Insomnia Insomnia

Cognitive-Behavioral Therapy 165
sleep. For instance, the therapist may ask, “When you are lying in bed imagining
being so tired tomorrow that you might perform badly at work, at that moment how
certain are you that your work will be ‘substandard’, how certain are you that you’ll
be ‘reprimanded,’” and so on. These data are represented in column 2. Next, the
patient is asked how frequently his or her sleep is poor, and for how many years he
or she has been suffering from insomnia. This number is coded as the “number of
days with insomnia” and is set to the side of the table (to be coded later in column
3). The final data needed from the patient is an estimate of how frequently each of
the catastrophic events have occurred. These are coded into column 4. The combination
of these four sources of data are then used to show the patient that there is a
substantial mismatch between his or her degree of certainty and the number of times
the negative events have actually transpired.
For example, the clinician might observe, “You have suffered from insomnia for
5 nights a week for the last 3 years. This means that you have had about 800 really
bad nights. You also said that when you’re thinking about what might happen if you
don’t fall asleep, you are 90% certain that on the next day you are going to perform so
badly that you’ll be reprimanded. If it happened 90% of the time and you’ve had 800
bad nights, then you should have been reprimanded about 700—lets say 500—times.”
These data are represented in column 5. The last column of data is then compared to
the list in column 4, so that the patient can see the mismatch between the number of
instances that should have occurred and the number of instances that actually
occurred. For an example of the chart just described, see Table 2.
Relaxation Training
Different relaxation techniques target different physiological systems. Progressive
muscle relaxation is used to diminish skeletal muscle tension (41–45). Diaphragmatic
breathing is used to make respiration slower, deeper, and mechanically
driven from the abdomen as opposed to the thorax. (It is interesting to note that this
form of respiration resembles what occurs naturally at sleep onset.) Autogenic training
focuses on increasing peripheral blood flow by having subjects imagine, in a
systematic way, that each of their extremities feel warm.
Most practitioners select the optimal relaxation method based on which technique
is easiest for the patient to learn and which is most consistent with how the patient
manifests arousal. Like cognitive techniques, learning to effectively use relaxation
training often requires substantial practice. Many clinicians recommend the patient
rehearse the skill during the day in addition to practicing prior to sleep. If relaxation
training causes some initial “performance anxiety” when integrating it into SCT instructions,
it may be best to have the patient practice in a room other than the bedroom.
It also should be kept in mind that some patients, especially those with a history
of panic disorder, may experience a paradoxical response to relaxation techniques.
Phototherapy
Although many clinicians may not consider phototherapy a behavioral intervention,
it is often important to integrate the use of bright light into the treatment regi-