday at 10 PM and got out of bed at 11 AM on Tuesday morning; thus the time spent in bed was 13 hours (include all time in bed during the day and nap attempts too). This should be done for each day. At this point, the therapist can explain the homeostatic system to the client. A more formal prescription of a sleep or wake schedule can be made in module 2 after collecting sleep diary information, but there is no need to wait a full month before trying to target morning activation. Below is a sample of how this might be achieved: 146 Combining Depression and Insomnia Therapies Therapist: I wanted to discuss some pro-sleep behaviors. In a week or two we will generate a more full list of pro-sleep versus pro-insomnia behaviors, but for now I would like to focus on one very important pro-sleep behavior. To do that, I need to explain one of our body’s sleep systems called the homeostatic system. This system regulates how much deep sleep we obtain on a given night and it is based on how much time we spent awake and active in a 24 hour period. From the moment we get out of bed, we build up sleepiness and a pressure to sleep. We have to create that pressure or we may have difficulty falling asleep, staying asleep, or our sleep may feel very light. So, suppose there were two people and one went to bed at midnight and got out of bed at 8 AM and the other went to bed at midnight, got out of bed at 10:30 AM and spent 2 hours on the couch in the middle of the day. Who do you think would have a stronger drive for deep sleep; the first or second person? Client: I guess the 8 AM person but I could never be someone that gets out of bed at 8 AM—I’ve never been able to get up early. Therapist: Yes, you are not a morning person. But let me ask the same question but let’s consider someone who is a bit of a night owl, like yourself. So, if there were two owls and one went to bed at 3 AM and got out of bed at 11 AM and the other went to bed at 3 AM, got out of bed at 1 PM and spent 2 hours on the couch in the middle of the day, which one has a stronger drive for deep sleep? Client: Ok, yes, I get it. It’s the person who has been out of bed more. I am noticing I am spending a lot of time on the couch in the middle of the day. Therapist: Yes, I am seeing some time in bed or on the couch napping on Tuesday, Wednesday and Friday. Client: The thing is that I’m tired. Therapist: So the extra time on the couch and in bed each day is because you’re tired right? Client: Exactly. Therapist: What do you think causes the fatigue? Client: I don’t sleep well. Therapist: If we know that the only way to get deep restorative sleep is to be awake and active for a sufficient amount of time each day, could it be that one reason why you are so tired? That is, is it that your sleep is not deep and restorative because you are in bed so much? Client: I’m not sure. Downloaded by [New York University] at 04:37 12 August 2016 Therapist: Would you be willing to test this idea over the next two weeks? Client: I suppose so. Therapist: In addition, you had said you feel bored during the day. What effect do you think boredom has on your energy? Client: Probably not good. Therapist: After spending a few hours on the couch do you feel rejuvenated and full of energy or sluggish? Client: Sluggish and unmotivated. Therapist: Ever heard of the saying an object at rest stays at rest? Client: [Smiles]. Combining Depression and Insomnia Therapies 147 Therapist: So can we think of a way to test whether decreasing your time in bed and scheduling some specific activities may be pro-sleep and pro-energy behaviors? Client: Looks like I have to get up early . . . Therapist: Given that your body clock is naturally on the late side, I wouldn’t say early, but we probably ought to pick a standard get out of bed time that allows for enough deep sleep drive to build for subsequent nights. This will also allow us to fight some of the sluggishness caused by the lower levels of activity, including nap attempts, in the daytime. Client: As long as I don’t have to get up too early, this sounds like a good idea.

Module 2: Sleep Scheduling, Stimulus Control and Modifying Avoidance The details of a SC and SRT session are contained in Chapter 5, so we will not go into much more detail here. Sleep diaries are introduced in Module 1 so SC and SRT can begin in the second module, although elements of these treatments may already be in place in Module 1 depending on what arises. For example, it is common that a standard rise time has already been selected based on environmental constraints (e.g., the rise time on work days) as a way of increasing time out of bed and increasing activities. The agenda for the first CBT-I session is to check-in on mood, suicidal ideation, and sleep, as well as the assigned homework, and to set the agenda to discuss sleep. After presenting psychoeducation about how sleep is regulated and the three main causes of chronic insomnia (e.g., irregular or ill-timed schedule given chronotype, inadequate sleep drive due to decreased activity or increased time resting, and/or arousal problems), we introduce a worksheet that asks the client to look at their sleep diary and check off any pro-insomnia behavior they see (see Table 9.2). In our lab, we present an adapted version of Table 9.3 in which the Pro-Sleep behavior column is blank and the client works on adding behaviors to this column. The completed form seen in Table 9.3 is for the reader only (i.e., as an example of a completed form). The therapist can help uncover any pro- insomnia behavior the clients are unable to identify. Once target-worthy behaviors are identified, the client is asked to generate pro-sleep behaviors. This allows the therapist to check in on what the client remembers about pro-sleep drive behaviors discussed previously. It also allows therapists to see the extent of accurate and inaccurate information the client has about sleep. The therapist can use questioning to uncover a more complete list of pro-sleep versus pro-insomnia behaviors (see Table 9.3). From the Pro-Sleep list, clients can refine pro-sleep goals using the Goal Tracking homework form (Figure 9.3), which in most cases will include: 1) a latest possible rise Downloaded by [New York University] at 04:37 12 August 2016 time, irrespective of how they slept, 2) an earliest bed time, 3) refrain from going to bed until sleepy, 4) get out of bed when unable to sleep and do not return until sleepy, 5) no naps, 6) refrain from wakeful activities in bed, and 7) establish a 1-hour wind-down buffer zone before bed. Please see Chapter 5 for how to show clients how to derive a sleep schedule. In those taking hypnotic medication chronically, they typically add a goal of using only the lowest recommended dose (i.e., a consistent low dose and no addition of other types of sleep aides including alcohol) each night at the same time, or as directed by the physician. Remaining biweekly sessions are most often devoted to checking for adherence and troubleshooting as needed (please see Chapter 7 for more troubleshooting details) as well as possibly teaching clients to assess whether sleep 148 Combining Depression and Insomnia Therapies

Table 9.3 Completed pro-sleep versus pro-insomnia behaviors

Pro-Insomnia Behaviors Pro-Sleep Behaviors Ruminate Out of bed problem-solving and reflection Try to produce sleep Have good sleep habits and then let sleep Go to bed early to catch up on sleep unfold naturally Doze or attempt to nap Go to bed when sleepy Stay in bed while awake Stay active if you find yourself dozing Vary the time you get out of bed by Have a regular rise time daily that does not an hour or more vary more than an hour Try to sleep-in Get out of bed when you cannot sleep and do Drink alcohol not return until sleepy Stay busy, avoid getting into bed until Be in bed for about the same amount of time the morning hours as you are sleeping Take sleep aides including natural Limit alcohol and marijuana, especially in the supplements, over the counter hour or two before bed medications, teas, etc. Healthy nutrition Consume caffeinated food or beverages Regular exercise, although not vigorously Sedentary lifestyle right before bed Withdraw from activities, e.g., working Limit caffeine to a cup or two per day and out, socializing, going outside never after mid-afternoon Cancel obligations because you feel Focus on hydration rather than caffeination tired, e.g., call-in sick after a bad night Protect an hour before bed as a wind-down Read and research about the negative period effects of sleep loss Process problems or concerns earlier in the Worry about sleep evening when at your problem solving best Talk about insomnia Keep physically active and schedule active Obsess about or control sleep breaks (i.e., enjoyable activities) environment, e.g., devices to Keep room safe, unlit, and a comfortable measure sleep, blackout shades, blue temperature—a strong sleep drive will take light filters on device screens, sleep care of the rest in separate room from partner out Understand and accept your body takes care of fear they will wake you, white of sleep and compensating for sleep noise machines, eye masks, ear plugs, deprivation naturally refuse to do childcare out of concern it will disrupt sleep etc.

extension as needed. Extending time in bed prescriptions by 15 minutes per week occurs once clients show signs of sleepiness (e.g., subjective complaint of sleepiness or evidence of sleepiness in the form of mean sleep onset latency less than 10 minutes or Downloaded by [New York University] at 04:37 12 August 2016 sleep efficiency greater than 90 percent). Of course, clients need to be taught some basic calculations from the sleep diary such as sleep efficiency (Computed Total Sleep Time or Time in Bed) and total sleep time (Intended Sleep Period-Total Wake Time); for more see Table 4.1 in Chapter 4). The sleep extension conditions above are meant to be guidelines rather than a rigid set of rules, as the decision should be collaboratively and flexibly reached, and consider the pros and cons of a change in prescription. For example, in a client complaining of sleepiness but without much sleep improvement in the absence of safety concerns, the client may extend sleep to address the sleepiness but may also consider an additional 2 weeks of the schedule to try and address the remaining problem before increasing time-in-bed. Downloaded by [New York University] at 04:37 12 August 2016

Name: Blake______Session Week # 5 GOA L T R A CKING FORM

Set GOAL Record of Goal Attempts Activity Frequency Duration M T W R F Sa Su

Getting out of bed by 7 AM 7 X N/A Y Y Y Y 10:00 AM 11:30 AM 10:00 AM

Showering before noon 7X N/A Y Y Y Y 1:00 PM N N

Take daughter to the park 3X 15 min. 15 min. N 25 min. 20 min. 15 min. N N

Watch a movie 1X N/A Y N Y N N N N

Eat breakfast before 10:30 AM 7X N/A Y Y Y Y Y N N

Go for evening walk 3X 5 min. 20 min. N 20 min. 20 min. 20 min. N N

Wind-down activities 1 hour before bed 7 X N/A Y Y Y Y Y N Y

Call Mom to check-in 1X 10 min. 20 min. N N N N N N

In bed only when sleepy but no earlier 7 X N/A Y Y Y Y Y Y Y than12:30 AM

No wakeful activities in bed 7 X N/A Y Y Y Y Y N Y

Out of bed when unable to sleep 7 X N/A Y Y Y Y N N Y

No naps 7 X N/A Y Y Y Y Y Y N

Figure 9.3 Sample Goal Tracking Form 150 Combining Depression and Insomnia Therapies The Goal Tracking homework form (for an example see Figure 9.3; for a blank handout, see Appendix F) is an essential part of Module 2 and also the last module because it is used to plan post-therapy goals. The goals are written by the client at the end of each session. After the goals are generated, the therapist queries about whether the goals are realistic, behavioral, and measurable. As with sleep diaries during this module, The Goal Tracking form is assigned as homework each week and reviewed at the start of every session. The first part of the review is to reinforce (i.e., praise) the client for bringing in the form, completing the form, attempting homework, and meeting goals. The second part is to check-in on the experience for the client. In cases in which goals were not met, the client and therapist conduct an analysis of what got in the way, which includes the possibility that the goal was too difficult and needs to be adjusted. In those who exhibit low in self-efficacy, goals can be set too low and although goals are met, the expectations are so low that it does not generate any increased self-efficacy. In those who are perfectionistic, setting anything less than very high goals can be met with resistance. The bulk of Module 2 is spent on teaching clients how to set and meet goals in a way that is realistic, provides positive reinforcement, and improves their mood. The TRAP or TRAC handout (see Figure 9.4 for a completed handout) is likewise an important part of this active treatment module (adapted from Martell et al., 2013). Using the TRAP (Trigger → Response → Avoidance Pattern) component of the worksheet, clients learn about triggers for and the consequences of their avoidance patterns. In the example presented in Figure 9.4, the client is triggered by situations in which he is feeling low energy at work. In response to feeling low energy, he begins ruminating about the symptoms, causes, and consequences, and the result is avoidance in the form of leaving work and canceling other obligations. This is a frequent avoidance pattern in insomnia. When clients feel low energy, it is a frequent trigger for rumination about the daytime symptoms of insomnia (Carney et al., 2010b). The rumination typically fixates on the presumed cause of feeling low, which is most often attributed to poor sleep (Harris, Carney, & Edinger, 2009a). The other consequence of rumination is the avoidance of tasks that could increase self-efficacy and the decrease in activities that could provide a break from fatigue, increase sleep drive, and increase positive reinforcement. After clients learn how to identify TRAPs, they complete the TRAC (Trigger → Response → Alternative Coping) component. The TRAC component encourages clients to identify alternative coping responses to the same triggers to produce a different, more desirable outcome. In the example provided in Figure 9.4, the client identifies fatigue coping strategies as an alternative to leaving the task, and Downloaded by [New York University] at 04:37 12 August 2016 work, altogether. One example of a fatigue coping strategy is taking a break before returning to the task. Related fatigue strategies could include re-hydrating rather than caffeinating, or stretching and focusing the eyes away from the screen for rest rather than staying at the desk and squinting. Alternative coping strategies should be easy to derive because they are essentially also found in Anti-depressant and Pro-Sleep columns of their respective worksheets. It should be particularly noted that there are redundancies built into this treatment to acknowledge that attention and retention of information can be difficult for those with depression. Therefore, when depressed clients are unable to generate alternative coping strategies, or remember critical information about sleep, it is important for the Combining Depression and Insomnia Therapies 151 TRAP

TRIGGER RESPONSE AVOIDANCE OUTCOME PAT T E R N

Feeling tired at Ruminating Leave work Get behind at work— desk about why I feel feel anxious so tired Lie around at home feeling tired Cancel other obligations TRAC ALTERNATIVE RESPONSE OUTCOME TRIGGER COPING

Feeling tired at Ruminating Take a break with Feel efficacious at work desk about why I feel another activity Feel more energetic so tired Return to activity after break

Figure 9.4 TRAP or TRAC Worksheet

therapist to utilize repetition and frequent check-ins about what the client remembers from session to session (e.g., check-ins are done after agenda setting at the start of each session).

