Treating Chroaic Iasomnia: A Cognitive-Bebivioud Group Therapy Approach

Alfonso Marino

A thesis sabmitted in conjandhn witb the reqairements for the Degrce of Doctornte of Ed~wtion,

Department of Addt Edocatioa, Commanity Development and CounseUing Psychobgy

Onhrio lnstitute for Stidies in Education of the Uaiversity of Toronto

Q Copyright by Alfonso Marino 2001

National Liirary IM dcmaa du "- Can """ uisitions and "9 Acquisitions et

Bib iographic Services services bibihgraphiques

The author has granted a non- exchisive licence aüowing the National Li'brary of Canada to reproduce, loan, distri'bute or s e l copies of this thesis in mi~oform, paper or electronic formats.

The author retahs ownership of îhe copyright in this thesis. Neither the thesis nor substantial extracts fiom it may be printed or otherwise reproduced without the author's permission.

L'auteur a accordé une licence non exclusive permettant à la Bibliothèque nationale du Canada de reprodirire, prêter, distn'buer ou vendre des copies de cette thèse sous Ia forme de microfiche/füm, de repdntion sur papier ou sur format électronique.

L'autwr conserve la propriété du droit d'auteur cpi protège cette thèse. Ni Ia thèse ni des exûaiîs substantiels de celle-ci ne doivent être imprimés ou autrement reproduits sans son autorisation.

TREAïïNG CHRONIC INSOMNIA: A COGNITIVE-BEHAVIOURAL GROUP THERAPY APPROACH

AIfonso Mhrh, EcLD., 2001 Department of Adult Education, Comrmitiity Development and Counselling Psychology

University of Toronto

ABSTRACT

Iasomnia is the most common of all sIeep disorders and its chronic form is

associateci with signiscant morbidity. Treaîmnt of insomnia has predominateIy focused

on hypnotic d over the couter-cemedies, which do not offer long term relie£ Research

has shuwn that individuai cognitive-behaviourai thetapy has been eEédve in the

treatment of iasomnk in cornparison, there is ümited research which bas exploreci the

efficacy of cognitive-behaviourai group therapy, in the treatment of chroaic insomnia

This study examined the efficacy of cognitive-behavioural group therapy (CBGT) in the

tmtment of cbronic hotunia with 35 participants who took part in CBGT and 35 wait-

list controL Measures included the Waiter R e d Pdormance Assesment Battay (Pm),

Sleep Diary, Insomnia Severity Index (ISI), the Beck Depression inventory II @DI-II)

and the Beck Anxie~y Inventory (BAI). ûutcome assessrnent was coducted at pre-

intervention, as wedl as two weeks, three months and six months post intervention.

CBGT participants were found to score SigniScantIy better on all sleep and cognitive

performance measures at two weeks pst therapy aud to show contmued improvement up

to three maths post treatment, when compared to 35 participants (wait list wntrol) who

did not receive the CBGT ûeatment, The study snggests that CBGT may be an effective

and cost-efficient atternative to individuai cognaive-behaviourai therapy m the ûwfment

of chronic insomnia

T i b k of Contemts

PPpe Abstract .................................................................................... ii

.............................................................................. List of Tables vi

.............................................................................. List of F i r e s vü

........................................................................ List of Appendices viii

Chapter one Introduction .............................................................................. 1

DeMion and Diagnostic feaîures of h t n n i a .............................. 3

Etiology of I n s o d ......................... .... ......................... 4

............................. 0 t h Sleep Disorders associated with lnsonmia 7

.................................................... Sleep (architecture & cycles) 8

...................................................... Co~l~equences of h m n i a : 11 ........................................................... Physical Health 11

................................................................. Depression 12 ...................................................................... Amie@ 14

................................................ Social h Domestic Issues 15 .................................................................. Accidents 17 .................................................................. Economic 19

............................................... Measures of Insomaia & Fatigue: 20 ................................................................ SZeep Diary 20

........................................... Inromnia Severi@ Index (BI) 22 ............................... Performance Assessrnent Ba~tery (Pm 22

...................................... Approacks to the Treatment of Insomnia 24 .................................. Psycho-PtmmmacoIogicai Treatments -24

........................ Cognitive-Behaviwal Treatment of Insomnia 28 The Application of Cognitive-BehaviotuaI Therapy

............................................ to the Tretrtnient of Insomma 30 .............. Cognitive-Behavioural Group Treatment of Imomnia 38

The Application of Group Ttrerapy to the Treaîment ............................................................... of Insomnia 4 1

XmplicatiDm and Suggahns for Future Researcb ...-....-.. . ... .. ... . . .. . . . 89

Referenccs . , . . . . . .. . . . . . .. . . . . . .. .. . . .. . . . .. -. . . -. .- -- -. . . . . . . . .. ... . .-. . . . .. . . . -. . . . . . . . 9 1

Appendices ...................... . ................................................... 101

List of Tables

Comparison of demographic â i s t r i i n s in the Protocol Groups ............. 61

...................... Cornparison of Treaîment and Control Groups at Baseiine 62

Mdtivariate Anaiysis of Covariance fbr the Performance ........................................................... Assesment Battery ( P M ) 63

Means and Standard Deviations and M y s i s of Covariance .......................................................... for the k e PAB Measures 66

....................... Muhivariate Anaiysis of Covariance for Sleep Measures 67

Means and Staradrtrd Deviations and Anaiysis of Covariance ................................................................... for SIeep Measures 71

Muhivariate Analysis of Covariance for Depression and .................................................................... M e t y Measures 72

Means and Standard Deviations and Analysis of Covariance .......................................... fbr the Depression and Anxiety Masures 74

Summary of Frequency and Percentages of Treatment Groups that did w t meet Cihicai Signiscance for insomnia based on Skep D i q Latency, Skep Diary Efficiency and Sleep Diary Duration çritefia ............ 75

10: Summary of Frequency and Pmentages of Treatment Gmups ................... Clinicai Status regarding the InSomnia Severity Index (ISI) 76

11: Summary of Frquency and Percentages of Treatment Groups ........... Chicai Statw regardmg Depression @DI-II) and M e t y (BAI) 77

12: Summary of Frequency and P-es of Treaîment Groups EvaIuation of whether they found intenentions iisted helpfùl in

......................................................... dealing with thex imomnia 79

13: Su- of Frequency and Percentages of Treatment Groups Evahiation of whether the &ors listed were heipfùl to them as

.................................. group members, m deaiîng with their i m o d 80

List of Fipires (Grr~hQ

F h n Pane .......................... 1: ln@ Reasoning- Pdormance Assessment Battery 64

.......... 2: Setial Additions/Subtraction RT- Performance Assesment Battery 64

....................................... 3: Manikin- Perfirmarrce Assessrnent Baîtery 65

.......................................................... 4: Sleep Diary- Sleep Latency 68

....................................................... 5: Sleep Diary- Sleep Efficiency 68

......................................................... 6: Sleep Diary- Sleep Duration 69

....................................................... 7: tnsornnia Severity Index (HI) 69

............................................ 8: 8eck Depression inventory II (BDI-II) 73

...................................................... 9: Beck &ety Inventory (BAI) 73

A ~ w n d k PPpe

....................................... A: MSOMNIA INTERVIEW SCHEDULE 101

.................................................... 1 . Insomnia interview Scheduie 102

B: INFORMATION & MFORMED CONSENT FORM ........................ 105

........................................................... 2 . informed Consent Fom 107

.......... C: COGNITIVE-BEHAVIOURAL CROUP TEERAPY MANUAL 108

1 . Tmtment Manuai- Treating Chroaic Insomnia: .............................................................. A CBGT Approach 109

................................................... D: PSYCHOMETRIC BATTERY 136

.................................................. 2 . Insornnia Severity index @SI) 138 3 .

......................................... 3 . Beck Depression lnventory II @DI-II) 139

.................................................. 4 . k k M e t y Inventory (BAI) 140

E: DEMOGRAPBICS QUESTIONNA[RE. GROW INTERVENTION EVALUATION. BELIEFS AND ATTITUES ABOUT SJAEEP SCALE.

............ & COGNITIVE MCNETTES RELATED TO INSOMNiA 141

..................................................... 1 . Demographics Questionnaire 142

................................................... 2 . Group Intervention Evaiuation 143

............................................... 3 . Belief5 and Attitudes about SIeep 144

....................................... 4 . Cognitive Vignettes related to lnsomnia 147

F: FREQUENCY AND PERCENTAGE TABLES OF CONTROL GROIJPS. CORRELATION TABLES & SLEEP PBYSIOLOCY BOOKLET .............................................. 154

2. Pearson Correlation Tables of performance, sleep, and depression . . . . . ,.- 156 3. Skp Physiology BookIet . ................. .......*... ....*................. . 158

Insomnia is a problem tbaî has afYected most individuais at one t h e or another

during kir lives. Ahhough the intensity and fkquency of insomnia varies, it is a

widespread and persistent problem that affects heaith, mood, performance, and

reIatiimhips (Lacks & Morin, 1992, Mellinger, Balter & Uhlenhuth, 1985). It is the

mst common of di sleep disorders and the mst Muent health cornplaint after pain

(Morin, 1993). Its predence has been reportai to be as high as 35% in the general

popdation (Meliiiger et aL, 1985). hnically, less than 20% of individuals with

insomnia ever discuss it with their doctors (Sbapiro, MacFariane & Hussain, 1994).

lnsomnia is d y discussed during visits for other medical purposes. Furthemore, 40-

60% of individuais with insomnia onty acknowiedge a sleep problem when specüidy

asked about it (Dement, 1991). in clinical practice, it has been reported that insomnia

sufférers seek treatment after enduring the problem for an average of 12 years (Morin,

Sonîe, McDonald, & Jones, 1992).

Ipsomnia can conûiiute to a diminished quaiity of iife. ItacreaSed daytime

sleepmess ami fitigw can &bit participation and enjoyment of everyday activities that

individuais without insomnia take for granted. There is an increase for accidental

physical injury as weU as long-term effects on general heaith and He expectancy

(Shapro et al, 1994). Even so, very fèw mdividuals with insomnia choose to do

something to treat their problem. It is estimated that 85% of insonmïa d e f e r s remain

antreated (Mebger et ai., 1985). What is more astonishing is tbat indMduals whh

insonmia tbat do seek heip eventuaiiy stop as their sleep pmblem conthes (Demeta,

1991). The reasons fbr this wuld be related to two pubiic misconceptions about

insomnia The hi is tbat k m n i a is mit &y a medicai problem and therebre ï t WU

go away on iîs own". Secody, ccbronic insomnia can only be c o n q d with the

. . gdminl.stration of sleeping pals (which are seen by some as ciaugetous or not helpful)

(Dement, 199 1). It bas been reporteci that up to 800/0 of indiduais with insomnia treated

with medication in the past, re-erœrge years later with th same problem (Morin, 1993).

This suggests that on its own, niedication is mt an effective mode of tretdment for mmy

individuais with chmnic insomnia

Cognitive-Behavioirral therapy (CBT) bas k n fuuud to be an effective approach

to treathg insomnia. This psycbthetapeutic intervention bas been one of the more

successful hrms of therapy, in that it treats the behaviourai and cognitive disruptions

associated with insoda (Espie, 1991; Lach & Morin, 1992; Morin, Culbert, K O W C ~

& WaEton, 1989). However, to garate fÙrtk public awateness and trust in this

particular inte~eation, more studies lleed to be dane. For instance, aithough k e is a

link between sIeep deprivation ami impaùed cognitive performance (Angus, Heslegrave

& Myles, 1985), tbere are no pdlistied studies which have eYamined cognitive

performance of individuals with insomnia fohwing either individuai or p u p CBT.

Furthemore, in the am of Cognitive-behavIoura1 group therapy (CBGT), there are fkw

pubLished studies (Jwbs, Benson & Friedman, 19%; Kupycû-Woloshyn, M a c F ~ ~ h e &

S b a p h , 1993; Morin, Kowatch, Barry & Walton, 1993). The purpose of this study is to

examine the efficacy of Cognitive-Behavbrwl group thnapy in treaîing individuais with

chmnic insomnia, as measured by cognitive p e r f 0 m , sIeep parameters and emotiond

weii-being. Such a study is in line with the need to b d efficient and cost-effective

psychotherapeutic ways of dealing with cbronic insomnia.

As an alternative to medidon, O- short-terni p u p therapy may make

individuais with chronic inSomnia more open b seek treatment and comply. More ficus

needs to be placed on non-pharmaceutid interventions. By seeking treatment sooner,

inso& related risk factors associated with health, generai weii being, work

performance and safety of the general public wodd iikely be reduced.

DeMion and Diannostic featutes of Insomnia

Insomnia is a sleep disorder c h i f i d a s a "Disorder of Initiating a d Maintainhg

Sieep" (DM). It is a wmpIabt of difficuky m sleephg (ICSD, 1990). Insomnia is best

understood as a group of relateci symptoms. The International Classincation of Sleep

Disorders (ICSD, 1990) and the Diagnostic and Statisticai Manuai of Mental Disorders,

fourth ediion @SM-IV, 1994), define c h n i c insonmia in terms of the foflowing

symptoms: a) subjective mmplajnts of poor sleep, b) diffcuities in Uiitiating (sleep onset

latency is greater than 30 minutes) andor main- sleep (sleep efficiency, only thne

asleep divided by time in bed is lower than 85%), c) sleep diBcuities are present 3 or

more nights per week, ci) duraiion of the problem is greater than 6 months, e) subjective

reporting of daytime &igue, performance impairment or mood disturbances, and f ) an

impairment in socid or occupational fllnctioning.

lnsomnia may be mdested in thcee ways: 1) sIeepaset problems mvolve sIeep

laîency longer than 30 minutes tuming Iights out, 2) sieep maintenance insomnia

hvolves eaher fiequent ami /or extaded noctunial awakenings totaling more than 30

minutes of wakefiilness after sleep onset, or premature awakening in the morning with

iess h 6.5 hours of sleep, W y , 3) mixed sleep-onset and sleep mainteriance h m n i a

nivolves a combination of dScuities with initiating and sustainhg sleep (Morin, 1993).

The severity of iasomnia varies h m acute to chronic. There are tIiree categories

of insomnia- transient, subacute, and chronic. Trawient hmnia usually iasts l e s than

one month (Morin et ai., 1999). Most individuals experience this type of insomnia at

some point in k i r life. It is usually caused by situaiional stressors, such as: death of a

fiimily member, financial diicuities, or cbange of job (Morin, 1993). It can also be

causeci by cimdhn rhythm disnqhons such as, jet hg or shiftwork. Short-term or

subacute insomnia, is characterized by the inability to sleep dlicientfy for a period of

one to six months. Cbronic insorxmia persists for a iength of six months or greater. It

ofken develops h m -ent insomnia. The efkted inâividual often d o m plays the

insomnia and tries to adapt- lndividuais with inSomnia mistakedy assume that "VU get

better on its own".

Often by treathg insomnM in iîs eariy stages, the development of choaic

insomnia can be prevented (Morin et ai., 1999). In most cases, eariy treatment of

insomnia can be combated with medication. However, the longer insomnia is Iefk

unûaîed, the greater the risk that it wiii becorne conditioned and chtoaic.

Eîioloav of lnsomnia

The challenges mvolved in the treatment of insoumia rnay relate to the vast array

of causes. The etiological &ors that have been attniuted to irisomnia include:

psychiatrie disorders (e.g. depression, anxiety, PTSD), sires mduced

psychophysioio~cal States (concüîioned inSomnia, bereaveniest, stress, finamial

pmbkm), pharmacologicaI substances (alcohol, de ine , drugs), otber sleep disorders

(s@ apnea, periodic leg movements), circadian rhythm disorder (jet-hg, shiftwork),

poor sleep hygiene (e.g. Enegular sieep and d e up t h ) , and biological conditions

(pregnam:yy aging) (Yousaf & Sedgwick, 1996). The mechanisms responsible for the

development of insonmia are unciear. However? i.esearch has suggested thslt insomnia is

a muiiidimensionai problem, that corisists of physiologicai, cognitive, emotional and

conditioning variables (Morin, 1993; Mo& et ai., 1992; Morin et d, 1999).

Autonomie activity mut be reduced in order to initiate sleep. A rapid kart rate

or muscle tension are examples of Mors that can manifest physiological arousai in an

individual, When these factors are present, onset of sleep is dificuit (Freedman &

Sattler, 1982). The aim is to lower the physiological arousaL This can be doue by using

relaxation techniques (Morin, 1993). Some of these techniques will be diiussed later.

Cognitive musai interfères with the abiiity to FdU asleep. Cognitive activity may

be manifesteci in tenns of worry, racing minci, rumination, intrusive thoughts, planning,

dyz ing , or difficuity in controlling exciting thoughts (Morin et al., 1999). Intnisive

thoughts need to be curtailed as they arc oflm associated with negative sleep cognitions.

For example, a fear of sleqdessness or performance anxiety (Morin, 1993).

Affect can influence cognitions, through beliefk, expectations and attriiutions.

This can contribute to insomnia. Individds with insomnia usudiy poses unrealisîic

expectations about sleep requirements a d the consequemes associated with insomnia

(Motin, 1993). They may aüriie the problem to extemal htors, such as biochemicd

imbalances. They may see steep as sotnethg that is uncontroiiable, ami consequentiy

may think th& problem cmmt change. Such dystùnctionai belid con tn ie to

emotionai distress ami inevitably insomnia (Morin, 1993).

The psychobgicai profile of iadividuals with insomnia, indicates that these are

individuais with hi@ levels of anxiety, dysphoria, worry or somatized tension

(Freedman & Sattler, 1982). This psycfmIogicai makeup may predispose individuais

with insomnia to heightened affective responses to kir poor sleep and consequentiy

influence. dysfiinctionai sleep cognitions (Fteedman & S&, 1982). Individuais with

inSomnia may be more enaotionaily reactive to stress. They may have Iess resources to

cope, and consequently internalize connict and nimÈnate about what they shouid have

done or said in a given situation (White & Nicassio, 1990). Normal sleepers are more

adaptive to such siîuations, they usually can communicate more assertively, and

coasequently can go to bed with no trouble (White & Nicassio, 1990).

The ability to fiii asleep is influencecl by principles of classicai and operaut

conditioning (Bootzin, 1985). On the other baad, these conditioning principies caa

comiute to diacuities in initiating and iaamtaining sleep, This theory postdates that

for good sleepers, stimuli such as the bed, bedroom, or bedtime can become cues for

sleep onset (Bootzin, 1985). However, if the bedroom becornes paired wiîh activities

incornpatibIe with sleep, a negative association may develop. An individuai who worries

at bedtime about projects, problems at work, Çiances or kir kbility to M asleep,

eventuaiiy associates this particuiar thne with fhstdon and sleeplessness (Morin, 1993;

Sloaa, Hauri, Bootzh, Morin, & Stevenson, 1993). This partiah s t M can lead to a

conditioned amusai, which may be LllEMifested m tenris of physiologicai, cognitive, or

emotional responses. AU of which prevent skep onset (Morin, 1993; Sloan et. aL, 1993).

Other Slee~ Disorders associateci with Insomnia

In treating insomnist, it is important to assess whether the pmblem is the result of

mther sleep disutder. A cornpiaint of poor sleep related to insornnia, could be the result

of sleep ap~xa, nocturnal myoclonus (RestIess Legs Syndrome), or Fi'btositis Syndrome

(Haini 1982). Using cognitive-behaviourai therapy under such c i r c m s would not

be beneficiai. 0th treating the other sleep disorder is sufficient to cm the insonmia

symptoms. Therefore, it is relevant to discuss other sleep disorders associateci with

insomnia.

Sleep apnea is a sleepmg disorder where a patient ( u d y overweîght) stops

breathing many tmies durhg nocturnai sleep (300 to 500 times per nia) (MendeIson,

1987). This usualIy leads tu the symptom of excessive daytime fàtigue. If mt deait with

appropriately, sleep apnea codd lead to death (Mendelson, 1987). There are three kinds

of sleep apnea: central, obstructive, and mixed. Central sleep apma occm when the

patient Mis asleep d the diaphragm stops moving. The brain fails to send impulses

through the nerves which control the mvement of the diaphmgm. ïhe result is that the

patient stops breathing, until he or she is awakened gasping for air (Mendehn, 1987).

These awakenings are numemus throughout the night and can conmibute to poor sleep.

Obstructive sleep apaea occurs when there is a loss of tone in the mriscles of the toque,

t h a î and larynx diiriag sleep. The resuit is the blockage of air flow (Mendelson,

1987). During an obstnictive episode, the diaphragm continues to contract chythmically

against a closed air way, mtil h i i y an awakening occurs a d normal breathing is

resumed. Mixed sIeep apneas is a combinaiion of both c d and obstructive apnea.

Sleep apnea usually precMes restorative sieep. The sleep is disturbed to such an extent,

the patient may feel they are not steeping.

Nocturnai ri3yocbnus is hi as repetitive movements of the Iower

extremities during sleep, d y consistmg of stereotyped leg muscle jerks (Moore &

Gurakar, 1988). Nocturnai myoclomis takes place mostiy d u h g non-rapid eye

movement (NREM) and is associated with light sieep. It is usualiy associaîed wiîh

testless legs syndrome as welL This is characteraed by painhi tingiïng or crawling

semations iu the legs when a individuai tries to sieep or is resting fbr long periods of

thetime The nadividuai is usually awakeiaed by the pain and feels the urge to aileviate it by

miovement, wkther it be by standing, walking, or sitting up (Moore & Gurakar,l988).

The sensations uwaiiy disappear d e r the above strategies are used, The pain

temporarily subsides, but returns shortly after.

Fr'brositis is a syndrome that is characterized by high amphdes of alpha waves

that intrude an M d u a i s sIeep pattern (HaUri I9û2; MoldofSky Bi Scarisbrick, 1976).

These alpba intnrsbns kpenily mix into other sleep wave stages and create mini

arousals fbr the individuai. Persons dispiaying such features often feel tbat &y did not

sleep and consequently do wt feel restod. The individual usually compIains of

f iess in the mrning, as weii as aches and pains (Hauri, 1982; Mokfofiky &

SIeeD Individuais w i h insomnia are Wduals who have llnpaired sleep. To truiy

appreciate this impairment, it is essentiai to undersiand what nomial sleep is and the

purpose it serves. A normal sleep cycle in good sleepers wnsists of non-rapid eye

niovement and rapid eye movement (REM) sleep. A normal sIeeper usually

expriences a sIeep laîency between 15 to 20 minutes after going to bed. The individuai

entas NREM sleep startbg with stage 1. This is the transiton h m waket'ulness to sleep

ami makes up abouî 5% of sIeep. Stage tm is the next stage of sIeep. It iilakes up 50%

of sleep. Stages 3 and 4 d e up approxhately 2&25% of sleep. These stages are

known as deep sieep a d serve a restorative purpose. Mer stage 4, the individual will

briefly enter stage 2 again, fôiiowed by REM. T b is the stage where dteaais are usuaiiy

ahdar& It maka up 20% of sleep. The entire cycle takes appxim&Iy 90 minutes,

and repeats four to six times dirring a n o r d sIeep period (Sbapiro et d, 1994).

In conprison to normative sieep, mdividuais with insomnia diffa in terms of

s k p fateacy, architecture, maintenatice, quality and qwntity- Individuals with insomnia

t y p i d y have excessive anmount of stage 2, an average of 20 minutes less of REM sleep,

l e s deep sIeep (*es 3 and 4) and more transitions between stages (Taub, 1978).

Individuais with insomnia emence pater puiods of wakefbkss a h s k p omet,

lowa sieep efficiency anù longer NREM cycles (Shapiro et ai., 1994; Taub, 1978).

Consequently, individu& with insomnia do mt get sdEcient restodve sleep. The

d c a t i o l l s of this will be discussed Mer.

As stated previously, skep serves a restomtive purpose, both physioIogicaliy and

psychologically (Flanigan & Shaprio, 1992). More speciiicaily, NREM sleep restons

physicd energy and REM s k p deals with cognitive fuactioning (Morin, 1993). The

restorative nature of NREM sleep is appareet when considering the high incidence of

ceIIuiar and homonai activity that occurs during this period. The highest peak of ceil

M o n (mitoses) occurs during M M sleep, and the r e b of approxjmately 80% of

d d y growth hormones coiacides with dtxp sleep (stages 3 & 4) (Flanigan & S-,

1992). WhiIe sleeping, the buman body consumes las oxygen to conserve (FIanigan &

Shaw, 1W). Sleep provides the fimion of produchg celis, teleasing hormones and

c o m d n g enefgy. W h an mdividual gets an abpi te amount of sleep, tkx

functions c o r n i e to k h g s of health and dertaess. These hndons are adwxseIy

efhted when individu& do not receive an adequate amount of sieep. Dejmhbn of

REM sieep bas demonstFeted an adverse efféct with memry consolidation. This

suggests that REM sleep has a fùnctiouai rok ia the retention of material that has been

learned during wakeflllness (Morin, 1993).

C i t c a d i a n R h ~

Insomnia can be nranifested by circadian rhythm disorders, such as jet-hg or

shiftwork. b m n i a can a h contribute to a dyncbronization of the circadian rhythm.

Physiological and biological activities (body temperature, chemicayhormonai secretion,

etc.) may becorne rnisalligned or s u p p d becaw the insonmiac is awake when he or

shc shouki bc asleep. When assessing insomnia it is important to assess whaî effects it

may have on the circadian rhythm, or conversely, what effects the circadian rhythm has

on insomnia.

Human beings are a rhythmic species, experiencing cycles every 24 hours

(Shaprio et ai., 1994). These 24 hour cycles are known as circadian rhythm or more

commoniy known as one's biological cbck W g a n & Shaprio, 1992). In detaminhg

an mdividuai's cacadian rhythm, a patticular variable (ie. body temperature, hormoue

secretions) must be measured repeatedly at different points of the day. When measufed

systernatic changes can be noted h m one time of the day to another. These changes are

consistent diiring a 24 hour period For example, when one is asleep and body

temperature is taken, it usuaüy goes dom durhg the night and early moming. This cycle

repeats over a 24 hour period.

The pirrpose of this inj.efllSil clock is to ptepare the body and brah for sleep ad

active wakefiilness at d E i tünes of the day (FIanigan & Shapno, 1992). Moreover,

the biologicai clock lowers body temperature, hart rate and biood ptessure and controis

the excretion of hormones like rneliitonb, which heip induce sleep (Monk, 1987). The

bioIogical cbck rtIso pmtects our sleep by suppssing hunger and m a i and bowel

f'unctions, permitting longer and more consolidateci sleep with minimal disniptions

(Monk, 1987). Combined, these factors produce a high quality of sleep.

Wéen the bioIogicai clock becornes misaiiigned, due to jet-lag or shiftwork, sleep

onset is difficult. A good sleep is miportant for it enables individuais to feel rehhed,

enefgetic and vigilant, aiding with daily fiinctioning (Monk, 1987). The inabiiity to fàll

asleep at a ''normal" tirne and obtain an adequate amount of sleep, can contriiute to

physical and psychologicai heaith difncuities, as weli as negative s a f i and hancial

issues.

Conseauences of uisomnia

As was discussed above, good sleep serves a restorative purpose. It is apparent

that individuals with insomuia do not get good sleep. Unfortunately, this contributes to

poor physicai aud mental heaitb, accidents, and negative economic factors. Discussing

these consequences m detail highlights the importance of treaîing insomnia.

Physical HeaItb.

Lung-tenn epidemioiogical -dies have shown that insomnia is directly related

to the development of kar t disease, high blood pressure, diabetes, and stroke (Ford &

Kamerow,l989; Knutsson, Akerstedî, Jonsson, & ûrth-Gomer, 1986). Individuais with

iasomnia are at higber nsk for becoming ill than are good sleepers. Men and women w b

report no trouble with sieep, have the Iowest mortaiity rates for khemic kart disease,

cancer and stroke (Knutsson et ai., 1986; Stoller, 1994). More than 50% of those

suBering k m insomnia reporteci two or more health probIems during a year, compared

with nomai sleepers (Stoller, 1994). It is Likely that insomnia is both a cause and effect

of poor heaith, îhe person with insumnia becomes trapped in a cycle of pain or illness that

intemtpts sleep, and simuheously, the lack of sleep compounds the disability. The

meclianism by which insomnia affects h e s s and moaality is mt clear. However, as

previoudy discussed, sieep is said to serve a restorative functiou. ûeprivation of this

restotaiive process may impair bngevity (Hammond, 1964).

Another common coqlaint essociated with insonrnia is gastrointestinal

dyshtion or stomach pmbkms (Monk & FoIkard, 1992). Iiisomnia can cause:

increased appetites, decreased appetites, constipation, dianhea, indigestion, and peytic

ulcers, The biological dock has important i n t d o n s with eating and voiding patterns.

Part of the f i o n of the circradian rhythm, is to suppress appeîiîe so that resdlll sleep

may be obtained. When insomnia desynchronizes the circadian rhythm, digestion

becomes disrupted (Monk & Folkard, 1992). Morwver, w k n unable to sleep during tk

night, the digestive system is o h uaable to adjust and remah active during the cycles

of day ami ni@. The geuerai predisposition of the digestive systern is to be resting

diiring one pbase of the circadian cycle. ui essence, what happeas is tbat the entire

digestive system is active all of the the, eventualty Ieading to the gastmintestinai

d i d i e s (Monk & Folkard, 1992).

Furiher to difiïculties with ischemic kart disease, cancer and stroke, individuais

with insornuia may a h experience: depression, amùety, and social and domestic

slresmrs.

Lklxession.

Depressive disotders bave a strong reIationship with insomnia (SoIdatos, 1994).

