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Chapter 8

Cognitive Strategies for Managing Anxiety

and Insomnia

Abstract
The previous chapter discussed the importance of cognitive processes

(described by Harvey, Behaviour Research and Therapy 40:869–893, 2002) in

perpetuating a sleep-interfering cognitive–emotional cycle as well as setting the

stage for sleep-interfering behaviors. The motivation for sleep-interfering behav-

iors appears to relate to reciprocating beliefs for the need to exert sleep effort

(described by Espie et al., Sleep Medicine Review 10:215–245, 2006) and feel-

ing helpless when these efforts have no effect or actually worsen sleep (Morin,

Insomnia: Psychological assessment and management. New York: Guilford Press,

1993); thus, we present step-by-step instructions for strategies for targeting these

cognitive dispositions. These include a review of worry management strategies

(including early evening and presleep strategies), cognitive restructuring (e.g., psy-

choeducation, Thought Records, behavioral experiments), and relapse prevention.

Such strategies are aimed at managing and, in some cases, modifying perpetuating

cognitive problems that contribute to insomnia problems.

We have discussed the importance of cognitive processes in perpetuating a sleep-

interfering cognitive–emotional cycle as well as setting the stage for sleep-interfering

behaviors. The motivation for sleep-interfering behaviors appears to relate to recipro-

cating beliefs for the need to exert sleep effort (Espie, Broomfield, MacMahon,

Macphee, & Taylor, 2006) and feeling helpless when these efforts have no effect or

actually worsen sleep (Morin, 1993). This process is arguably best described in

Harvey’s (2002) the model discussed in the previous chapter. In this chapter, we present

some strategies for managing and, in some cases, modifying perpetuating cognitive

problems that contribute to insomnia problems.

Worry Management Strategies

When discussing insomnia in the context of prominent anxiety, it may be best to

start with strategies to manage presleep cognitive arousal, and then focus on a spe-

cific form of presleep arousal, namely worry. Managing presleep cognitive arousal

C.E. Carney and J.D. Edinger,
Insomnia and Anxiety
, Series in Anxiety and Related Disorders, 109

DOI 10.1007/978-1-4419-1434-7_8, © Springer Science+Business Media, LLC 2010

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8 Cognitive Strategies for Managing Anxiety and Insomnia

involves strategies that focus on (1) somatic relaxation such as PMR (Lichstein

& Johnson, 1993), (2) eliminating arousal from the bed by leaving the bedroom

when it occurs (stimulus control) (Bootzin, 1972), (3) scheduling worry and problem-

solving outside of the bedroom (Carney & Waters, 2006; Espie & Lindsay, 1987),

and (4) facilitating processing of the day’s events (Harvey & Farrell, 2003). Stimulus

control and relaxation techniques are covered in the Chaps. 6 and 9, respectively,

so we will focus on scheduled worry and facilitated processing techniques in

this chapter.

Even in the absence of an anxiety disorder diagnosis, presleep worry can

contribute to presleep arousal and delay the onset of sleep. It is well docu-

mented that people with insomnia tend to worry before bed and in bed (Harvey,

2000; Wicklow & Espie, 2000). Even in good sleepers, experimentally induced

presleep worry can interfere with sleep (Gross & Borkovec, 1982; Hall, Buysse,

Reynolds, Kupfer, & Baum, 1996). Some presleep activity is not necessarily

affectively laden (e.g., focusing on environmental stimuli like noise). However,

the presleep content is often characterized by anxious thoughts about daytime

worries and sleeplessness (Fichten et al., 1998; Wicklow & Espie, 2000).

Stimulus control may be enough to deal with unintended mental habits like

thinking about the sleeping environment, but when negatively valenced mental

activity persists, it may help to try an early evening procedure intended to deal

with the day’s “unfinished business.”

Espie and Lindsay (1987) were among the first to suggest that those with insom-

nia should schedule a time in the evening to address, and then set aside concerns

that may interfere with subsequent nocturnal sleep. Carney and Waters (2006)

tested a similar procedure called Constructive Worry in an analog sample. Although

these strategies have not been tested in anxiety disorders populations, these two

studies suggest that this is a useful intervention for reducing sleep-interfering

presleep arousal in those with insomnia.

The instructions for Constructive Worry are straightforward and described in

full elsewhere (Carney & Waters, 2006; Edinger & Carney, 2008). Briefly, the

instructions are to set aside some time in the early evening, when the person is at

their “problem-solving best.” Arriving at a suitable time can take some discussion

as some people believe they do not have the time for such an experiment. Yet, with

adequate consideration of scheduling options, usually a time can be found for this

activity. During this scheduled time, the individual should identify and then

address worries using the worksheet shown on the following page. Those worries

or concerns that have the potential to keep the person awake that night should be

recorded on the first column of a 2-column form. In the adjacent second column

should be the “next” steps towards solving this problem. Carney and Waters

(2006) emphasize that the focus should not be on the ultimate or end solution as

people can become anxious and ultimately overwhelmed if the final solution will

take many steps to solve. Instead, the most proximal steps are the steps that are

written down so that something could potentially be done the next day to start

solving the problem.

