Case Studies in Insomnia

CRITICAL ISSUES IN PSYCHIATRY An Educational Series for Residents and Clinicians Series Editor: Sherwyn M. Woods, M.D., Ph.D.

University of Southern California School of Medicine Los Angeles, California

Recent volumes in the series:

CASE STUDIES IN INSOMNIA Edited by Peter J. Hauri, Ph.D.

CLINICAL DISORDERS OF MEMORY Aman U. Khan, M.D.

CONTEMPORARY PERSPECTIVES ON PSYCHOTHERAPY WITH LESBIANS AND GAY MEN Edited by Terry S. Stein, M.D., and Carol J. Cohen, M.D.

DECIPHERING MOTIVATION IN PSYCHOTHERAPY David M. Allen, M.D.

DIAGNOSTIC AND LABORATORY TESTING IN PSYCHIATRY Edited by Mark S. Gold, M.D., and A. L. C. Pottash, M.D.

DRUG AND ALCOHOL ABUSE: A Clinical Guide to Diagnosis and Treatment, Third Edition Marc A. Schuckit, M.D.

EMERGENCY PSYCHIATRY: Concepts, Methods, and Practices Edited by Ellen L. Bassuk, M.D., and Ann W. Birk, Ph.D.

ETHNIC PSYCHIATRY Edited by Charles B. Wilkinson, M.D.

EVALUATION OF THE PSYCHIATRIC PATIENT: A Primer Seymour L. Halleck, M.D.

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Case Studies in Insomnia

Edited by

PETER J. HAURI, Ph. D. Mayo Clinic

Rochester, Minnesota

With a Foreword by

WILLIAM C. DEMENT, M.D., Ph.D.

Springer Science+ Business Media, LLC

L1brary of Congress Catalog1ng-1n-Pub11cat1on Data

Case stud1es 1n 1nsomn:a 1 ed1ted by Peter J. Haur1 . w;th a foreword by W1ll1am C. Dement.

p. cm. -- <Cr1t1cal 1ssues 1n psvchlatryl Includes b1Dl1ograph1ca1 references and index.

ISBN 978-1-4757-9588-2 ISBN 978-1-4757-9586-8 (eBook) DOI 10.1007/978-1-4757-9586-8 1. Insomnla--Treatment--Case stud1es. I. Haur1, Peter.

II. Ser1es. [DNLMo 1. Behav1or Therapy--methods. 2. Insomn1a--psychology.

3. Insomnla--therapy. 4. Psychotherapy--methods. WM 188 C337] RC548.C37 1991 616.8"498--dc20 DNLM/DLC for L:brzry of Cc~gress

ISBN 978-1-4757-9588-2

© 1991 Springer Science+ Business Media New York Originally published by Plenum Publishing Corporation in 1991

Softcover reprint of the hardcover 1 st edition 1991

AII rights reserved

91-20965 CIP

No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming,

recording, or otherwise, without written permission from the Publisher

Contributors

Richard P. Allen Sleep Disorders Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21224

Richard R. Bootzin Department of Psychology, University of Arizona, Tucson, Arizona 85721

Andrew J Borson Sleep Disorders Center, Crozer-Chester Medical Center, Chester, Pennsylvania 19013

William C. Dement Sleep Disorders Center, Stanford University, Palo Alto, California 94305

Dana Epstein Department of Psychology, University of Arizona, Tucson, Arizona 85721

Milton K. Erman Sleep Disorders Center, Scripps Clinic and Research Foundation, La Jolla, California 92037

Judith Flaxman Illinois School of Professional Psychology, Chicago, Illi­nois 60604

Paul B. Glovinsky Department of Psychology, The City College of the City University of New York, New York, New York 10031 and Insomnia Treat­ment Center, New York, New York 10017

Peter J Hauri Sleep Disorders Center, Mayo Clinic, Rochester, Minnesota 55905

John H. Koewler Sleep Disorders and Research Center, Deaconess Hospi­tal, St. Louis, Missouri 63139