W& depressed popiations, epidenklogicai studies have reveaied insomnia to be

twice as prevaient m the depressed population than m non-depressed individu&, Iikewise

in the elderly population, and up to three times as ptevaient amng depressed adoIescents

(Soldatos, 1994). Two types of insornnia are observed in mood disorders incIuding

diffcuhies iniîiating skep and =ly m m h g insomnia with excessive daytime sleepiness

or -nt napping which is corrmion among young mdividuaIs with bipoIar illness

during the depressive phase- Up to 80% of depressed iruiividuals report k i r sleep to be

non-restorative. They also experience fatigue and tiredness dining the day dong with

concems of the qua@ and q u e of their sleep, which may inchde hgmented sleep

and early morning awakenhgs (Van Moffaert, 1994). Like anxiety, it is not known if

depression causes insomnia or if insomnia is the cause of depressioa However,

improvement in insomnia appears to correspond to irnprovernents in depression,

suggesting a common patfmgenesis, One study demoastrated that individuais who had

insornnia had a siightiy higher ri& of developiug major depression compared to

individuais without insomnia (Reydds, 1989). The onset of depression was 40 times

more iikely to occur w k n insoda was unresolved (Reynolds, 1989). These findings

suggest tbat w l y treatment of insomaia couhi reduce the hidence of fimw psychiatrie

disorders. This has p o t d ecommic gains whereby extensive hospaalinition may be

avoided with ttae earIy detection of sleep disturbances. Correct treatment strasegies which

directiy address the sleep disturùance are likely to avoid the development of depression if

the sieep disnrption is prevented h m deveIoping into a chromc state. Two studies

demonstraîed thst a reduction of depressive and anxious symptoms paraileleci sleep

improvements (Espie, Lindsay, Brooks, Hood, & T m y , 1989; Jaoobs, Benson, &

Friedman, 1993). Jacobs and coIIeagues (1993) reported sigdîcsuit reductiom on the

Center fbr Epidemiologicai Study of Depression scale, atad on the Spieiberger StateTrait

Anxiety Inventory witti insormiia Espie and coüeagues (I989), dewastrated

similar reductions of psychological symptonis with insomnia ûeatment.

kmia& M e î y hokis a significaut on the onset of insomnia Anxiety is usually

accoqanied by numerous physid and psychologicai symptoms including autonomie

hyperactivity (tachycardia and palpitations, irrinary fkquency, cümhea, dry muth,

sweating, fhishing, cold hanrfs], back.de, sbrtness of kath, hypewentilation,

difnculty d o w i n g , edginess, startle rqmase, fatigueabirity , numhess, headache,

mflexi%le muscles and muscle tension Psycbbgid symptoms include b o u s worry,

feelings of dread, a sensation of going crazy, hypervighce and insomnia These

symptoms may be present tbmrrgh the &y and inmase just prior to going to W.

Individuais with chronic insomnia are d y c o d over sieep pefi-e and

the* ability to fiinction the fbbwing &y with hck of dequate sieep. When atyciety

leads to poor sleep a cycle may develop wherein the wony over slep in itself prevents

sleep and becornes a self-fiilfilling prophecy wah the potenîiai of developing into an

ovenvklming situation (Sbapiro et ai., 2994).

Apptoximately 10% of individuais with i n s o d have the probkm secondary to

auxkty or panic disorder. Other studies have estimated values as hi& as 37% for those

mdividuais severeiy troubled by inSomnia, 19% of those with les severe k m n i a and

14% of those who had been troubled by hmniit some t;me in the past (MeIlinger et aL

1985). S@ and vigilance ptobIeins ate ofien incfuded in the -stic criteria for

anxiety disordem. This is due to the assumption that ifamiety causes sleep disttrtbances

it is also beiieved tbaî sieep depriv&n may produce symptoms which may be

coasidered as anxieîy. ProbIems in denning e e t y disorders are wmplicaîed by the

mxkknce of other mentai disorders andior addictive discrders. When symptoms

overiap with anxiety and other disorden, the attniution to one specifïc disorder is

difncuft and the "chicken and egg" conundnrm develops. More than 7û% of individuais

diagnosed with g e w d i m i amdm disorder are eady fatigueabIe, report havinig

dficuity concentratkg, are W l e and also have h m n i a with a tendency towards

chronic hyperarousal (Bourdet & Goknberg, 1994).

in the long-term, it appears that unresolved insomnia is a risk factor in the

development of both anxiety disorders and depression. One year follow-up studies

revealed a signincant krease in the numbef of anxiety and depressive diaposes for

those w h o ~ insonmia remaineci umesolved than for those whose insomnia did resolve

(Soldatos, 1994). Deptcssioa, azyiiety and reIated conditions (tension, psychic distress)

are quite wmmon within the population of p p i e with insa* According to severai

epidemiological studies, 25% to 42% of iadividuals with bt rmia are diagnosed with

various fom of anxieîy (idudbg phobias, obsessivecompulsive disorch and panic

disorder) (Ford & k w , 1989; Soldatos, 1994). Amiety disorciers, M o r e , are

more praialent psychologid diagraoses associated with insomnia c o q a m i with

depmsion (Ford & Kamerow, 1989; Soldatos, 1994).

Social&DomesticIssues,

Insomniacan lead to disnrptions m social and M y Me. V a y o h fatigue may

inhrIbit active participation in i b d y and social events. Irritability may m m i i e to

cornmimication break d o m . As a resutî of these mors, mdividuais with insomnia niay

be faced with an inabiiity to provide adequate levels of companionship, support and

protection. Fucthermore, intimate ad s e 4 rotes with a pactmr may also sder (Mott,

1965). Tlae individual must deal with the often ovenvhelming stress of balancing many

problems (Le. biologieai clock &tors, s k p factors aiad social/domestic Wors).

The social ramifications of M y , fiiends, employers and educaton can mate

severe strains. For example, individuals with excessive dame sleepiness (EDS), are

often perceived as iazy because of their excessive fatigue during the day anci evening.

Befoce h g diagmised, such individuais often corne to believe tbat they are hzy. This

often results in Iow self-esteem, alienation h m M y and immense pmblerns with

school and employrnent (Sleep\Wake Disorders Canada, 1993). uisomnia may lead to a

high incidence of worrying about threat of job dismissai, reduced earning capacity or

reduced opportunity for promotion (Broughton & Ghanem, 1976). Not surprisingly,

researchers have f o d high levels of stress amongst individuak with insomnia

(Coloquhoun & Rutenfiam, 1980). Prolongeci exposure to stress cm endanger an

individuai's he& and well-behg by disupting physiological rhyîhms and increasing

anxiety (Broughton & Ghanem, 1976).

Insornnia may aiso have a mle to piay with akoholism. The nite of dcoholism

among individuah with insomnia is twice that of good sleepers (Kales, Kales Bt BixIer,

1984). Some individuais with hm& use alcohol as a hypnotic. Ahhough alcohol

may bIp wiîh sleep onset, it fi;agments s i e q quaiity and contries to sleep

maintenance problems. One study demnstrated not oniy that bomnist may precede the

development of dcohol abuse, but ako suggesîed that treatment of insomnia may reduee

the risk of developing alcobol abuse (Ford & Kmaerow, 1989).

The physical and mental ailmenîs d i n g h m insomnia can be serious.

Research bas shown that sieep duration (5 hours or les) is a better predictor of rnortality

than a history of diabetes, hart disease, stroke or high bhod pressure (Krïpke, 1983).

Another study demonstrated that even when &tors such as physical health were

controlled, insomnia was stiii a predictor of death (Wiard & Berkman, 1983). This

particular study demonstrateci that sleeping fewer than six hours a &y carrieci the same

mortality risk as physical hctivity and hi& alcohol consumption (Wingard & Berkman,

1983). However, this is only accounting for mortaiity due to illness. The rate of injury or

mortality of individuais with insomnia increases when motor vehicle and industriai

accidents are considered.

Accidents.

Literature m the arwt of SI- diirders and sleep deprivation, strongIy supports

tbaî as people becorne more t i d or sieepy fOr wbaîever reason, their abiiiîy to -ion

mentaiiy may becorne impaired (Angus et al., 1985; Monk, 1991a; Monk, 1991 b; Reite,

Nagel & Ruddy, 1990; Thorpy, 1988). The effeets of this cognitive impairment are

detnmentai. Insornnîa may hamper the abiiity to drive a vehick safely. Individuais with

insomnia are reported to have vehicle accident rares t h e tirnes higher than the general

population (W&e Up Amerka, 1993). In a review of transportation safety issues,

sIeepmess has been reported as a major Wor in many catastmphic accidents (Monk,

1991a). Severe motor vehicIe accidents caused by individuais with daytime fàtigue are

fiquent (Monk, 1991a). This poses hanirds on the road and endangers the lives of the

affecteci indiduais, of other motorists aiad pedestrians.

The Space Shuttle Challenger explosion, Exxon Valdez groundinp, and the Three

Mile Island and Cheniobyl nuclear power phnts' near meltdown, were aii disasters that

occurred due to human error. In aii cases, employee fatigue and sleep deprivation, were

main coutri'buting fâctors to the accidents (Folkard & Totterdeii, 1993). industrial

accidents resubg h m sleepiness or fatigue are not uncornmon FoIkard & Totterdeli,

1993). One study reporteci thai 53% of idustrial accidents are caused by excessive

daytùne fitigue (Lavie, 1981). The rate of work related accidents m n g individuais

witb insomnia is estimated to be 1.5 times p a t e r than the general population (Lavie,

1981). h some cases, these individuais are in positions that require high levels of

vigiiance and alertness (e.g., truck drivers, air ûaffïc controllers, train engineem, LEeavy

equipment operators) (Reite, Nagel & Ruddy, 1990). A study demonstrateci the negative

ramifications of king hîigued when ni a position of responsiibility. The study assessed

the enécts of skepiness on nurses (Goid, 2992). It was reporteci that as a cesuit of poor

sleep, nurses were Wgued and experienced twice the amount of accidents or m r s than

nurses who had been sleepmg welL Emrs were oAen serious, such as givuig patients the

wrong medication or not giving them medication at al1 (Gold, 1992).

Studies have show that sieep 10s and fatigue contriiute to decrements in

performance ad subsequently work productivay (Angus et ai., 1985; D h g g 1987). For

example, one study reported thst sIeep l o s signincantly decreased response speed on

both auditory and visual tasks (Dingeq 1987). Another study demonstrateci that auditory

vigilance and subjective assessrnent of sleepiness and mood, deteriorateci dining

prolonged WakefirIness (Angus et al, 1985). Both snidies demonstrated that sleep los

caused participants to becorne sleepy. Co~l~equently, this sleepiness resuited in

decrements on performance tasks.

Economic.

There are many ecowmic consequences as a resuh of insamnia In the United

States, conservative estimates of the total auaual direct and indirect costs of insomnia,

been calcuIated at $92 to $107 billion (Wake Up America, 1993). Much of these

costs are not reiated to the treatment of insomnia, but rather are a direct remit of lack of

physician and public knowledge, skep laboratories and specialists (Stoiier, 1994).

There are maay direct a d indirect cosis associateci with insonmia, Direct costs of

imomaia mclude: prescription and non-p-ption medications, physician visits,

physician training and knowledge, psychologists, hospitaiîzation, and medicai iasurance

(Stollet, 1994). Indirect costs incMe: los of productivity due to missed work, decreased

work perfomiance, and acciâents rehted to tbe side effects of h g treatment (Stoiier,

1994).

A tecent sntdy mvestigated the mual costs of sleep related accidents in the

United States (Leger, 1994). This study caladateci totaI costs of sleep reiated accidents to

be between $43 to $56 b ion . It is estimated tbat 929 to $38 biliion is spent for sleep

reiated motor vehicle accidents, $10 to $14 balion fbr accidents at work, $2 to $ 3 billion

for home reiated accidents ami $1 to $2 billion for public accidents (Leger, 1994).

Due to the iricreased morbidity ad mortdity associated with uwirnnia, as well as

au i n c d rate of serious accidents, individuais with insonmia have a higher

dependence on the medical care system th individu& without iasornnia (Stolier,

1994). Hospitalization for W n a I s with c h n k insomnia is twice the rate of

idbiduals &ut insornnia (Kales et al, 1984). The! estimaXecl ecommic cost of this

hospitalizaton m the United Straes is $25 billion (Wake Up America, 1993).

It would appear h m the literature tbat the consequences of insomnia are

numerous and problematic. The ramifications of insonmia are Eu reaching, effecting not

ody the individuai, but society as a &le. For the insomniac, sleep is impaireci. As a

result, heaittt and weii-king are compromised, social and domestic He is disnrpted, and

safety and work perfomme becornes compromised. Insomnia can contn ie to motor

vehicle and indusiriai accidents. This compromises general public safety and increases

the likelihood of environmentai problems. AU of which contrii'bute to the spending of

massive tax doilars, in order to d u c e the negative consequences associateci with

insomnia, it is imperative to assess and treat it in the most efficient and cost-effective

manner.

Measirres of uisomnia and Fathe

Masures of insomnia and fatigue include self-report measures of sleep

disnrption, such as the sieep àiary or InSomnia Severity Index, mi performance batteries

wbich sssess individuais' cognitive Wioning.

S k q DiaW.

The majority of treatment studies (90%) have relied on daily sleep diaries to

document outcorne (Morin et al., 1999). Daily seif-monitoring of specific sleep

parameters (e.g, skep latency, sleep efficiency and duration) have proven to be similar to

poIysoniaography resuhs (Morin et al, 1999). Skq diaries provide sIeep chicians with

pertinent mforniation about the mdividuai's sleepwake cycle. A typicd sleep diary

incIudes the hbw& docruneniing the time of tetiring at nighî, subjective sleep iatency,

the duration of sleep and episodes dirring the ni& the le@ of the fmai

awakening, ami the time of arismg m the morning (Tborpy, 1988). It c m k used to

document the pattern of sleep and wakeWness over a period of two weeks. This can help

to pmvide a baseline once treatment is initiated with an individuai with insomnia, to see

if any progress has occiai.ed. The fobwing are measures derived Grom sleep diaries

which have ken used to estimate the clinical significaace of sleep miprovements in

treatment studies (any one of the indicators imply a cl inidy signifiant improvement):

1) sleep onset latency: a 50% reduction on the main met symptom; (2) latency duration:

an abhite value of sleep onset latency falling near or below the 30-35 minutes criteria

typically used to define insomaia; and (3) sleep efficiency the proportion of patients

whose sleep eficiency moved h m a dysfiinctional to normaîive level (Le. > 80%)

(Morin et al., 1999).

A number of W s have been conducteci which meamed the efficacy of

insomnia treatment by using a s1eep diary (Lacks, 1991; Morin et aL, 1999; Murtagh &

Greenwood, 1995). One study demonstrateci thaî approximately 50% of individuais

trated hr sleep onset insomnia with cognitive-behaviod interventions niet criterion of

meauingfûl clinical improvements as descrîaed above (Mtnrtagh & Gfeerrwood, 1995).

Another dudy demonstrateci a rnodest 30 minute inçrease Hi total sleep dirration

hbwing an individuai cognitive bebavioural intervention. Total sIeep increased h m

sixhoursto sixand halfhours,whereasthecontrolgroups s l e e p u n l y h d by4

&Utes (Morin et al., 1999). In additios one oîher study (lacks, 1991) showed that a

behanoural group interveaIion r e d d sleep onset he~~icy h m 72 minutes at i t h e to

40 minutes after a f ie week tmtmnt, and fiirther decreased to 36 minutes at a three

month foilow-up, and nnally continueci to decrease to 30 minutes at a one year hhw-up.

The study demonstrated that 39% of met c W significance for miproved

sleep latency. This figure increased to 490h at the three month foibw-up.

h m n i a Severitv index fiSn.

There are numerous seLf-report masures that have been developed for tlïe

evaiuaîion of insomnia. However, few have been validateci specificaily as screeniug or

outwme masure for insamnia (Bastien, Vallieres & Morin, 1999). ïhe ISI (Bastien et

ai., 1999; Morin, 1993) is a memm thai yieIds a quantitative index of sIeep impairment

(for a detaiIed description of the ISI, rek to the "Method" section). Research hs

demonsiraid îhe ISI as a reliable self report instnuaent in evaluating perceived sleep

diflicultig and as a valid measme m detecting the efficacy of treatttlent outcome

(Bastien et ai., 1999).

Performance Assessment Batterv.

Studies have been done with performance tests, to assess the fiinctionaI capacity

of inciiiduals who have experienced sleep los (Angus et al., 1985; Dinges, 1987;

Johnson et ai., 1998; Spiegel et ai., 1998; Thorrie et ai., 1983). Such performance tests

have been founci to be sensitive to sleep Ioss (Angus et ai., 1985; Dinges, 1987; Johnson

et al, 1998; Spiegel et ai., 1998; Thorne et ai., 1983). For example, one çtudy

demonstrateci that tbroughout 54 hours of sleep loss, participants progressiveIy did worse

on performance tasks (Dinges, 1987). The study demonstratecl a SiBnificant decrease in

response speed on both auditory and visuai tasks. Another stdy, conducteci by Angus

and colleagws (1985) atso used performance ta& to measure sleepiness. Individuals

who were sieep depriveci and inactive fbr 60 hours were asked to complete subjective

assessments of m e , sleepiness a d mood every three hours. They also perfbrmed an

auditory vigilance task every six hours and completed a mgnitive test battery every

tweive hous. The d t s demonstrated decrements in performance as a result of sleep

loss. A study by Spiegel and colleagues (1998) explored the alterations of performance

with parfial sleep loss for several conseartive days (which is the type of sleep deprivation

experienced by individuais with insomnia). The study also examineci performance &er

individuais were able to resume an extended duration of sleep (approximately 8 hours).

Participants sleep restriction varied îiom 4 hours per night to 9 hours per night, over 16

ni@ Performance cieteriorated over the 6 nights of sleep debt, but steadily improved

over 7 days as sleep duration increased to 8 hours per night. The study demonstrated that

reduced sleep contriied to decrements in performance, and that with the absence of

deep los, performance began to improve within days. These hding substantiate the

recuperative nature of sleep. Johnson and wlieagues (1998) found similar fmdings in

their sîudy which explored the effects of partial sleep deprivation and psychomotor

vigilance. The study demnstrated that resüicting participants sieep to 3-5 or 7 hours per

nighi for seven nights signincady impaired alertness and vigilance. The data also

showed that when sleep was increased back to baseline duration (approximately 9 hours),

performance decrernents were reversed and s t a b W over the week. Another study by

T'home and colleagues, (1983) demonstrated tbat sleep deprivation impairs alertness,

cognitive performance, a d m d The study found that when individuais were deprived

of sieep over a 72 hour @d of the, performance on the Serial AdditionlSubtraction

degraded over t h . Mental abilities declined by 25% for every 24 hom participants

were awake. His research s b w d that during sleep deprivation, overail performance

typically declines

Sleep deprivation studies such as the ones above, demnstrated that, although

participants did not bave a sleeping disorder, their sleep deprivation caused them to

beconme sleepy. Consequently, this sleepiness resulted in decrements with perforaiance

tasks. Many 0 t h s l u d k have been coducted showing significant adverse effects on

perfbnnance dirring sleep loss (Babkoff, 1985; Carskadon & Dement,1979).

h ~ r o a c h e s to the Tmîmmt of Insomnia

The most cornmon appmaches to the treatment of insomnia include psycho-

pharmacological treatnients and cognitive-behavioura1 interventions.

Psvcho-PbarmacoIoaicaI Treatments.

Short-tenn W of sleep promothg medication, bas been reported to be of benetit

for certain types of inscimnia (GiIIin & Byerley, 1990). For instance, in cases of

situational stressors (e-g., death of loved one, surgery), acute insomnia m y show relief

with the use of sieep medication (Morin, 1993). Short term use of hypmtics may aiso be

helpfui m treating jet lag. Mediacation can also k of ben& when treating iasUmnia

associated with other sEeep disorders (sleeq apnea, d e s s legs or periodic leg

movements), or an acute niedical condition (pain), or various psychiaûic disorders

(Morin, 1993). in such cases, medication should be used ody fbr a short d d o n and

should mt e x c d niore than two doses per week, in order to avoid habituation (NIH,

19û4). Hypmtic -y shouM be initiated at low doses to mhimh Averse effects and

prevent toierance and addiction (Czeisler & Richardson, 1991). S k p medication does

have limiîaîions and a variety of side effects.

The prescription of medication is the most comnsonly applied approach to

ireatmnt of insomnia by physicians. However, different reports have teported

limitations and side effects of s o n hypnotics (Morin et al, 1992). Certain factors

shouid be considered when using pharmacobgical tberapy m fzeatûg insomnia. The

potential costs and benefits of medication use r i be addresseû k r both long and short-

term gains. The long t m effects of medication are not weil researched Several

diîficuhies that can arise h m medication use either during the course of treatment or

&er its discontinuations include: aiterm*on of sleep stages, daytiiae residual effects

(cognitive and psychomotor impairmenî), rebound insomnia, a d dependence (Van

Bnmt, Riedel & Lichstein, 19%).

Continual or prolongeci use of hypwtics can produce a nmber of probIems which

may outweigh the tmefïts of the! hypnotic. Tolerance commonly develops with the use

of barbiturates, chlocal hydrate, and barbiturate-like agents wtiere individuais with

insonmia eventuaiiy need to krease the9 dose to gain the same eEect, Physical

dependence c m occur with the use of batbiturates and less cornmonly with

b e d i i n e s . It is preferable to take the hypnotic every third or hurth night or to

have a "drug holiday" every three or four weeks to avoid dependence. ûversedation

occurs when hypmtics are combinai with alcohol or taken m higher doses than necessary

(Seyone & Shapiro, 1995). Reboimd insomnia is particulariy wmmon m the elderiy who

tend to take medication on a long term basis and are thsrehre at greatest ri&

Discontinuation may be foüowed by numerous symptoms hcluding auxiety, depression

a d worsening of the sIeep dhption beyoad ievek previousIy eqmienced (Lader,

1994).

CMod hydratey comminly presctlbed in the 1970s bas serious adverse cetdrai

m o u s system (CNS) and CatdiOvaScuIar reactions wich a bigh fiiiahy rate wben used

with alcoiml Rapid tolerance can deveiop withm two weeks (Hussain & Shapiro, 1996).

Barbiturates can be enéctive Ïn reducing sleep onset latemcy and noctumal

awakenîngs, however, side efWs inchide impairments in cognitive and motor

fimctioning. Tolerance is rapid and p f b d withdrawd symptoms can occur (Hussain

& Shapiro, 1996). Benzodiazepines have contriied to several problems including:

tolerance to the drugs, wiîhdrawal effects, physi& and psychologicd deperdeme and

abuse. Cognitive and neutomotor iqahents have been detected. Discontinuation of

the drug has Iead to the foUowing symptoms: severe insomnia rebouml, agitation,

restiessness, hypervigilance, photophobi anxiety, panic, and seizures (Hussain &

Shapiro, 1996).

Various shidies ushg psychtberapy, ppharmacothetapy or a combination of both,

have demonstrateci tbat psychokaputic bteryentions worked best for cbronic insomnia

(Hauri & Wsbey, 1993; Morin et ai. 1992). As mted eariier, medication was effective in

instances that involveci traosient or shaîionai insomnh, but proved to be l es effective

than behaviod therapy der a one year hbw-up (Hami & Wibey, 1993). Chronic

insomnia requires a therapeutic intervention abmi at the perpetuating factors. The use

of sleepmg medication alone is limiteci to deaihg with cbnic insomnia and is usually

rtat successfiil (Morin, 1993).

In a study that evaiuated the acceptaace of psycéobgicai and phamwiçological

therapies for chronic insamnia, it was repocted that individuais with insomnia were mre

acceptmg of psychologid mtervenrions rather than pharmacologicai htemdons

(Morin et d, 1992). Regardless of how effective a given treatment is, 3s' acceptana by

individuais with insomnia determines how clinicaily usefüi it is (Morin et ai., 1992).

According to this study, the effectiveness of medication needs to be re-evaIuated m terms

of its side eff is , bw cody it is, and how socially desirable it is. Despite of the

widespread prevalence of sleep complaints, it is estimated that 85% of iasomnia sufferers

remain untreated (Mehger et a l , 1985). If the present hdhgs generalize to these

individuais, it is piaushle to asmm tbat their Mure to seek -nt may result h m

the expectatioa that a drug is the only treatment modality currenîly available for

insoumia. Instead of king pre-scni a sleeping pi& a large segment of these people

may elect to continue to endure insomnia (Morin et a!., 1992). This is apparent when

considering that mst individuais with insomnia wait an average of 12 years before

seeking assistance.

As previously medned, some studies have combinecl behaviourai and

phamacologicai thapies in an attempt to treat inSomnia (Kauri, 1997; McClusky,

MiIby, Switzer, W d h & Wooten, 1991; Miiby, Williams, HaU, Khuder, Wooten,

1993). The assumption wodd be tbaî the bio-behaviourai approach should hypothetically

maximke a favorable outcorne by utilinng the imrnediate curative e&cts of medicatiou

and the longer lasting effects h m cognitive-behaviourai interventions. One study

(McCIusky et al, 1991) aimpared using ttiazofam versus a regiment of stimulus control

and relaxation training, over a 3 week period Both treatments demonsttated simiIar

impmvements at posttteatmem (mean sleep Iatencies of 36 d e s ) . However, tbose

participailts ushg h . i zoh gnprOved frister &a the h t week of tteatment, whereas the

participants pcactîcing stimuhis control and rehxation began to show a greater

imptovement one month fobwing k i r üeatmnt and the5 improvement was sustained

over tirne. Amther study (Hauri, 1997) compared individuals who used a combination of

trizolam and cognitive-behaviourd therapy interventions, with individuais who were

sole@ exposed to behaviod strategis. At a 10 mnth follow-up, particrpants who were

treated only wah cognitive-behavioural t-y techniques fared better than those who

combined a regimen of trimiam and cognitive-behavioural therapy interventions (Hauri,

1997).

ïhe hdings suggest that hypmitic dmgs may produce faster sleep improvements,

especiaiiy in the first kw days of treatnmt, compated to cognitive-behaviourai thaapy

methods. Therapeutic gains in the intamediate term (four weeks), suggest thai cognitive-

behaviourai therapy mterventions and pharmacotogical treatment are comparable. The

long term (6-24 mon&) effects of medication versus cognitive-behaviourai therapy

suggest that cognitive-behavioural -y m u e s tetain their ciinicai benefits,

whereas individuais on medication retirm to baseline comiitions (McClusky et. ai., 1991).

Furthemore, evidence available suggests tbat individuals consuming both hypmtic drugs

d cognitive-behaviourai therapy do not retain kir clinicai gains at fobw-up as weii as

those individuais receiWng cognitivebehavioura1 therapy alone (Hami, 1997).

Coanitive-Behavioura1 Treatment of Iiisomnia

Studies have show that CBT is effective m treating individuais with chronic

insomnia (Espie, 1991, Lacks & Morin, 1992, Morin, CuIbert, Kowaîch & Waiton,

1989). such stuày involved imp1ernentit.g individuai CBT over a period of eight

weeks (Espie, 1991). Individu& wïth cbnic h m n i a were seen for one hour per

week, and were subjected to a variety of cognitive techniques (e.g. cognitive

restnrctining), bebaviourai techniques (e.g. sleep restnction) and psycéoeducational

tecIiniques. Leveis of &igue, depression, anxiety and sleep efficiency were taken before

the CBT mtementions and after the CBT interventions. The results indicated marked

impmvements in all aforementioned parameters (Espie, 1991). Amther study looked at

IO0 individuals (64 women and 36 men) with chronic insomnia over a five year period

(Lacks & Moriu, 1992). This study involveci providing CBT treatment (relaxation

techniques, sleep restriction, cognitive restructuring) on an individual basis. The format

was short-term and stnictured. The mean nurnber of therapy sessions was 7.8 conducted

over 14.3 weeks. These individuais with i o soda were assesseci with a nocturnai

plysamnography, sleep diary ami a clinical interview. The results indicated an overall

miuced t k to sleep induction, increased sleep maintenance and increased sleep

efficiency (Lacks & Morin, 1992).

Morin (1993) states that 70-80% of treated insomniacs are better off than

imtreated ones. The mgnitude of improvement can be as high as 60% after individual

tmtment bas been implemented (Morin et ai., 1992). Research has demonstrated that

with CBT treatment, total sleep duration is increased by at Ieast 30 minutes, h m an

average of 6 hours to 6.5 hours, whereas controIs or& improve by four minutes (Morin et

ai., 1999). Furthermore, sleep onset latency is reduced h m an average of 6065 minutes

at baseihe to approximately 35 minutes at posttreatment, whereas control participants'

sleep latency, is reduced by an average of only 8 minutes (Morin et aL, 1999). In

addition, a study using the Insomnia Severity Index @SI) demonstrated that participants

with a "moderate level" of insonmia at boiseliae* improved to a "subthreshold leml of

insomnian at 3 montlis po-nt, Miowing a CBT intervention (Bastien et d,

1999). O k m h has shown that 50% of individuah treated for sleep onset insomnia

with wguitive-bebavioural interventions meet criterion of meanbgfirl ciinicai

improvements (sleep onset < 30-35 minutes) (Miirtagh & Greeawooà, 1995).