Constructive Worry Worksheet Example

111

Constructive Worry Worksheet Example

Worry

Next possible step

Need to finish my annual report

Can make a to-do list right now

I need to call Bob tomorrow and get the final figures

I need to email Debra about how to complete Sect. 4

I can cut and paste from last year’s report

It is most important to orient people towards problem solving. Arguably, worry

is problem-solving thwarted by anxiety (Davey, 1994). If the individual can set aside

time to engage in effective problem solving, there is less likelihood of becoming

overwhelmed/anxious and greater probability of successfully dealing with sleep-

disruptive topics. Not all problems have an easily identified solution or even a solu-

tion at all. In such cases, it is important for people to consider asking someone else

for help or advice, accepting that there might not be a solution, or acknowledging

that there is not an immediate solution but they can write down that they will revisit

the problem tomorrow evening to see if a solution presents itself. At the conclusion

of the exercise, the individual should acknowledge having dealt with the problem list

as well as can be expected during a time of day when problem-solving is optimal,

and the individual should also recognize that trying to solve it at night will be inef-

fective, anxiety-provoking, and sleep-interfering. Some find it useful to fold the

worksheet over and ceremoniously put it away for the evening. The Constructive

Worry procedure appears to have good implementation feasibility as the effective-

ness of participants’ solutions was rated as high using the Means-End Problem

Solving Procedure (Platt & Spivack, 1975) in the Carney and Waters (2006) study.

A similar intervention is one that attempts to process information that is likely

to intrude into the sleep period. This intervention for insomnia (Harvey & Farrell,

2003) is based on the Pennebaker writing exercise described and tested in the health

and trauma literature (Francis & Pennebaker, 1992; Pennebaker, Kiecolt-Glaser, &

Glaser, 1988). An investigation of a Pennebaker writing exercise showed that poor

sleepers who complained about excessive mental activity in bed fell asleep more

quickly if they were instructed to focus on writing about emotional content than did

those who were not instructed to write (Harvey & Farrell, 2003). Just as with

Constructive Worry, this intervention has not been evaluated in those with insomnia

and an anxiety disorder. The instructions are simple and similar to the Constructive

Worry procedure. The rationale provided to users of this strategy is that there are

expected benefits to writing down thoughts or concerns before bed, and then “let-

ting them go”. They are encouraged to explore their deepest emotions and thoughts

during this exercise. The Pennebaker and Constructive Worry procedures typically

request that 20–30 min are set aside to complete the exercise. In contrast to the

Constructive Worry procedure that is completed several hours before bed, the

Pennebaker writing procedure is typically completed just prior to getting into bed.

Espie and Lindsay (1987) suggested a procedure that targets presleep arousal at an

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8 Cognitive Strategies for Managing Anxiety and Insomnia

earlier time in the evening and this approach may be more effective than procedures

conducted at bedtime. Sleep onset latency (on the PSQI) was measured, before and

after the Pennebaker exercise, whereas anxiety has not been assessed in this setting,

so it is possible that this presleep exercise could be activating in a clinical sample.

In the analog investigation of the Pennebaker procedure mentioned, the decrease in

sleep onset latency might suggest that this is not anxiety-provoking, but this needs

to be evaluated in a future study. It is not clear how successful people in the

Pennebaker experiment were with emotional processing; indeed, those in the control

group who wrote about their hobbies did not differ from the writing about emotional

topics group.

Cognitive Restructuring

Insofar as maladaptive beliefs about sleep or the self (i.e., helplessness) are perpetu-

ating factors in insomnia, we need techniques to modify and/or manage these cog-

nitions. Arguably, the three most common tools in cognitive restructuring are (1)

psychoeducation about sleep, (2) Thought Records and in-session Socratic ques-

tioning, and (3) behavioral experiments. We will discuss Thought Records and

behavioral experiments in detail in the ensuing sections. In the current section, we

consider the use of psychoeducation in cognitive therapy.

Psychoeducation remains an important part of insomnia treatment. Early CBT

trials used psychoeducation exclusively as a cognitive tool (Edinger, Wohlgemuth,

Radtke, Marsh, & Quillian, 2001). Psychoeducation is merely the verbal provision

of corrective sleep-related information. Some examples include an explanation of

the variability of sleep needs and the idea that humans do not necessarily require

8 h of sleep. We provide this information because it is a common misconception

among people with insomnia; when in actuality, some people require more sleep,

and some less. Even among those who require more than 8 h, there may be current

circumstances that will shorten sleep need temporarily. Thus, it is important for

people not to focus on a magical number as it is often incorrect and subject to

change. It is also helpful to provide people with an explanation of how their homeo-

static and circadian systems function to regulate sleep (described in Chap. 6). This

explanation may highlight how increased sleep effort interferes with normal

homeostatic and circadian sleep regulation and consequently contributes to insom-

nia. Discussing how sleep need decreases with advancing age and decreased activ-

ity as well as considering various causes for fatigue (i.e., boredom, circadian

factors, diet, caffeine crash, virus, or dehydration) other than deficit sleep is also

useful to correct common misconceptions and misattributions.

It is also important to provide normative values for sleep as some people with

insomnia have sleep that is actually within normal limits. Hearing that their sleep

is within the normal range can alleviate anxiety for some people so that no further

treatment may be necessary. For example, it is normal to take up to 30 min to fall

asleep and to be awake in the middle of the night up to 30 min. Psychoeducation