Module 3: Relapse Prevention and Termination Work By session 12 (for some clients this is a 12 session treatment so it will occur around session 10), clients have had multiple weeks of goal setting practice, appraising strategies to meet goals and readjusting goal setting when needed. They have also had ample practice with the TRAP or TRAC worksheets so that they have been practicing alternative antidepressant, pro-sleep, and pro-energy behaviors in response to triggers that previously triggered avoidance behaviors. Lastly, their sleep should be sufficiently improved and adjustments in time-in-bed are likely no longer necessary. For those who responded early in treatment and these skills are solidified, we may discuss whether the client would like to terminate at this point. If this is desirable for both parties, the therapist and client devise a relapse prevention letter and the client makes a list of post- treatment goals. In short, for some clients this module can be condensed into one session. Downloaded by [New York University] at 04:37 12 August 2016 More often however, clients see the benefit of additional sessions to practice their skills and build self-efficacy. In this case, the client and therapist contract for two more sessions and agree on the content and focus for the remaining sessions. In addition, an important part of this module is termination planning, which requires checking in with the client about how they are feeling about the impending end of therapy. For some, this is seen as a positive time—perhaps it is viewed as an accomplish - ment. For others, there is trepidation about whether they can continue the momentum gained during therapy after sessions stop. No matter how the client is feeling about termination, it is important to take time to check-in and make plans for the remaining sessions as well for post-treatment. 152 Combining Depression and Insomnia Therapies In planning for termination, there needs to be an appraisal of the areas in which the client wants to focus. Some clients may want to tackle a particularly challenging goal left on their list. Some clients want to loosen some of the sleep rules and want guidance on how they can proceed. Some anticipate a change or challenge to their sleep in the future (e.g., a trip to Europe, a new baby, or a change in work schedule) and want to discuss how they will adjust their current routine in the future. For others, the desire may be to continue working on goals to increase their confidence. It is important to navigate this final module collaboratively, but by this stage the client should be capable of assuming more of the leadership role. Conversely, in the first module or two, the process is collaborative, but the therapist takes on a more didactic role to teach skills. By the end, the therapist should mainly observe and fine-tune the plans and homework the clients set. It is imperative that clients have competencies in: 1) calculating their total sleep time, total time in bed and sleep efficiency from sleep diaries, 2) determining a time-in-bed schedule based on their total sleep time, 3) determining whether an increase in time-in-bed is needed (based on sleep efficiency greater than 90 percent, subjective sleepiness, and/or sleep onset latency less than 10 minutes), 4) setting or achieving realistic goals for activities, and 5) successfully completing the TRAP or TRAC worksheet. If clients do not exhibit independence on any of these tasks, there should be a focus on fostering autonomy in the remaining sessions. In other words, it should always be an explicit goal of treatment to eliminate the therapist from the equation. One relapse prevention tool used in depressive relapse prevention (e.g., Bieling & Antony, 2003) is the “letter to self.” When one considers Teasdale’s “mind in place” theory of depression, this is a particularly sensible approach (Teasdale, 1997). The “mind in place” idea is that in depression a different mindset is dominant, one that is pro-depression and largely impenetrable to disconfirming antidepressant ideas and behavioral possibilities. Throughout depression treatment, increasing activation of antidepressant areas through behavioral change leads to a different mindset, or, a different, mind in place. Because relapse may result again in a different, pro-depression mindset, the client writes a letter to the future depressive mind, acknowledging that the way they may be thinking, feeling and acting may more closely resemble themselves at pre-treatment. They write a future relapse-self a letter to remind themselves of all the behavior changes that were helpful in shifting out of this mindset. This is assigned as one of the last pieces of homework. The therapist should ask clients to include what behavioral changes were helpful for sleep and fatigue as well. We invite the client to read the letter at the last session, but we also respect that many clients want this letter Downloaded by [New York University] at 04:37 12 August 2016 to remain private. The writing of the letter is more important than reading it aloud. The client can be reminded to put the letter in a spot that they can easily access it when feeling low or having trouble sleeping. Lastly, because the letter is quite personal and may not have all the behavioral recommendations we would like the client to remember, the therapist can also prepare a letter using a template, and fill-in some more personally relevant material in the letter with the client. The letter contains all of the most common elements of treatment but leaves room to write in some idiosyncratic recommendations. Next to the common therapy elements are boxes that can be checked off if they apply to the client—this is done collaboratively. At the end of the letter, there is a reminder about red flags for a Combining Depression and Insomnia Therapies 153 mood or sleep problem returning, and a reminder to start monitoring activity and sleep to determine if all of the checked recommendations are currently implemented. This orients the client to start implementing the checked-off recommendations that were previously successful in addressing their sleep and mood problem. The pre-treatment and final assessment scores (e.g., BDI-II and ISI) are graphed for clients to see their progress in addressing their complaints. We use this as an opportunity to reflect on their therapy experience. See Figure 10.10 in Chapter 10 for Kelly, the case study in Chapter 10, for graphed ISI scores from CBT-I treatment. Although this client was not treated with BABIT the same graphic depiction is used in both treatments to display treatment progress.

Preliminary Evidence for BABIT: An Open Trial Both Behavioral Activation and Behavioral Insomnia Therapy are efficacious treatments so a randomized controlled trial confirming the efficacy is unnecessary. However, establishing that we can achieve large effect sizes (that match the effect size in the literature) across both conditions, without adding substantial length to the treatment, in novice therapists and without high dropout rates, would provide support for the utility of this combined approach. Although data collection is still ongoing for BABIT below we provide some initial data.

Participants There were 15 enrolled participants and 13 people completing the study at the time of this writing (enrollment is ongoing). This study is being conducted at Ryerson University’s Sleep and Depression Laboratory. Reasons for dropout included clinical nonresponse (at session 13) and travel (i.e., long commute to treatment sessions). Ages ranged from 18–69 years old (mean age was 48.8 years old). There were more females than males (n = 4), which is typical of MDD trials. Participants were predominantly Caucasian; there was one person who identified as West Asian and one who identified as Aboriginal Canadian. There were 8 participants taking antidepressant medications and 10 reporting taking sleeping medication; none met criteria for hypnotic dependence on the DSISD.

Procedures Downloaded by [New York University] at 04:37 12 August 2016 The study enrolled those complaining of both MDD and comorbid insomnia. Participants included both clinic-referred clients and individuals solicited from other ongoing research studies or via media advertisements. Women and men were considered for inclusion if they: (1) were aged 18–74 years old; (2) had an insomnia complaint of at least one month duration that met the Research Diagnostic Criteria (Edinger et al., 2004a) for an Insomnia Disorder; (3) showed a mean sleep efficiency (SE = [Total Sleep Time ÷ Time in Bed] ϫ 100 percent) < 85 percent during one screening week of sleep diaries with the Consensus Sleep Diary; and (4) met criteria for a Major Depressive Episode (without psychotic features) as verified by the mood module of the SCID; and (5) evidenced at least moderate depression symptom severity by having a 154 Combining Depression and Insomnia Therapies score of > 15 on the 17-item HAM-D administered at a screening appointment. We selected the HAM-D cut-off because it denotes full depressive symptomatology according to consensus definitions in the field (Frank et al., 1991), approximates the moderate level of depression seen at specialty sleep clinics or primary care settings (Gaynes et al., 2005), and allowed for sufficient severity to detect symptom change. We enrolled only those who were able to understand and complete study procedures, benefit from the treatments offered, undergo study procedures without undue discomfort or safety risks, and had no competing primary sleep, psychiatric, or medical disorders, or ongoing treatments that would limit or confound their treatment responses. Thus, excluded from the trial were those who: (1) need immediate psychiatric (e.g., imminently suicidal clients) or medical care (e.g., clients with acute cardiac symptoms), or with an attempted suicide in the past 6 months; (2) had a sleep-disruptive comorbid medical condition (e.g., moderate to severe rheumatoid arthritis; (3) score < 27 on the Mini-Mental Status Exam (MMSE) (Folstein, Folstein, & McHugh, 1975); (4) met criteria for Bipolar Disorder, Schizophrenia or any other psychotic disorders on the basis of a SCID interview; (5) met criteria for Antisocial Personality Disorder or Borderline Personality Disorder on the basis of a SCID II interview schedule; (6) reported frequent travel across time zones or work rotating or night shifts; (7) met criteria for sleep apnea, restless legs syndrome, or Circadian Rhythm Sleep Disorder on the basis of the Duke Structured Interview of Sleep Disorders; and (8) had a history of alcohol, narcotic, benzodiazepine, or other substance abuse or dependence in the 6 months prior to screening. Participants were permitted to use sleeping medications if they were taking them, as long as they were not hypnotic dependent and as long as they were agreeable to taking the medications noncontingently during the trial. Participants were screened using the MMSE, SCID, and DSISD to rule-out cognitive impairment, to confirm the presence of RDC for an Insomnia disorder (DSISD) and DSM-IV-TR criteria for MDD on the SCID respectively. The SCID was also used to exclude those with suspected Bipolar disorder diagnoses, Psychotic disorders, and substance-related disorders. The DSISD was used to rule-out those with hypersomno - lence, suspected sleep apnea, or circadian rhythm disorders. Upon initial acceptance they monitored their sleep prospectively for one week to determine if they met sleep diary criteria (e.g., mean sleep efficiency less than 85 percent). If participants continued to meet entry criteria, they completed a battery of pre-treatment measures that included the Beck Depression Inventory, Second Edition (BDI-II) (Beck et al., 1996) and the ISI (Morin, 1993). The other measures are not reported here as they will be part of the pub - lished effectiveness paper. After completing the battery of questionnaires, participants Downloaded by [New York University] at 04:37 12 August 2016 monitored their sleep prospectively for two weeks. The same battery and sleep diary monitoring procedures were repeated after the last treatment session and at one month post-treatment.

Results Figure 9.5 depicts the mean pre-post changes on the BDI-II and ISI. On t-tests, both sleep and depression significantly decreased from pre-treatment (t(12) = 7.38, p < .001 and t(12) = 4.38, p = .001, respectively). This was true even for the BDI-II with sleep item 16 removed (t(12) = 5.74, p < .001). Using Cohen’s d (Cohen, 1992), the effect Combining Depression and Insomnia Therapies 155

35 31.4 30 d = .83 d = 2.2 25 22.6 20

15 13.6 10.6 10

0 Beck Depression Inventory II Insomnia Severity Index

Pre-treatment Post-treatment

Figure 9.5 BABIT Depression and insomnia symptom outcomes N.B. The dashed lines denote the clinical cutoff for each measure.

sizes for insomnia (d = 2.2) and depression (d = .83) were large. The mean scores at post-treatment for BDI-II and ISI were below the clinical cut-offs for the measure.