Patricia Lacks Psychology Department, Washington University, St. Louis, Missouri 63130

v

vi CONTRIBUTORS

Stuart J. Menn Sleep Disorders Center, Scripps Clinic and Research Foundation, La Jolla, California 92037

Merrill M. Mitler Sleep Disorders Center, Scripps Clinic and Research Foundation, La Jolla, California 92037

Sidney D. Nau Sleep Disorders and Research Center, Deaconess Hospital, St. Louis, Missouri 63139

Steven Poceta Sleep Disorders Center, Scripps Clinic and Research Foun­dation, La Jolla, California 92037

Russell Rosenberg Northside Hospital, Atlanta, Georgia 30342

Thomas Roth Sleep Disorders and Research Center, Henry Ford Hospital, Detroit, Michigan 48202

Arthur J. Spielman Department of Psychology, The City College of the City University of New York, New York, New York 10031 and Insomnia 'freatment Center, New York, New York 10017

Neil Steinberg Clinical Sleep Services, Santa Rosa, California 95402

Edward J. Stepanski Sleep Disorders and Research Center, Henry Ford Hospital, Detroit, Michigan 48202

Michael M. Stevenson North Valley Sleep Disorders Center, Mission Hills, California 91345

James K. Walsh Sleep Disorders and Research Center, Deaconess Hospi­tal, St. Louis, Missouri 63139

Marsha K. Weinstein North Valley Sleep Disorders Center, Mission Hills, California 91345

James W. Wood Department of Psychology, University of Arizona, Tucson, Arizona 85721

Vincent P. Zarcone, Jr. Palo Alto VA Medical Center, Palo Alto, California 94304 and Department of Psychiatry, Stanford University School of Medi­cine, Stanford, California 94304

Frank J. Zorick Sleep Disorders and Research Center, Henry Ford Hospi­tal, Detroit, Michigan 48202

Foreword

If ever a book could be called timely, this is it. Sleep disorders medicine has made rapid advances in recent years. The field has attained growing respectability, with a textbook recently published, a congressionally man­dated National Commission on Sleep Disorders Research, and a growing public awareness of the importance of sleep disorders. However, this rapid growth has made the discrepancy among certain components of the field all the more obvious. Thus, we find that patients who complain of insom­nia are almost never in the majority of those seen in sleep disorders centers, in spite of the well-known fact that the prevalence of such individ­uals in our society is by far the largest.

Current articles on insomnia abound, but they tend to be facile recitations of diagnosis and impractical global recommendations for treat­ment, without providing the essential details. Indeed, the clinical profes­sions really do not know what to do about insomnia. This is reflected in a number of observations I have made in the recent past. For example, the majority of individuals who complain of insomnia take alcohol, aspirin, over-the-counter medications, hot baths, and a host of other nostrums, but rarely seek a physician. In the unlikely event that a physician is consulted, he is likely to prescribe a sleep medication but without any particular consistency, or any clear instructions on its use.

For the most part, patients who have insomnia go to doctors for other reasons, and even in these cases, no interaction about the problem takes place. We have carried out studies of clinical practices where we find that only from 2 to 10 percent of patients may spontaneously present sleep complaints to their doctors, but when questioned following office visits, 40 to 60 percent of these patients reveal that they have sleep complaints. We have come to believe that doctors do not want to ask about sleep problems because they do not know what to do to alleviate them.

In dramatic contrast to the above statement, the authors of this book do know what to do, and they tell us in clear, precise detail. Hallelujah!

vii

viii FOREWORD

Editor Peter Hauri has pulled together the knowledge and expertise about insomnia and has made the council of these experts available to patients and their therapists. Furthermore, much of the clinical experience docu­mented in this book can be available in sleep disorders centers.