Research has also demonstrateci tbat the durabiiity of sIeep improvernents is weii

maintaineci at short (3 month) and intermediate (6 monîh) range foliow-up assessments

(Morin et aL, 1994; Mitrtagh & Greenwood, 1995). The average duration of follow-up

assessments for treatment efficacy was six month (Morin et d, 1994). Such foilow-up

studies have show tbat 49% of individuais demonstrate reliaHe changes in k i r sleep

and that 63% have at least a 500h decrease in their insomnia complaints. One study

found that sleep oaset latency at posttreatment was 37 mhutes and continued to *ove

at the six month mark, to 33 minutes (Morin et al., 1994). in addition, another study

demonstrated thai total s k p t h e increased h m 349 minutes at baseiine to 378 minutes

at posttreatmwt, and coritinueû to miprove to 3% minutes at 3 months foUow-up

(Murtagh & Greenwood, 1995). Morin and coUeagues (1999) suggested that because

CBT treatnients are typicaiiy implemented in hief periods of time (6-8 sessions),

participants usualIy begin to M y integraie the m l y Iearned cimical procedures 2-3

months foliowing the Iast session. Thecefort, it is quite normal to see participants

continuhg to d e significant i m p r o m 2-3 m o h following treatment. To

summarize, mdividuai CBT has ken hund to be effective in the ûeabnent of ciironie

insonmia and to be associated with maintenance of -nt gains for at Ieast 6 mmomtis

(Morin et ai., 1994; Murtagh & GreenWood, 1995).

The Application of Connitive-Behaviourai Th- to the Treatmmt of lnsomnia

Conceptualizmg . - insomnia h m a cognit'mbebaviourd fhmework is necessary

wbm attempting to treat this sleep disorder with CBT. Chnic insomnia is a

. . muMtmensiod problem. h reflects an intefaction of physiologicd, cognitive and

emtional arousal, as weii as conditionhg variables (Morin, 1993). The stimulus-

o r g a n i s m - r e s p o ~ ~ n c e model is derived h m social learning theory (Haynes &

O'Brien, 1990) and it provides a usefiil conceptual fhmwork for examining the

inteffelationships among otgaaismic, temporal and environmental variables (Haynes &

O'Briea, t 990; Morin, 1993).

Hyper-an,d is the central feature of insomnia Arousal regdates the balance

h e m skep and wakefulness. Therefore, when arousal is present, sleep m y be

inhriited Different stimulus conditions can heighten emotional, physiological and

cognitive arousal of an individual above a criticai threshold, causing it to hterrupt the

naturai sequeme of reIaxation, drowsiaess, and sleep onset (Morin, 1993). For example,

der a féw episodes of sleepless nighîs, a pemn may CO= to w i a k certain bedtime

routines and bedroom m d i as stimuli thaî ause worries, apprehension and féar

of king unable to sleep. The amount of t h e tbat it takes for this wnditioning pmcess to

dewbp, varies h m person to petson. Daily events or interpasonal contlicts that are

f h t d q or problematic may activate a r o d for some individu& which is taken to the

becbom, and consequeutly prevents sleep. They may temain worked up at bdtime as

they Nminate over the daily evems, which then k l s amusal a d amplifies the

conditionhg process (Morin, 1993).

f i n peopie experiencz s k e p I e respnses may include wunies over sIeep

bss, nmimations about kir @mame the fbllowing &y and mus& teasion. In

addition to these d o n s , ttiere is a tendency to &y barder to go to sleep, which in &If

enbances performance auxiety (Morin, 1993). Excessive musal causes perceptual

distortions of elapsed tirne, which firrtber accentuate subjective sleep cüfEcukies and

distress. Eventually, the sleep drive becomes compeiiing ewugh timt it oyertides ail

tIlt!se Competing factors.

The next day ConseQuences involve &igue, mood disturbances (imbbility),

socid discomfbrt, aad performance impairments. These perceived sequehie, wkîher

accurate or amplined, otdy remind an iudividuai of how miserable sleep was on the

p m a h g ni& and txigger îürther dyshctional cogniîions about oneself and abu t

sleep (Morin, 1993). ûver tirne, a sense of learned heiplessness becomes ingrained and

individu& with chronic insomnia corne to believe that th& insomnia is imwntroiiable,

UnpredictabIe, and solely attriutable to exterrial causes (Morin, 1993). IrievitabIy, îhese

negative self-stateinents set the individuais up for a chah reaction of emotional upset,

more cognitive musai, and finther sleep distrrtbances.

In order to cope with insomnia, people may develop mahiaptive sIeep habits,

such as: excessive tirne spent in bed, inegular sleepwake schedules, aad daytime

aapping (Morin, 1993). Although these coping strategies may temporady m b h k e

skep bss, ovet the Iong nm they interfere with the synchronizing effect of a reguiar and

constrained sleepwake rhythm. T d e n t use of hypaotic medications may also improve

skep, buî with Iong-term use it eventually becornes part of the problem. Cognitive

distortions (e.g., fàuIty belieç about sleep pmoting practice, mealistic errpectatioas,

mkaîtri'butiom of the causes of insomnia, and amplincations of its corisequences)

produce emitiod distress and aggravate the insomnia p r o b h fiather (Mo& 1993).

Chronic hmnia is not a disorder tbat &vdops overnight. in mst cases it is

preceded by sihiational insomnia that is ùrought on by stressfitl Life events, but hiis to

improve der the stressors are removed (Morin, 1993). ConsequentIy, it can evolve in a

graduai îàshion, where the individual becomes incmsingly coasumed by the sleep

probiem and by its presunled impact on daytime fiuictioning. Whether the probkm is

transient in nature or develops &O fuli-fledged c h n i c insomnia, depends on how the

individuai perceives and appraises the sleep diff~cuity h m its onset. For example, the

individual who is subjected to a few nights of poor sieep, but is able to continue with his

or her usual mutine without wonying about it, is wt likely to devebp persistent or

c h n i c iasomnia On the other band, someone who becomes overIy concenied and

atutious d e r a kw nights of sleeplessness and b e g h to catastrophize over the negative

consequences on daytime functioning, is likely to enter a vicious cycle of iasomnia,

emotiooai and cognitive amusai, and furthet sleep disturbances (Morin, 1993). Excessive

rumination about sleeplessness quickly becornes the centre of the individual's

prericcupations. Performance impairment or mood disturbances during the &y tend to be

exclusiveIy aüriied to poor sleep. Apprehension builds up m the evening, and as

bedtime approaches, fearfulness of king unable to sleep becornes magnified, FoIIowiag

a poor nighî's si-, not only does the individuai worry about the previous ni& but he

or she aEready anticipates the next one with apprehension (Morin, 1993). Hence,

irmrmiia ùecomes a self-fulf'tlling prophecy.

As can be seen kom this model there is a bi-directional influence betwew causes

and consequençes of insomnia and it becornes very dïfiïcuit to disentangle their causal

relationships (Haynes & O'Brien, 1990). This conceptuai h e w o r k has several

impiications for the management of chronic insomnia. To begh wih, learned

behavhural and cognitive respouses pIay a major c o n t n i r y role in mamtammg . . .

insorimia. Treatment should thus focus not ço much on uncovering the ptecipitating

events as on altering its perpetuating conditions. The primary targets for intervention are

therefore the maladaptive sleep habits and dysfiinctionai sieep cognitions

Cognitive therapy consists of ident@ing the clients dysfunctiod sleep

cognitions, challenging k i r validity, and replacing them with more adaptive substituîes

through the use of testnictirring techniques. The primary goal of cognitive therapy is to

guide clients to re-evaluate the accuracy of theù t W g about sleeplesmess, its causal

fàctors, and presumed consequences. The implementation of cognitive therapy for the

treatment of insomnia is primarily basecl on cognitive restnrcniring techniques such as

reappraisal, reattn'bution, and decatastrophizhg (Beck & Weishaar, 1989). The client is

guided to mmmine the vai id i i of his or her belie&, and to r e h e and replace them

wdh more adaptive substitutes (Morin, 1993). DeScnimg the re1ationsh.i~ between

cognitions, affect and behaviour is necessary in order to establish a conceptual

framework. This can be done by ushg hypothetical situations either relatai or umeiated

to sleep disturbances. For example, the client may be asked to think of a situation that

made him or her angry or sa& and to verbalize a seif-statement to accompany that

emotion. Dysfunmional sleep cognitions n o d y consist of: 1) unreaiistic sleep

-ans, 2) misconceptions of the causes of hsomnia, 3) misattnions or

amplifications of its consequences, 4) dimhkhed perceptions of contruI and

predictabiIity of the sleep ptocess, and 5) faulty beliefk about sleep-promoting p c t h

(Morin et at, 1999). These dysfiinctional sleep cognitions can be f d m expbred by

introducing a series of vignettes tbat illustrate the ciients' underlying maladaptive

information processing. Once identined, these cognitions need to be explored and their

vaiidity ne& CO be chaiienged Adaptive and ratibnal substitute cognitions shouid be

explored with the client. This can be achieved by ushg reattriiution, hypothesis testing,

reappraisal, and decatastrophizing techniques (see Methods section for mre detail)

(Morin et ai., 1999).

In addition to work on dysfunctional cognitions, behaviod treaîment

components involve the aiterations of temporal, cirritextual and behaviourai fhctors. The

intention is to ensure that the timing of sleep is set according to circadian principles

(temporal), in an environment that is conducive to sleep (contextual), while maladaptive

sleep habits (behavioural) are bemg m o d i i (Morin, 1993). Behavioural treatment

hcuses on m o d w g malaname behavioural practices that perpetuate insornnia. The

goal of the bebavioural téerapy d d e is twofold: 1) to strengthen the association

between sleep behaviours and stimuli such as the bed, bedtime, and the bedroom

surrodings; and 2) to consolidate sleep over shorter periods of t h e actually spent in

bed (Morin, 1993). Sthmius conûol therapy is used m an attempt to aîtain the first goal.

The seconci goal is pursued through the hplementation of sleep restriction In both

cases, the rationde for usiug such procedures is that sIeep is a behaviour that is

susceptiile to conditionhg processes which are govemed by environmental and temporai

stirmili When these stimuhis conditions Iose their association to sIeep the fomdation for

chronic niSomnia begins to take form. More specifidy, an individuai who is exposed to

transBent b m n i a resuhing h m stressors such as marital conflicts or personai losses,

may begin to resume m d sleep patterns once the stressors M e away. However, some

individuah may deveiop negatiw responses to siimuii thas are w r d y conducive to

sleep (e.g. bed, bedtime, bedtoom). Bedtime or the bedroom may have been stimuli

which were once associaied with tehaîion and s k p , but with repeaîed occurrences of

sleeplessness a conditionhg process evolves which corrtn'butes to amusai and M e r

sleep distutbances.

The objective of stimulus control hrapy is to re-deveIop or condition an

association between sleep and the coditions in which it normaily occurs in (Morin,

1993). iizdividuals with insomnia are instnrcted to go to bed only when drowsy.

Eliminating the propensity for sîaying in bed awake, etimiiiates potential periods of thne

where the individuai may begin to ruminate, worry and engage in internai monologues

which are incompatible with reiaxation mi sleep, and can strengthen maladaptive

association between the b e h m and sleeplessness. Thetefore, the individual with

kmnia is mstnicted to k v e their bedroom ifthey cannot fall asleep within 20 minutes.

They shouid engage m non-stimuiatimg activities which are monotomus or boring and

ody return to bed when drowsy. This produre is qmted rmtd they acîuaiiy Ei11 asleep

withm 20 minutes.

Sleep restriction limits h e amount of t h e spent in bed to a d sleep time.

fndividuais with insomnia tend to spend excessive amounts of tirne in ûed in an attempt

to make up for a sIeepless night. Sleep restriction incorporates a formula for caicuiathg a

sIeep efficiency. Sleep efficiency is caIcuIated by dividing total sIeep time by total t h e

m bed and muhiplving the ration by 100. The goal wÎth sIeep restriction is to imwe an

mdual's skep effiiciency to above 85%. The sleep restriction strategy would for

example, suggest to an individuai w b steeps tbr 4 out 8 hours in bed, to deep ody hm

hours. When his or her sleep efficiency is above 85%, kir sleep time (or "sleep

window") ïucreases by an additional 15 miuutes. This procedure continues until the

desired sleep thne is reached (Morin, 1993)- The importance of a sleep diary is apparent

when implementing sleep restriction, as it provides an approximate duration of sleep time

and tirne in bed, in order to calculate the sleep efFciency.

An integrai coqnent of CBT in the treatment of insomaia is relaxation training.

Arousal interferes with sleep. Physioiogical activity must be reduced in order to initiate

sleep. Physiologid arousal can be d e s t e d by a rapid heart rate or muscle tension

koughî on by fiusmion or anxiety over mt beiag able to sleep (Freedman & Sattler,

1982). Similady, cognitive musal may k d e s t e c i b u g h worry, d a t i o n ,

Uitnisive thoughts and pianniug (Morin et al, 1999). Cognitive musal often becorne

assochted with negative sleep cognitions. ïhe objectives of relaxation techniques are to

distract the individual with insomnia fiom hcusing on intrusive and disnrptive thoughts

and to heip lower physiological arousai. Learning to focus one's attention on reiatively

pleasant, monotonous interna1 sensations may be mCompatibIe with worrisome thoughts

and images that prevent sleep omet (Borkovec, 1982). Relaxation techniques such as:

progressive muscle relaxation, guided imagery, deep breathing and autogenic training are

alI common techniques used in an attempt to reduce individuais physiological and

cognitive amusa1 in relation to Ïnsomnia (Moriu, 1993; Morin et ai., 1999).

Finally, the CBT approach ta the tmtment of cbronic k m n i a aiso empioys an

educationai component, &y teachmg basic sIeep hygiene principles. Different

MestyIe and environmental &ors that can be couter-productive to obtaniing a good

night skep are d e s c r i i a d discussed- Diet, d o n , exercise, aicohol, &me

consumption, cigateaes, napping, Li& mise and tempetature are examples of things that

clients should be intormed about (for m ~ r e detail about sleep hygieue see Manuai

section). P m sEeep hygiene can ofkm hider tberapeutic progress and compiicaîe the

client's insonmia.

Studies have demonstrated that a mukifkceted approach to treating iasomnia (as

descr i i above) is s i g n i n d y mire effective than no tnxtment (Edinger & Stout,

1985; Jacobs, Benson, & Friedman, 1993). The besî outcornes h m muiticomponent

interventions have been reporteci when sieep restriction and/or d m u b conîrol

procedures were integrated with otber &O& such as cognitive testructuring, sieep

hygiene and relaxation methods (Jacubs et al, 1993). Effective ciinicai management of

insomnia willoften involve a combmation of treatment procedures (Jacobs et ai., 1993).

There is considerable reçearch on ushg idhiduai cognitive-behaviourai therapy

wiîh individuais that bave insomnia (Shan et ai, 1993). However, the focus of this study

is to assess the effdveness of CBT in a group setiing for individuais with insomnia

Group therapy has ken kmiwn to be effective m working with a variety of

psychiaîric populations, m particuiar with psychosomatic disorciers (Stein, 1971).

However, with the exception of a Eiw siudies (Jacobs et d, 1996; Kupych-Woloshyn et

ai., 1993; Morin et aL, 1993), there appears to be a void in the Iitaamre as IO the

effectiveness of Cognitive-bebaviourat group -y in working with mdnriduais with

insonmia, particuIar1y wkn llssessiug mgnitive performance,

A strrdy by Morin and co~eagues (1993) demonsûated thai late-life insomnia

couid be effectively treated with mgnitive-behaviour p u p thempy (CBGT). Trwrtment

was effiective in reducmg sleep l a t q and emly morning awakeningq as weU 9s

increasing sleep efficiency and these gains were maintaineci at 3 mnth ami 12 mon&

bbw-ups. Twenty-four participants with late-life insomnia were randody assigneci to

an immediate tmtmemt group or a wait-list control group. Treatment conskted of an 8

week intemation aimed at changîng maMaptive sleep habits and alterûig dysfünctional

beliefs about sieeplessness. Measures included an overnight polysomnogtaphy, sleep

diarie the Beck Depression hventory @Di), the Staîe-Trait Anxiety inventory (STAi)

and the Pronle of Mood States (POMS). No performance masures were used.

Participants continueci using sleep medication dinring the study. Ail participants were

over the age of 60, with a mean age of 67.1 y-. Participants receiving the CBGT

mtervention reduced their sleep latency h m 39.6 minutes at baseline to 20.6 minutes at

the fint posttreatment fobw-up, 21.3 minutes at the 3 month hbw-up and 22.4 minutes

at the 12 month foiiow-up. Totai sleep duration mcreased h m 328.3 minutes at baseline

to 341.4 minutes at the nrst posrereacment blow-up, 364.4 minutes at the 3 mouth

foUow-up and 393.8 minutes at the 12 math fobw-up. F d y , sleep efficiency

improved b m 68.5% at baselme to 82.8% at the first posttreatment fbllow-up, 8 1.1% at

the 3 month foiiow-up and 83.6% at the 12 month follow-up. A signincant reduction of

deptessive scores as measured by the BDI was also de!tected in the cognitive-behavioura!

tIierapy tremnent group-

Amthet study found thit using a group intervention dong with cognitive-

behavioural and educational techniques, was helpfiil in miproving both s k q ~ and mod

of iiadMduais with insoinnia (Kupych-Wobshyn et ai., 1993). The study invoived 30

mdividuais with insomnia who were treaîed m hur groups of six to eight people each tàt

a @od of eight weeks. The groups received coguitive-behaviourd mtervenîioxts tbat

inwtlved sleep restriction, cognitive testnictiiring and relaxation techniques. Measures

included sleep diaries and the Beck Dcpression invenîory. No performance measures

were used. There were no fbkw-up assessments and no control group was used. Based

on participants' subjective reports, the study sbwed that group members benefited iiom

the cognitive-behavioud interventions.

A study by Jacobs and coiieagues (1W6) suggested that fobwing a CBGT

approach for the treatment of insomnia, participants' sleep signincautly improved. The

group approach included: sleep restriction, stimulus control relaxation techniques and

cognitive restnictining. in total 102 participants were included m the study. Sessions

were provided on a weekly basis for 10 weeks. Cognitive performance was not assessed

aad no conml groups were d. Sleep parameters were assessed tbrough retrospective

measures. Participants also continueâ using sleep medication dttrrng the study. The

r e d s of the study demonstrated that 58% of participants reporteci significant sleep

imptovements, 33% moderate and 9% süght improvement. A six month foiiow-up

showed that 90% of participants mabined kir sIeep improvernents.

In addition, a study by Lacks (1!291) bnstraîed that behaviour -y was

successfùi in treating individuais with insomnia in a group setting. WhiIe this study cüd

not assess cognitive-behaviorrral therapy, it impiied that the psychothmàutic dynamics

of group therapy were effective in the treatment of insomnia (see below for more d e t a .

The behaviourai approach was based on stimulus wntrol therapy. The study involved

400 participants over an eight year period. Parîicipants were randomly assigneci inîo

groups of 5-7 people a d adminhered f i e sesïoas of behavioinal thetapy. Measures

hIuded sieep diaries. No perfE>rmance measlaes were used. The study demnstrated

thai a behaviourai group mtervention reduced sIeep omet latency h m 72 minutes at

baseime to 40 minutes after a five week treatment. Sleep Iatency fkher decreased to 36

minutes at a three month foilow-up and contimed to decrease to 30 minutes at a one year

foilow-up. The study demonstrated that 39% of participants met deria h r signincant

inprovernent in sleep latency, that is a sIeep iatency Iower than 30 minutes. This figure

mcreased to 49% at the three month bbw-up.

The Application of h i q , Theravv to the Tmînmt of Insomnia.

The authors (Kupych-WoIoshyn et d, 1993; Lacks, 1991) reported thai the

therapeutic factors of group therapy were important because of the foUowing principles:

a) the group settiug helped demomte to the participants that they were not suffering in

isolation and tbat their problems were not unique; b) inter-individuai differences became

points of discussion, thereby exciuding the notion of a singular recipe for sleep; c)

validation and acceptance by the group alIowed MdMduai group members to move

beyoncl dering in isolation; d) a preseaIation of a variety of pomts within the group

pmvided individuais with a poss~'bility of severaf hypotheses to explain theu own sleep

problem; and e) provision of some structure provided a secure environment w&ich

kiliiated self-disclosure in the members.

individuais with h m n i a may be mire emotionaUy reactive to stress. They may

have l e s resources to cope and coamninicate. Curisequently, they internalize conflict

and ride about wbaî they shouId have dom or said in a @en situation (White &

Nicassio, 1990). By leaniing to communicate and giteract with 0 t h group rnembers,

t h e y m a y ~ î ù t m e w n i k t a a d nimination. The expnssion of emotion enhances

thie dwelopment of cohes'ieness and sim-usiy e h e s wdi king (Yalom, 1975).

Instillation of bpe is imprtant m order to k p the ciient in therapy. Seeing

other group naembers get better can k nispirhg especially der deaihg with insomnia

for years (Morin, 1993).

The essence of u n i v ~ can alleviate clients' experience of bemg Mereut and

socialiy bkited. The group gives an opporhmity for clients to speak about their

concenis wbile providing validation (Yaiom, 1975). Mviduals with insornnia may need

to speak with others about how insomnia has eEected their iives.

Providiug information to ciients in a group regarding the process of the iliness

(insomnia) cm help the group bind together. The p u p cm then discuss the infbrmation

together. Direct advice b m other goup members is received more d y . Mer the

proces, rather than the content, is vaiued w k n clients corrnect through mutual interest

and carhg (Yalom, 1975). L m e d behaviourai techniques which are teinbTQBd by

p u p kapists tead to show the greatest improvements compared to those Wb0 l e m the

techniques on their own. Perhaps this is because mode1 ciients who diligently adhere to

the clinical procedures can prove strong allies to the therapist in convincing other clients

to compiy with the prescrii regimen (Lacks, 1991)-

A h i m aiiows ciieuts to receive h u g h giving. Smce many clients witb

h o & have long considemi themsehes as burdens, the experience in nnding that they

are bpaant iu otbm through providing reassurance, suggestions, msight and similar

problems may h s t thtir seIf-esteem. CIients who bave completed the!rapy commody

report other m e m k as behg pivotal to k i r ïmprovement (YaIom, f 975).

Developmeat of socializing techniques is common to aii îherapy groups.

Members are encourageci to provide fkedback to others regardhg maladaptive behaviours

(Yaiom, 1975). Imitative behaviours a b w members to observe ohers revealing private

rnatters and coping with similar probkms (Yalom, 1975). As a remit, socid Ieamkig and

ahmism d u c e sociai aDxiety and enhance seE-esteem (Yaiom, 1975).

Faicilitating the dyaamics of p u p therapy for mdividuals with chronic insomnia

require that the client move h m a passive mode of tirnctioning to a pmblem solving

mode (Lacks, 1991). A therapistlfiicilitator should bave a sense of humor to lighten up

the pmceedings and rapidly develop rapport with group members (Lacks, 1991).

Modeling seIfdiScIosure, openness and problem solving will also help clients. The

therapist needs to be a directive group leader who gives feedback, reinferces participants

efforts and encourages k i h e r probkm solvhg (Lacks, 1991).

In addition to the themputic benefits of group therapy' there are also economic

benefits (Lacks, 1991). Gmup therapy allows for more clients to be treatni within a

iimited t h e (Kadis, Krasner, W i c k & Foulkes, 1963). For therapeutic settings that are

not subsidized, group î k a p y allows for Iowa fks than individuai therapy. in a sethg

where clients do not have to pay for ûeatrœnt, group therapy can substmt i i d u c e a

waiting üst (Kadis et ai., 1%3). This bene* the clients' and aIso reduces the economic

burden that hospitais and other mentai h i t h iastitutions are h e d with.

Hpotheses

Chronic insomnia is a relatively pvaient condition wiih muItiple heaith and

behaviourai consequenœs to afiècted iudividuais and to Society. SSIeep cognitions and

maladaptive deep behaMours cm be influencing facors in the etidogy of insomnia.

Individual cognitive-behvi0ura.i t k a p y bas been fou& to be efikctnce in the treatment

of chronic msomniri-

To date, féw stndies have employed a group approach to cognitive-behaviour

tberapy with people Mering h m insomnia (Jacobs et al, 1996; KupycbWoloshyn et

ai., 1993; Morin et al, 1993). However, these studies do present with a m b e r of

methodological limitations.

For example, a shdy conducteci by Jacobs and coiieagues (1996) was able to

demonstrate îhat CBGT treatment was effective in impmvhg participants sleep.

However, participants did use sleepmg medication while simuhaneously receiving CBT,

which confounds the res& of the 'Jtudy- Another limitation was thaî no control groups

were used, making it imposs1Ible to detefmizle wbether gaias were due to the therapeutic

treatment. Findy, ody subjective outcome rumures were used.

Another study (Kupych-WoIoshyn et ai., 1993) a d CBGT as ao effective

treatment for bmnia based on participants' subjective reports. The study, however,

had methodoIogicai limitations as well. To begin with, the inclusion criteria for

. . piartmpants was too b r o d Iadividuais experiencing insamnia as a result of other sleep

r e W disordm were hluded in this study. Using CBT with individuals who are

experiencing insomnia due to s k p apnea, for example, m y be inappropriate. The sieep

apnea shouid be deah wiîh nrst, to assure patients' saféty. It is Wrely that if this is done,

the k m n i a wuld aIso dissipate. Smiiiarly, as was d e m i ! above, participants using

sieepmg medication while smiuhaneousty receiving CBGT, were also included in the

study. Io addition, no contml groups were used and ody subjective outcom measUres

were dministered. Fratherm,re, no M)iiow-up assessments were taken.

A study by Morin and coiieagues (1993) h w e d thaî the CBGT mtervention

improved participants skep latency, duration and efficiency. The study had fewer

methodologicaI ünhtions when çompared to the two shidies above. The study did

however consist of a srnail sample size (N 34). It also was not representative of the

general popaiation, as the CBGT treaûnent focused on late-life insomnia and was

implemented to an older sample (average age = 67.1 years). Participants aiso wntinued

to take midication during the study.

A study by Lacks (1991) measured the effectiveness of behavioural group

treatmwt to insomnia based on sleep diaries. W e not assessing cognitive-behaviod

k a p y per se, tbe study suggested the efectiveness of a group approach to insomnia

Despite the reportai V ies or h w s in aforementioned studies, they were useW

mdels m expbring the contniuîion of group therapy to the matment of h h a .

The purpose of this research was to examine the efficacy of cogaitive-bhavioirral

group therapy in the treatment of chronic insomnia, using both objective and subjective

masures and a contml group. Such a sntdy is in üne with the need to h d effective and

costefficient psy~hotberape~c ways of d&g whh iasomnia.

It was hypotheshd tbat der a cognitive-behaM0ura.i group therapy intervention,

participants wouid demonstrate an iniprovement m cognitive performance (memory,

spatial a g i e s , logical reasoning & concentration), sleep parameters (total sIeep time,

sieep onset & sIeep efficiency) and a decrease in sleep bpahmt . Furthemore, it was

hypothesized that both depressive and anxiety leveis muici aIso decrease. More

specindy, the fohwing hypotheses were made:

1. It was predicted that pdcipaa5s that received CBGT treatment would demonstrate

simiificant improvements m k i r cognitive performance, fbiIowing their participation

in the CBGT. It was expected t&m& scores on the Logid Reasoning, Serial Reaction

Time and Manikin tasks wodd demonstrate statisticdiy significaat improvements at

the pst assessrnent time (2 weeks post treatment). It was aiso

hypothesized that treatment gamS wouicl be rriaintained throughouî the foilow up

period It was aiso hypothesized th the w maîmnt control groups performance

wodd deteriorate over the duration of the study.

2. It was predicted that participants in the treatment groups would denionstrate

discerniile improvements m re&n to skep parameters (sleep latency, sIeep

efficiency & sleep duration) at the fk follow-up measurement (2 weeks post

treatment) and continue to improve to at feast the second measurement miiestone (3

months post treaîment). Furthermore, m reIation to meeting sleep d i i criteria for

signiscanî sleep improvements (i.e. sIeep lateacy < 35 minutes, or sleep e5ciemy

greater than 80%), it was expecîed that 4û#!! of participants who receiwd CBGT

ûatmnt would demonstrate such c h i c a i improvements. It was aIso pdc ted tbet

average sleep d d n would inmase by at ieast haif an hour, and thaî subjective

sleep impairment masures (ISL) woufd also improve. No such changes were

hypothesized for the no treatmeiit control groups.

3. It was predicted that participants in tbe treatment groups wodd demonstrate

signincant improvements in relation to depressive and anxiety levels while no such

changes were hypotheshd for the no treatment conirol groups.

4. It was predkted that p u p members wouM subjectively assess the muiti-faceted

treatment as heiphil in dealhg with th& iusomnia and that they wodd rate the

Mirent componients of the CBGT (ie. guideci imagery, progressive muscle

relaxation, sleep hygiene, stïmuius contml sleep restriction and cognitive

restructuring) as helpfiil.

5. It was predicted that group members would fhd Merent therapeutic cornponents of

group therapy as helpfiil m dealing with k i r insornnia These include: catharsis,

instillation of hope, universality, a h u h , imiîative behaviour, group cohesiveness

and interpersonal lecwing.

Chapter 2

Method

Particiuants

A sample of 70 individuais (35 experirnentd group and 35 wait list controI) with

chronic k m n i a were c e d e c i h m the University of Toronto Centce for Sleep and

Chronobioiogy at The Toronto HospitaÿWestm Division, The age of participants

rangeci between 26 to 61. AU participants were diagnoseci with psychophysiological

hmnia Diagnoses were made througb the use of a semi-stnicnaed clinical i n t e ~ e w

(Appendix A) by a referring sleep specialist. Participants were mformed that a study was

bebg conducting on a cognitive-behavioural group therapy approach to iasomnia on a

vohirrteer basii and that their access to the usual treatment would not be affected by not

participating in the study. The referring sleep specialists then provided participants with

an Infiormation Sheet (Appendix B). If interested they were invited to contact the

researcher.