Conclusions Thus, in this initial open trial of BABIT, BA, and BT for insomnia were feasibly and easily integrated without adding substantively to the length of treatment. This treatment was highly effective, even though the treatment was delivered by novice graduate student therapists. There were both statistically and clinically significant improvements for sleep and depression. Moreover the magnitude of the improvement was large—this mirrors the literature on these therapies when delivered alone. Although in particular settings, particularly sleep settings, CBT-I may be used on its own with positive effects for mood in addition to sleep, CBT-I is not a depression-specific therapy and we have no data to tell us whether the mood improvements are sustained. Thus a combined approach is a reasonable approach to address both sleep and mood, and both CBT-I and BA show long-term benefits (Dobson et al., 2008; Edinger et al., 2001). BABIT is only one possible version of combined therapy and it is unknown as to whether Downloaded by [New York University] at 04:37 12 August 2016 combining the cognitive elements of treatments for depression and insomnia would enhance outcomes. Nonetheless, BABIT is a simple treatment that was easy to train and supervise and thus should be considered at graduate student training clinics where the issue of comorbid insomnia and depression would be highly prevalent. It is perhaps not surprising that combining approaches is so effective. It is, however, exciting that a combined therapy is simple and quick to deliver. This trial originated out of necessity to address the needs of those who were unable or unwilling to take medication, and thus, ineligible for our NIH trial. Reviewers for the NIH trial also asked us to raise the age of entry for the trial out of fear of giving antidepressant medications to those under the age of 21 years. Thus, there are multiple advantages for BABIT. There 156 Combining Depression and Insomnia Therapies is no reason to think that CBT approaches for insomnia and depression could not be similarly combined, although CBT approaches tend to be longer in duration than BA and BT for insomnia, so treatment duration may increase. Nonetheless, given the importance of insomnia in depression and the ease at which it can be treated, BABIT holds much promise for access to brief, efficacious, easily disseminated treatment.

Summary

• Combined evidence-based approaches for depression and insomnia are the best choice for MDD-I clients. • Combining behavioral activation and behavioral insomnia therapy is easily achieved in a brief integrated treatment package delivered by therapy novices—the effect sizes associated with BABIT are large and comparable to those reported with the monotherapies. • BABIT has three modules: 1) an orienting or assessment-focused phase from which a case formulation is formed, 2) an active module that involves: scheduling activities including the sleep schedule using goal tracking forms; using rumination as a cue for activation during the day and stimulus control at night, identifying alternative coping strategies to avoidance patterns, and 3) relapse prevention and termination planning. Downloaded by [New York University] at 04:37 12 August 2016 10 Case Study Kelly

Throughout the book we have provided sample dialogues between therapist and client based on a fictional client named Kelly. Although fictional, Kelly is an amalgam of numerous examples of cases that are in many respects quite typical of clients with MDD- I. In this chapter, we present session by session information about Kelly to provide an example of what the treatment looks like in practice.

Assessment Session Kelly is a 60 year old female with current MDD and a presenting complaint of sleep maintenance insomnia and fatigue. She arrived at the clinic early with all of her requested materials including her completed sleep monitoring forms. She is self-referred and lists her reason for coming to the clinic, as “I can’t sleep.” Kelly was interviewed today with a clinical interview and the Duke Structured Interview for Sleep Disorders. Prior to the interview, she completed an Epworth Sleepiness Scale, medical history checklist, Fatigue Severity Scale, Dysfunctional Beliefs and Attitudes about Sleep Scale, the Daytime Insomnia Symptom Response Scale, Beck Depression Inventory, Second Edition, Penn State Worry Questionnaire, State-Trait Anxiety Inventory, and the ISI. Kelly also reports that she is in menopause. She is a full-time school teacher. She is divorced with a 21 year old daughter named Barb. Although she complained of lifelong sleeping difficulties, further query about sleep during childhood revealed that as a child and adolescent she actually slept reasonably well and that the complaint of insomnia appeared to originate in her early twenties, around the time of a major depressive episode and a highly stressful life event. She started medical school in her twenties and then switched programs to attend teachers’ college. She reports three MDD episodes Downloaded by [New York University] at 04:37 12 August 2016 (including this current episode): the first of which was in her twenties when she was struggling to make the decision about whether or not to switch programs. This episode lasted three years and resolved without treatment. The second major depressive episode began coincident with a separation and eventual divorce from her partner at age 42; this episode resolved a year later after several months of taking a prescribed tricyclic antidepressant. However, she appeared to remain somewhat dysthymic post-recovery until her most recent, and ongoing episode, which started 6 years ago (age 54). She takes 20 mg of citalopram each morning and reports she finds it helpful, although she still suffers from pervasive depressed mood, fatigue, insomnia, self-critical thoughts, increased appetite, concentration problems, and anxiety. She reports having had suicidal 158 Case Study ideation in the past but denies any current ideation, and denies any past or current intent or plan for self-harm. She was prescribed trazodone for sleep (50 mg at bedtime) but because she does not like the way she feels the next day, she takes it intermittently. She acknowledges a tendency towards all or none, perfectionistic thinking and engages in harsh self-talk when she views herself as “screwing up.” She reports a problem with rumination, although she views rumination as problem-solving, i.e., it gives her a chance to figure things out. Kelly reports having sleep onset problems, although her main complaint was that she cannot stay asleep throughout the night, and the sleep produced is experienced as “light.” She has occasional hot flashes (about three to six times per month). She is currently on hormone replacement therapy which she reports as helpful in decreasing the frequency of hot flashes. When asked what she does during hot flashes, she reports fanning herself in bed and drinking water. She reports that it takes “hours” to get back to sleep after a hot flash. She attempts to nap at her desk at work or on the couch on weekends but is unable to fall asleep. However, she reports that she occasionally dozes unintentionally while watching television in the evening. Despite feeling very tired in the evening when she goes to bed, she feels instantaneously alert and has difficulty falling asleep. If she is unable to fall asleep within an hour she takes a trazodone. She stated that one of her goals is getting off the trazodone because it makes her groggy the next day. She uses blackout shades and a white noise machine to control the light and noise in her bedroom. She describes her time awake in the beginning of the night as unbearable and says that she cannot “shut off” her brain. Her score on the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS16 = 5.1) suggests a high degree of unhelpful beliefs about sleep. Kelly’s Epworth Sleepiness Scale score was a 3 which is not suggestive of clinically relevant daytime sleepiness. During the Duke Structured Interview for Sleep Disorders she met criteria for an Insomnia Disorder. Despite the reported dozing in the evening particularly in front of the television, she did not meet criteria for hypersomnolence. She denied any symptoms suggestive of circadian rhythm disorders, restless leg syndrome, periodic limb movement disorder, sleep disordered breathing or narcolepsy; she denied any unusual behaviors during sleep (e.g., parasomnias). Her medical forms indicate a history of gall bladder problems starting in her 40s and low back pain (two herniated disks) for the past 12 years for which she takes non-steroidal anti- inflammatory medication (NSAIDs). Her Fatigue Severity Scale score was clinically elevated (FSS = 5) and suggested a high degree of fatigue symptoms severity. Her score on the Daytime Insomnia Symptom Response Scale (DISRS = 59) is suggestive of a Downloaded by [New York University] at 04:37 12 August 2016 pervasive tendency to respond to feeling tired with repetitive, ruminative thought about her symptoms. Her score on the Penn State Worry Questionnaire was below the clinical cutoff for the measure, as was her trait score on the State-Trait Anxiety Inventory. Her responses on the ISI were suggestive of severe insomnia symptoms (ISI = 28). Kelly was mailed the core version of the Sleep Diary; an expanded one is typically preferred in complicated cases, especially for cases in which it is important to track medication, alcohol and/or caffeine use (see Figures 10.4, 10.6, and 10.8 for an expanded sleep diary). For sleep diary summaries, we used the most recent week for ease of presentation, it is advisable to enter the two weeks and use the mean of both weeks during the assessment session (see Figures 10.5, 10.7, and 10.9 for examples of calculated Case Study 159 diaries). Kelly attempted to monitor her sleep on the sleep diary, but she reported some difficulty in completing all of the entries and returned diaries with missing data (see Figure 10.1). She expressed concern about whether she was estimating correctly. Follow- up inquiry revealed some degree of perfectionism in approaching the task, she was however fairly easily redirected to providing a “guesstimate” and she reported that she did not anticipate a problem completing diaries in the future. The partially completed diaries provided some corroboration of her sleep onset and maintenance difficulties. The diaries suggested that she lingers in bed in the morning after the final awakening and there was some (e.g., over 2 hours) variability in her rise time. She took trazodone on two nights and Advil PM on one night as sleep aides during the monitored week. She reported that she took them because she “couldn’t take another night without sleep.” When queried about whether she did not sleep on the previous nights, she acknowledged that she slept, albeit poorly. There was no evidence of Sleep State Misperception. Kelly reports that she feels wide awake and then frustrated when getting into bed. She also reports worrying and occasionally experiencing hot flashes in bed. During interview, there were instances suggestive of sleep effort-related beliefs. She stated that she tries to get “every scrap of sleep” possible, thus lingering in the morning and attempting to nap. She acknowledged that because she feels so tired during the day, she has decreased her activities. Specifically, she no longer works out, she only occasionally socializes or engages in leisure activities. She currently has two cups of coffee (one in the morning and one after lunch) and will drink an energy drink or two in the afternoon if she is very tired. She denied use of any energy drinks during the last week. Formulation or Proposed Treatment Plan: Four biweekly sessions focused on the following:

1. Light, fragmented sleep is likely due to diffused sleep drive. The inadequate sleep drive may be due to dozing, delaying build-up of sleep drive by lingering in the morning, nap attempts, and decreased activity. Although occasional low back pain and NSAIDs may contribute, the LBP is episodic (and not currently active) so this is not a major factor at this time. Plan: Sleep restriction and scheduling activities. It is also possible that the antidepressant medication may be fragmenting sleep— plan: proceed with CBT-I first and assess response. 2. Conditioned arousal due to staying in bed while awake, frustrated, worrying, ruminating, and in the midst of a hot flash. Plan: Stimulus Control during wakefulness. Downloaded by [New York University] at 04:37 12 August 2016 3. Daytime fatigue may be due to irregular circadian input and excessive resting. There was over 2 hours of variability between the earliest and latest rise time on the sleep diary which may be producing jetlag symptoms. Plan: Psychoeducation about jetlag and the circadian system, and Stimulus Control (i.e., set standard rise time 7 days per week). Encourage client to increase activities. A scheduled evening activity may also help with the current problem of evening dozing. 4. Eliminate contingent use of trazodone or other aides such as Advil PM. 5. Belief that one cannot cope with sleep loss: challenge via behavioral experiments and eliminate sleep effort behaviors (e.g., contingent use of caffeine and sleep medications). Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-Core (Please Complete Upon Awakening) NAME: Kelly Sample

Today’s Date 4/5/08 1/8/14 1/9/14 1/10/14 1/11/14 1/12/14 1/13/14 1/14/14 1. What time did you get into bed? 10:15 11:15 10:45 10:45 11 PM 11 PM 10:45 11 PM PM PM PM PM PM 2. What time did you try to go to sleep? 11:30 11:15 10:45 10:45 11 PM 11 PM 10:45 11 PM PM PM PM PM PM 3. How long did it take you to fall asleep? 55 min. 30–45 ?. ? 45–60 ? ? ? min. min. 4. How many times did you wake up, not counting your ﬁnal 6 times 3 2 2–3 1 3 2 1 awakening? 5. In total, how long did these awakenings last? 2 hours 80 min. 15 min. ? 30 min. 90 min. 45 min. ? 5 min. 6. What time was your ﬁnal awakening? 6:35 AM 6:30 AM 6:30 AM 6:30 AM 6:30 AM 6:30 AM 8:10 AM 7:45 AM

7. What time did you get out of bed for the day? 7:20 AM 7:10 AM ? 7:10 AM 7:15 AM 6:30 AM 8:30 AM 8:45 PM

8. How would you rate the quality of your sleep? Very ✓ Very ✓ Very ✓ Very ✓ Very ✓ Very Very ✓ Very poor poor poor poor poor poor poor poor ✓ Poor Poor Poor Poor Poor Poor ✓ Poor Poor Fair Fair Fair Fair Fair Fair Fair Fair Good Good Good Good Good Good Good Good Very Very Very Very Very Very ✓ Very Very good good good good good good good good 9. Comments (if applicable) I have a trazodone Advil PM trazodone cold 50mg 50mg

Figure 10.1 Case Study 161 6. Rumination: Challenge belief that it is advantageous or productive with behavioral experiment. Use counter arousal strategies to manage rumination. Consider mindfulness as a strategy for repetitive thought. 7. Perfectionistic beliefs: Challenge via Socratic questioning and thought records.