Although some feel (quite rightly) that sleep disorders medicine has come of age, it cannot claim full maturity until clear guidelines for the effective diagnosis and treatment of insomnia are in place. Whether this comes about in terms of performing more effectively as a tertiary center or a consultative service offering expertise and advice to primary care physi­cians, or as a kind of cooperative effort, or whether or not the diagnosis and treatment can become so efficient that patients should go directly to their local sleep disorders center, one cannot tell. However, it is absolutely time to get moving. One could easily estimate, from reading this book, that at least 75 percent of all chronic insomnia patients can benefit. Formidable problems remain, but the path is clear, and success, if sleep disorders specialists are willing to make the effort and follow many of the principles outlined in this book, is almost guaranteed.

If the population of the earth is over five billion individuals, and if the various prevalence reports for serious chronic insomnia are reasonably accurate, perhaps a billion people have insomnia. What a sad thing for life to be suboptimal for so many people.

Peter J. Hauri has been dedicated to the problem of insomnia since his days with Allen Rechtschaffen at the University of Chicago, which re­sulted in a doctoral thesis in 1966. He received the prestigious Nathaniel Kleitman prize for 1989, awarded by the American Sleep Disorders Asso­ciation. Among other things, he was commended for his consistent contri­butions to the problem of insomnia.

I was honored and pleased to be asked to write this foreword, particularly because I had a chance to read the book perhaps a year or so before I otherwise would have seen it. I can sincerely say that the authors have done a great service for sleep specialists and insomniacs the world over. It is quite true, as Peter J. Hauri says, that much of the good work on insomnia has not been published. It would be a challenge to bring the different approaches discussed in this book together in one central place, but that is a happy challenge, with the likelihood of a favorable outcome. In the Preface, Dr. Hauri also comments that he hopes the book will go "beyond a mere 'how-to-do-it' cookbook," but even "how to do it" is of inestimable value to us all, and just what we do not have currently. I cannot think of a better example where a huge need has been met so decisively.

Sleep Disorders Center Stanford University Palo Alto, California

William C. Dement, M.D., Ph.D.

Preface

There has been a quiet revolution in the treatment of insomnia. Twenty years ago, insomnia was seen either as a manifestation of depression and anxiety or as an annoying disorder to be extinguished with hypnotics. In the late 1960s, I once asked Dr. Jacobson, who developed the progressive relaxation technique, if he ever used it to treat insomnia. He seemed annoyed and said, in essence, that insomniacs were a bunch of chronic complainers that one best kept away from one's practice.

In the 1970s and 1980s, a number of psychologists and psychiatrists disregarded Jacobson's advice and developed different behavioral and psychotherapeutic approaches to deal specifically with insomnia. These strategies were gradually refined and improved until, in a conference on insomnia at Stanford in December 1988, the consensus was that at least three of every four chronic insomniacs could be helped quite markedly with psychological and behavioral treatment techniques.

Unfortunately, much of the good new work that has been done on insomnia is either not published or published in specialty journals not available to the general mental health professional. I felt that there was a need to bring all the different approaches on insomnia together, and I hope that this book will fill that need. I invited most of the leading insomnia specialists in the United States to describe their approaches to insomnia, and I asked them to do this in steps that can be followed by any trained professional. Most agreed to help with this project.

Although many authors in this book are identified with specific techniques, in clinical practice, most of us are quite eclectic, tailoring parts of different techniques to the needs of the individual patient. My main difficulty as the editor of this book was to keep each author from covering the entire field of possible treatments of insomnia, to keep the contribu­tions distinct and focused on the specific area in which each author was an

ix

X PREFACE

authority. Nevertheless, it is easily apparent in this book that the time of using only one narrow technique or one narrow school of thought has passed. One needs to be proficient in a wide variety of treatment ap­proaches to insomnia and adapt the different techniques to the individual patient's needs.

Although the individual techniques may be widely different among those who treat insomnia, the patients we all see are about the same. This book, therefore, emphasizes the case study method, the time-honored practice to teach and to learn by discussing individual patients. However, we go one step further. Each author was asked not only to present a successful case, but also an unsuccessful one. Successful cases show a given method at its best and they illustrate how the technique should work ideally. However, we often learn more from our unsuccessful cases if we study them carefully. They teach us the limits of our techniques, the theoretical flaws in our understanding, and the complexities of our pa­tients.