AU participants were diann<ised with Psychophysiobgical Chronic uw>mnh

Participants had a sleep efficiency (time asleep divided by tirne in bed) of l e s than 85%.

Participants also had difficuity sleeping at les t three times per week for a minimum of 6

months. Participants also expressed a wiliingness to participate m a group therapy

%mai. Aii participants spoke Engiish and had at Ieast a higb school educaîioo. An

participants were not interesteci in use of medication for the treatmmt of theu insomuk

ofien because they bave not found medication helpfüi.

Exclusion Critek

Individuais who had k m a i a associateci wÎth other primary sleep disorciers (e-g.

sleep apnea) were not included m the study. individuals who were usiag or would be

using medidon to treat their insoïmiia were also excluded h m the study. Finaiiy, dnig

dependence and severe p s y c W c disorciers (such as schizophrenia or psychotic

disorciers) were also exchuiing factors, in thai the group dynamics could have been

negatively affecteci by the presence of such participants.

Treatment Protoc01

Copitive-Behaviourai Gram Treatment.

A manual of cogNtive behaviod p u p therapy was developed and used by this

mearcber. The manuai consistai of specific tmimnt interventions for chronic

insomnia (Appeedix C). Each group consisted of five participants (seven treattlaent

groups and seven conml groups). Sessions were 1.5 hours in length, once per week, and

iasted eight weeks. Supervision was ptovided by Dr. Shefdon Shaui, a psychiatrist and

sleep specialist. The p u p s were fàcîiitated by the author of this dissertation. For the

purpose of supervision and adherence to the manuai, al1 group sessions were audio taped

with participants' consent. P r e d n of infermation, p u p discussion, problem-

salving approaches, relaxation techniqyes and cognitive-behaviolaal strategies were

implemented withm îhe dynamics of group mrk The interventions utilized are o u t h x i

in the b h d (Apperadix C). The goah of the treatment p u p s included the provision a

fonun for the sharing of problems and soiutions amng people dering h m cbronic

iasomnia, identifjkg auci overcoming batna to M y sleep, altering dysfunctional

cognitive attitudes, examining sieep hyghe factors, and teaçhing reiaxaîion techniques.

Out-

Outcorne measutes were a d m m i s t d two weeks prior to üeatmnt, two weeks

fohwing -nt, three months biiowing treatment, and six mnths followiag

treatment. ûutcome measures can be classifiecl into objective and subjective measures.

Performance Assessrnent Batterv Subscales (PABL

The Walter Reed Perbmmce Assessment Baîtery (PAB) was used to assess

psychomotor, perceptual and cognitive skiiis, including: memory, spatial abiiities, logicai

reasonhg, and comenûahn (Thme et ai, 1985). The PAB is used as a valid research

device for bllowing changes in performance over periods of tirne (Thom et al., 1985).

The change in perfbtmance can be used to indicate fatigue. The PAB is cornputer

generated, wntmlled and scored. Test items and visual stimuli are shown to participants

on video rnonitors. Participants respond to the stimuli by pressing one or more keys on a

conwmtiod keyboard (T'home et al, 1985). Many different tasks can be implernented

using the PAB, includii: the cboice reaction tirne, tirne estimation, mentai anthmetic,

a d logical reasonhg. The PAB btis been used in a vast a m y of studies, inchiding: s1eep

deprivation, sastamed @rmance, physicai faîjgue, and jet lag (Angus et d, 1985;

Dinges, 1987; Thom et ai., 1985).

Learning effect is cirrtailed because random changes in the order and patte. of all

tasks are automaticaily coatroiied by a cornputer program. Individuai t& are

autumetically generated, pteserised, recoded and scoreci on the PAB. The score

producsd by the PAB is called the throughput, *ch is a speed-accuracy pduct. The

higher the score, the better the performance.

Tbe test battery that was used in this study was configured to take 15-20 minutes

to cornpiete, with a total of three tasks. The three tasks were as fobws: the Logical

Reasoning, Manikin, ad, Serid AdditionlSubtraction. When performing these tasks,

participants were inhrmed that k y sbdd respond as quickiy and accurateiy as

poss~lbie. For ibis study, participants had one practice nm on the PAB. Results on the

second attempt were s c o d

The Logicd Reasoning test has been shown to be very sensitive to fatigue effects,

and inchdes different reasonhg tasks. The ietters "AB" or "BAn appear in the centre of

the monitor, with a statement about the rekionship between the two letters. The

statement may or may not be W. The test-retest rebbility for this task was found to be

.78 (Thorne et d, 1985).

The second ta& was the SeriaI Addition and Subtraction. This is an arithmetic

task that mpires sustained attention and concentration. Two nurnbers appear in the

centre of the mouhor, one der the o k . The numbers are then followed by a "+" for

adding or a "-" for subtracting. The participant either ad& or subtracts the numbers

accordiagly. ïhe m e r is then typed in, usiug the numbered keys on the right side of

th keybard. However, the partic'- has two important things to note wben

performing the ta&. The first is that if any answer consists of two digits, then only the

second digit is to be typed in. The second thing that bas to be noted is th whmever any

response is a negative integer, 10 bas to ùe added to the final amver (Ryman, 1974).

The test-retest r e W i for this task was formd to be -82 (Thom et al, 1985).

The third and fast task in the per£r,rmance battery was the Manikin. This task

assesses spatial abilities (Ryman, 1974). A hrmian figure appears m the centte of the

monltor. The figure is enclosed either by a green circle or a red square. The human

figure holds a smali green circle m one barxi and a small red sqm m the other. Based

on the stiape surrounding the figure's body, the pariicipant must indicate which band the

correspondhg shapt is ia The letter Y" is pushed if the shape is m the lefi hand or the

letter "Mn is pushed if the shape is in the right hand The test-retest reliability for this

task was fond to be .74 (Thorne et ai., 1985).

Subiective Masures.

The self report questionnaires package included a sleep diary, insornnia Severity

Index, Beck Depression Inventory II, Beck Anxiety Inventory, as weli as a demographic

sutvey and a group evaluation.

1) SIeep Diary:

The sleep diary (Appendix D) can provide extremely usefiil clinical information.

A sIeep diary quires daily recordhg of tk following parameters: bedîime, aising tirne,

sieep onset latency, number and duration of awakenings, time of last awakening, naps,

meais, snacks, caffeinated drinks, exetcise, and any use of sleeping medication. It is

simple to use, and its design gives a quick pictorial display of a participant's sleep

patterns over a two week period. A clinician can at a glace gain an understanding of the

nature, fhqumcy, d aadensity of insomnia of nightly variations in sleep schedules and

of some cornmon perpehiatmg factors (e.g. daytime naps). It includes estmiates of time

in bed, sieep the, and wake tirne, so that a global sleep efficiency ratio can be calcdated.

This is obtamed by-dividing "total sleep timen by "time m bed" and multiplying by 100.

In this study partkipants compteteci two weeks of sieep diary mformaîion at each

assessrnent thne. Treatmens efficacy was d ushg the following measures: 1)

participants displayhg a 50% duction on th main target symptom (sleep omet

Iatency); 2) an absohte vaiue of that symptom fiilling near or below the 30-35 minute

d e r i a typ idy used to define insomnia; 3) tbe proportion of patients whose sleep

efnciency moved h m a dysfirncb'ooal to normative Ievel(> 80%) (Morin et ai., 1999).

2) insomniaseverity Index:

The hsomnia Sev* Index (BI) (Morin, 1993) (Appeirdix D) is a 7 item

measure that yields a quantitative index of sleep impairment. The participant provides

ratings (on a 5 point Likert scale, "0" = not at al& "4" = ex&mely) of the seventy, degree

of interfietence with daiiy functioning, Ievel of distres caused by the sleep probiem, and

satisfaction with current sleep patterns. These subjective ratings provide vahiabIe

information on the participoint's perception of his or her sleep problern (Morin, 1993,

Bastien et al, 1999). Total scores range h m O to 28, with high scores indicating grater

hmnia severity. A score of 0-7 Mdicates no clinicaiiy significant insomrth, while 8-.14

indiCates subthreshoid insomuia A score between 15-21 suggests a clinical insomnia

(moderate severity) and, M y , a score between 21-28 indicates c k l homnia

(swere) (Eastien, et ai., 1999). Interna1 consistency was hund to be 0.74. C o n c m

validity was found to be 0.65 when compeirin% changes over time with ISI and sieep

diaries (Bastien et ai., 1999). Thse hdhgs suggest îhat the ISI is a valid and reliable

mstnmient for assessing insomnia

3) Beck Depression Tnventory-II:

The Beck -on hveentry--II @DI-II) (Beck, Ward, MendeIson, M& &

Erùaugb, 1961; Beck & Steer, 19%) (Appendix D) is a kquently used self-report

method of assessing depressive symptomatology. It is a 21 item self.-report imtrumut

that assesses the affective, cognitive, motivational, and physiological symptoms of

deptession. Item categories inclde mod, pessimism, Crymg spells, guiit, ini tab'i ,

sleep aud appetite disturbance, and Ioss of libido. For each of these categories of

symptoms, there is a graded series of four aiternative statements, tangmg h m neutral to

a rmximum level of severity. The items are scored fiom O to 3, so that the totai BDI-II

score can range fiom O to 63. GeneraiIy, a total BDI-II score of 0-13 indicates a minimal

depressed state, 14-19 reflects a mild level of depression, 20-28 reflects moderate

d-on, and 29-63 indicates a severe level of depression. The test-retest reIiabii for

the BDZ-II was found to be 0.93 (Beck & Steer, 1996). Interna1 consistency was fou& to

be 0.92 (Beck & Steer, 1996). Depressive disorders have a strong relationship with

insomnia (Soldatos, 1994). Studies have deriionstrateci that a reduction of depressive and

anxious symptoms paralleIed improvements in sleeping patterns (Espie et al, 1989;

Jmbs et d, 1993).

4) Beck Anxiety Inventory:

ïhe Beck Wety Inventory (BAI, 1993 Edition manual) (Eeck, Epstein, Brown

& Steer,1988) (Appendix D) is a 21 item self-report scde used to assess the severity of

anxïety in ad& and adolescents. It evaiuates the affective, cognitive, motivatwnaI, and

physiological symptoms of anxiety. Descriptive symptom labels inciude feeling hot,

sweaty, scared, afkaîd of dying, and ficuity breathing. Each symptom is rated on a 4-

point scaie mghg h m O to 3. ûmemUy a total BAI score of 0-7 indicates a minimai

anxious state, û-15 reffects a mild level of anxiety, 16-25 refiects moderaîe anxïety, and

26-63 iudicates a severe Ievel of anxiety (Beck & Steer, 1993). The test-retest reliability

for the BAI is 0.75 (Beck & Steer, 1993). Intemal consistency is 0.92 (Beck & Steer,

1993). Auxiety blds a signiscant bearing on the onset and mamotenance of insomnia

Therefore, it is imprtant to be able to assess for amiety as an outcome measure (Espie et

al., 1989; Jacobs et aL, 1993).

5 ) Demograpàic Survey awf Group Evaiuation:

A demographic survey (Marino, 1998) (Appendix E) was developed for the study.

It included information about participants' age, sex, niarital status, duration of the

insomnia, and previous use of medication or other treatment modalities. The

demgraphic survey was admhktered at the first assessment time.

The "Evaluation of Group Intervention" survey (hilarino, 1998) (Appendix E) was

administered in the foiiow-up questionnaire battery. This survey was used to assess

participants' response to the group Mtervention.

Procedures

Administrative consent h m the Toronto HospitaI was obtained for this study.

Participants attendhg the Center for SIeep and Chronobiology at The Toronto Hospital

due to a s k p disturbance were assesseci by Dr. Shaui, a psychiatrist and sIeep specialist.

Diagnoses were made through a semi-sîructured clinicai interview based on the SCID, a

standa&ed assessment battery (Appedx A). Participants diagnosed with cfuonic

insomnia were mvited to participaie in an eight week cognitive-behaviouxd group for

insomnia by distriiting d e n Siformation about the shidy (Appendix £3). AU

participants were informed that hir assessment or the provision of the usual treatment

protoc01 at the S M Clinic would not be affecteci m any way, if they chose wt to

participate or withiraw h m the study. Interestecl participants contacted the tesearcher

via the phone and were provideci with a verbaI description of the shidy.

Participants were infomd tbat îhe pinpose of the study was to examine the

effects of Cognitive-Behaviourai Group Therapy m treating Chronic Insomnia They

were Uzformed that they would be randomly assigned to an immediate treatment group or

to a deiayed group, which wodd receive treabnent m approxhately eight months the.

Participants were also informed of the length and duration of the cognitive-behaviod

group therapy (1.5 hours per week, for eight weeks). A description of aii assessment

measures were then provided. Those who were interested in participating in the study

signed the consent form (Appendii B) at the pretreatment assessment tirne. Aii

participants were notitied that Iliformatioa discussed in the group sessions would be kept

in strict confidence (except if they were Ui imminent danger of harming themselves or

others or indicate tbat a child is at risk of abusefneglect at the tirne of study or if there

was a subpoena by the court). They were also infofmed that aü data couected would be

assigneci a research code number and that their confidentiality would be maintained with

respect to any pubiication or presentation.

Lnnited by the nurnber of referrals provided, only 10 participants at a time were

randomived to either an immediate treaûnent group, or to a delayed aeatment group (5

per group). The delayed treatment group secved as an 8 month control group (no

treatment). The ten names were chosen randomly (through a lottery system), one at a

the, and placed in each group. The subsequent IO retérrals foiiowed the same process;

each name chosen randody and assigwd to the immediate treatriient group or deiayed

treatment group. The process was rep ted seven times m total

The study was conducteci at the Center for Sleep and Chnobiology at The

Toronto iiùspitai (Western Division). AU technical eqniprnent was provided by the sleep

c h i c and sessions were held m a conference room at the Toronto Hospital. Sleep

disorder consuitation was provideci by Dr. ShauL AU sessions were audio taped for

purposes of supervision by Dr. Shaui and adherence to the manuai (Appendùr C).

The sample size and group size chosen was based on samples used in other

e s that explored the effects of CBT in the treatment of insomnia (Lacks, 1991, Motm

et aL, 1992, Kupych-Woloshyn et ai., 1993). The number of sessions used for this study

was also based on standards found in the literature (Lacks, 1991, Morin et al, 1992,

Kupych-Woloshyn et al., 1993). In addition, six months was the average period of tirne

that was used for foUow-up evaluations (Morin et al., 1999).

Implementation of Coimitive-Behavioural Grouu Thera~~ intemention.

A manual (Appendoix C) was used when implementing the CBGT. The same

muai was implemented in ail treatment groups. The treatment agenda was covered

durhg eight weekiy groups session. Session one began with a brief repeated introduction

of the study and of the limits of confidentiaiity. Participants were then h k e u up h o

subgroups of two or three members. They were asked to obtain uiformaîion (name, age,

sleep probIem, duration of problem) about the other participants. This information was

then brought back to the group as a whole. As the facikitor of the group, it was

important to mode1 selfdisclomre and opemess with the participants. Having worked in

a sleep clhic for s e v d years, a job that mvolved shiftwork, thk writer was able to

disclose sleep relateci problems tbat were similar to those conveyed by group members.

Paaicipants were encorrraged to discuss their sleep probiems in their own words and

descrii how insomnia bas effêcted k i r Iives. C m t b g a sense of tmiversaüty was

essential m order to heip participants feel that they were not isolated in the+ experiences

of hsomnia It was also explained to participants that sessions would begin with a

"check in" ad "self monitoring", where they disçuss how their week had been with

respect to their sleep, emotions and physicai and cognitive fbnctioning. A review of the

sleep diary was also conducted and any questions that participants had were answered.

This became an opportunity for other group members to make suggestions or comments

to feiIow members who may have had a particuiariy difficult week, thereby mahg the

processes of imparting of information and al- possible. The diversity of the group

and the sleep difficuities they experienced was used to provide participants with possible

explmations or rationaies to misconceptions they have had with their own sleep problem.

Session one aIso d e s c r i the cognitive-behaviourai therapy approach. A social

leamhg explanation of b m n i a was then provided. Sleep physiology was discussed in

order to give participants an idea of what sleep reaiiy is, what it look Iike and how it

changes over tirne.

Session two began with a "check in" and with a review of the sleep diary. An

introduction of the behaviourai mterventions (stimuIus control and sleep restriction) was

provided. The behaviourai treatment rationale was also provided. The directions for

both stirnuius control anci sleep resîriction were also provided as handouts,

Session thtee had the usud "check m" and review of the sleep diary. Bebaviourai

procedutes were reviewed. Feedback pertaining to stimulus control and sleep restriction

was discussed. Problems encoimtered, predomtnately with adherence, were discussed.

The encouragement of probiem solving was seen as important m an effort to move the

group xnembers h m a passive mode of functoning to a more active mode and to create

greater cotaesivewss amongst the group members. Positive feedback aiiowed for

constnrctive changes to be implemented by others and to instiU hop. Session three also

consisted of a kief introduction and an ovewiew of the reIaxation techniques.

Reiaxation techniques consisted of progressive muscle reiaxation, guided irnagery, deep

breathing and autogenic training. Handouts of these descriptions were provided to

participants.

Session four reviewed the usual "check in" procedure and sleep @, as weU as

behaviourai procedures and reiaxation techniques. Cognitive therapy and its rationale

were also introduced. Participants' beliefs and attitudes about sleep were identified

through non-staradardkd d e s and cognitive vignette handouts (Appendix E). These

handouts were explored within the group for various dysfunctional sleep cognitions and

misconceptions about insomnia. Once identified, the objective was to challenge these

fady beiiefs and cognitive m r s and replace them with more appropriate ones.

Session five aliowed for fùrther exploration of participants' dysfunctional sleep

cognitions. Cognitive restnrcturing techniques such as reappraisai, reattn'bution, and

decatastrophiptlg wete used wben exploring their sleep beliefs. A brief introduction to

sleep hygiene education was provided m session five dong with a han do^

Session six continueci to review participants' "check in", as weii as the

behaviourai, cognitive and relaxation technique procedures. Session six aIso c o n h u d to

expIore sleep hygiene and discussed issues specinc to d e m e , nicotine, alcohol and

environmental factors.

Session seven was similar to çession six in that it consisteci of a review of al1 the

behaviourai, cognitive, and educational mterventions. It aiso integrated the separate

thetapeutic components. Feedback was provideci by this fâcilitator and by other group

members.

Session eight covered ways m which members could continue to adhere to

treatment and maintain any gains. ReIapse prevention was a h discussed where

members were informeci that even with major gains, the inevitability of having occasional

poor sleep in not musual. A "ûroup Evaiuation" (Appendii E) was diiiuted.

Statistical Anaivsis

The data were anal@ using a mixed multivariate anaiyses of covariance. For

al1 the measures in the study there was not sufl?cient statistical evidence to conclude that

the assumption of parallelism underlying anaiysis of covariance was violated. The basic

design, applied where the assumption of parailelisin was not violaieci, was of Age as the

single covariate, Protocol group (ûeatment groups/control goups), Repiication group

nested within Protocol group as a blochg factor, Gender, the interaction between

Gender and Rotocol group, and Replication group nested within the interaction between

Gender and Protocol group, with, tirne of masurement (baselinefI0 weeksn months/6

months) as the repeated measures fàctor. Replication group is a 14 level fktor

corresponding to the Protocol groups into which the sample was divided as described

within the Methods section. Cornparisons of individual marginai means were d e using

T tests with Bonfmni comcted p values.

Resuits and Findin~s

Descriptive Statistics for the Obtained S m l e

There were 24 males (343%) participating m the study with an average age of

40.3 years, and 46 females (65.7%) with an average age of 42.1 years. Ages canged from

26 to 61. Most participants were d e d and completed University or cokge. M y a

mioonty of the sample (les than 25%) had insomnia for les than 4 years. No sigaificant

ciifferences were found between the treatment and control groups. No participants were

using medication during the shrdy (see Table 1).

Mdc

F e d c

High Schml E d W d Aniinmcm

Univcigty or Cdlcge

T h e were 47 participants who pteviousIy used medication to treat their

insurunia. Participants tbat had previously used medication to treat their insomnia, ali

reported that it (medication) provided only temporary relief of thek insomnia symptoms.

Furthermore, a tolerance developed when medication was used for proIonged periods of

time (pater than 3 months). This was the main reason why participants discontinued

îhe use of medication. The average dm'on of h m n i a reporteci by participants was

seven years.

T-tests were used to compare treahnent and control groups on aii objective and

subjective outcorne measures. No signincant ciifferences were found (see Table 2).

BAI 2450 2.22 2535 2.40 1.54 0.13 N e Buth gro~ps consista! of ip35 subjcus. - Performance Assessrnent B q Outcome of the Treatment and Control Grou~s

On al1 measures of the PAB, the treatment groups changed differently than did the

control groups: hgïcai Reasoning @ (3, 129) = 150.76, p < .001), Seriai Addition and

Subtraction (!? (3, 129) = 219.92, p < -001) and Manikin @ (3, 129) = 139.22, e < -001)

(see T x P &or in Table 3).

S x R(PxG)wichin 43 (116.67) (457.71 ) (24.86) Gmupcrmr

W i i Subjcus

Time 0 3 0.02 5.1 1- 1.02

As can be seen m Figures 1-3, the tmitment groups had better average throughpt

scores oa the Logid Reasoning, Seria1 AdditiodSubtmztion Reaction Time and

Manikin tasks when compared to the control groups. Figures 1-3 demonstrate that the

treatment groups coatulued to show improvement in their performance ftom the initiai

assessment time up to the 3 month foilow-up period. Furthemore, the controI groups

performance appears to deterioraie up untü at Ieast the 3 month fo£iow-up mark. The

MANCOVA h u p factor amss ail assessment times was found to be signincantly

diffe~ent between the treatment and control groups.

Logical Reasoning

30 O

Table 4 details means, standard deviations and results of the analysis of

covariançe for each PAB measure. With regard to performance on the Logical Reasoning

task, the treabnent groups' average level of performance irnproveà h m badine to

initial pst treatntent measmement at the IO week mark (j (129) =14.O 1, p < 0.005).

There was aiso statistical evidence of further improvement at the 3 month mark (t (129) =

5.14, p < 0.005). No discemiile change in the treatment gtoups' performance was fotmd

beyonsi the 3 month mark. The level of performance for the control groups appeared to

get worse at the 10 week pomt @ (129) = 3.16, p < 0.05). Furthemore, th= was furtber

sigiticant change at the 3 month mark @ (129) = 3.36, p < 0.09, and continueci

deterioration at the 6 mnth mark @ (129) = 4.67, p < 0.005).

Similady, the treatment groups performance on the Serial AdditionlSubtraction

improvesi h m basehe to initial post treatment measurement at the 10 week @ (129) =

14.75, p < 0.0005). There was further improvement at the 3 month mark (129) = 14.70,

p < 0.0005) and no signiscant changes with the ûeatment groups performance beyond the

3 month mark The level of performance for the control groups appeared to get worse at

the 10 week mark @ (129) = 3.16, p < 0.05), at the 3 month mark (f (129) = 3.36, p <

0.05) and 6 month mark (1 (129) = 4.67, p < 0.005).

Finally, the treatment groups performance of the Manikin improved fiom baseline

to initial pst treatment measurement at the 10 week (1 (129) = 14.40, p < 0.005).

There was also a discemile change at the 3 mnth mark (f (129) = 8.55, p < 0.005). No

further change was found beyond the 3 month point. The level of performance for the

control groups appeared to deteriorate beyond the 3 month point (f (129) = 6.22, p <

Table 4

Mun8 and Shndrrd bviabionr and AnJnis of Covirlinci for the îhm PA6 mmsunr

On aü measures of sfeep and &igue the treatment groups changed differently

than did the control groups: Sleep D e Latency @ (3, 126) = 52.11, c .001), SIeep

Diary Efficiency @ (3, 129) = 55.78, Q < .ml), Sleep Diary Duration @ (3, 129) = 58.75,

p < -001) and the lnsomnia Severity index @ (3, 129) = 138.38, p < -001) (see T x P

factor in Table 5).

Table 5

PxG 1 1.17 9.01 0.11 0.12

&x RRPxG) within 43 (SU.57) (130551 (1.53) (Z.21) Cimup amr

Witlun Subjtctr

T x G 3 0.49 0.03 0.06 0.15

As caa be seen in Figures 4-7, at aI1 different times of measurement the treaîment

groups were found to be sleeping beîîer a d repoamg Iess Mgue. Figures 4-7

demonsrne thai the matment groups continued to show improvement m th& sIeep fiom

the initial assessment time up to the 3 month fôUow-up @O& The control gronps sleep

appears to remain uachanged throuqhouî the entire duration of the study.

Steep Diary - Sleep Latency

Sleep Diary - Sleep Efficiency 80,

m e n t

Sleep Diary - Sleep Duration

Table 6 details means, standard deviations, and resuits of t h analysis of

covariance betwa the treatment and control groups. With regard to the results on

the Sleep Diary Latency, the treatment groups average latency to sleep onset

improved fkom b a s e h to Uiial post treatment measuremmt at the 10 week mark

Q (129) 43-21, p < 0.001) and îùrîher improved as of the second post treatment

measurement taken at the 3 month mark (t (129) = 6.88, p < 0.001). There were no

discemible changes beyond the 3 month mark. The sleep fatency fm the control

group appeared to be constant throughout the 6 month duraiion of the study,

Furthmore, the treatment groups Sleep Diary Efficiency increased fiom

baseline to initial post treatment measurement at the 10 week mark (129) =

14.29, p < 0.005). There was a fùrther increase to the 3 month mark 0 (129) =7.94,

p < 0.005). Beyond the 3 month mark there was no discemible change in the

treatment groups Sleep Efficiency. There were no statisticdly significant changes

to the controi groups SIeep Efficiency throughout îhe duration of the study.

In addition, the treatment groups SIeep Diary Duration rose h m basehe to

initial post treatment measurement at the 10 week mark (t (129) 4-63, p < 0.005).

SIeep duration continued to increase t'urther between the 10 week and 3 mmth and

no signifiant changes occurred to Sleep Duration beyond the 3 month mark. The

control groups had no discernile chmges tbroughout the entire period of the

study.

Findly, the ireatmnt goups resuIts on the lnsomnia Severity Index (BI)

showed an improvement in participants' seventy of insomaia fiom basehe to initial

post treatnient measuremeut at the 10 week mark 0 (129) =I9.12, p < 0.001), and

fùrther impvement at the 3 month point (t (129) =7.88, p < 0.001)- There were no

furher discerniile changes arnong the treatment groups beyond the 3 month mark.

The control groups results indicate no discemile changes throughout the duration of

the study.

(SI t52S 25.W 17.34 2521 15911 2531 15.85 25.47 13838 <.a005 (1.44) (1.42) (2dR) (3.12) (3.03) (328) (322) I3.48)

No<c V d ~ ~ p r r m k # r n p r c P c a t S m n d u c i D c v i r n ~

On both m a u r e s of depressim and amie@ the trament groups changed

diflkmatly than did the cmtrol groups: the Beck Depression Inventory-II @ (3,129) =

123.67, e < .001), and the Beck Amiety Inventory @ (3, 129) = 259.98, < -001)

(see T x P fàctor in Table 7).

T x A

T r P

As can be seen in Figures 8 and 9, at al1 times Iater than the baseIiae

rneasurement the treatment groups were Fouad to be Iess depcessed (BDI-II) and

amiou (BAI) than the control groups. The îreatmmt groups appeated to show

improvemeat up until the 6 rnonîh ma&, wh~rwis tae control p u p s depression and

amiety levels remained reMvely mchanged during the entire study.

Beck Depression Inventory II (BDI - II)

Beck Anxiety lnventory (BAI)

TabIe 8 describes the means and standard deviations of and conûol

groups for the BDI-II and BAI. The treatment groups scores on the BDI-II decreased

h m baseline to mitial post katnmt meamernent at the 10 week mark @ (129) =18.05,

p < 0,ûûI). A firrther decrease in the scores took piace at the 3 month mark & (129)

=7.35, p < O.ûûl), and coatimied to decrease at the 6 month phi @ (129) ~7.53, p <

0.ûûI). The control p u p had no discernible changes regarding scores on the BDI-II

throughout the entite duraiion of the study.

Fidy , the treatment groups resuits on the BAI suggest a signifiant decrease to

the initial post treatnaent measurenient at the 10 week mark (1 29) 30.84, p < 0.001).

Also, at the 3 month mark thme was evidence that the treatment groups lm1 of anxiety

demead & (129) = 8.86, p < 0.001). In addition, k r e was a diicenii'ble change at the 6

month inark & (129) = 7.42, p < 0.001). Tiiere were no dtsttnguishab . . . le changes in the

controf groups throughout the duration of the study.

Tibk 8

Table 9 descrii the fkquency and perçentages of treatment group mernbers that

did not meet clinical criteria for cinonic insomnia on the measmes of Sleep Diary

Latency, Eficiency awf Duration. At the 10 week measurenient time* 22.9% of the

approximately 55% of the subjects m the treatment groups did not meet the conditions of

chical signincance fot sleep diary 1-y.

At the 10 week measunment time, 143% of the subjects in the treatment groups did

not meet the conditions of cIinical signincance of Msomnia) for sleep diary

efficiency. At al1 measurement h e s ôeyond the 3 month mark, approximately 40% of the

subjects in the treatmeut groups did not meet the conditions of chical significance

(indicative of insornnia) for sleep diary sieep efficiency.

As was hypothesized, the intervention is associated with an improvement in sleep

t h e duration which is still detectabIe at six month aRw the intervention. At aU

measurement times beyond the 10 week mark, 100% of treeitment groups members did not

meet conditions significant of insomnia based on sleep diary duration. It was observeci that

the marnent groups experiencd a 22 hour i n c m in sleep time duration on average

between baselie and the six month meamrrement, t(129) = 12.54, k< -0005.