Assessment Session Homework: Continue monitoring with sleep diaries. Return to clinic next week to begin CBT-I.

Session 1 Plan • Reinforce sleep diary completion and troubleshoot any issues. • Make calculations of sleep efficiency. • Introduce Stimulus Control, Sleep Restriction, and the Buffer Zone. • Establish non-contingent medication use.

Session 1 Notes ISI was completed; score was suggestive of severe insomnia (ISI = 29). Suicidal ideation check revealed no current ideation. Her BDI score was suggestive of moderately severe depression (BDI-II = 26). She correctly and consistently completed the sleep diaries; the following mean sleep indices (see Figure 10.2) are calculated from the sleep diaries: mean sleep onset latency was about 50 minutes, wakefulness after sleep onset (WASO) was an hour and forty minutes, total sleep time was about 5.6 hours and sleep efficiency was 61 percent. There were 3 hours of variability in the earliest and latest rise times during the recording period. She reported that these values were fairly representative of her sleep generally. Based on information during the assessment of dozing in the evening, followed by sleep onset problems when relocating to the bedroom, the therapist used this information to explain the concept of conditioned arousal and the rationale for Stimulus Control. In delivering this information, the therapist learned the client has concerns that getting out of bed will limit her sleep opportunity.

Therapist: I want to make sure I understand. You have concerns that if you get out of bed when you are unable to sleep, you won’t get “enough” sleep? Client: That’s right. If I stay in bed, at least there is a chance that I could sleep. Therapist: I suppose it is possible that you could fall asleep quickly but if your report Downloaded by [New York University] at 04:37 12 August 2016 and the diaries are true, it would appear that once you wake up, it takes you considerable time to fall back to sleep. In other words, when you wake up, you are not ready to return to sleep right away, so it doesn’t seem like this strategy gets you what you want. Client: What’s the alternative? Therapist: You said you were worried that it could take you longer to fall asleep if you got out of bed, let’s say that you are right, what is the advantage of staying up longer with respect to your sleep the next night? Client: It’s hard to think of it like an advantage, but I guess you would build-up more sleep drive? Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-Core (Please Complete Upon Awakening) NAME: Kelly Sample

Today’s Date 4/5/08 1/15/14 1/16/14 1/17/14 1/18/14 1/19/14 1/20/14 1/21/14 1. What time did you get into bed? 10:15 11:15 10:30 9:15 PM 11 PM 11:20 10:45 10:45 PM PM PM PM PM PM 2. What time did you try to go to sleep? 11:30 11:15 10:30 9:15 PM 11 PM 11:20 10:45 10:45 PM PM PM PM PM PM 3. How long did it take you to fall asleep? 55 min. 40 min. 40 min. 80 min. 40 min. 50 min. 40 min 60 min.

4. How many times did you wake up, not counting your ﬁnal 6 times 1 1 2 1 2 3 3 awakening? 5. In total, how long did these awakenings last? 2 hours 80 min. 60 min. 100 min. 90 min. 180 min. 90 min. 120 min. 5 min. 6. What time was your ﬁnal awakening? 6:35 AM 6:30 AM 6:30 AM 6:30 AM 6:30 AM 6:30 AM 8:10 AM 7:55 AM

7. What time did you get out of bed for the day? 7:20 AM 7:10 AM 7:40 AM 7:10 AM 7:30 AM 7:30 AM 9:00 AM 9:45 AM

8. How would you rate the quality of your sleep? Very ✓ Very ✓ Very ✓ Very ✓ Very ✓ Very Very ✓ Very poor poor poor poor poor poor poor poor ✓ Poor Poor Poor Poor Poor Poor ✓ Poor Poor Fair Fair Fair Fair Fair Fair Fair Fair Good Good Good Good Good Good Good Good Very Very Very Very Very Very Very Very good good good good good good good good 9. Comments (if applicable) I have a trazodone Hot ﬂash trazodone cold 50mg 50mg

Figure 10.2 Case Study 163 Therapist: And what is the advantage with respect to conditioned arousal? In other words, if you are wide awake when you get into bed and wide awake when you wake up in bed, how would getting out of bed help with getting rid of that association? Client: It’s supposed to get rid of it but this sounds horrible. Therapist: Do you play chess? Client: A little. Therapist: I wonder if giving up a night or two to get rid of the conditioned arousal, especially knowing that you would be rewarded with deeper sleep subsequently is sort of like giving up a pawn to clear the path to take your opponent’s king? Client: I see what you mean. Therapist: Staying in bed won’t win the game because we see that it is associated with insomnia for you. It is kind of difficult to give up “trying” to sleep if you stay in bed. Client: I would be willing to give up my pawn I guess [smiles] but I am a little skeptical. Therapist: Fair enough. Can we re-evaluate whether it was worth it after two weeks? Client: OK.

Given the TST of 5.6 hours, the time-in-bed prescription was set at 6 hours. The client selected 6:30 AM as the standard rise time, which means that the bedtime was 12:30 AM. However, the therapist pointed out that there were no times at which the client stayed up until 12:30 AM currently and in fact, the client reported dozing in the evening. The therapist suggested to move the bedtime earlier to 11:30 PM and set the rise time at 5:30 AM, to correspond to the client’s early circadian tendency. The therapist reviewed the rationale and rule of beginning wind-down activities (i.e., the Buffer zone) an hour before the prescribed bedtime. The therapist requested that the client either keep the medication dose and timing every night throughout treatment or discontinue it altogether. The client expressed ambivalence about taking the medication but ultimately decided to keep it steady throughout the treatment and to discuss this plan with her family doctor at her scheduled appointment this week. The therapist provided a summary of treatment recommendations (see Figure 10.3). The therapist discussed the caffeine recommendation and they agreed that the client Downloaded by [New York University] at 04:37 12 August 2016 would limit use to two cups per day (with the last cup around 1 PM).

Assigned Homework Session 1 • Complete two weeks of diaries. • Follow the prescription on client summary (schedule is 10:30 PM–5:30 AM) and institute Stimulus Control. • Take trazodone at same time each night. • Limit caffeine to two cups of coffee. • Return to clinic in two weeks. 164 Case Study

My plan for better sleep Over the next two weeks, I will do the following: 1. I will use a standard get-up-out-of-bed time, seven days per week, regardless of the sleep I obtain on any particular night. My latest time out of bed is: 5:30 AM . To accomplish this I will set an alarm for every morning at this time. 2. I will go to bed only when I am sleepy, but never before my earliest possible bedtime. My earliest bedtime is 11:30 PM . 3. I will get up out of bed when I can’t sleep. I will give up the effort to sleep, and go to another room until I feel sleepy enough to fall asleep quickly before returning to bed. 4. If I still cannot fall asleep when I return to bed, repeat step 3. 5. I will avoid doing wakeful things while in bed. In other words, I will use the bed for sleeping only. If sexual activity is not alerting, this can be an exception to the rule. 6. If I find myself worrying, problem-solving, ruminating, planning in bed, or engaging in sleep effort, I will get up and stay out of bed until this thinking dissipates and I feel sleepy enough to return to bed. This includes if I wake up because of a hot flash. 7. I will avoid daytime napping or spending time lying down throughout the day except in the case of safety. 8. I will fill out my sleep diary each morning, preferably within an hour of rising, so that I can track the impact of this plan on my sleep. Other helpful hints: I will limit caffeine to one drink as far away from bedtime as possible, and attempt to refrain from alcohol and smoking, including marijuana. I will ensure my bedroom is quiet, dark, and cool. I will attempt to exercise, although not right before bed.

Figure 10.3 Treatment plan summary example: Kelly

Session 2 Plan

• Review diaries, complement completion and/or troubleshoot incomplete sleep diaries. Downloaded by [New York University] at 04:37 12 August 2016 • Check-in on homework and troubleshoot any adherence issues. • Assess for whether sleep extension is warranted (i.e., check for an elevated sleep efficiency on the sleep diary or ask about subjective sleepiness). • Time permitting, add some activity scheduling to help with fatigue, combat dozing, and challenge the idea that life stops when experiencing fatigue.

Session 2 Notes ISI was completed; score was suggestive of moderately severe insomnia (ISI = 21). Suicidal ideation check revealed no current ideation. Her BDI score was suggestive of Case Study 165 moderate level of depression (BDI-II = 21). She correctly and consistently completed the sleep diaries; the following mean sleep indices are calculated from the sleep diaries: mean sleep onset latency was reduced from session 1 (M = 20 minutes) and within normal limits, WASO was reduced from session 1 (M = 25 minutes) and now within normal limits, total sleep time was about the same 6.2 hours and sleep efficiency was improved from 74 percent to 80 percent. She reported that the diaries were representative of her sleep generally. The session began with a complement about her completion of the diaries, a mood and sleep check and an invitation to talk about her experience in following the new sleep rules. The client reported some difficulty following the recommendation to get out of bed by 5:30 AM. Figure 10.4 depicts a summary of the sleep diary data from the most recent week. Again, we typically use 2 weeks’ worth of data but for ease of presentation, we are using the most recent week. The mean rise time was 6 hours and 57 minutes which is almost an hour and a half later than the prescribed rise time. The average final awakening was over 30 minutes later than the prescribed wake-up time (6:05 AM) and further query with the client confirmed that she stopped setting the alarm clock about 4 days after the previous session. The client cited a few reasons for this difficulty which included not wanting to feel cold when getting out of bed. The client agreed to take the blanket to a transition spot to stay warm and also to keep socks by her bed to put on before getting out of bed. The therapist used an analogy of willingness to sacrifice a pawn and experiencing less time in bed to experience better quality sleep. The client agreed to test it out by setting an alarm every morning. This discussion also uncovered some anxiety about sleep loss. Anxiety about the consequences of sleep loss was cited as a reason for non-adherence to the caffeine recommendations, i.e., evidence of increased use of energy drinks in the late afternoon. Upon further exploration, the client revealed a high degree of anxiety and aversion to the experience of fatigue. The therapist explored whether openness to the experience of fatigue would be a helpful new stance (see Chapter 9 for the exchange). The client acknowledged that contingent caffeine use was an unhelpful avoidance strategy and she agreed to eliminate the energy drinks. The client reported following stimulus control recommendations to get out of bed in the middle of the night, including when the awakening was caused by a hot flash. There was one hot flash in the past week and the client reported that she got out of bed and read until she was sleepy again. Of note is that her WASO improved from almost an hour to within normal limits (WASO M = 25 minutes). Downloaded by [New York University] at 04:37 12 August 2016 The client reported some difficulty following the recommendation to go to bed no earlier than 11:30 PM. The average bedtime was 30 minutes earlier than the prescribed 11:30 PM bedtime (see Figure 10.5). The client also reported some dozing in the evening. To address this issue, the therapist discussed the sleepiness or fatigue distinction and they discussed activities that would decrease the likelihood of dozing in the evening. In a discussion of fatigue, it was revealed that the client felt bored and was somewhat inactive. A life compass exercise revealed that fatigue and insomnia prevented her from living a life consistent with her values. Moreover she often felt isolated because of her lack of activities outside the home. The client agreed to schedule at least 2 activities and to monitor her activity level on a monitoring form. Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly

Today’s Date 11/22/14 11/23/14 11/24/14 11/25/14 11/26/14 11/27/14 11/28/14 1. What time did you get into bed? 11:30 11:30 10:45 11:20 10:30 11 PM 11:10 PM PM PM PM PM PM 2. What time did you try to go to sleep? 11:30 11:30 10:45 11:20 10:30 11 PM 11:10 PM PM PM PM PM PM 3. How long did it take you to fall asleep? 30 min. 20 min. 40 min. 5 min. 40 min. 30 min. 20 min. 4. How many times did you wake up, not counting your final awakening? 1 1 2 1 2 1 1 5. In total, how long did these awakenings last? 60 min. 10 min. 40 min. 10 min. 40 min. 25 min. 10 min. 6a. What time was your final awakening? 5:30 AM 5:30 AM 5:30 AM 5:30 AM 6:15 AM 6:20 AM 6:40 AM 6b. After your final awakening, how long did you spend in bed trying to sleep? 0 15 min. 30 min. 45 min. 30 min. 1 hour 2 hours 6c. Did you wake up earlier than you planned? No No No No No No No 6d. If yes, how much earlier? N/A N/A N/A N/A N/A N/A N/A 7. What time did you get out of bed for the day? 5:30 AM 5:45 AM 6 AM 6:20 AM 6:45 AM 7:50 AM 9 AM 8. How would you rate the quality of your sleep? ✓ Very ✓ Very ✓ Very ✓ Very ✓ Very Very ✓ Very poor poor poor poor poor poor poor ✓ Poor Poor Poor Poor Poor Poor Poor Fair Fair Fair Fair Fair Fair Fair Good Good Good Good Good Good Good Very Very Very Very Very Very Very good good good good good good good

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly

Today’s Date 11/22/14 11/23/14 11/24/14 11/25/14 11/26/14 11/27/14 11/28/14 9a. How many times did you nap or doze? 0 0 1 1 1 0 1 9b. In total, how long did you nap or doze? 0 0 15 min. 25 min. 20 min. 0 20 min. 10a. How many drinks containing alcohol did you have? 0 0 0 0 0 0 1 10b. What time was your last drink? N/A N/A N/A N/A N/A N/A 9:30 PM 11a. How many caffeinated drinks (coffee, tea, soda, 2 2 2 3 2 3 3 energy drinks) did you have? 11b. What time was your last drink? 1 PM 12:45 PM 1:15 PM 4:10 PM 1 PM 4 PM 4:45 PM 12. Did you take any over-the-counter or prescription Trazodone Trazodone Trazodone Trazodone Trazodone Trazodone Trazodone medication(s) to help you sleep? 50 mg 50 mg 50 mg 50 mg 50 mg 50 mg 50 mg If so, list medication(s), dose, and time taken 10:30 PM 11 PM 9:45 PM 11 PM 9:30 PM 10 PM 10 PM 13. Comments (if applicable)

Figure 10.4 Continued Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly

Today’s Date 11/29/14 11/30/14 12/1/14 12/2/14 12/3/14 12/4/14 12/5/14 1. What time did you get into bed? 11:30 11:30 10:45 11:20 10:30 11 PM 11:10 PM PM PM PM PM PM 2. What time did you try to go to sleep? 11:30 11:30 10:45 11:20 10:30 11 PM 11:10 PM PM PM PM PM PM 3. How long did it take you to fall asleep? 5 min. 20 min. 30 min. 5 min. 40 min. 25 min. 20 min. 4. How many times did you wake up, not counting your final awakening? 1 1 1 1 1 1 1 5. In total, how long did these awakenings last? 10 min. 20 min. 30 min. 10 min. 45 min. 20 min. 40 min. 6a. What time was your final awakening? 5:45 AM 5:50 AM 5:50 AM 5:35 AM 6:15 AM 6:40 AM 6:40 AM 6b. After your final awakening, how long did you spend in bed trying to sleep? 10 min. 15 min. 10 min. 45 min. 30 min. 2 hour 2 hours 6c. Did you wake up earlier than you planned? No No No No No No No 6d. If yes, how much earlier? N/A N/A N/A N/A N/A N/A N/A 7. What time did you get out of bed for the day? 6 AM 6:15 AM 6 AM 6:20 AM 6:45 AM 8:50 AM 8:30 AM 8. How would you rate the quality of your sleep? Very Very Very Very Very Very Very poor poor poor poor poor poor poor ✓ Poor ✓ Poor ✓ Poor ✓ Poor ✓ Poor ✓ Poor ✓ Poor Fair Fair Fair Fair Fair Fair Fair Good Good Good Good Good Good Good Very Very Very Very Very Very Very good good good good good good good

Figure 10.4 Continued Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly

Today’s Date 11/29/14 11/30/14 12/1/14 12/2/14 12/3/14 12/4/14 12/5/14 9a. How many times did you nap or doze? 0 0 1 1 1 1 1 9b. In total, how long did you nap or doze? 0 0 10 min. 15 min. 10 min. 10 min. 15 min. 10a. How many drinks containing alcohol did you have? 0 0 0 0 0 1 0 10b. What time was your last drink? N/A N/A N/A N/A N/A 9 PM N/A 11a. How many caffeinated drinks (coffee, tea, soda, 2 2 2 3 2 4 3 energy drinks) did you have? 11b. What time was your last drink? 1 PM 1 PM 1:15 PM 4 PM 1 PM 6 PM 4:35 PM 12. Did you take any over-the-counter or prescription Trazodone Trazodone Trazodone Trazodone Trazodone Trazodone Trazodone medication(s) to help you sleep? 50 mg 50 mg 50 mg 50 mg 50 mg 50 mg 50 mg If so, list medication(s), dose, and time taken 10:30 PM 11 PM 9:45 PM 11 PM 9:30 PM 10 PM 10 PM 13. Comments (if applicable) Hot ﬂash

Figure 10.4 Continued Downloaded by [New York University] at 04:37 12 August 2016

11/29/14–12/5/14 sample day 1 day 2 day 3 day 4 day 5 day 6 day 7 AVERAGE Dates 1/1/2011 Bedtime (Time went into bed) 23:30 23:30 23:30 22:45 23:20 22:30 23:00 23:10 23:06 Bedtime Lights out (Try to go to sleep) 23:45 23:30 23:30 22:45 23:20 22:45 23:00 23:10 23:08 Lights out Latency to sleep (minutes to fall asleep) 30 5.00 20.00 30.00 5.00 40.00 25.00 20.00 20.71 Latency to fall asleep Minutes awake in middle of night (how long awakenings last) 60 10.00 20.00 30.00 10.00 45.00 20.00 40.00 25.00 Mins. awake in middle of night Wake time (time of final awakening) 7:00 5:45 5:50 5:50 5:35 6:15 6:40 6:40 6:05 Wake time Mins awake too early (how many minutes earlier) 30 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Minutes awake too early Out of bed (out of bed for the day) 8:00 6:00 6:15 6:00 6:20 6:45 8:50 8:30 6:57 Out of bed for day

Time in Bed (TIB) 8.25 6.50 6.75 7.25 7.00 8.25 9.83 9.33 7.84 Time in Bed Total Sleep Time (TST) 5.75 6.00 5.67 6.08 6.00 6.33 6.92 6.50 6.21 Total Sleep Time Sleep Efficiency (SE) % 69.70% 92.31% 84.00% 83.86% 85.71% 76.73% 70.40% 69.67% 80.38% Sleep Efficiency

Figure 10.5 Kelly sleep diary calculations from week 2 of session 2 Case Study 171 Assigned Homework: Session 2

• Complete two weeks of diaries. Follow the prescription on client summary (schedule is 11:30 PM–5:30 AM). • To address issues with feeling cold when getting up, place socks by bed and take blanket to a second location to transition. • Set alarm all 14 days. • Schedule some activities out of the house as well as some evening activities to minimize dozing, and track progress on activity monitoring form. • Return to clinic in two weeks. Session 3 Plan: • Review diaries, complement completion and/or troubleshoot incomplete sleep diaries. • Check-in on homework and troubleshoot any adherence issues. • Assess for whether sleep extension is warranted (i.e., a self-report of sleepiness or elevated mean sleep efficiency on the sleep diary). • Time permitting, add a mindfulness activity to help with repetitive thought. • Challenge perfectionistic thinking about functioning or sleep. • Check-in on thoughts and feelings about termination. • Assign Letter to Self for relapse prevention.

Session 3 Notes The ISI was completed and the score was suggestive of moderate insomnia (ISI = 15). Suicidal ideation check revealed no current ideation. Her BDI score was suggestive of moderate level of depression (BDI-II = 17). She correctly and consistently completed the sleep diaries; the following mean sleep indices are calculated from the sleep diaries: mean sleep onset latency reduction from session 1 was maintained (M = 18 minutes) and within normal limits, WASO was again reduced from session 1 (M = 25 minutes) and is within normal limits, total sleep time remains around 6 hours and sleep efficiency was improved to 82 percent (61 percent at pre-treatment), and not suggestive of objective sleepiness. She reported that the diaries were representative of her sleep generally. The diaries and her self report revealed continued problems with adherence to the rise time prescription. Her average rise time was 6:40 AM; over an hour from the scheduled rise time. See Figures 10.6 and 10.7. Her final awakening was variable and the average time was 6:02 AM (30 minutes later than the scheduled alarm time). Follow- Downloaded by [New York University] at 04:37 12 August 2016 up inquiry confirmed that the client was not consistently setting an alarm. The solution proposed by the client was to keep a sticky note to remind herself to set the alarm. There were several instances during the session in which the client exhibited unhelpful thinking styles (e.g., perfectionism about sleep). These were challenged via Socratic questioning and also a thought record done in session. The client reported that the TR was helpful and agreed to complete TRs between sessions when encountering a troublesome thought. Similarly, the client reported that she ruminates less at night because she is sleepier but was distressed about rumination during the day this week. The therapist initiated an in-session behavioral experiment to test if rumination is helpful. The result was that thinking about concrete “what’s” of the situation worked Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly

Today’s Date 12/6/14 12/7/14 12/8/14 12/9/14 12/10/14 12/11/14 12/12/14 1. What time did you get into bed? 11:30 11:30 11:45 11:30 11:30 11:20 11:30 PM PM PM PM PM PM PM 2. What time did you try to go to sleep? 11:30 11:30 11:45 11:30 11:30 11:20 11:30 PM PM PM PM PM PM PM 3. How long did it take you to fall asleep? 30 min. 15 min. 10 min. 15 min. 10 min. 30 min. 20 min. 4. How many times did you wake up, not counting your final awakening? 1 1 0 1 1 1 1 5. In total, how long did these awakenings last? 30 min. 10 min. 0 10 min. 40 min. 15 min. 10 min. 6a. What time was your final awakening? 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 6b. After your final awakening, how long did you spend in bed trying to 30 min. 15 min. 15 min. 15 min. 45 min. 1.5 1.5 sleep? hours hours 6c. Did you wake up earlier than you planned? No No No No No No No 6d. If yes, how much earlier? N/A N/A N/A N/A N/A N/A N/A 7. What time did you get out of bed for the day? 6 AM 5:45 AM 5:45 AM 5:50 AM 6:15 AM 7 AM 7 AM 8. How would you rate the quality of your sleep? Very Very Very Very Very Very Very poor poor poor poor poor poor poor ✓ Poor Poor Poor Poor Poor Poor Poor ✓ Fair ✓ Fair ✓ Fair Fair Fair Fair Fair ✓ Good ✓ Good ✓ Good Good Good Good Good Very Very Very Very Very Very Very good good good good good good good

