Insomnia and Anxiety

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1 Insomnia and Anxiety

2 Series in Anxiety and Related Disorders Series Editor: Martin M. Antony, Professor, Department of Psychology, Ryerson University, Toronto, Ontario, Canada For other titles published in this series, go to

3 Colleen E. Carney Jack D. Edinger Insomnia and Anxiety

4 Colleen E. Carney Department of Psychology Ryerson University Toronto ON Canada Jack D. Edinger Department of Psychiatry and Behavioral Sciences Duke University Medical Center Durham, NC USA ISBN e-isbn DOI / Springer New York Dordrecht Heidelberg London Library of Congress Control Number: Springer Science+Business Media, LLC 2010 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

5 For Shannon and Sydney Colleen E. Carney In loving memory of my parents who always encouraged my best efforts and to my wife Wanda who tolerated those well over the years. Jack D. Edinger v

6 Acknowledgements We would like to thank our students for their help with this manuscript and for inspiring us to write it. vii

7 Contents 1 Anxiety and Insomnia: An Overview... 1 What is Insomnia?... 2 Diagnostic Considerations for Insomnias... 3 The Case of Comorbid Insomnia: More Nosological Issues... 4 Cognitive Behavioral Model of Insomnia and Anxiety... 7 Summary... 9 References Considerations for Assessment Assessment of Sleep Actigraphic Measurement of Sleep Subjective Assessment of Sleep Clinical Interview Self-report Measurement Global Sleep Symptom Questionnaires Cognitive Insomnia Questionnaires Behavioral Insomnia Questionnaires Daytime Insomnia Symptom Questionnaires Assessment of Anxiety Structured Interviews for Anxiety Clinician-Administered Interviews for Anxiety Clinician-Administered Interviews for Specific Anxiety Disorders Self-Report Measures for Anxiety Symptoms General Measures for Self-Reported Anxiety Anxiety Disorder-Specific Self-Report Questionnaires Case Example 1: Generalized Anxiety Disorder and Insomnia Case Example 2: Sleep-Specific Worry References Anxiety Disorders and Accompanying Insomnia Panic Disorder Generalized Anxiety Disorder ix

8 x Contents Posttraumatic Stress Disorder: PTSD Obsessive Compulsive Disorder Social Phobia Specific Phobias Summary References Cognitive Behavior Therapy for Insomnia: Treatment Considerations What is Cognitive Behavior Therapy and Who Can Benefit from It? Cognitive Behavior Therapy Model The Evidence Supporting CBT for Insomnia Treatment Delivery Issues References Medication Considerations Will Cognitive Behavior Insomnia Therapy Work with Those Who Use Sleep Medications? Prescription Hypnotics: Advantages and Disadvantages Over-the-Counter Medications, Herbal Remedies, and Alternative Treatments Antihistamine-Based Sleep Aids Herbal Compounds and Dietary Supplements Melatonin Alcohol Can Common Anxiety Medications Cause Insomnia Symptoms? Combining Sleep Medications with CBT for Insomnia Sleep Medication Discontinuation Strategies References Behavioral Strategies for Managing Insomnia Assessing the Sleep Problem Using the Sleep Diary Setting the Stage for Treatment Recommendations: The Role of Psychoeducation Presenting Behavioral Insomnia Treatment Recommendations Addressing Sleep Hygiene Issues The Value of Follow-Up Sessions Assistance with TIB Changes Reviewing/Reinforcing Adherence Trouble-Shooting Problems Case Case Case References... 97

9 Contents xi 7 Sleep-Related Cognitive Processes Harvey s (2002) Cognitive Model The Role of Thoughts Unwanted Repetitive Mental Activity The Role of Distress Beliefs in Insomnia Attention and the Threat of Sleep The Role of Attributions Maintaining the Status Quo References Cognitive Strategies for Managing Anxiety and Insomnia Worry Management Strategies Constructive Worry Worksheet Example Cognitive Restructuring Thought Record Decreasing Safety Behaviors and Behavioral Experiments Focus on Relapse Prevention Action Plan for Addressing Insomnia Red Flags for a Possible Problem with Insomnia What Tools Work for This Problem? References Other Issues in Managing the Sleep of Those with Anxiety Relaxation-Based Strategies PMR Treatment Outline Cognitive Behavioral Treatment of Nocturnal Panic Craske s Nocturnal Panic Protocol Treating Claustrophobia Associated with Sleep Apnea Treatment Dream/Nightmare Rescripting Is it Time for a Sleep Specialist Consultation? References Index

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