Insomnia Insomnia

Cognitive-Behavioral Therapy 157
Morin et al., for example, found that patients with primary insomnia have a number
of maladaptive beliefs about sleep, including unrealistic views about what constitutes
adequate sleep and catastrophic beliefs about the consequences of insomnia.
Such beliefs presumably contribute to insomnia by increasing sleep-related performance
anxiety and by prompting and promoting maladaptive compensatory
behaviors. Support for the role of such factors derives from data showing that successful
CBT of insomnia is associated with a reduction in negative beliefs and attitudes
about sleep (9,10). Although this is suggestive, more work is needed to
demonstrate the “insomnogenic” potential of such cognitions. This is so because
one can easily imagine that successful therapy may change one’s thoughts and
beliefs, but also that such changes may not be responsible for the treatment gains.
Hall et al. and Harvey and colleagues focused more on cognitive process (vs
content) issues (5,8). Central to this area is that patients with insomnia often complain
that they are unable to sleep because of intrusive thoughts or excessive worry.
These thoughts and images are characterized as being “intrusive” and may occur in
isolation or as unwanted perseverative-type problem solving (worry). The content
of the “thoughts and worry” may be centered on the kind of dysfunctional attitudes
and beliefs described previously, but they are often more general in content. The
ideation and imagery that occurs as intrusive thoughts is often related to mundane
daily activities and/or work or relationship issues. As with dysfunctional attitudes
and beliefs, intrusive thoughts and perseverative thinking (from within the radical
cognitive perspective) are thought to be responsible for the occurrence and severity
of insomnia. The more moderate view is that these phenomena are, along with behavioral
and conditioning factors, contributory.
Support for the cognitive perspective comes from a variety of studies that have
found that patients with primary insomnia complain of higher levels of pre-sleep
rumination compared to normal controls (11,12). Investigations of pre-sleep thought
content have found that the pre-sleep cognitions of patients with primary insomnia
tend to be more negatively toned, and that patients report increased general problem
solving and thoughts pertaining to environmental stimuli at or around sleep
onset (13–15).
Neurocognitive Perspective
In sharp contrast to the cognitive model, the neurocognitive perspective all but
suggests that dysfunctional beliefs and worry are epiphenomena. It is posited that
cognitive factors are likely to mediate the occurrence and severity of insomnia when
the disorder is acute. When, however, the disorder is chronic, cognition occurs secondary
to conditioned arousal. Put differently, patients with chronic insomnia are
not awake because they are given to rumination and worry, but rather ruminate
because they are awake.
The neurocognitive perspective (3) is an extension of the traditional behavioral
model. As laid out by Spielman and colleagues (1), the behavioral model allows for
a compelling conceptualization regarding how maladaptive behaviors lead to con-