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly

Today’s Date 12/6/14 12/7/14 12/8/14 12/9/14 12/10/14 12/11/14 12/12/14 9a. How many times did you nap or doze? 0 0 0 0 0 0 0 9b. In total, how long did you nap or doze? 0 0 0 0 0 0 0 10a. How many drinks containing alcohol did you have? 0 0 0 0 0 0 0 10b. What time was your last drink? N/A N/A N/A N/A N/A N/A N/A 11a. How many caffeinated drinks (coffee, tea, soda, 2 2 2 2 2 2 2 energy drinks) did you have? 11b. What time was your last drink? 1 PM 1:45 PM 1:15 PM 1 PM 1 PM 1 PM 12:45 PM 12. Did you take any over-the-counter or prescription Trazodone Trazodone Trazodone Trazodone Trazodone Trazodone Trazodone medication(s) to help you sleep? 50 mg 50 mg 50 mg 50 mg 50 mg 50 mg 50 mg If so, list medication(s), dose, and time taken 10:30 PM 10:30 PM 10:45 PM 11 PM 10:30 PM 10 PM 10 PM 13. Comments (if applicable)

Figure 10.6 Continued Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly

Today’s Date 12/13/14 12/14/14 12/15/14 12/16/14 12/17/14 12/18/14 12/19/14 1. What time did you get into bed? 11:30 11:30 11:45 11:30 11:30 11:30 11:30 PM PM PM PM PM PM PM 2. What time did you try to go to sleep? 11:30 11:30 11:45 11:30 11:30 11:30 11:30 PM PM PM PM PM PM PM 3. How long did it take you to fall asleep? 5 min. 20 min. 20 min. 5 min. 30 min. 25 min. 20 min. 4. How many times did you wake up, not counting your final awakening? 1 1 1 1 1 1 1 5. In total, how long did these awakenings last? 10 min. 20 min. 30 min. 10 min. 45 min. 20 min. 40 min. 6a. What time was your final awakening? 5:30 AM 5:50 AM 5:50 AM 5:35 AM 6:15 AM 6:40 AM 6:40 AM 6b. After your final awakening, how long did you spend in bed trying to sleep? 10 min. 15 min. 10 min. 45 min. 30 min. 1 hour 1 hour 6c. Did you wake up earlier than you planned? No No No No No No No 6d. If yes, how much earlier? N/A N/A N/A N/A N/A N/A N/A 7. What time did you get out of bed for the day? 6 AM 6:15 AM 6 AM 6:20 AM 6:45 AM 7:50 AM 7:30 AM 8. How would you rate the quality of your sleep? Very Very Very Very Very Very Very poor poor poor poor poor poor poor Poor Poor Poor Poor Poor Poor Poor Fair ✓ Fair ✓ Fair Fair Fair ✓ Fair Fair ✓ Good ✓ Good ✓ Good ✓ Good Good Good Good Very Very Very Very Very Very Very good good good good good good good

Figure 10.6 Continued Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly

Today’s Date 12/13/14 12/14/14 12/15/14 12/16/14 12/17/14 12/18/14 12/19/14 10a. How many times did you nap or doze? 0 0 0 0 0 0 0 10b. In total, how long did you nap or doze? 0 0 0 0 0 0 0 11a. How many drinks containing alcohol did you have? 0 0 0 0 0 0 1 11b. What time was your last drink? N/A N/A N/A N/A N/A N/A 9:30 PM 12a. How many caffeinated drinks (coffee, tea, soda, 2 2 2 2 2 2 2 energy drinks) did you have? 12b. What time was your last drink? 1 PM 1 PM 1:15 PM 1 PM 1 PM 1 PM 1:35 PM 13. Did you take any over-the-counter or prescription Trazodone Don’t see No No No No No medication(s) to help you sleep? 50 mg the point If so, list medication(s), dose, and time taken of the 10:30 PM trazodone —stopped 14. Comments (if applicable)

Figure 10.6 Continued Downloaded by [New York University] at 04:37 12 August 2016

12/3/14–12/19/14 sample day 1 day 2 day 3 day 4 day 5 day 6 day 7 AVERAGE Dates 1/1/2011 Bedtime (Time went into bed) 23:30 23:30 23:30 23:45 23:30 23:30 23:30 23:30 23:32 Bedtime Lights out (Try to go to sleep) 23:45 23:30 23:30 23:45 23:30 23:30 23:30 23:30 23:32 Lights out Latency to sleep (minutes to fall asleep) 30 5.00 20.00 20.00 5.00 30.00 25.00 20.00 17.86 Latency to fall asleep Minutes awake in middle of night (how long awakenings last) 60 10.00 20.00 30.00 10.00 45.00 20.00 40.00 25.00 Mins. awake in middle of night Wake time (time of final awakening) 7:00 5:30 5:50 5:50 5:35 6:15 6:40 6:40 6:02 Wake time Mins awake too early (how many minutes earlier) 30 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Minutes awake too early Out of bed (out of bed for the day) 8:00 6:00 6:15 6:00 6:20 6:45 7:50 7:30 6:40 Out of bed for day

Time in Bed (TIB) 8.25 6.50 6.75 6.25 6.83 7.25 8.33 8.00 7.13 Time in Bed Total Sleep Time (TST) 5.75 5.75 5.67 5.25 5.83 5.50 6.42 6.17 5.80 Total Sleep Time Sleep Efficiency (SE) % 69.70% 88.46% 84.00% 84.00% 85.36% 75.86% 77.07% 77.13% 81.70% Sleep Efficiency

Figure 10.7 Kelly sleep diary calculations from week 2 of session 3 Case Study 177 better than thinking about the “whys”. The client agreed it was not helpful and agreed on a plan to use rumination as a cue for getting out of the bed at night, and BA during the day. During this conversation, the client reported attending a Mindfulness Based Stress Reduction group in the past. She stated that it was helpful for her rumination but had since stopped mindfulness practice. The therapist explored ways in which mind - fulness may allow her to take a step back from thoughts that excessively draw her attention. The client agreed to reintroduce mindfulness to her life by adding mindful - ness to her early evening walk.

Assigned Homework: Session 3

• Complete two weeks of diaries. Follow the prescription on client summary (schedule is 11:30 PM–5:30 AM). • Continue to place socks by bed and take blanket to a second location to transition. • Continue to set alarm all 14 days; put sticky note on alarm clock to remember to set each night. • Schedule some activities (e.g., evening walk, joining the weekend card game) out of the house as well as some evening activities to minimize dozing, and track progress on activity monitoring form. • Add mindfulness to evening walk. • Write “Note to Self” for Relapse Prevention. • Return to clinic in two weeks.

Session 4 Plan

• Review diaries, complement completion and/or troubleshoot incomplete sleep diaries. • Check-in on homework and troubleshoot any adherence issues. • Assess for whether sleep extension is warranted (i.e., a self-report of sleepiness or elevated mean sleep efficiency on the sleep diary). • Challenge perfectionistic thinking about functioning or sleep. • Check-in on thoughts and feelings about termination. • Review Letter to Self; relapse prevention. • Enter ISI score into spreadsheet and share progress with client (see Figure 10.10). Downloaded by [New York University] at 04:37 12 August 2016 Session 4 Notes The ISI was 9 suggestive of mild sub-syndromal symptoms. In reviewing the ISI graph (Figure 10.10), the client expressed that the graph matched her experience of gradual improvement and being satisfied with her sleep currently. She had one remaining complaint: daytime sleepiness. There were notable improvements in her depression symptoms (BDI-II = 13), beliefs about sleep (DBAS16 = 2.7; below the clinical cutoff for the measure), fatigue (FSS = 3.4), and rumination in response to feeling tired (DISRS = 39). Of note, the BDI-II score at pre-treatment was in the moderately severe range and is now below the clinical cutoff for the measure (BDI-II = 13). The client remains 178 Case Study on citalopram. She voluntarily discontinued nightly trazodone use 3 weeks ago without any rebound or other discontinuation issues. A review of her sleep diaries (see Figure 10.8 for diaries and Figure 10.9 for a summary) revealed 8.57 minutes in wakefulness during the night, a sleep efficiency just above 90 percent, and a sleep onset latency of 10 minutes. The therapist and client discussed whether the time-in-bed prescription should be increased. It was agreed that the client should try a 15 minute extension and assess sleepiness after the period. The client demonstrated a good understanding of how to make the sleep diary calculations and how to assess whether an extension is needed. Both the diaries and self-report suggest that the client is now adherent to the rise time schedule; she reported that the sticky note reminder to set her alarm was helpful. The client read aloud her Letter to Self. She stated the following changes were particularly helpful: setting an alarm to maintain a regular rise time, scheduling activities so that she is not bored and prone to dozing, getting out of bed when she cannot sleep, particularly when she has a hot flash, and accepting the experience of fatigue. The client reported that the mindful walk has been helpful and she has instigated a 20 minute mindfulness practice with her colleagues over the lunch hour. The client expressed gratitude that she feels able to connect with her valued life and said that she feels confident that she could enact these strategies in the future if the insomnia returned. It should be noted that based on the remaining adherence issues in Session 3, an extra session could have been added. Based on the notable improvements (e.g., steadily falling ISI score and a sleep efficiency above 80 percent) and the fact that the therapist was confident that the remaining adherence would be improved in time for the last session, the therapist kept to a typical 4-session protocol.

Assigned Homework: Session 4 • Continue with diary monitoring to assess the impact of the 15-minute sleep extension on current sleepiness. Extend an additional 15 minutes if sleepiness unresolved. Provided her with link for sleep diaries: www.drcolleencarney.com. • Continue with treatment plan including the prescription (schedule is 11:15 PM- 5:30 AM), socks by the bed, alarm 7 days a week, mindfulness evening walks and scheduling activities. • Follow-up with clinic in the future if sleep extension does not resolve the sleepiness or if new sleep symptoms arise, particularly, excessive daytime sleepiness, Downloaded by [New York University] at 04:37 12 August 2016 breathing-related symptoms such as loud snoring, choking; repeated urges to move the legs in the evening.

In most cases, four sessions (sometimes less) is sufficient to resolve insomnia symptoms. At the end of the four sessions, there may be planned adjustments to time-in-bed for the upcoming weeks and months after treatment (most commonly extending time- in-bed). Thus, it is important to have a written plan and decision guide for the client to make adjustments. A primary goal in CBT-I is to increase sleep self-efficacy, so it is important that the client receive training in how to make calculations and adjustments to their time-in-bed so that they can confidently change their sleep habits independently. Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly

Today’s Date 12/20/14 12/21/14 12/22/14 12/23/14 12/24/14 12/25/14 12/26/14 1. What time did you get into bed? 11:30 11:30 11:45 11:30 11:30 11:20 11:30 PM PM PM PM PM PM PM 2. What time did you try to go to sleep? 11:30 11:30 11:45 11:30 11:30 11:20 11:30 PM PM PM PM PM PM PM 3. How long did it take you to fall asleep? 30 min. 15 min. 10 min. 15 min. 10 min. 30 min. 20 min. 4. How many times did you wake up, not counting your final awakening? 1 1 0 1 1 1 1 5. In total, how long did these awakenings last? 30 min. 10 min. 0 10 min. 40 min. 15 min. 10 min. 6a. What time was your final awakening? 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 6b. After your final awakening, how long did you spend in bed trying to sleep? 30 min. 15 min. 15 min. 15 min. 45 min. 1.5 1.5 hours hours 6c. Did you wake up earlier than you planned? No No No No No No No 6d. If yes, how much earlier? N/A N/A N/A N/A N/A N/A N/A 7. What time did you get out of bed for the day? 6 AM 5:45 AM 5:45 AM 5:50 AM 6:15 AM 7 AM 7 AM 8. How would you rate the quality of your sleep? Very Very Very Very Very Very Very poor poor poor poor poor poor poor ✓ Poor Poor Poor Poor Poor Poor Poor ✓ Fair ✓ Fair ✓ Fair Fair Fair Fair Fair ✓ Good ✓ Good ✓ Good Good Good Good Good Very Very Very Very Very Very Very good good good good good good good