Contrary to the treatment groups, the control groups met conditions of ciiical

signifimce (indicative of insomnia) on atI sleep parameter measms (sleep latency,

efficiency and duration) kom baseiii to the 6 month foUow-up point (Appendix F).

Table 10 desrri'bes the fkquency md percentages of the treatment groups chicd

stahis regarding the severity of bsomnia as measured by the ISI. At baseline, most (97.1%)

of the treatment groups sufked h m severe insoinnia as measured by the lnsomnia Severity

Index (ISi). In conmut, 85,Ph of the treatment groups had attained moderate to subthreshoid

Ieveis of insomnia by the 10 week mark, as measured by the ISI. This trend did not continue

over the mainhg measurements.

Ume the katment gmps, no consistent changes were found througimut the

duration of the study with regard to the hequency and percentages o f the control grwps

chical status based on the ISI (Appeadix F).

Table f f descriles the hquency and percentages of the treatment groups chical

statu regarding depression and BIlXiety as measuted by the BDI-II. and BAI, respectively. At

basehe, most of the îmtment groups (97.1%), sufEred fiom moderaîe depression, as

m d by the Beck Depression Inmtory-lf (BDI-0. There was a c h g e at the 10 week

mark, where 743% of the tceattneut gronps cevealed a miid tevel of depression, as measured

by the BDI-II. These W m g s remamed rehtively stable tbroughont the dunition of the

study . In reknce to the Beck Amciety Inventary @AI), between the IO week and 3 month

marks the number of subjecîs who &ad a t b î d miki a[IXiety Ievels as indicated by the BAI,

rose 6 fold hm its prior level. Over the course of the intervention, 67% of the treatment

grwps who had severe leveis of anxiety had attained iess than severe Levels of anxiety.

The conirol groups did not demoastrate any consistent cbanges during the study with

regard to the fkquency and peilcentages of their clhical status on the BDEU and BAI

(Appendix F).

Table II

CI'mialS- BDI-n BDI-U 801-n BOC-Il BAI BAI BAI BAI

MinimJ 1 (2.9) 5 (14.3)

Mild 26 (743) 27 ( 7 ï . I ) 23 (65.7) 2 (5.7) 11 (31.4) 18 (51.4)

Modauc 34 (97.1) 9 (25.7) 7 (20.0) 7 (20.0) 26 (743) 30 (85.7) n ( 6 ~ 9 ) 16 (45.3

Observed Prefmnces for Comuonenis ofthe CBGT Intervention

Table 12 desmies the lkquency and percentages of the matment p u p s evaluation

ofwhether they found the interventions Iisted below helphl m d d i g with their insomnia.

Guided Imagerv.

The prefèrences expressed for guidai irnagery appeared stable across masurement

times in the study. Roughiy 23% of participants who received the CBGT intervention found

guided imagery very helpfûi, while the o h 77% of participants found guided hagery only

Across the period of the study, it is apparent tbat there was a constaut deche in the

portion of pafticipamg who fouml progressive muscie relaxation (PMR) to be very helpîùt

However? al participants téet that PMR is at Ieast somewhaî helpfiil

Breathing Exercises.

The ptefetences expressed for breathmg exmises appeared stable across

measurement times in the study. Approximately, 14% of participants who received the

CBGT mtervention found breaîhhg exercises very helphi, while the other 86% of

participants found hathing exercises only somewhat helpfiil.

Autoaenic Trahine.

Throughout the study, it appears that there is a constant declme in the portion of

participants who found autogenic training to be somewhat helpfut However, a majority of

participants never kIî that autogenic training was helpful

Sleep Remidon.

There appears to be a trend towards higher leveis of participant positive evaluation

for sleep restriction. At the 6 month follow-up point, approximately 66% of treatment groups

members found sleep restriction as somewhat help h l and 34% found it as very helptùl. B y

the end of the study, no participants felt that sleep restriction was not helpfÛL

Stimulus Cantrol.

Participants evahution of stimulus control appeared to be coostant mer the period of

the study. Approximately 66% found stimulus control somewhaî helpfial and 20% faind it

very helptiil. However, appnnrimately 14% found stimulus control not helpfirl at ail.

Sleep Hvniene.

The prefêrences expressed for sieep hygiene appeared stable actoss measurement

times m the study. ApproxPnateIy, 60% of participants f d sieep hygiene as somewhat

hefpfil and 40% found it as very heiphl.

tt appears that participants rateci cogniLNe restnrcturing positively, with

approlrimately 55% ratmg the technique as very helpfid at h e e and six months,

CO@ to 46% a the IO week ~mk.

Approximately 74% of participants found sleep physioIogy information as very

helpful at the 10 week mark This rating steadily declind by the six month folIow-up

m e a m , with only roughiy 54% rat@ it as very helpfd

Table 13 d e a c r i i the kquency and petcentaga of tteaIment p u p s evabîion

of whe&er they fouad Wors of group therapy as heipfùl m deaiing with their insomnia

A majority of participants (62-97%) rated the hilowing htors as intensely helpful, m

dealing with their insomnia: eltpressmg my concerns and fèelings, indhion of hop,

my probIems and fèehgs are not unique, geüing advise fiom other menibers, féeling of

belonging, ùelping others, and learning h m watcbiug others.

Tibk 13

Chspter 4

Discussion

Prier to discussing these results fiirtber, it is of relevance to mention the

i;m;tations of the study. The miin Iimitation of the study rehtes to the nature of the

control group. This control group was a no treatment conbol group. Gains made in the

îreatment groups may relate to noi~specinc therapy components of king in the therapy

group, rather tbao specincally to the CBGT components. Group sessions foiiowhg an

aheniative therapeutic approach may have been preferable in assessing the specific

effectiveness of CBGT. In addition, a longer term foihw-up wodd have yieIded

important mformation about the longer-term maintenance of therapeutic gains. Another

limitation of the study relates to the participant selection. The process of r e f e d to the

study disallowed keeping a coqlete record of what petcent of etigiile patients seen at

the sieep cihic chose to participate in the study or how representaîive the study sample

was of the chic patient popdation In addition, research diagnoses were based on a

semi-stmcîmd rather than a firlly süuctured interview guide and no inter-rater reliability

measures were employed. The researchcr, bwever, did repeat the semi-structured

duation d constantiy agreed with the ~isychiatrists' diagmsis.

Taking the above Iimitations h o consideration, the purpose of this study was to

impIement and evaiuaîe cognitive-behavburai group therapy (CBGT), for the treatment

of psychophysioiogical insomnia Specincally, the study evaluated w b the

impIemeatation of the CBGT intervention would @mve participants' quaIity of Me in

the blloWmg areas: cognitive performance, skep and fktigue, and emotiooal =Il-king,

All objective (PAB) and subjective measures wete found to be s t a b t d l . .

ysiPnifi-

Signifiant gains were f o d on aU objective and subjective measures during the

treatment period wittr maintenance of therapeutic gains during the foUow-up period.

CBGT was found to be effective in improving both cognitive performance and sleep.

Tbe CBGT aIso appeared effective in ameliorating exnotional weii-king, indicated by a

decrease in depression and amiety levels.

The resuhs indicating improvement m sleep anci emotiooal weli-king replicate

similar hdings m other studies which employed an individuai cognitive-behaviour

approach (Espie, 1991; Espie et al, 1989; Jacobs et al., 1993; Lacks & Morin, 1992;

Morin et aL, 1989; Murtagh & Greenwood, 1999, as weii as studies *ch Mplemented

a group therapy approach (Jacobs et ai, 1996; Kupych-Woloshyn et aI., 1993; Lacks,

1991; Morin et al., 1993). There are no pubiished Wes concerning irnprovement with

regard to w@ve performance, foiiowing either an individual CBT or CBGT

himention for people with insonmia. This is one of the ht studies to expktre this

s p d c area. The resuhs of this research demonstmted statistically signtficant

differences in cognitive performance betweetl members of the CBGT treatnsent groups

and members of the control groups. These findings are in iine with the resuits of studies

that demonstrateci that sleep deprivaiion was shown to accompany iowered coguitive

pertormance (Angus et al, 1985; J o h n et ai., 1998; Spiegel et ai., 1998; Thorne et al,

1983).

Comitiive - Petformmce

As was hypothesiped, participants' cognitive performance, as d by the

Wafter Reed Performance Assessrnent Battery (PAB), was faund to show statistically

signincant miprovements up mil the 3 month foiiow-up *od. Morin and cofleagues

(1999) suggested that kause CBT treatments are typically implemented in brief periods

of time (6-8 sessions), participants d y begin to M y intepte the newiy i d

clinid procedures 2-3 months following îhe lasî session. Therefore, it is quite usual to

see participants contins to rnake significant improvements 2-3 months hllowing

trestment. At aii different times of measurement subsequent ta the CBGT intervention,

the treatment groups were found to have higher throughpid (see Method section for

definition) with regard to cognitive perfiormance when CO@ to the control groups.

The control groups performance deterioratecl over the duraiion of the study, as

their sleep remained hpakd. This was not surprising smce the control groups Iacked

treatment for insomnia, ttiereby mamtammg . S . a level of sleep deprivation and consequently

mcreased impairment in performance. That is to say, the more sleep deprived an

individual remains, the more kely their performance is to deteriorate ( J o h n et ai.,

1998; Spiegel et al, 199%; Thorne et aL, 1983).

The làct that the treatrnent groups demonstrated impmved cognitive performance

is not surprishg given that they aiso demonstrated improvement in their sleeping

patterns. As pmbus research has demonstrated, sleep deprivation adversely affects

cognitive performance. The observeci improvement in cognitive performance of the

treatment groups is Iikely the result of improvement in the quality and quantity of sleep.

For example, a srudy (Angus et ai., 1985) demonstrated that individuals who were sIeep

deprived and mactive for 60 hours and completed assessments of fatigue, sleepmess and

m o d every three hous, vigilance task every six houn, and a cognitive test battery every

twelve hous, were f o d to exhiiit decrements m kir @orniance. Furthemore,

another study (SpiegeI et al, 1998) demonstrateci that reduced deep contn'buted to

decrements in participants' pehniiaoce, aiad that within days of king able to resume a

normal sleep routine, prticpartb' performance begm to show improvemerrts. These

iïndjngs paralle1 the resuhs of this riesearch in that participants wbo have been p a d d y

sieep deprivecl for years exhibited a Ievel of performance h t kgan to steadiiy impmve

once theù sleep became Iess restricted. These hdhgs were aise substantiated by a d y

coaducted by Johnson and coUagues (1998), wtiete they were able to show that partial

sleep deprivation over several days negatively effected participants psychomotor

vigilance. The study demonstrated that when sIeep was mcreased back to basefine

duration (approximately 9 hours), performance decrememts were reversed and stabifid

over the week These studies ais0 demonstrated that as sleep was p r o p i v e l y deprivai

over tirne, participants' level of performance continued to deteriorate. These hdings

paralel the resuhs that were obtained h m this study, where the no treatment control

groups performarice progressively deteriorateci up rmtil the 6 month hhw-up period.

S f e e b P ~ e T S

In conjunction with the assessrnent of cognitive performance, this study assesseci

s l q parameters associateci with the sleep dhry in keeping with the practice m the

m h ütaature (Espie, 1991, Lacks, 1991, k k s & Morin, 1992, Morin, Culbert,

Kowatch & Waiton, 1989, Morin et ai., 1993; Murtagh & Gteenwood, 1999, almg with

the assessrnent of additional sleep parameters associated with imamnia (Insomnia

SW* M x ) .

As was hypotkizd, at all different times of meamernent subsequent to the

CBGT hterveniion, the trament groaps always exhibited less sevm symptoms of

bsmuk, relative to the controt pups, as mwwted by the leveb of tbek sIeep

parneters (sleep latency, sleep efficiwcy, s k p duration, and imornnia severity). These

resuits parallel the effects of indMduai a d gmup cognitive-bebaviour therapy. reported

in numemus previous studies (Kupych-Wobshyn et d, 1993; Lacks, 1991; Morin et d,

1993; Morin et al, 1994, Morin et ai., 1999; Murtagh & Greenwood, 1995).

Furthemmre, in keeping with the merature, it was expected that appmximately 4 W / o of

the participants who received CBGT treatnment wouid demonstrate chicai improvements

with their sieep (Jacobs et ai., 19%; Lacks, 1991; Morin et aL, 1994, Murtagh &

Greenwood, 1995). The magdude of improvement bas been repotted to be as high as

60% after individual treatmeat (Morin et d, 1992). The afotemenîioned expectations

were met in this study.

The tmûment groups exhiited clinicdly sigxifïcant improvements in sIeep

latency, as was hypothesiied, As was the case with cognitive performance, it was

observeci that the proportion of participants exbiiiting clinically signifiant

improvements in sleep laîency stabilized at tlae 3 month mwisuremem and beyond. This

m y be because, as previously descriid the Cognitive-Behaviod treatment was

implemented over a relatively brie€ perïod (8 weeks) and tberefbre iikely required more

time to M y mtegraîe the newly lemmi ciinicai procedures (i.e. relaxation techniques,

sleep restriction, stimulus control etc.). The resuh of tbis study (57.1% of participants

with chicai signifiant n n p r O v e m m sleep btency) are sirdar to those of Mirrtagh

and Greeirwood (1995) study, w k e a 50% Enprovernent was foimd among study

participarrts. A study by Lacks (1991) derno- that 39% of mdividuais who were

treated for insonmia h u g h behaMour group therapy met clinical signXcance for

improved sIeep iatemy. Thts figure Bicreased to 49% at the three month follow-up

assammt. Am>ther study (Morin et al, 1993) demonstrated that Miowing a CBGT

approach to treat late-life insomnia, participants sleep latency improved h m 39.6

minutes at baseiine, to 20.6 mbutes at the first posttreatment follow-up a d remained

relatively stable up until the 3 month (21.3 minutes) and 12 month (22.4 minutes) f5LIow-

up *O&.

The treatment groups exhibiteci an inmase m the proportion of participants d o

Md to mxt the ciinïcai sleep efficiency siandards b r insomnia, as was hypothesized.

Specifically, the cihical standard for insomniii. based on sEeep efficiency, is a ievei below

800/0-85%. As was the case with sleep latency, it was observeci that the proportion

(approxbately 40%) of participants exhiiiting clinidy signifiard improvements in

sleep efficiency stabilized at the 3 month measurement and beyonh These hdings are

coasistent with the iiteraîure (Morin et d, 1994). Morin and coileagues (1994)

demonstrated that 53% of the5 participants had a sleep efficiency greater than 80%.

Another study (Morin et ai., 1993) showed that sieep efficiency improved h m 68.55% at

b a s e h to 81.12% at the 3 month foihw-up id 83.68% at the 12 month foiiow-up.

Thete are m criteria for ciinicaiiy si- improvernents in sleep t h e

dudon, aithougb, Morin ad ~~Iieagues (1999) suggest thaî a half hour inmase is a

d e s t miprovement. We observai an average 2 hours and 20 minutes mcrease in sleep

thne duration six months fobwing the CBGT intervention On the basis of the p u b W

staodatd fit modest miprovement, ~ E E CBGT intenrention appears to be associated with

at least a modest improvement m sleep the cidon. This improvement @eh sin&

fhdings of amither study (Morin et aL, 1993) whkh demonstrated that hUo* a CBGT

intervention for msOmia, participants . . sleep duration mcreased h m approxhately 5

boum and 15 niinutes at baseline to 6 hom and 30 minutes at a 12 m o d foibw-up.

Approximately an improvement of 1 hour anci 15 minutes.

The treatment groups exbtbited statisticaüy signüicant improvements on ail

subsequent measurements of the Insomnia Severity Index (ISI), up to t h e montbs after

the CBGT intervention. These fïndings, in the context of CBGT, are consistent with

recently published research studies on improvements on the ISI m individuais foilowing

participation in individual cognitive-behaviouraI treatment. For example, a study using

the lnsomnia Severity Index (ISI), demonsttated that participants with a "moderate lever'

of insomnia at baseiiie, Mproved to a "subthreshold IeveI of insomnian at 3 months

posttmtmnt, foUowing a CBT intervention (Bastien et ai., 1999). The present study

demonstrateci a movement h m "severe" insomnia to both ïnoderate" and

"subthmhold" msOmnia at the 3 month mark

I k m s i o n and Anxietv Measures

Staristicai improvements m depression and anxiety were observai to occur

between di successive measurements fôllowing the CBGT intervention It was observed

tbat both depressi*on and aaxiety, as measrrred by the Beck w o n Inventory-ii (BDI-

n) and Back Amciety inventory (BAI), respectively, improved within the treatment

groups up uutil the six month mark. In contrast, the average depression and anxiety

ieveis within the control groups, did not change throughoui the study. These fïndings

concerning a reduction in depression and anxiety in association with improvements in

sleeping patterns are consistent with those m the published literature (Espie et ai., 1989;

Jacobs et at, 1993; Morin et ai., 1993). It was observed that whems sleep and

pe&mance measures improved oniy up to the three month mark, depression and anxiety

conîjnued to impmve up to the six mnth mark. The mntinuitig improvement m

depression and anxiety may be due to positive changes in varied aspects of participants'

Lves which are enhanced by the improved levels of sleep and performance. The

treatnr=nt groups exhiited an increase m the proportion of participants with a less severe

clinid status of depression artd -ety.

Preferences for Compnents of the CBGT intervention

As was predicted, it was found that members of the treatment groups did find the

muit-faceted tmtment as hefpfbi in dealing with their insomnia This is in keeping with

other studies which have denmnstrrrted that a combined approach is significantly more

effective than no treatment (Edinger & Stouî, 1985; Sacobs et aL, 1993). These studies

dso demonstrated that the best outcornes from muhicomponent interventions included

sleep restriction and /or stimulus control procedures, integrated with other methods such

as cognitive restructining and relaxation metéods (Edinger & Stout, 1985; Jacobs et ai.,

1993). These studies demonmateci that effective clinid management of insomnia ofien

involves a combination of treatment pncedures .

As was hypothesiped, the Group Evahiation measure d e d that participants in

the tmtment groups rated psychotherapeutic fàctoots of group therapy as moderately to

intensely helpfbl in d d g with their insomnia. Participants rated fàctors such as:

catharsis, instilIzdion of hop, imiversality, inîerpersod learning, p u p whesiveness,

impartmg information, ahmim, and imitative behaviour as belpftL These fàctors are

pertinent to the principles and findings set forth by Lacks (1991) and Kupych-Woioshyn

aud colleagues (1993). The group fomiat heips demonstrate to participants that they are

not alone in their sufking and that tbeir probiems are shared by others. Inter-individuai

differences become points of discussion, thereby valiùiy excluding the notion of a

singuiar recipe fbr sleep. Iniprovemenî in some mernbem of the groups instiiis hope in

others.

Imglications and Sumzestions fiir Future Research

The study suggest that CBGT may be an effective and cost-efficient treatment

approach to chronic insomnia. At the t h e of cuts to the firnding of heaith services, the

provision of cost-efficient treatment becornes imperative.

Firrther studies of this approach to îhe treatment of chronic insomnia are therefore

indicated. The observed improvement in cognitive performance suggests that , beyond

the benet3 of reduced stress to individualq effective treatment will benefit the Iwger

society through improved work perfomiance and reduction in insomnia rehted accidents.

Beyond therapy groups to individuais with chronic insonnia, relevant psychoeducational

and cognitive information rnay be shared h u g h brochures and other forums, such as

work phce workshops.

Ftrrther study of the CBGT approach to chronic insomnia may take daerent

directions. A study compariug the d e c t of CBGT to thaî of sleep medication will be

informative in affecthg normative ctinical procedure which often involves dmg

prescription. The combimation of CBGT and dnrg treatment couid be compared to CBGT

or drug treatment only. Cross validation of the results of the study in different chic

popuiaîions is needed as weiL A iarger scaie study with diffaent cornparison groups

rnay aüow the separaiion of cogniîive behaviourai components h m the thetapeutic

factors inherent m group setîings.

The inîeraction of cognitie-behaviouraI therapeutic components witii group

therapy components COUM be studies through process research. This may lead to

dînements in the treatment mdeL

To conchide , the CBGT approach was found to be promising in the treatment of

chronic insomnia Further research with this mode1 may lead to changes cornmon in

clinid practice whkh involves drug prescription or individual treatmed

American Psychiatrie Association, (1994). Diagnostic and statisti'cal munual of mental disorders (4th ed). Washington, DC: Autéor, 553-557.

American Sleep Disorders Association, (1990). InterMtionuf clm9t@ation of sleep dhrders: Diagnostic and coding mamcaf. Rochester, MN: Author.

Angus, RG., Heslegrave, RJ., & Myles, W.S. (1985). E f k t s of prolongeci sleep deprivation, with or wittiout chronic pbysical exetcise, on mood and performance. PsychophysioIogy, 22,276-282-

Babkoff, A (1985). The effects of progressive sleep loss on a lexical decision task: Response lapses and response accuracy. Behmbr Research Methods, Imhuments and Computers, 1 7,614-622.

Banasiak, A. (1989). The validity of the polygraphic score of sleepiness in normal subjects. In J. Horne @d.), SIeep488. New York: Gustav Fischer Verlag, 199.

Barton, J., Folkard, S., Smith, LR, Speiten, E.R., & Totterdeii, P A (1992a). Stmdmd Ship Work Index M~mucll. MROESRC Social & Applied Psychology Unit. The University of Sheffield. SAPUiMemo No. 1 159.

Wer, MB., & Uhlenhuih, EX. (1992). New epiûemiologic hdings about insomnia and its treatment. Joumai Clinical Psychiatry- 53: 34-39.

Bastien, C.H., Vallieres, A., & Morin, CM (1999). Validation of the insomnia severity mdex as an outcorne rneasure for insonmia research. Sfeep Medicine. 80: 1 - 1 1.

Beck, AT., Ward, C., Mendeha, M., Mo& J, & Erbaugh, 1. (1961). An inventory for measuring depression: Archives of General Psychiatry, 4,56 1-57 1.

Beck, AT., Rush, M., Shaw, B-F., & Emery, G. (1979). Cognitive therupy of depression New York: Guilford Press.

Beck, AT., Epstein, N., Browu, G, & Steer; R.A. (1988). An inventory for measuring clinid 8alciety: Psychornetric pmpetties. J o t a ? ~ ~ f of C o d t i n g and Clinical Psychologv, 56,893-897.

Beck, AT. & Weishaar, ME. (1989). Cognitive Therapy- In RJ. Corsmi & D. Wedding (Eds.), Cment Psy~hother~es , 4th h t ion . Illinois: F.E. Peacock Publishets, Iuc., 285-320,

Beck, AT. & Steer, R A (1993). Mamral for the Beck Anxiety Inventoiy. S a n Antonio, TX: The Psychoiogicai C O ~ ~ I L

Beck, AT, & Steer, R.A. (19%). Manualfor the Beck Depression Inventory D. San Antonio, TX: The Psychological Corporation.

BootPn, RB. (1985). Insotunia. In M. Hersen & C. Last (Eh.), Behatior therqy c41peboot New York: Springer.

Bootzin, R.R. (1991). Stimulus contrai instniction. In P. Hauri (Ed.), Case studies in insomnia. New York: Plenum Press, 19-28.

Borkovec, T.D. (1982). lnsonmia Joumal of consulting und Clinical Psychology, 50, 880-895.

Bourdet, C., & Goldenberg, F. (1994). lnsomnia in anxiety: Sleep EEG chauges. J Psychosomatic Research. 38 (suppl 1 ) , 93-104.

Broughton, R (1989). Vigiiaace and Sleepmess: A Laboraîory Adysis. In A. Coblentz (Ed.), Vigilance maà Pejormance in Automatized Sysiems. The NetherIands: Kluwer Academic Publishers, 25 1-258.

Broughlon, R (1982). Qualitatively Diffetent States of Sleepiness. In RJ. Broughton & RD. Ogilvie (Eds.), Sleep. Arma1 und Pe$ormance. Boston: Birkhauber, 45- 46.

Bmughton, R, & Ghanem, Q. (1976). The Impact of Cornpouxi Narcolepsy on the Life of the Patient. In Guiüemhadt (Ed.), Nmcolepsy. Nem York: Spectnim Publications, Inc., 206-207.

Bulletin of European S W o r k Topics (1 391). Guidelinesfor Shifn~r,rhrs, Ireland, European Fomdaîion for the Impmvement of Liviug and Working. Number 3,1991.

Ciuskadon, M.A. (1984). A M d for Polysomnography Technicians, Sîmfird Universi& &ho01 of Medicine, Sianfiord, California: Stanford University.

Carskadbn, MA., & Dement, W.C. (1981). Curmilative Effects of Sieep Restriction on Daytime Sleepiness, Psychophysioology, 18,107-1 13.

Carskadon, M A , & Dement, WC. (1979). Efkcts of Sleep Loss on Sleep Tendmcy, Perceptiral and Motor SkilIs, 44% 495-506.

Coates, TL (1982). Estimating sleep patametets: A mdthd-muhimethod analysis. Journal of Ctnmlring and ondinical Psycholop, 50,345-352.

CoIqutiotm, W9. & Rut* J. (1980). Srudies of f i#wurt London, Taylor mi Franïcs.

Czeisler, C.A., & Richardson, G.S. (1991). Detection d assessnient of hmnia. Clinical T%erapeicr, 13 (6), 663-679.

Delmonte, M. & Ryan, G. (1 983). The Cognitive-Somatic ArvEiety Questionaaire (CSAQ): A factor analysis. Bn'trSh JimnaZ of Clmica/ Psychology, 22, 209-212.

Dement, W. (1991). Foreword. In C. Morin, Imomnia: Psychological Assessrnent and Management. New York: The Guilford Press.

Dinges, D.F. (1987). Temporal PIacement of a Nap for AIertness: Contriions of Circadian Phase and Prior Wakefulness, Sleep, 10,3 13-329.

Dinges, DS., & Kriihs, NB. (1991). Performing While Sleepy: Effects of Experimentally-mdud Sleepiness. Io T X Monk (Ed), Sleep, Sieepiness and P e r f m c e . West Sussex: John Wdey and Som, h., 1 16.

Dukes-Dobos, F.N. (1 97 1). The Blink Method as an Assessment of Fatigue. In Khashimoto (Ed.), Methodology in Human Fatigue Assessrnem. London: TayIor & Francis Ltd, 3 1-41.

Edinger, E.D. & Stout, AL. (1985). Efficacy of an outpatient treaIment program for insomnia: A preüminary report. Prof Psychologicol Research Practice, 16: 905- 909.

Espie, C. (1 99 1). The Psychologicai treatment of homnia. Chichester: Wiley.

EspK, C.A., Lindsay, W.R, Brooks, DN., Hood, E., & T m y , T. (1989). A controiled comparative investigation of psycblogical tresmnents for chronic sleeponset hmnia Behav Resemh Therqy, 27: 79-88.

Ford, DE. & Kamerow, Da. (1989). Epidemiologic study of sleep distub~ces and psychiaûic disordersan opportrmity for p e n t i o a JAMA. 262: 1479-1484.

Flanigan, U, & Shapiro, C. (1992). Seep Soltcttons. St-Laurent, Kommunicom Publications.

Freedmaa, RA.., & SaItler, EU. (1982). Physioiogicai and psychoIogical factors in sleep- onset ~~ Jou171~I ofAbmnna1 Psycholugy, 91,380-389.

Folkard, S. & Totterâeli, P. (1993). Dissectmg çircadian pfbnnance rhythms: Implications for shiftwork Ergonomies, 36,283-288.

Fukui, T., & Morioka, T. (1971)- The Blink Method as an Assessment of Fatigue. In Khashhoto (JX) Methwblogy in Furigue A s s ~ e n î . London: Taylor & Francis Ltd, 23-29.

Gaükd, A.W.K. & Steyvers, F.J.J.M. (1989). SM Los and Sustained Performance. in A. Coblentz W.), Yigiance and Pe$otrnQllCe in Asdommized Systems. The Netklands: Kiuwer Academic Pubiishers, 246-249.

Güh, J-C., & ByerIey, W.F. (1990)- The diagrnisis and management of insomnia New Engrand Journal of Medicine, 322,239-248.

Glenviiie, M. & Broughion, R (1979). Reliability of the Stanford Sleepiness Scale compared to short duration performance tests and the Wifkinson auditory vigilance task. In P. Passouant & 1. O d (Eh.), P h a c o l o g y and the States of Alertness. Oxford: Pergamon, 235-244.

Godbout, k (1990). F d a m e d aad Clinid Neuropharmocbgy of Sleep Disorders. In J. Montplaisir & R Godbout (Eds.), Sleep ond Biological Rhyrhms. New York: Oxford University Press, 227-229.

Gold, D. (1992). Rotating shiftwotk, skp, ~QCI accidents related to sleepiness in hospital nurses. American Journai of Public Healrh, 82, 101 1- 1014.

Hammond, E.C. (1964). Some prehhary findings on physical cornplaints from a prospective study of 1, 064, 004 men and women. American Journal of Public Health. 54: 1 1-23,

lhtmam, E- (1988). hnmia: Diagnosis and Tmtxwnt. III R Waeiams, 1. Karacan & C. Moore (Eh.), Sleep Disorders: Diagnosis and Treatment, 2nd Edition. New York: John Wdey & Sons, 2946.

Hauri, P. (1982). Disortiers of Excessive Somnolence. in P. Hauri (Ed.), The Si'eep Dborders. Kalamazoo: The Upjohn Company, 5 1-55.