Studying insomnia treatment by the case method does not mean that each new patient has to be approached in a totally new idiosyncratic way. In Chapter One, Spielman and Glovinsky struggle with the task of finding common threads and building a conceptual framework for insomnia. Finding common themes in insomnia has direct practical effects. The unwieldy array of clinical presentations can be better understood, and both diagnostic and treatment efforts are thereby enhanced. Spielman and Glovinsky's contribution brings structure and order into our thinking about insomnia, and their discussion of predisposing, precipitating, and perpetuating factors has benefited the field tremendously.

This book tries to accurately reflect the current state of knowledge and skill. It does not present a united, common point where controversies remain unresolved. One controversy is the question of the use of hypnotic medication. If an insomniac came to, say, Bootzin, he would not receive any hypnotics. If he came to me, he would likely receive a few pills for occasional, special nights, and if he came to Stepanski, he might get a hypnotic every night for a month. Listen to what each author says and make up your own mind. Similarly, some of us are strictly behavioral, others search for underlying psychological causes. Some send most in­somniacs for a sleep study before they treat, others do this rarely or never. Only time will tell what is best for each type of insomniac.

This book is written for mental health practioners, including family practitioners, psychiatrists, psychologists, social workers, nurses, and others. Prerequisites for using these techniques and approaches are clini­cal skills in interviewing, in treating mental and physical problems in general, and some training in the rudiments of supportive psychotherapy.

PREFACE xi

Note that this book is written for the professional. It is not a self-help book. It will be very difficult to apply what you learn in this book to your own case if you, yourself, have insomnia.

Together with the other authors, I sincerely hope that this book goes beyond a mere "how-to-do-it" cookbook, and that it helps you to under­stand the foundations of insomnia treatment. Summarizing the different techniques and approaches, it also imparts hope. Insomnia is no longer a chronic condition without treatment. It takes time and skill and patience, but most insomniacs today are treatable.

Peter J. Hauri, Ph.D. Rochester, Minnesota

Contents

Chapter One Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Arthur J. Spielman and Paul B. Glovinsky

Part One Specific Behavioral Techniques

Chapter Two Stimulus Control Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Richard R. Bootzin, Dana Epstein, and James M. Wood

Chapter Three Stimulus Control in a Group Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Patricia Lacks

Chapter Four Sleep Restriction Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Paul B. Glovinsky and Arthur J. Spielman

Chapter Five Sleep Hygiene, Relaxation Therapy, and Cognitive Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Peter J. Hauri

Part Two Psychotherapeutic Techniques and Pharmacotherapy

Chapter Six Insomnia: Psychotherapy or Not? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Vincent P. Zarcone, Jr.

xiii

xiv CONTENTS

Chapter Seven Short-Term Psychotherapy for Chronic Insomnia . . . . . . . . . . . . . . . . 103 Andrew J. Borson

Chapter Eight Pharmacotherapy of Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Edward J. Stepanski, Frank J. Zorick, and Thomas Roth

Part Three Comprehensive and Integrated Approaches

Chapter Nine Selecting a Treatment Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Michael M. Stevenson and MarshaK. Weinstein

Chapter Ten Breaking the Vicious Circle of Insomnia: A Treatment Model . . . . 155 Neil Steinberg

Chapter Eleven Sleep Behavior Management .................................. 175 Sidney D. Nau, John H. Koewler, and James K. Walsh

Part Four Disorders of the Sleep-Wake Schedule

Chapter Twelve Assessment and Treatment of Delayed Sleep Phase Syndrome . . . 193 Russell Rosenberg

Chapter Thirteen Early Morning Awakening Insomnia: Bright-Light Treatment .... 207 Richard P. Allen

Chapter Fourteen

Part Five Specific Populations

Insomnia in the Chronically Ill ............................... 223 Merrill M. Mitler, Steven Poceta, Stuart J. Menn, and Milton K. Erman

Chapter Fifteen Insomnia in the Older Adult .................................. 237 Judith Flaxman

Index ....................................................... 249