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly

Today’s Date 12/20/14 12/21/14 12/22/14 12/23/14 12/24/14 12/25/14 12/26/14 9a. How many times did you nap or doze? 0 0 0 0 0 0 0 9b. In total, how long did you nap or doze? 0 0 0 0 0 0 0 10a. How many drinks containing alcohol did you have? 0 0 0 0 0 0 0 10b. What time was your last drink? N/A N/A N/A N/A N/A N/A N/A 11a. How many caffeinated drinks (coffee, tea, soda, 2 2 2 2 2 2 2 energy drinks) did you have? 11b. What time was your last drink? 1 PM 1:45 PM 1:15 PM 1 PM 1 PM 1 PM 12:45 PM 12. Did you take any over-the-counter or prescription Trazodone Trazodone Trazodone Trazodone Trazodone Trazodone Trazodone medication(s) to help you sleep? 50 mg 50 mg 50 mg 50 mg 50 mg 50 mg 50 mg If so, list medication(s), dose, and time taken 10:30 PM 10:30 PM 10:45 PM 11 PM 10:30 PM 10 PM 10 PM 13. Comments (if applicable)

Figure 10.8 Continued Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly

Today’s Date 12/27/14 12/28/14 12/29/14 12/30/14 12/31/14 1/1/15 1/2/15 1. What time did you get into bed? 11:30 11:30 11:30 11:30 1:00 AM 11:30 11:30 PM PM PM PM PM PM 2. What time did you try to go to sleep? 11:30 11:30 11:30 11:30 1:00 AM 11:30 11:30 PM PM PM PM PM PM 3. How long did it take you to fall asleep? 5 min. 10 min. 10 min. 5 min. 5 min. 15 min. 20 min. 4. How many times did you wake up, not counting your final awakening? 1 1 1 1 0 1 1 5. In total, how long did these awakenings last? 10 min. 15 min. 10 min. 10 min. 0 5 min. 10 min. 6a. What time was your final awakening? 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 6:20 AM 5:30 AM 6b. After your final awakening, how long did you spend in bed trying to sleep? 15 min. 15 min. 15 min. 30 min. 30 min. 1 hour 1 hour 6c. Did you wake up earlier than you planned? No No No No No No No 6d. If yes, how much earlier? N/A N/A N/A N/A N/A N/A N/A 7. What time did you get out of bed for the day? 5:45 AM 5:45 AM 5:45 AM 5:40 AM 6:00 AM 6:20 AM 5:30 AM 8. How would you rate the quality of your sleep? Very Very Very Very Very Very Very poor poor poor poor poor poor poor Poor Poor Poor Poor Poor Poor Poor Fair Fair ✓ Fair Fair Fair ✓ Fair Fair ✓ Good ✓ Good ✓ Good ✓ Good ✓ Good Good Good Very Very Very Very Very Very Very good good good good good good good

Figure 10.8 Continued Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly

Today’s Date 12/27/14 12/28/14 12/29/14 12/30/14 12/31/14 1/1/15 1/2/15 9a. How many times did you nap or doze? 0 0 0 0 0 0 0 9b. In total, how long did you nap or doze? 0 0 0 0 0 0 0 10a. How many drinks containing alcohol did you have? 0 0 0 0 2 0 1 10b. What time was your last drink? N/A N/A N/A N/A 12 AM N/A N/A 11a. How many caffeinated drinks (coffee, tea, soda, 2 2 2 2 2 2 2 energy drinks) did you have? 11b. What time was your last drink? 1 PM 1 PM 1:15 PM 1 PM 1 PM 1 PM 1:35 PM 12. Did you take any over-the-counter or prescription No No No No No No No medication(s) to help you sleep? If so, list medication(s), dose, and time taken

13. Comments (if applicable) New Year’s Eve

Figure 10.8 Continued Downloaded by [New York University] at 04:37 12 August 2016

sample day 1 day 2 day 3 day 4 day 5 day 6 day 7 AVERAGE Dates 1/1/2011 Bedtime (Time went into bed) 23:30 23:30 23:30 23:30 23:30 1:00 23:30 23:30 23:34 Bedtime Lights out (Try to go to sleep) 23:45 23:30 23:30 23:30 23:30 1:00 23:30 23:30 23:34 Lights out Latency to sleep (minutes to fall asleep) 30 5.00 10.00 10.00 5.00 5.00 15.00 20.00 10.00 Latency to fall asleep Minutes awake in middle of night (how long awakenings last) 60 10.00 15.00 10.00 10.00 0.00 5.00 10.00 8.57 Mins. awake in middle of night Wake time (time of final awakening) 7:00 5:30 5:30 5:30 5:30 5:30 6:20 5:30 8:52 Wake time Mins awake too early (how many minutes earlier) 30 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Minutes awake too early Out of bed (out of bed for the day) 8:00 5:45 5:45 5:45 5:40 6:00 6:20 5:30 5:49 Out of bed for day

Time in Bed (TIB) 8.25 6.25 6.25 6.25 6.17 5.00 6.83 6.00 6.11 Time in Bed Total Sleep Time (TST) 5.75 5.75 5.58 5.67 5.75 4.42 6.50 5.50 5.60 Total Sleep Time Sleep Efficiency (SE) % 69.70% 92.00% 89.28% 90.72% 93.19% 88.40% 95.16% 91.67% 91.49% Sleep Efficiency

Figure 10.9 Kelly sleep diary calculations from week 2 of session 4 35

0 Assessment Session 1 Session 2 Session 3 Session 4

Figure 10.10 Kelly’s Insomnia Severity Index scores throughout treatment

Lastly, it is important that the therapist models a curious, open stance to problem-solving so that the client can remain confident, when troubleshooting independently. When clients understand their sleep system and experience improvements based on imple - menting their behavioral change strategies, they will be confident in the post-treatment phase. CBT-I is a robust, durable treatment, and effective insomnia treatment may have preventative or ameliorative effects on the depression; thus, CBT-I is an easy and important clinical endeavor. Downloaded by [New York University] at 04:37 12 August 2016 Appendix A: Core Sleep Diary

General Instructions What is a Sleep Diary? A sleep diary is designed to gather information about your daily sleep pattern.

How often and when do I fill out the sleep diary? It is necessary for you to complete your sleep diary every day. If possible, the sleep diary should be completed within one hour of getting out of bed in the morning.

What should I do if I miss a day? If you forget to fill in the diary or are unable to finish it, leave the diary blank for that day.

What if something unusual affects my sleep or how I feel in the daytime? If your sleep or daytime functioning is affected by some unusual event (such as an illness, or an emergency) you may make brief notes on your diary.

What do the words ‘bed’ and ‘day’ mean on the diary? This diary can be used for people who are awake or asleep at unusual times. In the sleep diary, the word ‘day’ is the time when you choose or are required to be awake. The term ‘bed’ means the place where you usually sleep.

Will answering these questions about my sleep keep me awake? This is not usually a problem. You should not worry about giving exact times, and you should not watch the clock. Just give your best estimate. Downloaded by [New York University] at 04:37 12 August 2016 186 Appendix A Item Instructions Use the guide below to clarify what is being asked for each item of the Sleep Diary.

Date: Write the date of the morning you are filling out the diary. 1. What time did you get into bed? Write the time that you got into bed. This may not be the time that you began ‘trying’ to fall asleep. 2. What time did you try to go to sleep? Record the time that you began ‘trying’ to fall asleep. 3. How long did it take you to fall asleep? Beginning at the time you wrote in question 2, how long did it take you to fall asleep? 4. How many times did you wake up, not counting your final awakening? How many times did you wake up between the time you first fell asleep and your final awakening? 5. In total, how long did these awakenings last? What was the total time you were awake between the time you first fell asleep and your final awakening? For example, if you woke 3 times for 20 minutes, 35 minutes, and 15 minutes, add them all up (20+35+15= 70 min or 1 hr. and 10 min). 6. What time was your final awakening? Record the last time you woke up in the morning. 7. What time did you get out of bed for the day? What time did you get out of bed with no further attempt at sleeping? This may be different from your final awakening time (e.g. you may have woken up at 6:35 AM but did not get out of bed to start your day until 7:20 AM) 8. How would you rate the quality of your sleep? ‘Sleep Quality’ is your sense of whether your sleep was good or poor. 9. Comments If you have anything that you would like to say that is relevant to your sleep feel free to write it here. Downloaded by [New York University] at 04:37 12 August 2016 Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary Core-M (Please Complete Upon Awakening) ID/NAME: ______Sample

Today’s Date 4/5/11 1. What time did you get into bed? 10:15 PM 2. What time did you try to go to sleep? 11:30 PM 3. How long did it take you to fall asleep? 55 min. 4. How many times did you wake up, not counting your ﬁnal 3 times awakening? 5. In total, how long did these awakenings last? 1 hour 10 min. 6. What time was your ﬁnal awakening? 6:35 AM

7. What time did you get out of bed for the day? 7:20 AM

8. How would you rate the quality of your sleep? Very Very Very Very Very Very Very Very poor poor poor poor poor poor poor poor ✓ Poor Poor Poor Poor Poor Poor Poor Poor Fair Fair Fair Fair Fair Fair Fair Fair Good Good Good Good Good Good Good Good Very Very Very Very Very Very Very Very good good good good good good good good 9. Comments (if applicable) I have a cold Appendix B: Expanded Sleep Diary

General Instructions What is a Sleep Diary? A sleep diary is designed to gather information about your daily sleep pattern.

What should I do if I miss a day? If you forget to fill in the diary or are unable to finish it, leave the diary blank for that day.

Will answering these questions about my sleep keep me awake? This is not usually a problem. You should not worry about giving exact times, and you should not watch the clock. Just give your best estimate. Downloaded by [New York University] at 04:37 12 August 2016 Appendix B 189 Sleep Diary Item Instructions Use the guide below to clarify what is being asked for each item of the Sleep Diary.

Date: Write the date of the morning you are filling out the diary. 1. What time did you get into bed? Write the time that you got into bed. This may not be the time you began ‘trying’ to fall asleep. 2. What time did you try to go to sleep? Record the time that you began ‘trying’ to fall asleep. 3. How long did it take you to fall asleep? Beginning at the time you wrote in question 2, how long did it take you to fall asleep? 4. How many times did you wake up, not counting your final awakening? How many times did you wake up between the time you first fell asleep and your final awakening? 5. In total, how long did these awakenings last? What was the total time you were awake between the time you first fell asleep and your final awakening? For example, if you woke 3 times for 20 minutes, 35 minutes, and 15 minutes, add them all up (20+35+15= 70 min or 1 hr. and 10 min). 6a. What time was your final awakening? Record the last time you woke up in the morning. 6b. After your final awakening, how long did you spend in bed trying to sleep? After the last time you woke-up (Item #6a), how many minutes did you spend in bed trying to sleep? For example, if you woke up at 8 AM but continued to try and sleep until 9 AM, record 1 hour. 6c. Did you wake up earlier than you planned? If you woke up or were awakened earlier than you planned, check yes. If you woke up at your planned time, check no. 6d. If yes, how much earlier? If you answered ‘yes’ to question 6c, write the number of minutes you woke up earlier than you had planned on waking up. For example, if you woke up 15 minutes before the alarm went off, record 15 minutes here. 7. What time did you get out of bed for the day? What time did you get out of bed with no further attempt at sleeping? This may be different from your final awakening time (e.g. you may have woken up at 6:35 AM but did not get out of bed to start your day until 7:20 AM)

Downloaded by [New York University] at 04:37 12 August 2016 8. In total, how long did you sleep? This should just be your best estimate, based on when you went to bed and woke up, how long it took you to fall asleep, and how long you were awake. You do not need to calculate this by adding and subtracting; just give your best estimate. 9. How would you rate the quality of your sleep? ‘Sleep Quality’ is your sense of whether your sleep was good or poor. 10. How restful or refreshed did you feel when you woke up for the day? This refers to how you felt after you were done sleeping for the night, during the first few minutes that you were awake. 190 Appendix B