Hauri, P.J. (1991). Sleep Hygiene, Reiaxathn Therapy, and Cognitive interventions. In P.J. Hauri @ci.), Case studies in ittsomnia. New York: Plenum Press, 65-84.

Hauri, P.J. (1997). Can we mix bebavioral therapy with hypnotics when treating insomniacs? Sleep. 20,1111-1 118.

Hauri, P.J., & Wisbey, J, (1993). Cari we mix betiavioral therapy and hypnotics? Sleep Research, 22,207.

Haynes, S N & O'Brien, WH. (1990). Functiod analysis in %havior therapy. Clinical Psychology Review, 10,649-668.

Ho* P. (1973). QmHmtkn of Sleepiness: A New Approach, Psychophysioloogy, 10,431-436.

Hoddes, P., Dement, W.C., & Zarcone, V. (1972). TIae development and use of the StanfOrd Sleepiness M e . PsychopIsysroZogy, 9,150.

Hohagen, F., Rmk, K., & Kappler, C. (1993). Prevalence and treatment of insomnia m general @ce- a longihidinal study. Ew Archives Psych CIinicaZ Netaoscience, 242,329-336.

Home, M. (1991). Dimeosions to Sleepiness. In TH. Monk Pb), Sleep, Sleepiness and PeTformance. Wesi Sussex: John Wdey and Sons, h., 175.

Hussain, M.R.G. & Sbapiro, C. (1996). Hypmtics in insomnk Specialist Medicine, 3, 43-58.

Jacobs, G.D., Benson, H., 8 Friedman, F. (1993). Home-based central m u s system assessrnent of a mdtifhur behavioral intervention fbr chronic sleep-onset Uisomnia. &hm ïkrupy. 24, i S%lï4.

Jacobs, GD., Benson, R, & Friedman, F. (1996). Perceiveci benefits in behaviod medicine &&a program: A C S i d Report. Amen'can J m a I of Medicine, 100,212-216.

Johnson, D., Thorne, D., Rowland, T., Bakin, H., Thomas, M., Wesensten. N., Redmond, D., Russo, A., Webh, R, AIaddin, R, Cephus, R. HaU, S., Powel J., 8 Dinges, D. (1998). The effects of partial steep deprivation on psychomotor v i g k . Sleep, 21,235.

Johnson, L.C. (lm). Daytime Sleepiness in Good Sleepers: Measuremeats and Correlates. In RJ. Broqhton & RJ). Ogiivie (Eck), Sleep, A r o d and Pe@nnance. Bostoa. Birkhauser, 220-227.

Kadis, AL., Krasner, J.D., Wmick, C., & Foulkes, S H (1963). Apractictan of group psychofherapy. New York: Haqm & Row, P u b b , 10-35.

Kales, J.D., Kaies, A, & Bixier, E.O. (1984). Biopsycbobehavioral correiaîes of insomnia V. CIinicaI characteristics and behavbral correlates. Amencan J o r n 2 ofpsychia~, 141,1371-1376.

Karacan, 1, & Howeil, J. (1988). Diagnosis, Evahiation and Classifichn of Sleep DisorderS. In Wereiams -1, Sleep fiorders: DiagnosrS and TreaimentI (2nd ai). New York: John Wdey and Sons, inc., 93.

Kwtsson, A., Akerstedf T., lo~sson, B.G. & Orth-Gom, K. (1986). lncreased risk of ischaemïc kart disease M shift workers. Lmcet, 2,89-92,

Kripke, D.F. (1983). Sleep related mortaüty and mrbidity in the aged. In M Chase & E. WeitPrian (Eds.), Sleep Disorders-Basic and Clinicul Resecach. New York: S- 4 15-429.

KupychWoloshyn, N., MacFarlane, J. & Shapiro, C. (1993). A gtoup approach for the management of bmuia. J o m i of P~ychosomanc Resemh, 37,39-44.

Lavie, P. (1981). SLeep habits and sleep disturbances in industriai workers in Israel: Main hdbg and some characteristics of workers complaining of excessive daytime sleepiness. SZeep, 4, 147-1 58.

Lavie, P. (1989). Tbe Effects of 7.5 mg Midazolam on Sleep Disturbances Associated with Jet Lag and Rotating Shifi-Work In J. Horne Gd), Sieep'88. New York: Gustav Fischer Verlag, 33-35.

Lacks, P. (1991). Stimulus control in a p u p setting. In P J. Hauri (Ed.), Case studies in insomnia. New York: Plenum Press, 29-47.

Lacks, P. & Powiishta, K. (1989). Improvement foiiowing behavioral treatment for insornnia: clinicai signiricance, Iong-term maintenance, and predictors of outcorne. Behav Theropy, 2 4 117-134.

Lacks, P. & Morin, C. (1992). Recent advances in the assessrnent and treatment of insomnia Jutami of Cod t ing and Clinical Psychology (in press).

Lader, M. (1994). Anxiety or depression during withdrawai of hypnotic treatments. J o m I of Psychosomatic Resemch, 38,113-123.

Leger, D. (1994). ïhe cost of sleep related accidents: A teport for the National Commission of Sleep Disorders Research. Sleep. 17,84993.

Levine, E.A. (1988). Daytirne Sleepmess in Young Ad* Sleep, 11,39-46.

McClusky, H., Milby? J.B., Switzer, PK, Williams, V., & Wootea, V. (1991). Eff iay of behaviorai versus triazolam treatment in persistent sleep-onset insomnia. American J m i Psychiany, 148,121-126.

Mebger, GD., Wer, M.B., & UhIenhtrth, E H (1985). Insomnia aad its treaîmlrt: prevalence and correlates Archives of General Psychiatry, 42,225-32,

Mendeison, B.W., (1987). Hunian Sleep: Resemch und Clinical Cure. New York: Plenum Pubiishing Corporation, 197-200.

Mendelson, WB., Gillin, Cl, & Wyatt, R.J. (1977). Hinnan SIeep and iis Disordrs. New York: Plenum Ras, 3.

Milby, J.B., Williams, V., bü, IN., KhuQet, S, & Wcmten, V. (1993). Efféctiveness of combineci triazolam-behaviorai -y f8r primary insormila Amenkm J m a l of Psychahy, 150,1259-1260.

Mer, M.M. (1986). Tnaûnent ofNatcoIepsy: Objective studies on methylepknidate, pemoline and proûiptyline. Sleep, 9,26&264.

MitIer, MM, Gujavarty, S. & Browrnan, C2. (1982). hbbienance of Wakefiihess Test: A polysonmographic technique for m i n g treatment efnciency in patients with excessive somnolence. Elecrroencephfography Clinical Nèwop~siology, 53,658-661.

Moidofsky, R, & Scarisùrick, P. (1976). Induction of Neutasthenic muscubskeletai pain syndrome by selectivt s k p stage deprivation. Psychosomatic Medicine, 38, 35-44.

Monk, KT. (1987). Work Sckduks, In G. Salvendy (Ed.), Hmdbook of Hwnnn Factors. New York, Hohn Wdey and Sons, Inc., 8 19-843,

Monk, H.T. (1 99 1 a). Wace. In T H Monk (Ed), Sleep, SIeepiness and Pe$ormmice, (Prefhce XI-MI). West Sussex: khn WiIey and Sons, inc.

Monk, ET. (1991b). C i aspects of Subjective Sleepiness: a behaviourd Messenger. In TB. Monk (Ed.), Sleep, Sleepiness mid Per$onnance. West Sussex John Wdey and Sons, im, 52.

Monk, H.T. & FoIkard, S. (1992). Making Sh@mrk Tulerable, London, Taybr & Francis Ltd.

Moore, GC., & Gurakar, A (1988). Noclumal Myocionus and Restless Legs Syndrome. In Wereiams (Eds.), Sleep Disorders: Diugnosrs and Treatment, (2nd d). N e w York: John Wdey and Sons, h, 73-83.

Morin, C. ( 1 993). Imoninia: Psychologicai Assesment mrd Management. New York: The Guildord Press.

Morin, C, Culbert, J. Kowatch, Rk, & Walton, E. (1989). Efficacy of mgnitive- behaviorai treatments for ixwmnia: a metaaalytic review. Sleep Research, 18, 272.

Morin, C., Gaulier, B., Barry, T, & Kowaîch, R (1992). Paîieins' acceptame of psycbiogid d pharmacobgbi therapies for iasoda. 9 e q , 25 (4), 3M- 305.

Morin, C., Kowatch, R, Barry, T., & Waiton, E. (1993). Cogaitkebehaviur thaapy for Me-life b m n k Joiarml of Codtnlg and Clinicd Psycholugy, 61,137-146.

Morin, C-, Cuibert, J.P., & Schwarfi, M.S. (1994). Non pharniacologicai intementions for h s o e A mtamidysis of treatmed efficacy. American Journal of Psychirrtry, 151,1172-1180.

Morin, C., Hauri, PJ., Espie, CA, Spielman, A.J., Buysse, DJ., & Bootzin, RR (1999). Nonpharmacobgic Treatment of Chronic Insomuk Sleep, 22 (8), 1 134-1 156.

Mo* P. E. (1965). Shifr wurk: The Socid, PsychologicaI and Physical Comequences. Am A t h , The University of Michigan Press, 214-220.

Mitrtagh, DR, & GreenWood, K M (1995). Id-g efkctive psychological treatmerrts for insomnia: A meta analysis. J o m I of Consiting and Clinical Psychology, 63: 79-89.

Nahon, J.P. & Hedouh, U (1988). Sleep. France: brie-Poulenc, 30-35.

Naitoh, R (1989). Napphg, StimuIant, and Four-Cimice Performance. In RJ. Broughton & RD. Ogilvie (Eck.), Sleep, Arot(sa2 and Pei-fomce. Boston: Birkbwber, 1 98-2 17.

Nationai Inditirte of Health 0. (1984). bugs a d b n m i a : The use of medications to promote s k p . Journal ofthe Americm Medical Association, 1 8,24 10-24 14.

ûrzack, F. (1968). A Reseacc Report on the Antiîatii effects of Mrtgnesium Pemoline. PsychophamacoIogiu, 13, 41341 7.

Reite, L X , Nagei, EK, & Ruddy, RJ. (lm). The Evaluution and Management of Sie? Disorders. Washingîon, DC: American P s y c W Ptess, Inc, 10-76.

Reynolds, CJ. (1989). The irnplicatmns of sleep dkwbces epiderniology. JAUQ. 262,1514.

Richatdson, S. (1978). Excessive Daytime Sleepmess in man: MuItipIe SIeep Latency measnrement in narcoleptic and control subjects Electrwncephuiography ünd CIinicuI Neraophysioiogy, 21 5,621 -627.

Ryman, D.H., B i , RJ. & La Rocco, J.M. (1 974). ReLiabilities and VaIidities of the Mwd QucstibMltlite. Psychoi'ogr'cal Reports, 33,479484.

Seyune, C., & Shapiro, C. (1995)- hng-term îhqy of i n s o d BûilliereJs Chical P s y c h . , 4,605-637.

Shaph, C., MacFarlane, J. & Hussain, M (1994). Conquering Insomnia. Hamihon: E m p o w e f i n g ~ .

SIeep\ Wake Disorders Ca& (1 99 1). NmcoIepy, Vol 3.

Sloan, E., Hauri, P., Bootzin, R, Morin, C., & Stevenson, M. (1993). The nuts and bits of behavioral therapy for insoumis, J o m l of Psychosomatic Research, 37, 19- 37.

Skene, T. (1989). Melaionin, Jet-Lag & the SIeepWake Cycle. In J. Horne (Ed.), Sleep'88. New York: Gustav Fischer Verlag, 39-40.

Soldatos, C.R (1994). Iasomnia in relation to depression and anxiety: Epidemiologic onsiderations. Journal of Psychosomatic Research, 38 (suppl 1): 3-8.

Spiegei, K-, Santucci, J., Colecchia, E., Kosstyn, S., Stickgold, R, & Van Cauter, E. (1998). Aiteration of sleep, fatigue, m o d and cognitive hmtion during sleep &ction and sleep extension. Sleep, 21,232-233.

Stein, A. (1971). Psychosornatic Disorders. In S R SIavson (Ed.), The Fielh of G r q Psychotherapy. New York: Schocken Books inc, 40-58.

Stoller, MX, (1994). Ecuwmic Effécts of Insomnia CZinical Therapeutics, VOL 16,s: 873-897.

Taub, J.M. (1978). Behavioural aad psychophysiological cordates of irregularity in chmnic sleep routines. Bi02 Psychofogy, 7,37-53.

Thorne, DX, Genser, S.G., Sm& H.C., & Hegge, F.W. (1983). Plumbmg human performance limits during 72 hours of high task load. Neurobehavioral Toxicology and TeratoIogy, 7,4 1 5-4 18.

Thom, DR, Genser, S.G., S b , H.C., & Hegge, F.W. (1985). The Waiter Reed Performance Assessrnent Battery. Behmtiw Resemch Methods, Inrh.uments and Cornputers, VOL 17,4, 415-41 8.

Thorpy, JM (1988). Diagnosis, Evaluation and Classincation of Sleep Disorders. in Wereiams (EL), Sieep fiorders: Dragnosis and Treatment (2nd ed.). New York: John Wdey a d Sons, h, 12-19.

Van Brunî, D., Riedei, B., & Licbstein, K (1996). I n s o ~ In V. Van Hasseh & M. Hersen (Eds.), SoMcebook of Psychologictrl Treaîment M~ntulIs for A& Disorders. New York: Pkmum, 539-553.

Van Moffiiett, M.P. (1994). Sleep disorciers and depression: The "chicken and egg" situation, J o m i of Psychosomtic Resemh, 38,991 3.

Wake Up America (1993). A Ndional Sleep Alert. VOL 1. Executive Summary and Executive Report. Report of the National Commission on Sleep Disorders Research. Washington: National Institutes of HeaIth, US Government Prim Office.

Waiiace, M (1985). 'Quali& of Life Surveytfor Telecom Ausfrafia. Brain-Behaviour Research Instiîuîe, School of Bebaviourai Sciences, (Melbourne, La Trobe University).

m e , J.L., & Nicassio, P. M. (1990). The reiationship between daily stress, pmsleep musal, and sleep disturbance m good and poor sleepers. Behawior Therapy, 16, 28-38.

Wiikmson, RT. (1992). The Meamment of SIeepiness. III RJ. Broughton and RD. Ogilvie (eds.), Sleep, Arousd und Pe$onnance. Boston: Birkhauser, 257.

Wmgard, D.L. & Berkman, LI. (1983). Mortality risk associated with sleeping patterns among aduits. Sleep. 6: 102-107.

Yalom, ID. (1975). The Theory d Pructice of G r q Psychotherapy, 2nd Edition. New York: Basic Books, Inic.

Yousaf, F. and Sedgwick, P. (1996). Skep disorders. British Journal of Hospital Medicine, Vol 55, No 6' 353-358.

Zinchenko, N. (1 985). The Psychomefrics of Fatigue. PhiIadelphia: Taylor & Francis Ltd., 6-29.

INSOMNIA iNTERVtEW SCHEDULE

Insomnia interview Schedule

1. N o ~ e of SI- Wake Probiem

Do yw have a problan wiîh W i g asleep? Do yar have a p d e m wiih staying asleep? Do you have a pfoblan with walring up tao early in the mmüng? Do you have a publm with smying awakc During the &y'?

At what time do you Iast awakat m the moming?

What is yoiar usual arising tirne cm wedcdays?

Do you have ihe same sleepwake schedule on waekends?

How ofhi do you take naps (mcluding unm taitional naps)?

How many nigtuslweek do yw have a problan with hllm&taying aslap?

(h a miail night (pst math), how many timcs do yai wake up dwing the middk of the night?

What wakes you up at night?

(ki a typiciil Nght, how loag do p u spmd a* m the middle of the ni@ (tocil no. ofmmutcsm~~r~ for aü awalenings)?

No Mild Modaate Sevae No Mild Moderate k e n

No Mild Modaate Sevae

NO Mild Modaate Sevece

YES NO

How many hotus ofsleep pcr ni@ do you usually get? - holm - minuies

In the past 4 wecks have yw uscd sleeping pi&? E S Which dnigs? Rcraibed, onr-the-countct, or bath? Wbadossge? How many nightslwcdr?

Ifno, have yar ever? Wben did you 6rst use sleep medication? Whai did you last use sleep medidon?

In the pst 4 wcdcs, have you used dcohol as a sleep aid? YES What kind and how many ounces? How many nighVwedc?

If no, have you ever?

4. Sieepirq Problem Hulory (omet. corne, h w n ) How lmg have yw beni suffiig fIrim insanaia? Y e a r s - months Wae thae any stressfiil Iik cvcnts nlated to its onset (deeth of tond me, divorce, rrtinmaiî, medical œ emotimal poblans, etc)? GreduPlœsuddaioriset? Wbat ims bem the course of your insomnia problan sine its anset @&tmt, cpisaiic, seasanal, etc.)?

5. F v n c i i d Amlysis Wh;a is ywr pnkdtime mutine Sie? What do yai do whcn you can't faI asleep a retum to SI-? 1s ywr sitep bcita/wOrrclsme whm yw go away fiom home? Is your slaep bata/-semc al weekaids? What types of fjietas QcPccrbate yaur slcep pmblan (eg. stress at wwk, üavcl plan,ctc.)? What types of ihms improve slœp (tg. vacdm, seg cie)? How cononed ore you about s l c q f i i i a ? What ûnpaci does m-a have on your lifk (maxl, aiatness, pdxmance)? H m do you cope with th- daytime sequele? Have yau necimi haîmmt in the past othn diaa slœpmg aids? Whatpranptalywtosedr ùuannia~cntatîhiu timt?

6. ss.niponts of O r b Skèep Dismkn b i o g a w#L do y w œ bsd prmia notice the following? a) Rcstless legs: Crawlmg œ achmg künp in the lgs, (caives) and inaôiiity ta kcep legs stili. b) Pcriodic iimb movemcnts: Leg twitches ajaks dioing the night, walMg up with m p s in 1- C) Apnm Saring, pauses in breathing at night, shamess of breaîh, choking at m&g hadaches,

chest ph, dry matîb. d) N- slap aüacks, slcep pa&& hypnagogic haiiucinaîims, cstaplexy. e) Gasrrasophageal nflw: Sour Eiistc in mailh, hartknn, rdiux. f ) PamsaamS: Nightmsns, night tams, skcpwaûcin~rng, biaism. g) SIacpwake schedule disada, d g shift œ night Shi mrk jet-leg.

Weight: Hught:

Have you a anyone in your h i l y ever ken îmtai f a anotimal a mental healih problans in die pas&?

Have you or anyoae in yam family ever baen a m a psychiaûic hospltal?

Ha. afwhol a any dmg eva causcd a pmblem fa pu?

Has anything happtned lately that has kai csprcially &ud fa you?

Wbat about diffimfties at wodc a wiiti yaa îàmiiy?

In the last mondi, has mat been a of tirne whai you wae feeling depss a dom mast of the day nearly evay day? if yes, as long as 2 waks?

What about king a Id Iess intslesi in most things a mable to aijoy the thiigs you trsed to enjoy? If yes, was it nearly evay day?

F a the past couple of yesrs, have yw baai b o t h d by d e p d mood mast of the day, m a t days than not? More thm half the t h e ?

Have yau eva bœn afhid of gomg out of the house alme, Wig m mwds, standmg in a hc, a traveling onbuscsatrams?

Have y w eva bœu b h d by tiioqhtr aat didn't maice any secise and kqt ooming back to you even whai yai tria! not to have ibw?

in the 145t 6 mmths, wwld you say that yw have bem warying most of the iime (mae days than na)?

APPENDIX B

INFORMATION AND INFORMED CONSENT FORM

1. Information S k t

2. Mo& Consent Fom

INFORMATION SHEET

uirestipatars: Alfollso Marino, UEd*, IX. Niva P h * and Ck. Sheldat Sbaul** The (nitario lnstiRde fœ Sbidies m Educatiau, Univasity of T m t o * üqmrûncnt ofPsydiiauy, The Tœmto HospiWWestan Division8*

[nsomnia is a pobian diet has aneaed most individuels at aie tirne œ anaha duing their iim Althougb the intaisity and ~ ~ c y of insannia varies, it is a widcsprcsd aod pasistmt problcrn îhat a5mâs. heaiîh, mood, pbfprmance, and nlatiaiships Far some, insomnia can becorne a persistait and dcbiliîatmg poblan thai ImpaÎrs am's quality of life. 'Ihe pi~posc of this stidy is examme the efficacy of Cognitive-Bchavid g r q th- m W g iadividuals with chronic insoannia Such as study is in liae with the n a d ta ünd Psyctiotharpartic ways of dealing witb inSomnia Tbis nseptch is king caiducted as a thesis p j a â in camcctim wiih the Chtario Institute f a W i e s m Educirtiai ( ü n i d t y of Taoato) and îüe T a m Hospital (Westan Dmsioa).

nie trratmant hvolves panicipatiai in a group of44 mdividrrals who also have dironic msomnia (thae will be no fâ fa ireatmmt). Issues relatai to ywr slœp pmblan will be d i i and mtawntims will also be povidcd, induding some homework assignmmts. sessions will be once pcr wedc, fk 8 wcdrs, and wae last 1.5 h m Smce the amber ofgroups that can be run simultaicous1y is l i i t d , pnrticipants will bc m d a d y assignai to eitha: (1) an immediate tnstmait group a (2) a &Iayed treatment graip (which wili canmaia six months &a the immediate matmat group has beai ampleted, approxhately eight manths wait m total). If you a g m to psriicipate m this study, you will be Pdred to cunpleie a of diffcnnt tnsks fhat will k pcsented to yat m a amputer. You wili be required to a w e to the Skcp Chic two wcdcs priot to treatmeat and wili be givm 2 sessions an the amputa. Each tasic set wiII takt about 20 mmutes to complett, You will nd regriin any cornputer skills. You will also be gim a padcage of questionnaires to cornplde. Ihis will take tppaximateiy 20 minutes amplete. A si- diary will aiso be givai. This is cornpletai ava a two weck paiod and can k rmmied whar tratmmt beginn 'Ihe cornputer tasks, questionnaires and slecp diary will k completai cm 3 m m OCClSioll~: hno wedrs following the aid of trcatment, three maths follow-up, and six months follow-up. Whai &miment stans, sessicm will be audio t , sûictiy fa the pirpoçes of supavision and adhbenœ. TapeswiUbcdestroysdwhaitheshidyiscanplae.

Thcre me no riski assoc&d with this shldy. infotmatim d i d in Group wiU be kept in strict confidaiœ (*acœpt m the evait ofchild abuse a self-hami*). AU data mllcaed will be kept mfidaitial ad yaut mmymity with nspect to any pubLidm a pcraitatkm of this mataiPl wac be maintanid me dsEa will be stasd m mfidaitial'i (inly thiï tcSeafehu (Alfmso Marino), and ~~~ PiFanmi Sheul willhavtaccess to thediita

Your ppriicipaiiai in this shdy is compluely voluntary and you may discaitiuue your perticipaiion without pejudia and wiîhout &mg your msdial arc Yai may withdraw h m the study, a may withhw your data ûom the sndy at any t h e up mil the time aiat If» study is published

if yau are mtaestad ai pmtiapetaig in the study a wouid Iike more hfamatian, pl- caatact me.

LNFORMED CONSENT FORM

invesfi*gatm: A l f i Marino, ME#, Ik. Niva Puain* and IX. Sheldai Shaul- The ûntario uistiMe tàr Shrdics in Educaricm, University of TamW Deparhnent of Psydiiaûy, 'lhe T m t o HospitaWestern Division*'

1, , have been asked to participute m a shidy beiig waducted at the Sleep disorders Clmic at the Toronto HospitaWestern Division in association with The Ontario Mitute for Studies in Education, University of Toronto.

Tbe purpose of this study is examine the efficacy of Cognitive-Behavid group îherapy in treating indiduais with chronic insomnia. Such as study is in line with the need to find psychoshaapeutic ways of dealing with Uisomnia i n f i i t ion diiussed in Group sessions will be kept in strict confidence (*exccpt in the event of child abuse or seif-hm*). Al1 data wllected will be kept contidential and your anonymity with respect to any publication or prcseataîion of this materiaI were be maintaincd The data wiil be stored in confidentialii. OnIy this cesearcher (Alfonso Marino), and supervison Drs. F i n and Sbaul wiii have access to the data.

1 undetscand that since the numbcr of groups that can be run simuhnmusly is limited, 1 will be raadody assignai to either. (1) an immadiatc treatment group or (2) a &layeci treatment poup (which will commence six months a h the irnmediate treatment group has been wmpked, approximately eight months wait in totaI). 1 understand that if 1 agrec ta participate I tbis study, [ will be asked to complete the following: a variety of differcnt tasks that will be presented to me on a amputer, qucstioruisues aad sleep diary. 1 understaad biat this information wiU be collected: two wecb befote the tmtment, at tbe end of treatment, 3 months bllowing treatment, and 6 maths following trament. I understand that my in this study is completely voluntary and t h t 1 msy discontinue my participation without prejudicc and without affecthg my medical are. 1 undemaml that 1 may withdraw from the study, or may withdraw my &ta h m the study at any tirne up rmtiI tbe time ibat îhe study is published. A copy of the signed cornent f m wiU be availrble to me upon request. A summary of the resuits wiU bc provided to me upcm cornpldion of the d y at my tequest. if 1 desire the nsuhs, i will place a chcckmark in the sprce provided bebw and provide my addtoss.

My sigoature below indicates that I have read and understood this consent form, 1 have had ail of my qucstiors amvcred to my satipfictioa, and have volunîarüy agreed to participate in the study that has beai outliacd

Date

APPENDiX C

COGNITIVE-BEHAVIOURAL CROUP THERAPY MANUAL

Manuai: Coping Strategies & Interventioas for Insomnia

TREATMENT MANUAL

Treating Chronic Znsomnia: A Cognitive- Behavioural Croup Therapy Approach

Tables of Contents

Ovrrview of Twa6nent Sessions

Treatment Session 1

Treatment Session 2

Treatment Session 3

Treatment Session 4

Treatment Session 5

Treatment Session 6

Treatment Session 7

Treatment Session 8

Stimulus Control

Sleep Restriction

Rehution Techniques a) Progressive muscie refmaliun 6) Guided Intagery c) Breathing 9 Autogenic iraining

~nitivcStrritcgics

Positive Self Talk

EdUCOtiOllal Sm@

Sleep Hygiene

Nutrition

Physical Fitaess

Asseasment of Iasomnia (oU shodd be a&i&kd 2 wceRr prior to îreaîment & 2 weeks, 3 months anâ 6 niowhsfollowingbruramart)

a) Stnictured Interview by clinician b) Sleep Diary c) Sleep f q a h e n t index d) BDI-II e) BAI f) Demographic Informaiion g) Evahiation of Intervention (ody to be given after ûeaîment) h) Waiter Reed PerfÔnnance Assessrnent Battery (PM)

1. SeIf-monitoring a Re* sleep diary b. Answer questions pertaiaing to diary ody c. Reinfiitce patieat fOr se~monitorbg

2. h g r a m overview a Behav iod Chaaging maiadaptive sleep habits b. Cognitive: Reft.aming dysfiinctional beliefi and attitudes c. Educational: Skep physiology and Prornoting good sleep hygiene

3. Agen& of therapy sessions 1-8

4. NaMe ofself-managemnt appmch a Emphasize the notion of self-control aod problern solving skills b. conûast tbis approach with dependency upon sleeping pills c. Stress the active role of patient in ttwdment pmcess d Discuss the tirne-limited format of the &mention program

5, Social leaming expianation of insomnia a Descn'be contdwting factors: pfedispusing, precipitatiag, perpetuating hctors b, Rwiew conceptual mode1 of insomuia c. Relate this nmdel to the patient's persoaal sleep problern history

6. Basic facts about sIeep and changes in sleep patterns over the W e - p a) Thie nature of sleep (stages 1-4 NREM, REM)-handout aud overheads were be used b) Changes m slecp patterns over the course of the taespan

7. G d settiag- what they hope to get out of group

Materiulss: slecp diary Handout: Sieep PhysioIogy Booklet and show overhead

Remidrs: Importame of self-monitoring

Tmtment Session 2

1. Self-monitoring a. Rwiewsleepdiary b. Ammer questions pertainuig to d i only c. Reinforce patient for ~e~fimonitoring

2. Introduction of behaviourd (sleep restriction and stimuIus contru~ procehes a R&t t h e in bed to -buts per night b. Optionai daytime naps (< I hour) no later thaa 3 p.m. c. Go to bed only wben sl-y ci. Get out of bed when umbk to fiil asieepheturn to sieep within 10-20 minutes. e. Repeatthispmcedureasoftenasnecessary E Arise at the same îime every moming g. Do not use the bed(bcdroom for nonsleeping activities

3. Behaviowal Treiatmmt Rationale

Materais: Sieep diary Handouts of stimuIus wntrol & sleep m t r k h n procedures (see bebvioural -ion of manuai)

Remindersr Importance of seIf-monitoring

1. &rf-monitoring a Review sleep diary b. Answer questions pertaining to diary only c. Reidbrce participants for self-monitoring

2. Review of behuviowal procedures and their rationale a Restrid time in bed to -!murs per night b. Optional daytime naps (< 1 hoin) no later than 3 p.m. c. GU to bed only when sleepy d. Get out of bed when unable to faii asIeep/retm to sleep within 10-20 minutes. e. Repeat this procedure as o h as necessary E Arise at the same time every moniiag g. Do not use the bedlbedroom hr nonsleeping activities

3. Review of problems encountered in home practice

4. Generufion of me thd to enhance cornpliance a Find activities to engage in when getthg out of bed b. IdentQ cues to determine sieepiness a d time to retum to bed c. Use alarm clock to maintain regular arising time d Find comp*ing activities to fight urge to take uap or ovembclming skephess before

p m i bedtime e. Secure support fiom spouse/signifim others f. Remember the tirne-limiteci formai of program g. Pace activity levels and change their timing

5. Review of homwrk assignment andsleep window (restriction of time in bed)

6. Introduce Relmation Techniques a Progressive muscle relaxation b- Iinagery c, Bnashtog 6 Autogenic Training

7. Preview of session 4- cogniriw t h e r w

Mizterials: Sleep Diary Handouts of Relaxation techaique procedures for PMR, imagery, Breathing and Autogenic training.