11a. How many times did you nap or doze? A nap is a time you decided to sleep during the day, whether in bed or not in bed. ‘Dozing’ is a time you may have nodded off for a few minutes, without meaning to, such as while watching TV. Count all the times you napped or dozed at any time from when you first got out of bed in the morning until you got into bed again at night. 11b. In total, how long did you nap or doze? Estimate the total amount of time you spent napping or dozing, in hours and minutes. For instance, if you napped twice, once for 30 minutes and once for 60 minutes, and dozed for 10 minutes, you would answer ‘1 hour 40 minutes.’ If you did not nap or doze, write ‘N/A’ (not applicable). 12a. How many drinks containing alcohol did you have? Enter the number of alcoholic drinks you had where one drink is defined as one 12 oz. beer (can), 5 oz. wine, or 1.5 oz. liquor (one shot). 12b. What time was your last drink? If you had an alcoholic drink yesterday, enter the time of day in hours and minutes of your last drink. If you did not have a drink, write ‘N/A’ (not applicable). 13a. How many caffeinated drinks (coffee, tea, soda, energy drinks) did you have? Enter the number of caffeinated drinks (coffee, tea, soda, energy drinks) you had where for coffee and tea, one drink = 6-8 oz.; while for caffeinated soda one drink = 12 oz. 13b. What time was your last caffeinated drink? If you had a caffeinated drink, enter the time of day in hours and minutes of your last drink. If you did not have a caffeinated drink, write ‘N/A’ (not applicable). 14. Did you take any over-the-counter or prescription medication(s) to help you sleep? If so, list medication(s), dose, and time taken: List the medication name, how much and when you took EACH different medication you took tonight to help you sleep. Include medication available over the counter, prescription medications, and herbals (example: Sleepwell 50 mg 11 PM). If every night is the same, write “same” after the first day. 15. Comments: If you have anything that you would like to say that is relevant to your sleep feel free to write it here. Downloaded by [New York University] at 04:37 12 August 2016 Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: ______Sample

Today’s Date 4/5/11 1. What time did you get into bed? 10:15 PM 2. What time did you try to go to sleep? 11:30 PM 3. How long did it take you to fall asleep? 55 min. 4. How many times did you wake up, not counting your ﬁnal 6 times awakening? 5. In total, how long did these awakenings last? 2 hours 5 min. 6a. What time was your ﬁnal awakening? 6:35 AM

6b. After your ﬁnal awakening, how long did you spend in bed 45 min. trying to sleep? 6c. Did you wake up earlier than you planned? ✓ Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No 6d. If yes, how much earlier? 1 hour Downloaded by [New York University] at 04:37 12 August 2016

7. What time did you get out of bed for the day? 7:20 AM

8. In total, how long did you sleep? 4 hours 10 min. 9. How would you rate the quality of your sleep? Very Very Very Very Very Very Very Very poor poor poor poor poor poor poor poor ✓ Poor Poor Poor Poor Poor Poor Poor Poor Fair Fair Fair Fair Fair Fair Fair Fair Good Good Good Good Good Good Good Good Very Very Very Very Very Very Very Very good good good good good good good good 10. How rested or refreshed did you feel when you woke-up for Not at Not at Not at Not at Not at Not at Not at Not at the day? all all all all all all all all rested rested rested rested rested rested rested rested ✓ Slightly Slightly Slightly Slightly Slightly Slightly Slightly Slightly rested rested rested rested rested rested rested rested Some - Some - Some - Some - Some - Some - Some - Some - what what what what what what what what rested rested rested rested rested rested rested rested Well- Well- Well- Well- Well- Well- Well- Well- rested rested rested rested rested rested rested rested Very Very Very Very Very Very Very Very well- well- well- well- well- well- well- well- rested rested rested rested rested rested rested rested Downloaded by [New York University] at 04:37 12 August 2016

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: ______Sample

Today’s Date 4/5/11 11a. How many times did you nap or doze? 2 times 11b. In total, how long did you nap or doze? 1 hour 10 min. 12a. How many drinks containing alcohol did you have? 3 drinks 12b. What time was your last drink? 9:20 PM

13a. How many caffeinated drinks (coffee, tea, soda, energy 2 drinks drinks) did you have? 13b. What time was your last drink? 3 :00 PM 14. Did you take any over-the-counter or prescription ✓Yes Yes Yes Yes Yes Yes Yes Yes medication(s) to help you sleep? No No No No No No No No

If so, list medication(s), dose, and time taken Medica - Medica - Medica - Medica - Medica - Medica - Medica - Medica - tion(s): tion(s): tion(s): tion(s): tion(s): tion(s): tion(s): tion(s): Relaxo- Herb

Dose: Dose: Dose: Dose: Dose: Dose: Dose: Dose: 50 mg

Time(s) Time(s) Time(s) Time(s) Time(s) Time(s) Time(s) Time(s) taken: taken: taken: taken: taken: taken: taken: taken: 11 PM 15. Comments (if applicable) I have a cold

People think and do many different things when they feel tired. Please read each of the items below and indicate whether you almost never, sometimes, often, or almost always think or do each one when you feel tired. Please select only one answer. Please indicate what you generally do, not what you think you should do.

1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always

1 2 3 4 1. Think, “I won’t be able to do work because I feel so bad” 1 2 3 4 2. Think about your feelings of fatigue 1 2 3 4 3. Think about how hard it is to concentrate 1 2 3 4 4. Think about how unmotivated you feel 1 2 3 4 5. Think about how your thoughts are cloudy or muddled 1 2 3 4 6. Think about how everything requires more effort than usual 1 2 3 4 7. Think, “Why can’t I get going?” 1 2 3 4 8. Think about how sad you feel 1 2 3 4 9. Think about how you don’t feel up to doing anything 1 2 3 4 10. Think about your feelings of achiness 1 2 3 4 11. Think about how bad you feel 1 2 3 4 12. Think about how hard it is to keep your mind on task 1 2 3 4 13. Think about how tired you feel 1 2 3 4 14. Think, “I can’t shake this feeling off” Downloaded by [New York University] at 04:37 12 August 2016 1 2 3 4 15. Think about how irritable you feel 1 2 3 4 16. Think about how sleepy you feel 1 2 3 4 17. Think, “I can’t seem to pay attention” 1 2 3 4 18. Think, “I’m so forgetful” 1 2 3 4 19. Think, “I can’t be around people when I’m feeling this way” 1 2 3 4 20. Think about how you don’t have the energy to get through the day Appendix D: TRAP or TRAC Worksheet TRAP

TRIGGER RESPONSE AVOIDANCE OUTCOME PATTERN TRAC ALTERNATIVE RESPONSE OUTCOME TRIGGER COPING Downloaded by [New York University] at 04:37 12 August 2016 Appendix E: Daily Activity Monitoring Form

Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday 6–7 AM 7–8 AM 8–9 AM 9–10 AM 10–11 AM 11–12 AM 12–1 PM 1–2 PM 2–3 PM 3–4 PM 4–5 PM 5–6 PM 6–7 PM 7–8 PM 8–9 PM 9–10 PM 10–11 PM 11–12 AM

Downloaded by [New York University] at 04:37 12 August 2016 12–1 AM 1–2 AM 2–3 AM 3–4 AM 4–5 AM 5–6 AM Appendix F: Goal Tracking Form

Name: ______Session Week # ____ GOAL TRACKING FORM Set GOAL Record of Goal Attempts Activity Frequency Duration M T W T F Sa Su Downloaded by [New York University] at 04:37 12 August 2016 Appendix G: Blank Pro-Depression and Anti-Depressant Worksheet

Pro-Depression Behaviors Anti-Depressant Behaviors Downloaded by [New York University] at 04:37 12 August 2016 Appendix H: Blank Pro-Sleep versus Pro-Insomnia Worksheet

Pro-Insomnia Behaviors Pro-Sleep Behaviors Downloaded by [New York University] at 04:37 12 August 2016 Appendix I: Blank Pro-Energy versus Pro-Fatigue Worksheet

Pro-Fatigue Behaviors Pro-Energy Behaviors Downloaded by [New York University] at 04:37 12 August 2016 Appendix J: BABIT Continuum Exercise Establishing Insomnia and Depression on a Continuum of Symptoms

No Depression Severe depression diagnosis depression

No Insomnia Severe insomnia diagnosis insomnia Downloaded by [New York University] at 04:37 12 August 2016 Appendix K: Behavioral Experiment Monitoring

Belief to test:

Week One Experiment:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Week Two Experiment:

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abbreviated behavioral and cognitive early morning awakenings (EMAs) 9, therapy (ABCT) 29 100–101, 119 actigraph 34, 48, 114 Electroconvulsive therapy (ECT) 19–20 American Academy of Sleep Medicine: Espie, C. 9, 12, 13, 18, 24, 26, 28–29, 39, guidelines for treating insomnia 14–15 75–76, 81–82, 107 arousal system: dysregulation 8 etiology of insomnia 2–3 assessment of sleepiness 49–50 etiology of insomnia in MDD 12–13 excessive daytime sleepiness 49–50 behavioral activation (BA) 49, 90–91, 105, 108, 122, 125, 133, 135, 136–154 Group Therapy CBT-I 32–3 Behavioral Activation with Behavioral Insomnia Therapy (BABIT) 67, 136–156 Harvey, A. 9, 12, 18, 24, 48, 76, 81–83, 86, behavioral experiments (BE) 89–93, 99, 105, 93, 95, 107, 116–117, 120 108, 120, 122, 171, 177 Homeostatic Psychoeducation script bibliotherapy for CBT-I 34 3–5 brief behavioral insomnia therapy (BBIT) Homeostatic System dysregulation 3–5 29 hypnotic medication discontinuation Buysse, D. J 1–2, 10, 14–15, 26, 29, 41, 48, 30–32 115 hypnotic medications 20–1

chronotype 6 internet-delivered CBT-I 35 Circadian Psychoeducation script 7–8 Circadian Rhythm Disorders 54–56 Kupfer, D. 1, 10, 41, 111 circadian system dysregulation 5–8 Cognitive Behavior Therapy for Insomnia Manber, R. 2, 13, 26, 28–29, 34–35, 62–63, (CBT-I) 15, 24, 26–36 96, 113, 126, 131, 134–136 Downloaded by [New York University] at 04:37 12 August 2016 Cognitive Model of insomnia 81 melatonin supplements 23 Cognitive Therapy 32, 60, 83 metacognition 122–125 conditioned arousal 9, 63, 66, 163 Mindfulness Based Treatment for Insomnia Consensus Sleep Diary 41, 185–193 122, 123, 131 contraindications for CBT-I 27, 36 Morin, C. 1, 15, 24, 26, 28, 30–32, 40–41, 49, Coping Cards 93–94 58, 60, 63, 68, 73, 76, 81, 83, 95, 107, 136, counter arousal strategies 32, 60, 75–77, 78, 154 161 narcolepsy 53 Diphenhydramine (off-label use) 22 Doxepin 21–22 obstructive sleep apnea (OSA) 50–52 226 Index

Pennebaker technique 76 smart phone applications 33 periodic limb movement disorder 53 Socratic questioning 86–89 polysomnography (PSG) 34, 47, 114, 132 Spielman’s 3P Model 2 positive airway pressure (PAP) device 20, Stimulus Control 60, 63–67 27, 51 St. John’s Wort 19

rapid eye movement sleep markers in Thase, M. 2, 136 depression 9–11 Thought Records 84–86, 87 relaxation therapies 76 Transcranial magnetic stimulation 20 resources for those with insomnia and trazodone 16–17 depression 35 troubleshooting avoidance 105–106 restless leg syndrome (RLS) 17, 52 troubleshooting cognitive difficulties 112 Riemann, D. 10–11, 14, 16, 28 troubleshooting eveningness/night owl rumination 12, 18, 48, 80, 82, 120–122 problems 99–100 troubleshooting problems with anhedonia sleep diaries 41, 61, 114 104–105 sleep disordered breathing 50–51, 118 troubleshooting problems with fatigue sleep effort 12, 58, 67, 82 106–109 sleep hygiene 60, 72–75 troubleshooting problems with mobility sleep inertia 98–99 109–110 sleep restriction 60, 68-72 sleep state misperception 115 Vagus nerve stimulation 20 slow wave activity marker in depression 9 5-Hydroxytryptophan (5-HTP) 24 Downloaded by [New York University] at 04:37 12 August 2016