Reminrfers: Importance of self-monitoring

Tmatment Session 4

1 . Seljmonitoring a. Review sleep diary b. A m r questions pertaining to d k y ody c. Reinforce participants for self-monitoring

2. Review of home practice and problems with behavioural procedures a. Restrict time in bed to -heurs per night b. Optionai daytime naps (< 1 hout) M, later tban 3 p.m. c. Go to bed only when sleepy d. ûet out of bed when unable to hrll asleeplretuni to s k p within 10-20 minutes. e. Repeat this procedure as often as necessary E A- at the same t h e every morning g. Do not use the bed/bedroom for masleeping activities

3. Enhancing cornpliance wirh îreutment requirernenis a F i activities to engage in when getting out of bed b. Fibd cornpethg activities to 6ght sleepiness at inappropriate times c* Secure support fioul spouse/signiscant others d. Use a h cbck to maintain reguIar arising t h e e. ldmtify behavioural nies of si&iness (yawning heavier eyelids)

4. Review Relwtion Techniques a Progressive muscle r eh t ion b- c. Breathing d Autogenic Training

S. Cognitive Therapy a introduce basic principies, rationaie, aad goals of cognitive therapy (see cognitive therapy section of manual) b. Discuss ciinical relevance of this 6zuneworic with regard to bnmia c. Sekt exampies of dysfiuictionai cognitions and iook at Beiiefk a d Attitude Scde as

well as Cognitive Vignette hdouts d E d e , cchaenge and replace dysfimctiod cognitions

i) Correct misconceptions abut the causes of insonniia U) Alter dysfhhnal beIiefS about the impact of insomnia iii) ModifL unreaiistic sleep expectations iv) Enhance perceptions of control and pred'iility V) DispeI myths abut good s k p practices

e. Generate additional maladaptive self-statemests specifiç to the particmts

Muieriak Sleep D k y BeIiefi and Attitudes About Sleep Sc& & CognitÏve Vignettes Handout

1 - Seff-monitoring a Review sleep diary b- Answer questions pertainiag to diary only c. Reinforce participants for self-monitoring

2. Review of home practice and probiems wlh behmtioiaal procedtues a. R&t t h e in bed to -hrs per night b. Optiod daytime naps (< 1 horn) no later than 3 p m c. Go to bed only when sleepy d. Get out of bed when unable to MI asIeep/retuni to sleep within 10-20 minutes. e. Repeat this procedure as ofien as necessary f. Arise at the same time every moming g. Do not use the bedhxiroom for nonsleeping activities

3. Review Relmüton Techniques a Progressive muscle relaxation b- Iniagery c. Breathing 6 Autogenic Training

4. Cognitive Therapy a. Review principteq ratiode, and goals of cognitive therapy b. Discuss ciinicai relevance of this hmework with regard to insomnia c. Seiect examples of dysfuoctiod cognitions and look at Beiiefs and Attitude Scale as

well as Cognitive Vignette hdouts d. Iden*, cchallenge and replace dysfuactiod cognitions

i ) Correct misconceptions about the causes of insomnia iii Aiter dysfunctiod Mie& about ihe impact of insomnia iii) Modify d i s t i c sieep expectations iv) Enhance perceptions of control and predictability V) Dispel myths abouî good sleep practices

e, Generate additionai maladaptive seIf-statements spec%c to the participants

5. Review of progress and goal artaiment

6. Prwiew of session 6- sleep hygiene ediication

Materiais: Steep Diary B&e& and Attitudes About SIeep Scde Cognitive Vignettes Haodout

Tmtment Session 6

1 . Serf-monitoring a. Review sIeep d i q b. Answer questions pertaining to diary only c. Reinforce participants for self-monitoring

2. Review of home practice and problems with behav iod procedures a Restrict time in bed to -Murs per night b. Optional daytime naps (< 1 hour) no later than 3 p.m. c. Go to bed only when sleepy 6 Get out of bed when unable to fail asleep/retutn to sleep within 10-20 minutes. e. Repeat this procedure as often as necessary f. Arise at the same tirne every morning g. Do not use the bedkdmorn for nonsleeping activities

3. Review Relaxation Techniques a. hgressive muscle relaxation b. Imagery c. Bteathing d. Autogenic Training

4. Cognitive Therapy a Select examptes of dysfiuictional cogitions and look at Beliefs and Attitude Scale as

weU as Cognitive Vignette handouts b. Identify, challenge and replace dysfunctional cognitions

i ) Correct misconceptions about the causes of insomnia iï) Alter dysfuactional beiiek about the impact of insomub iii) Mo@ unreaiiiic sleep expectatioas iv) Enhance perceptions of control and predictability v) Dispel myths abut good sleep practices

5. Sleep hygiene erhccution a Caneine b. Nicotine c. Akohol d. Exercise f Noise, light, temperature

Materiak SIeep Diary Beiiefk and Attitudes About SIeep Scale Cognitive Vignettes Handorit Sleep hygiene handout

Tmtment Session 7

1. Self-monitoring a Review sleep diary b. m e r questions pertaining to diary ody c. Reinforce participants for self-monitoring

2. Answering questions and resolving problems regarding sleep hygiene principles

3. Brief review and integraiion of al1 therapy components

4. Feedback to paîient a Provide f d b a c k regadhg progress and cornpliance with treatment b. Emphasize specific problem areas that need more attention c. Examine pro- and outcorne relationships d. Increase time in bed so that it gets closer to baseline d u e s

5 . Review of hume practice mdproblem with behmiowal procedures a Restrict time in bed to -heurs pet nigbt b. Optional daytime naps (< 1 hour) no later than 3 p.m c. Go to bed only when sleepy d. Get out of bed when unable to hl1 asleep/return to sleep within 10-20 minutes. e. Ekpeat this procedure as often as necessary f. Arise at the same tirne every morning g. Do not use the bed/bedroom for nonsleeping activities

6. Review Relmation Techniques a Progressive rmiscle reiaxlaion b- lmagery c. Breathiag d. Autogenic Training

Tmtment Session 8

I . Serf-monitoring a Re- sleep diary b. Answer questions pertainnrg to d k y only c- Reinforce participants for self-monitoring

2. Brief rwiew and integration of all treufmenr procedures

3. Main faining îreament gains a Motivation and cornmitment b. Contmued adherence to treaîment (making part of lifestyle) c. Social support h m spouse or si@cant others

4. Relapse prevention a Make distinction among iapse, relapse, a d wllapse b Discuss the inevitability of ha* an occasionai poor night's sleep and caution a g d

interprethg this as evidence that c h n i c insolmiia has retunied c. Identify high-risk situations

ï) Negative emotional states (e.g. stress, aaxiety, dep-on) ii) Positive emotiod states (eg. anticipation of a trip, baby)

d. Give tips for coping with the ineviîable i) Stay caim- no need to panic, itjust d e s things worse ii) Analyze antecedents or precipitating circumstances iii) Reinstate restriction of time in bed and folIow stimuIus control procedures iv) Ask for furthec help phone call, b a r session

e. Give tips for wping with daytime sequelae of itwmnia i ) Cbange the timiog of scheduled activities ii) Engage in sensory stimulation and time management to increase performance Üi) Inctease toIeraace to sleep loss

5. Rmkw of progress d g d anainment- humbut evaIutation of grmp intervention

Muteriah: Sleep diary Evaiuation of group intervention

Behaviour~l Stntegies For S k p :

Sometimes probIems arise with sleep when people engage in activities at bedtime

that are incompatible with h h g s asleep. For example, they use their bedrooms for

readmg, taiking on the phone, watchiag television, snacking, listening to music, paying

the bills, planning the next days events or wocrying. The bottom Line is that the bed and

bedtirne becorne cues for amusa1 rather than sleep. As mentional above, the bedroom

becornes a cue for anxiety d frustration when trying to fiil1 asleep. The goal in order to

resolve this problem is to help the person to Wl asleep quickIy and to maintain sleep.

This is done by helping the person to associate the bed as a cue for sleep, and to weaken

it as a cue for activities that rnight interfere with sleep. The foiiowing technique may

help in this process:

a) Lie down to go to sleep, O& when you are sleepy.

b) Don? use your bed for anything except sleep and s e d activity.

C) If you find you c a m t Mi asleep in about 10 minutes der going to bed, get up and go into another mm. Stay up as long as you want, read, iisten to relaxing music, do things that are sedentary, then wlen feeling sleepy return to the bdroorn to sleep.

d) Remember, p u want to associate your bed wiîh faliing asleep quickly. Therefore, if you still cannot fail askep &er trying Rule Y", repeat it again.

e) Set your ahrm and get up at that same t h e every moniing, regardIess of how much sleep you got the night befbre. This were help your biologicai clock acquire a consistent sleep rhythm.

9 AppIy k s e same rules, if you problem is waking up but mt behg able to fàll back asleep later on in the night.

Slw Resîricfion T k e m -

Many studies have show that sfeep becornes mbust once it has been deprived. The

objective of Sleep Restriction Therapy is to do just tbat. For this particular intervention,

a Sleep Diary is very helpiùl. First, estimate the amount of tirne you think you each

night, for exampie, four bours (sleep does not include the amount of time you have stayed

in bed trying to sleep, it oniy hcludes the tirne you think you have actuaiiy slept). Once

you have established your sleep time, resüict your bedtime to that amount of tirne (Le.

four hours), w h e t k you have slept or not- Once faur hours have gone by, get out of bed

to start your &y. This of course were make you feel tired during the day. However, this

is a temporary side effect tbat is to be expected, Once you feel you have slept for the

complete four hours, you may add another 15 minutes to your bedtime. If you continue

m to sleep better and longer, then continue to add 15 minutes to your bedtime until you

teach a desired Iength of sleep tirne. However, if you have a poor night's sleep, you

should again decrease your total sleep tirne by 15 minutes, untiI your sieep improves

again-

Rdamdbn T d n q r e s :

There are many relaxation techniques that m q help you tiril asIeep. You may try

experimenting with a d e t y to see which works best for you Meditation, yoga,

abdomina1 breathing, autogenic training and progressive muscle relaxation are some

forms of relaxation tbat may k l p you to fa11 asleep. Autogenic training were be

discussed Mer. The main fonn of relaxation that were be di~scussed here is progressive

muscle relaxation This form of relaxation is rather simple to do and easy to l m

However, do not try this relaxaiion technique while driving, because it can make you

sleepy, and this is not what you are looking for while driving. Before we discuss

progressive muscle relaxation, it's worth discussing how relaxation may k lp you in

falling asleep. Accordhg to Borkovec (1982), learning to focus one's attention on

relatively pleasant, monotomus, internai sensations may be incompatible with worrisome

thoughts and images tbat prevent sleep ouset. The cognitive re-focusing may be the

sleepinducing mecbaniscn rather than the actual tension that is released. Whatever the

case may be, relaxation techniques have proven to help with sleep onset.

I) Progrcrsive M d e RclPxorian- It's a method of tensing and rebxiag various muscle

groups bugfiout the body. Beginning wiîh your head and working d o m to yout toes,

contract each muscle group at a time for twenty seconds. Make yourseifaware of the

sensation, then slowIy reIax, experïencing the relaxation for anotber twenty seconds.

You then move down to the aext muscle group and repeat the procedure. Contract the

muscle group for twenty seconds, d e yourseif aware of the sensation, then slowIy

relax, experiemiug the relaxation for another twenty seconds, t k n again move down to

another musde group. At the very end once you have doue each muscle group, contract

your whole body for 20 seconds, and reIax. Do this three times. You should spend about

15-20 minutes doing this exercise whiIe lying in bed before trying to go to sleep. Kou

can also do this in a chair durhg the day whm feeling tense or stressed.

Remember contnct for 20 seconds, then relax for 20 seconds, Begin with the muscles in: a) pwforehed f i ha& k) pur whole body, 3 îhes b) da- c) Mc& M rrpperlegs 4 shoufdus i ) louer legs 4 0nrtF j) fm b toes

2) Gircdcd Iniogerp various visuai reIaxation techniques can be used in an attempt to

relax The body bas the abiiity to react to mental p i c m as if they were real. The

following visualization exercises may help one to relax by taaving an image of oneself in

the various seîiings, either as yourseif or as an ioanimate object. The foliowing may be

rnodified, changed completely or done exactly as described:

a) Seushore: Relax, by breathing deeply, closes eyes, and Unagine strolling dong a quiet

k h on a balmy &y. Imagine wearing a swim suit, and feeling the warrn sun on the

skin and the sand between the toes. Smell the fie& sea air and Listen to the waves

bteakllig on the sand. Enjoy aii of the soothiag surrounding as walk coatinues down the

b) Bubbles: Imagine that your hughts are bubbles, which float up and out of you,

clearing your mind as they go- ûr picture bubbles rising to the surfgçe of a glas of soda

mer. As the carbnated bubbIes reach the surface and burst, release any thoughts you

may have with them. Clear p u r mînd and continue watchmg the glas. As each bubble

ceaches the surface, related it to the letting go of pur own bubbiing tensioa Continue to

celease your tensions as you watch aii the bubbles escape, until you have relaxecl your

rnind and body and the glass of carbonateci water is crystd cIear ad uadishirbed.

C ) Escalator: Imagine stepping onto the top of a long, sIow-moving escalator. While

you slowly ride down this escalator, feel yourself going down, down, d o m into a deeper

and deeper state of relaxation. AUow your entire body to relax as you continue to ride

dowu this escalator.

d) Floating do&. Explore a féeling of airiness and lightness with this image. Close

your eyes and picture a brighi, sunny day. The air is still except for a fèw wispy clouds

that glide by. Imagine yourself as one of those white f l u e clouds. Feel the sensation of

weightlessness as you aiiow yourself to drift through the sky. You feel warmed by the

sun, and very buoyant. If you have any difficuity with this image, you may first want to

visualize yourself in an airplane. Gaze out of your window ad see the sea of Cotton

clouds below you. Imagine yourseifsafeiy stepping out of the plane and onto the clouds.

You bounce fiom one moud to another until you land on the one you were becorne.

Imagine lying d o m on this cIoud bed, then allow yourself to becorne the floating c l o d

e) Hot oit ballwn: P i i putself as a colourfui inflatable balloon, Mentally inflate

yourseif with evwy inhalation. Imagine yourself gently rising to the ceiling, or if

outdoors, to the sky. Take in the scenery around you as p u gently continue to rise.

Notice ai i the details of your sunaundings: the colours, objects, mlIs , tempetatllte, and

so on. You caa fiat as Iong as you wish, and wtien you are ready to return, slowly

exhale, Wnh eaçh exhalation, gentiy retum to your original position Take time to enjoy

this &hg.

3) Breathbzg- should be in a quiet cornfortable room. The practice begins in a sïttiig

posture and progresses to a lyingdown position. it takes approximately 20 minutes to

complete. In the sitting position, sit in a comfortable chair, pnferably one providing

good lower back support. Place both f& on the fiwr, with knees slightIy apart. Wear

loose clothing so you do not kl constrkted. begin by stroking your abdomen gently to

h g your awareness there and to heip you let go of tense, tight muscles. Breathe as you

stroke, for the next fèw minutes. You may cluse your eyes in order to bring awareness to

your breathuig. What do you feel? As you k a t h out, make a soft whrspered "Hama"

sound. Allow your shouiders to stay relaxed Slowly and gently inhale through your

nose anci exhale through your muth whisperiag "Haaaa". Notice any tension in your

abdomen and let it go. The same process is repeated d e r a few minutes in the lying

down position.

In the Iying position, choose a cornfortable surfixe such as your bed. Lie on your

back with your feet shoulder-width apart and your amis a few inches away h m the

body. Be sure you are comfortable, try pkmg one pillow under your knees for the lower

back support and one under your ùead. Thea be ready to place a 2 to 5 pound weight on

pur abdoariien This can be a book or a bag of rice or h. Begin to take slow deep

breaths. The breatbing should be effortless.

4) Aulagmic Tminmg- this is a technique that requires Cocusing one's attention on

various parts of the body (particularly your limbs), coupled with self-suggestions of

heaviness and warmth.

Cwnitive Strateeies For Sleee:

hhc@ks of CBT- Cognitive-behaviourai therapy looks at the reiationship kween

hughts, beûaviours and emotions. Cognitive therapy is an active, directive, time-

limited, structured approach, The philosophy of cognitive therapy is largeIy based on the

ratiode that individuais affect, or emotions, and behaviour are largely detennined by the

way in which they structure the world (cognitions). These structures or cognitions are

mted in attitudes or assumptions developed h m previous expiences. Aiterations in

the way somme structures his/her world c m Id to mbsequent changes in affect and

behaviour which cm ultimately lead to an improvement in the way he/ she furmctions. A

mudel of CBT, linlcs the environment or 'Activating' events to the emotiod

'Consequences' by the intervening 'Belief. Becoming aware of maladaptive beIiefs and

the negative emotionaI consequemes of these beiiefs, can empower clients to actively

aiter the. beliek which w& subsequently alter the emotiod consequences.

CBT d C h n k IkmmniP- The 6rst step in cognitive therapy is to identifj the client's

specific dysfunctional sleep cognitions. As a startmg point in therap y a questionnaire on

personal beIiefs and attitudes about sleep is given to clients. It is used to help ident*

cognitions to work on diiring treatmerd Once the cognitions have ben identifid ,

clients are asked to monitor them at bme, both at ni@ and diniag the day. Cognitions

need to be identsed, ciarified and challenged and tki. validity needs to be tested.

F i d y dysfunctionai cognitions need to be replaced with more adapk substitutes.

(Shan et ai., 1993)

There are four main targets for cognitive therapy in insomnia The fïrst is to

0 change the unidimemional explanations of b m n i a , for exampie, 'insomnia is entireiy

due to some chernical imbalance and therefore the oniy treatment that can work is a

sleeping pill', and to give the individual more control over changing the factors that are

causing the insomnia. nie second is to address some misattniutions or amplifications of

the wnsequences of uisomnia. Some people feel that whenever they feel bad during the

day it is because they have not slept well the night before. This may be ûue to some

extent but it appears t be ampiified in chronic individuals with insocnuia. The third targd

is to change unredistic explanations about sleep, such as the absolute need to have 8

hours of sleep per night in order to fùnction the next day. Finally, the issue of

performance anxiety, fear of losing control or the idea that insomnia is destroying one's

l ie completely, and the leamed helplessness that is associated with insomnia, neeû to be

addressed,

Psychophysiological insomnia may be manifested by increased interna1

physiological musa1 and conditioning fàctors (Hartmann, 1988). The characteristics of

internai arousai can include: a tendency to high muscle tension, &ety about specific

daytime events (anxiety in the sense of fear of Mure), a fear of letting go in many

dïerent senses, obsessional characteristics associated with holding on and an inability

to kt go of anything, perfectionistic tendencies- a need to do everything right, and

personaiity feanires of anger and paranoia. Sleep is associated with reduced autonomie

activity. Coasequently, when physiological arousal is present, sleep becornes ùnpaired.

An important principle in many cognitive therapies is to enlist the patient as

"coscientistnn Instead of passively iistening to the advice of the experts, the patient

shouià be asked to make and test their own recommendations. In î h forum of a group

setting this could include the collaboration of other group members who are expetiencing

simiIar problems. Being an active participant can be done by keeping a sleep diary,

where the he or she notes how t k y sIept. Using a day Iog, cm help the participant keep

track of activities which in t k i r opinion, might be rehted to sleep quality. Daily events

wn be rated on a scaIe fiom O to 10 every night before going to sleep, Mer the

individual has kept the &y logs and for a week or two, one can evaiuate whether or not

tkre is acnially a relationship. Instead of king a helpless victim of insomnia who has to

be cured by the therapist, the patient now becames an active collaborator in the task of

fmding solutions to a c imunscr i i problem (HaUn, 1991)

C h n i c insomnia is seen as a symptom of a breakdown in wping and in

adaptaiion, Emotional arousal is seen as king precipitated by unexaminecl, unresolved

emotional confîicts. A goaI of therapy is to belp determine the nature of these codicts, - --

to correct misperceptions, and to encourage a resolution of the codict (Hauri, 1991).

Going to bed with a racing mind were almost guarantee you d i i b e d sleep, if

any. This anxiety teinforces that you were mt be able to sleep, which then causes tÜrtkr

anxiety, which then perpetuates your Uiability to sleep. It's a vicious cycle. Cognitive

süaiegies try to heip you to deal with your wonhome preoccupations and aim to replace

tbem with calnmess. The petson who fies in bed ami is constantIy tosshg, turning and

cursing that they cannot sleep, and Y'm going to €te a wreck tomrrow!", were only be

perpetuating fÙcther anxiety, making sIeep that much more diicuh. Cognitive

mterventioas try to focus on wbat patients thnik and tell themselves anâ correct irrational

"catastrophizing" tbougfits with caiming ones. When going to bed and feeling anxious or

baving many thoughts race through pur mind, try some of the folIowing:

P d h e Sclf-Tdk- try to have a positive attitude towards your sleep and try repeating the hüowing points to yourself:

a) i have set aside time to deal constructively with my problems tomonow.

b) if 1 awaken early tonight, i were not dweii upon it, but were remain relaxed with my mind in neutrai.

C) Nightly arousals are normal.

d) Devebping these poor sleep habits took tirne, so it were also take time for them to r e m back to n o d

Edacational S tmtwies For S k p SIeen Byviene:

ïüae is no aie qui& fix solutiai ai how to fa11 as@ and how to slecp well. Everyone is different. You should be @cnt and see what waks best for you This may require a Little tirne and m e trial and amrs. However, it's well wath it aice you find the systan thaî best works for you. 'ihe following are some niggestions:

a avoid naps, except for a brief 10-15 mmutes nap 8 h m arising

a resrria sleep paiod to average n m k of hours actually slept per night in the p d i n g week Too much time in bed can deaease quality on subsequent nigtit

a get at least 20 minutes of exercise, 3-5 days per week. [t's best to finish exercise6 hours before bed

a take a hot bath to raise your temperature 2 degrees Celsius for 30 minutes within 2 houn before bedtirne. A hot drink, (wam mik) may promote relaxation.

0 keep a regdar time out bed 7 days a w d

a limit exposure to bn'ght Iight durhg the night

do not smdre dlaùig the night

do not smoke a b 7 p.m.

avoid caffeine ailer IO am..

Heavy smoking can dismb sleep (2 packs a day). Yom body reacts to the tirne of the last cigaretic afta 3 hourn Nicotine is a stimulant Therefore, a cigiueue More sleeping may awaken yw. Quithg smdung ail togeîha, may came same slecp probiens due to withbwal. However, this shwld &ide (Community Health Nctwak, 1984).

avoid alcohol connimptiai. Alcohol mn -ait sIecp. Alcohol is not a good aid to sleep. it may help you to fiII asleep, but the sleep is of poor quality and it causes carly awakmings

a The best sleep happais without sleeping pills. Slaphg pilts can pmvide temporary relief to insomnia, but cm have varid short and long tam efkcis. Sleeping pills becune less effective with regulaf use and can bacwie addidldlve. Try to w than aily if you have to.

a Some sleeping pills mtaisify the effeets of a l d o l and Mœ v a s a The canbmation of the two shwld k avoidai

do not eat a drink heavily f a 3 haurs befm bedâime, A Iight bedtime snack may help (wann ml%). A sudden change in dict can disupt your deep. Too heavy or spicy a meal kf'e bed may wake you, and so may hunga. Nat eating m the 1st two to fmn houn befm bcdtime may help. Try to stick to normal mealtimes if possible.

reduce drinking a fiw hours befac bed nie human bladda wially has an emptying fhquency with a day rhythm. Therefon, sleq is mon likely to k üitantpted by ihe necd to lainate. So nmùig down the amount of drinking gives your bladda less stimulus to w o k Avoid caffeine (coffce, tea, cola, diocolate and some pilis) two hours before slap. Caftëiine should be a v o M for at least five hours befm trying to go to sleep. A warm $as of milk b c f i M has h d to help sleep quality.

lkt prdems, -es or thmgs that yw have to do on a piece of paper, w l e m for the following &y. Do not bring any amcems mto the bed with yoa

kep dock face turned away with alann set, diii avoids excessive wony with regard to toial slap t h e

use bcdroom only for sleep, do n d work ofdo otha activities that can lead to polonged amusai.

kecp roaa dark, quiet, well ventilated and at amfortable tempaanae Light bom the stm, really creates problems m trying to sleep. Melatonin, wtiich has a circadian rhythm, is a honnone which induces sleep, However, light inhibii this homone. 'Ihaefore, makmg sure it's dark in your b e d m and avoiding light were help to faIl asieep. Heavy airtains and an eye-mask mIIy helps.

Fresh air in the bcdroom befote you sleep should help. Using an airumditiona if the r o m gets tao hot, col& humid a dry shoutd be helphL Slecp is best at abwt 15 to 18 degrees Celsius

Beds oftm detaiorate over tirne. Upgrade if it's m poor conditiai. 11s mattress shwld be b l y spnmg, with no sag

use a bedtimeritual, nadmg befae lights-out may be helpfil. Go iiuough the sarne tihlals of going to b a i as you usually do befue night slecp. B d m g your teeth and puthg ai sleeping c l d e s may help you kl rcaûy for slecp. A warm bath or shower may also help you to fcel sleepy.

Sa whaha you nad tirne to wind down aftu wwk It may be helpfiil to relax if y w are d l y tense. it may be wisc to read a watch TV to calm down.

Trying to get m the right h e of mind for slecp is important If you have difficulties €blling asleep, uy gaitly music a a relaxation tape or sane of the relaxation techniques that wae be discuned tata m the workshop. Gettmg angy that yw cannot slcep, wcre only make it more dificutt to slecp.

Working ihe mornmg shifi may cause some anxicry about waking up in tirne. This anxiety cm p m t you h having a g d night's res t Makiug sure îhat you have a fbolpmof a l m can help redua this anxicty. Far example, get an alann that repeats, or an a l m that macases its volume, a set two alanas aie that tims on baies and one that yw can plug in.

keephg a mord of your sleep, its problans and suaxsscs, and of thme guidehcs, rnay heip p u to build up ywr acpa-encc and expertise more quickly. It may allow you to follow in a systematic mannu, what needs to k waked on and what is wotking well for you You are the best expert m your own sleep.

Nutrition: Good Nutrition equab Good S k e ~ :

Nutrition plays a role in how we feeL Depending on what you eat, you may h d

you are more alert when working night sh ih and that you can sleep better. Having a

meal tich in protein boosts concentrations of chernicals in the brain which can stimulate

activity. Eating meals cich in carbohydrates ùicreases concentrations of serotonin, a

sleep-induchg chernical in the bcain. However, there are other vitamins and minerais

that one shouId know about, especially if you are having diEculty sleeping. The

fôliowing is a description of vitamins and minerals thaî can help you sleep: Hauri, P.J.

(1991). Bootzin, RR (1 99 1). Bulletin of European Shiffwork Topics (1 991) Monk,

H.T. and Folkard, S. (1992)

1. The B vitamins: These vitamins regulate the body's use of amino acids, inciuding

tryptophan. Some studies have shown that Vitamin 8-3, enhances the effect of

tryptopb Tryptophan is one of the 22 amino acids hund in protein. Tryptophan is the

substance fiom which the sleep-inducing brain chemical serotonin is made. This vitamin

is reported to be effective in alleviating the type of insoda suffered by people who hl1

asieep readily but who are unable to Ml k k asleep after awakening later in the night.

The current Recommended Dietary Allowance @DA) for vitamin B-3, which is hund in

hi&-protein foods such as fish, liver? kidney, chicken, peanuts, miik and eggs is 15

milligrams a &y. Other research indicates that some sleep problems can mise fiom a

deficiency Infalic acid, which is a member of the Vitamin B hnily. This can be found in

asparagus, broccoli, cauliflower, cabbage, green peas, kidney and lima beans, beets,

sweet potaüws, whole-grain cereals and breads, oranges, d o u p e and organ meats.

The RDA is 180 micrograms per &yY B vitamins can be easily leached fiom our body

through cigarette smoking, akoho l biah-contro 1 pills and stress.

2. Calcium: This mineral is a naturai relaxant that bas a calming effect on the central

nervous system. Some studies have shown that even a minor calcium deficiency can

cause muscle tension and uisornnia Stress also rapidly depletes our bodies of calcium.

Therefore, you sbuld take enough calcium daily. The RDA is 800 milligrams daily. If

you are allergic to milk or just do w t üke Ït, try supplemental forms of calcium, like

mustard greens, dandelion greens, broccoii, spinach and sardines.

3. Mamesium and wtnssium: Magnesiun (which is found in potatoes, whole-grain

bread, rnilk, meat, fish, poultry, eggs, dark green le@ vegetables and c h ûuits), is a

natural sedative. Studies bave shown that magnesiurn deficiency can cause insomnia.

0 The RDA is 280 milligrarns a day. Potassium (which is found in meat, milk, potatoes,

bananas, oranges, apricots), in combination with magnesiun has also been found

effective m alleviating chronic fatigue.

4. Zinc: A deficiency in zinc cao contribute to insomnia. This mineral can by hund in

oystws, hwring, meat, mik, eggs, whole grains, peas, beam soybean curd, raisins, dried

figs and apriwts. The RDA is 12 milligrams per day.

5. Iron and CORW~. Recent studies reported that a deficiency in either copper or iron

has an effect on sleep patterns. Women who received insufficient amounts of copper or

iron, reported that they found themselves sleeping longer than usual and also waking

more k q u e d y dwing the night. They also reportai that they would awaken tired and

not r e M There is no RDA for copper. However, it can be found in whole-grab

cereals and breads, sheiifish, nuts, organ meats, eggs, pouItry, dried beans and peas and

Q Ici@ dark-green vegetables. The RDA for iron is 15 miliigrams a day. it is found in

organ mats and dark-green leafL vegetables, as weil as in beeE sardines, oysters, p m s

and 0 t h dried hits, peas and lima beaas.

Pbysical Fitaes:

Trying to keep fit is important for several reasoas. Many jobs do not provide the

opportunity for the human system to maintain kart, lungs and muscles in good working

order. The human body has evolved under a physically active life and stays healthier

when there is some regular physical activÏty. Doing at least twenty tuinutes of exercise,

three times a week is said to ixnprove mood and increase resistance to stress. Shift

workers are in a dficuit position because of their hours, in thai, their working hours can

interfere with normal participation in reguIar team sports and group physicai activities.

m The foiiowing are some NLS that can heIp with physicai fitness:

1. Keep your stamina UD. Try to take part in some physical activity. Aiming to raise

your hart beat is a good start. This cm be done by training for 20 minutes a day, 3 thes

a week. The purpose is to raise your hem-beat h m its normal 72 b a t s per minute

towards a üaiaing-rate: a minimum of 180 minus your age, Le. 140 for a 40 year old.

Using iarge muscle groups, iike in your legs is quite effective. Such exercises include,

swimming, cyciiig or jogging. Brisk w a h g is also effective.

2. Make pood use of vout dam When working nights, you are usually k e duting the

day while most people are at work. This means you can take advantage of avoiding

crowds for leisure activities üke golf, mvimming-pools, etc.

3. Don't over do it. Do mt exercise too ~ u o u s l y before starting your night SM-

You do not want to exhaust yourseff before work

4. Viiit your doctot for an annuel check. You should have a regular medical check-

up, at least once a Farar Many problems can be treated if detected early.

5. Check yourseif out. Be aware of any gradua1 developrnents of probkms that may

result kom shiftwork. Such as, weight 105s or gain, gastric or digestive problems,

excessive fatigue or nervous disordem. These are early signs of ill-effects resulting h m

night work

6. Take care of yoar life-style. Working diierent hours can lead to health relateci

babits, like smoking, drinking cafîieine or alcohol and dependency on sleeping pills.

Keeping a diary of your We-style, may help to wani you of any growing problem areas.

APPENDM D

PSYCHOMETRIC BATTERY

I. Sleep D k y : Center for Sleep and Chronobiology- University of Toronto

2. Tbe Insomaia Severity Index (ISI)

3. The Beck Depression Inventory-U @DI-IP)

4. Tbe Beck Anxiety Inventory (BAI)

0 1. Sleep Diary

S L E E P D I S O R D E R S C L I N I C Center for Sleep and Chronobiology

University of Toronto

-1 ! I I

! / I I I l I l l i / I i

COMMENT S

SIeep Disorders C h i c 340 College S w e ~ Suite 580 Toronto, Ontario M5î 3A9

~aldofsky/~a&rlane Copyright @ 1990

t . Please rate the m t s d t y of your insumnia problmi(s): Naie Mild Modnate Severe Vay

Difficulty fhlling aslcep: O I 2 3 4

4. Kow naticeable to &as do p u ttrink your sleeping problern is in tenns of impairing the quality of p u r lif'e?

Nd at a11 A Iiüie Somewhat Much Very much

5. How worriedldisbessed are you abaut your cumt sleep @lm?

Not at al1 A i i ie Somewtiat Much Very much

O 1 2 3 4

Marital Stanis: Age: Sex:

Instructiotls: This questio~lnaire coPSiSts of 21 p a p s of statements. Please read eadi p u p of stafements carrfully, and then pick out the one statement in each group that best describes the way you bave been f a h g during the past h o a&, Uiciading -y. Ckle the numkr ksi& the statemear you have picked If severai statements in the group seem to apply equaily well, &le the highat numkr for that _mup. Be s w e rha< you do not choose more than one suternent for any group. includiag Item 16 (Changes in Sleeping Pattern) or Item 18 (Changes in Appetite).

1. Sadness O 1 do not feel sad. 1 1 feel sad much of the the.

2 Iamsaddthetime. 3 1 am so d or unhappy thar 1 can't stand it

2, Pessimism O 1 am not discouraged about my fuwe.

1 f e l mort discouragecf about my future than 1 used to be-

Z r do not erpct Wgs to work out for me.

3. Past Failunr O 1 do not feel iike a faiIure. 1 1 have failed more th 1 should have. 2 AsIlookback,Isetal~toffaiture~~

O 1 get as much pleasurc as 1 ever did fiom the things I cnjoy,

1 1 don't enjoy things as much as 1 wd to. 2 1 get very litîle pleasure h m the things 1 used

to enjoy- 3 1 can't get any pleasure h m the tbgs 1 used

to enjoy.

5. Guilty Feelings .

\

0 1 don? fetl particulariy Oouilty. 1 I kI guiIty over many hhgs I have done or

should have doue. 2 I ikel quite bguiity most of the thne- ' 3 Ifiguiltyallofthenrm

6. Punishment Feelings O 1 don't f e l I am king puaished 1 IfeelImaybepunishtd 2 1 expect to be punished. 3 I feel1 am being punished.

7. Self-Dislike O 1 feel the same about myself as ever. 1 1 have lost confidence in myseif. 2 1 am disapgointcd in myselt 3 I dislike myself.

8. Self-Criticalness O I don't criticize or blame myself more than usual. 1 1 am more aiticai of myself than 1 used to be, 2 I criticize myseIZ for aII of my fauits. 3 I biame rnyseif for everything bad that happens.

9. Suiddal Thoughb or Wisha O 1 don? bave any thoughts of kiUing myself. 1 I have thoughis of k i h g myseff, but I wouid

not cany thcm out. 2 1 would Likt to Lill myself. 3 1 wouid kiii myseif if I had tht chance.

IO. Ctying O I don't cry aaymore than 1 used to. 1 cry mon thm 1 uscd to.

2 E cry over every liitle thing. 3 1 feel iike qiug, but 1 can't

4. BAI

NAM€ D A E Below is a i i i of common sym toms of amidy- Please camfu read each item in the list Indiie hwr much yw have been bothered by each sympiorn during the PAST ~ E K , INCLUûiiüG TODAY. by &~ng an Y in Ihe mmpowng rpass h h column nxt 10 each symptarn.

1 . Numbness or tingling. -

2. Feeling hot.

3. Wobbliness in legs.

4. Unable to relax.

5. Fear of the worst happening.

6. Dizzy or lightheaded.

7. Hean pounding or racing.

@ 8. Unsteady.

9. Temfied.

10. Ncrvous. -- I 1. Feelings of choking.

12. Hands trembling.

1 3. Shaky.

14. Fear of losing control.

15. DiCficulty breathing.

16. Fear of dying.

17. Scared.

18. Indigestion or discornfort in aMSmen,

19. Faint.

20. Face flushed,

2 1 . Sweating (not due to heat).

DEMOGRAPHICS Q~STIONNAIRE, CROUP INTERVENTION EVALUATION, BELIEFS AND ATTITUDE ABOUT SLEEP SCALE, AND

COGNITIVE VIGNETTES RELATED TO INSOMNIA

1. Demographics Questionnaire

2. 'eoup Intervention" Evduation

3. Beliefs and Attitude about Sleep Scaie

4. Cognitive Vignettes Related to Insomnia

1. DEMOGRAPHICS

1) Today's Date:

2) Age:

3) Sac: Male Fende

4) C m n t Sbm: a) Smgle 4 m t e d (Please &le) b) Marcid e) Divorced

c) Living with a parhia f) Widowed

5) How long have you beai s u f f ' g fim insomnia?

6) Do you have difficuIty with: (please circle) a) falling asleep b) -Ying =lecp c) wakmg up early d) al1 of the above e) both "a" and "b" f) both "a" and "c" g) M "b" and "c"

7) Are you currently taking medication for your insomnia? a) No (ifno, please go to question #8) b)Yes (ifyes, please speci@ the type and amount)

8) Have you ever taken medication in the past to mt your insomnia? a) No b) Yes (if yes, please m e r question #9)

9 ) i ) Type of med;.cation and aaount:

ii) How long did you take the medication for : ï i i i Was it heipful (please circle): No Yes iv) Why did $XI diP (use spa& bebw):

10) Have you ever sought treatment for your insomnia before? a) No b) Yes (if yes, answer question #Il)

1 1) What type of treatment did you receive?

Did you find the following interventiais heIpfuI in dealmg with your hsomnia

Noi Slightiy Somwkat Vay 8t dl m ~ c h

6) progressive muscle reiaxation O 1 2 3

d) autogaiic training O I 2 3

h) Cognitive rstnictiiring (changing beliefi & attitudes regardmg O 1 2 3 pur slecp and insomnis)

Please indiate whetha the f8cion i i i below, wac helpfiil to you as a group member, in dealing wirh yout insumia.

Not MinimrlIy Modaxtdy I n W y u dl

Ginng me a fbanœ to help &as O 1 2 3

3. BELAVS AND A T ï ï ï ü û E S ABOUT SLEEP (as adap<ed €ian Mon'is C (1993). fntonuiio: Pryrhlogicol

Asessrnent ond Menogonciirenogonciir New Y a k The GuiIdani Press).

SeveraI statanaits refleEtmg people's beliefi and about si* are listed below. Please uidicate to what extent you pasonally agree a d i i with each statement Thae is no right or wrong answer. Fa awh statancnt, place a mark (/) almg the Iime wtiaever pur pasonal rathg Mls. Try to use the wtide scale, ratha than placing marks at me a d of the iine.

1. I need 8 hours of sleep to kl mûeshed and h a i o n well during the day.

2. When i dcn't gct a papu amount of sleep on a given nighf 1 need to catch up on the next day by napping a on the next night by sleeping longa.

3. Because I am gating olda, I need t e s sleep.

4. 1 am worried that if 1 go for me or two nights without slecp, 1 may have a navous bteakdown.

5. 1 am mcaned that chronic -ia may have seriws msequences for my physical health.

6. By spendmg m m t h e m bu!, 1 usuaily get more slcep and feel better the next

7. Whai 1 han trouble @mg to sleep, 1 should sîay in bai and try harda.

8. I am -ed that I may Iose conml over my abilities to sleep.

9. Beoiuse 1 am geüing older, 1 stiodd go to bed carlia m the evenhg,

Mec a poar night's slecp, I h o w hat it will interfere with rny daily activities an the next day.

In orda to be alat and fimctian w l l d h g the day, 1 am better off taking a sleeping pi11 ratha than having a poor night's SI-.

Whai 1 feel imitable, dcpessed. a anxious during the day, it is rnostly because 1 did not sleep well the ni@ befae.

&cause my bed p m a fiills aslaep as socm as his a h a hcad hits the pillow and stays aslecp diorough the ni& 1 should be able to do so too.

1 feel that insomnia is bssically the result of aging, and thae isn't much that can be done about this problan.

Whai 1 have a good nigtit's sleep, 1 know îhat 1 will have to pay for it on the followuig night.

Whai 1 slecp poarly cm one ni& 1 know it will d i i b my slœp schedule for the whole week,

Wiîhout an adequate nigbt's sleep, I can hardly timction the next day.

1 can't ever prcdict wtietha rlI have a good or poor night's sleep.

20. 1 have littîe ability to manage the negativc COClSequcnces of d i i sleep.

When I fée1 tired, have no aiagy, a just seem n a to fimdim we1I dtauig the day, it is gmerally because I did not sleq welI the nighî before

1 get overwhehed by my thoughts at night and offai k I i have no amtrol wcr my rachg minci.

I fœl I can si11 lead a satisfaaory lifë despite sleep diffiarlties.

i feel insomnia is ruining my a b i l i to enjoy Iife and prevents me hm doing what I want

t avoid oc cancd obligaticnis (social, h i l y , occupaticmal) afier a poor night's slcep.

A ïiightaipn befort M m e is a goal solution to sleep problems.

My slacp is geaing wase all the the. and i h ' t betim myone can help.

it usuaüy shows in my physical -ce when [ havm't dept well-

Situation One:

Eafing break$& in the moming

Cognitioadthoughts: "How am Igonna gel through the day afer such a miserable night? "

Feelings: Depressed, helpless

Situation Two: Poor fiinctioning at work

Cognitons/tboughts: "1 just can 't do my work ajier a &ad night 's sleep ".

Feeiings: Angry, imtable

Situation Three: Watching TV in the evening

Cognitiondthoughts: "1 must have some sleep tonight ".

Feeüngs: Anxious or apprehensive

Situatioa Fout: Getting d y for bed

Cognitiodthoughts: "What's the use of going to bed tonight when 1 know 1 won? be able to go to sieep?"

Feeüngs: Heipless, out of control

Five Tmical Dvsfunctional S l m Comitions:

1) Misconceptions of the causes of insomnia 2) Misattributions or amplifications of its consequences 3) Untealistic sleep expectahns 4) Diminished pmptions of control and predictability of sleep 5) Fauity beliefs about s k p promoting practices

Vignette 1 : Misconceptions of Insomnia Causes

Dysfunctional Cognition: "1 feel my insomnia is basically the result of some biochemical imbalance or ph. "

Underlying Beliefi " Unless these underlying problems are conected, there is nothing I can do 10 improve my sleep. "

Cognitive Errors: Mïwitribution9 f a w ev ikng &dide thinking

Interventions/Altemative Interpretations: 1) Exclusive attniution of inJomnia to these extemal causes is selfaefeating because

you may indeed have Little control over them

2) Regardles of the initial precipitating causes, psychologid and behavioural variables are almost always mvolved in chronic insornnia

3) Because you have some conml in changing these variables, you can also Unprove your sleep patterns.

Dysfunctional Cognition: "Ifeel my sleep problem is essentiaiZy the remit of aging and I can 't do anything abouf if. "

Underiying Beiief: "Distwbed sleep is an inevitable consepence of aging. '"

Cognitive Errom: ~iscraaibutton9 fa* evidence, ahsoluîe thinRing

InterveationdAlternative Interpretations: 1) Do aii older people you kww bave sIeep disturbances?

2) Beyond some normal age related changes in sleep pa!tenis, not d older peopb suffer h m insomnia; therehre, other factors unut be involved.

3) Lifestyle changes accompanyhg retiremeat may alter put sleep pattm; thus, you can make some adjustments in t h e areas to improve sleep.

Vignette 3: Magnificaîio nshkami'butions of lnsomnia Consequences

Dysfunctional Cognitions: ''Afler u p r night 's sleep, 1 how I w n 't be able to jhtion the next &y. ."

"Wkn IfieZ irnVuble. depressed, or unxious M n g the &y, it is because I haven 't slept well the night before. "

Underiying Beiiefi "lmmnia is mcessmily detrimentu1 tu &ytime fwcrioning "

InterveationdAltermativt Iaterpretations: 1) Do you always experience daytime hpairments aiter a poor night's sleep?

2) Are these daytime sequelae always experienced with the same intensity?

3) 1s it possiile that other factors mi& also be causing these pmblems?

Vignetîe 4: Consequences of I ~ m n i a

Dysfunctionrl Cognitions: "lm c o n c e d thut chronic insomnia may have serious comquences for mypwcul health. "

Underlying Miel: 'Insomnie is neeem-iy &trimental to health. "

Interventions/AHernaîive Interpntrfioas: 1) There is no evidence that anyone bas ever died h m Iack of sleep dom.

2) Excessive worrying about insomnia may be more detrimental to heahh than sleeq l o s itseK

Vignette 5: Sieep Requirements Expectations

Dysfuictioirt Cognitions: "I must get 8 hows of sleep every nighi. "

Uaderiyiag Beiiel: "It is essential to sleep 8 hours tofeel refieshed and fünction well dunng the a& "

Cognitive Erron: U d l i s t i c cirpecrorions, ahwluîe thinking

InterventiondAittrnrtive lnterpreîatioas: 1) Sleep aeed vary widely aniong individuais, and there is no "gold staradardn that

everyone shouid aim for.

2) Avoid placing undue pressure on yourself to achieve such a standard, as it nmy increase pur anxiety d perpetuate insomnia

3) Remember also, tbat too much sleep may be a waste of tirne; somc very productive people ate short sieepers.

Vignette 6: Umeafistic Expectations of seIf

Dysfunctional Cognitions: "Becaure my spouse (signijcant other) falls asleep in minuîes, I sbuld be able to do the same. "

Uodertyfng Beliefi "Everyone mwt sleep alike. "

InterventioodAiternative Inttrpretatioas: 1) Do d people p u lahow have the same height and weight?

2) Beyond some normative range, ttme is wide variability among hdMduaIs in teris of how fast &y fidi asleep, how 0th they d e up, and the overaii qwlity and duration of sleep.

3) It is best to aavid social comparisons, as there wiü always be somone who is weaithier, is talier, and sleeps better tban you

e Vignette 7: Diminished Conml o w Sleep und Pe$onnance Anxiety

Dysfunctionil Cogaition: "I am crfiai'd of Iosing control over my sleep abililies. '" 'Y IuTve lost control of my sleep. '"

Underlying Beüef: "lt is essentid to be injull control of aIl aspects of one 's Iife. "

Cognitive Errors: CtiilrrdrcrpAIMg; W m a l kluf

IntervcntiondAlternrtive lntcrpretntions: 1) What is the worst thing that couid bappen if you never got to skep tonight? It is not

2) The harder you try to control SI-, the kss contro l you will achieve; it is much easier toforcewakefiilnesstbantofàilasIeepatwill.

3) Sleep d l corne more easily if p u do not try so bard to conûol it.

Vignette 8: Unpredictabilii of Sleep atui Leanied Helplessness

0 Dysiinctional Cognitions: "I w i l ) con 'tpredict whether 1'11 have a good or poor night 's sleep. " "1 mut m'y on a sleeping aid to make my sleep more predictabie. "

Underiyiag Belieîi YNo matter whut I d0, it has no effect on sleep. Imomnilr is mody a r e d of externat factors that I have linle control over I am a vidim "

Cognitive Emn: Ovcrgcn- fwEIpevi&nce, criruCornaroning

interventioadAlternatCve httrpretations: 1) When you use a sleepmg pi11 aad arperience some temporary relief, it only reinforces

yaur conviction that you bave liitfe contrai owr steep.

2) Nightthe sleep is not Endepeadent of daytime activities, thoughts, and îëeüngs; therefore, you must camfbily examine eXamme theseiationships in order to make your sleep nme prediile and develop m>re seW-control,

3) Remember also that the most predictable coIlSequences of sleeplessness is ttiat it will

Vignette 9: Excessive Emphasis on SIeep am3 Control

Dysfiindionil Cognitions: "Ifeel insomnia is &sfroying my entire lge. " "I have Iirtle control in m g i n g the negaiive consequences of disntrbed sleep. "

Underlying Beüel: "I am klpIessniopZess; unless sleep improves, my I i f e will remain miserable. '"

Cognitive Erron: Milgnàjkarbn; o w q ~ n ; wtadrophiurg-

I[nterventiondAlternative Interpretrtlons: 1) Since sleep is supposed to occupy ody a third of your Me, aren't you giving it more

2) 1s it possiile the oext the you have a bad nigiit's sleep to ignore it and go about your daily mutines just pretending you skpt weii?

Vignetie 10: Misconceptions about Good Sleep Practices

ûysfunctional Cognitions: " When Idon 't get an &quate amount of sleep, I need to catch tp by sleeping late the next morning or by napping the next akg~ "

Underiying Beiicf: "If is essenha2 ro maAe up for al1 sleep loss. "

Cogoitive Erron: F a w ciridurce; abrduic &inking.

Interveotioa/Altermtive Interpretrtiosr 1) Sieeping too late in tbe mrniog or taking d a y t k naps is likeiy to deby sleep onset

2) Sleep deprivation experiments have shown thai people only need to make up for

about oue-third of previous sleep bss.

Vigneîîe Il: Other Misconceptions abut Good Sleep Fractices

Dysfunctional Cognitions: " W h n I have îrouble sleeping, I should just stay in bed

and try hmder- "

Underlying BeüeB: "lfl get out of 6ed I wii2 wke up men more and surely

won '1 be able to go h c k to sleep. "

Cognitive Emra: Fwltyprs-Nidenm

InterventiondAlternPtive Interpretations: 1) The harder you try to induce sleep at di, the less likely you are to succeed. Have

you ever noticed that you fàll askep unintentionalty when you are not even trying

(e.g., readiing, waiching TV)?

2) When you stay in bed awake for too long, ît only strengthens the association between your deep surroundhg and t e n s i o d ~ a

Vig~ette 12: Further Misconceptions about Good Sleep Practices

Dysfunclioail Cognitions: "YI just sped more tinte in bed, I will evenlu~li'y get a11 the sleephest I med "

Underlyiog Beiiei: "Lying dom in bed men $1 am mke, provides some very nee& rest. "

Interveations/Altemative hterpreîatioas: 1) Have you ever paid cbse aüentbn to tbe way you fée1 &r spendiag 12 hours in

2) It is test to spend less time in bed d sleep mre efficiently.

FREQUENCY AND PERCENTAGE TABLES OF CONTROL CROUPS, PEARSON CORRELATION TABLES & SLEEP PKYSIOLOGY BOOKLET

1. Frequency and Percentage Tables of Control groups that did not meet clhicai significauce for sleep iatency, deep efftiency, sleep duration, insomnii! severity, depression and anxiety.

2. Pearson Correlation Tables for performance, sleep, ami depression and anxiety measures.

3. Sleep Physiology Boo klet

2. PEARSON CORRELATION TABLES

9. BAI 4.31. -0.56- 9.5im* 0.50'. 4,#** 4.56** 0.61" 0.62.. p c . 0 5 . - p < . o t .

l. -al b n i n g

t SaPl MdlSub

3. Minikm

4. Sleep Lanicy

5. 9ccp Ef!iciaKy

6. Slœp hmtioo

7. ISI

8. BDI-U

3. SLEEP PHYSIOLOGY BOOKLET

SLEEP PHYSIOLOGY

Treating Chronic Insomnia: A Cognitive- Behavioural Group Therapy Approach

Whv Do We Slee~? Restorative Theory of Sleep

Many studies have shown that one of the main reasons we sleep is for restorative purposes. The restorative nature of sleep happens in slow wave sleep, stages 3 and 4. The following is a summary of studies that supports the above theory of Restorative Sleep:

'Exercise & Slee~: Some studies have shown that when exercise has been performed there is:

a (1) a decrease iri the time it takes to fall asleep (2) an increase in slow wave sleep (3) a suppression of REM sleep (4) an increase in total sleep time. Some studies of marathon runners have shown that Slow wave sleep increases dramtically after ninning a marathon.

*Preanancy: lncreased metabolism and growth was present during prignancy which coincided with increased slow wave sleep. Other studies have show that when subjects had their sleep disrupted or deprived, subsequent sleep had a greater proportion of slow wave sleep.

Cell Division: Studies have shown that the highest peak of cell division (mitoses) occurs during sleep. This supports the theory that sleepis a period of growth and restoration

*Growina at niaht: Some studies have shown that there is a massive increase in growth hormone release shortly after sleep onset. This also tends to wincide with slow wave sleep. Approximately 80% of the daily release of growth hormones are released in the first two slow wave sleep cycles at night. Other studies have shown that after two sleep studies, one of normal sleep and the other after depriving subjects of sleep for 40 hours, the second study found that their was a great increase in the nocturnal growth hormone on the second sleep.

*Enerav Consum~tion durina Sleeo: After an intense-energy consuming day, the body tends to conserve energy during the night whiie asleep. Oxygen consumption is lowest during slow wave sleep, thereby serving a restorative function. Usually after a good night of-sleep we awake

0 refreshed and alert.

Stages of Sleep

Staoe 1 -alpha waves twn into theta waves, slower it makes up about 5% of sleep -transition from wakefulness to sleep *an be awoken very easiiy

Staae 2 irery abundant, makes up 50% of our sleep its the mal flmt stage of ûue sleep -/EB marked by K-complexes and spindler

Staae 3 & 4 -known as slow wave sleep -it occupies about 20% of ow sleep ,-these are recuperaüve stages of sleep - if awoken in this stage, person will be iri a state of confusion -made up of delta waves

Ra~id Eve Movement (REM) -rnakes up about 20% of Our nights it looks very close to wake or stage 1, but the rnusde tone is much lower dreams are very abundant in this stage and are usually more emotional than when we dream in other stages

Normal Sleep Cycle -4 to 6 altemating cycles of NREM (Stages 1-4) and REM sleep, each cycle lests in approximately 90 minute intervals.

-Subject usually falls asleep in NREM sleep

-stages of sleep descend into deeper sleep, passing from Stage 1 to 2 to 3 to 4.,

-fmm stages 1-4, the waves become slower and more abundant

-there is then a brief return to Stage 2, after which the Int REM episode begins

-REM is usually intempted with a body movement, and the Subject entes Stage 2 sleep again or is awoken and begins the entire cycle again

-In the beginning of the sleep, Slow wave sleep is abundant, but becomes less frequent as the night progresses

-Inversely, REM sleep is less in the beginning of the night, but progressively increases in the latter part of the night sleep

-the amount of SWS depends on how long the subject has been awake

-REM sleep on the other hand, is based more on a Circadian Cycle, where it seems to take place during the night when the Subject's body temperature rises.

F i p 1 Changes in sleep stages with Agi%.

Young Adutt

Middle Aged

26.6%

=REM

ILight-stages 182- Wake

1 TOTAL HOURS OF SLEEPI

Figure 2 Graph showing changes with age in total amounts of NREM and REM sleep. There ls a aharp diminuatlon of REM sleep in the early years. REM sleep falle from 8 houn at Mrth to less than 1 hour in old age. The arnount of NREM sleep remains more constant, falllng from 8 hours to 5 hours.

5

Figure 3 Plasma co&A and Melataiin levels fmm the same group of nine heaithy young abjects. From 'Mahg Shiftwak Tolerabien by T. Monk and S. Foildard, 1942, pp. 12. Nde that the Codh~l levds are I ~ r i n t h e n i g M j u s t ~ g o i n g t o b e d . Howwer,thel~&eKrease throughout the night and morning, until awakening. Notice th:t the opposite is tnie of the Melatonin. Melatonin provokes slmp and increases around bedtime and the early moming, but decreases just before awakening.

Cortisol 16 n

14

12 .

10 -

4 .

O 21 23 1 3 5 7 9

Tme of day

Melatonin

* Body Temperature and Alertness Figure 4 Body temperatun and aiertness from a group d 15 subjects exporiencing 72 hourc of condant wakefulne-. Note that es the temperature rises so does alertness. Temperature is usually higher during periods of awake and goes dom during periods d deep. ( after

(wide awake) 40

ri Temperature

10 7 4 1 10 7 4 1 (-)

I pm I am I pm 1 am 1 pm 1 am bm Time of day

- a fnm cf insorrmia caused by tensions and learned associations that prevmt sleep and resdt in a cornplaint of insomnia and decteased f'unctioning during wakefûlness

Mild Insomnia: occurs almost nightly patient receives an insutlicient amount of sleep or doesn't feel

r d this really doesn't affect one's social or occupational fiincti0ni.q usually fed irritable, mild amiety and d a m e fatigue

Moderate Insomnh: occurs nightly patient receives insufncient sleep and doesn't feel rested there's moderate impairment to social and occupational

functioning there's feehgs of fatigue, tiredness, irritability and mild anxiety

Severe Insomnia: ocours nightly patient receives insufEcient sleep and doesn't feel rested there's severe impairrnent to social and occupationai hctioning feekngs always associated with feeiings of anxiety, daytime

fatigue, tiredness, restlessnas and kitability

@ Jet-lw Svndrome: The jet-lag syndrome is a common disorder of the sleephke schedule. It results ftom airplane trips that may span ovex 4-5 times mes when going east or west bomd. This tends to dissociate m e r s endogenous rhythms (which includes cortisol, proIactm and potassium secretion) and extemai synchronizers or stimuli like SU1]TiSe, sunset and social activities @ahon & Hedouin). Jet-lag le& to decreased alertness and insomnia Research has shown that it takes anywhere fiom 1-6 days to resynchronize after a wesî-bomd trip and 3-1 1 days afta an east-bound trip (Nahon & Hedouin).

Shiftwork Slem Disorder: Night shift work and aiternating schedules can also lead to disorders

a of the sleep/wake scheduie. Night shift work affects approxhately 20% of the active population in Canada and the U.S. About one million Canadians work shiftwork. This kind of work however, inevitably afEêcts the sleepMe rhythm in that even if one cunstantly works nights shift, conventionai time-scheduies will be resumed in ordet to avoid social isolation. Because the hinnan body does not have a predispositim to sleeping durhg the &y and because of environmental faaors like n o k and light, mperative sleep for night shift workers is vay poor. The d t is what's called "blue-collar jet lq". Tbis can lead to pmblems that can range h m feeiiap bodily aches and pains, to lack of concentration, to even personality problans (Nhon & Hedouin). niree flictors contribute to the diminished alertness and pafo~nallce of night-shift workers: (1) Misaligament of circadian phase

0 (2) Chronic and acute sleep deprivation (3) hcreased duration of waking houn before begmning night work.