In Quiet Your Mind and Get to Sleep, two psychologists specializing in sleep and mood disorders show readers with insomnia and often comorbid disorders such as depression, anxiety, and chronic pain proven methods from cognitive behavioral therapy for getting the sleep they need and improving their symptoms in the process.

Colleen E. Carney, PH.D., is assistant professor and director of the Sleep and Mood Disorder Program at Ryerson University in Toronto, Canada, and is adjunct professor at Duke University. Rachel Manber, PH.D., is professor of psychiatry and behavioral sciences at Stanford University in Palo Alto, CA, where she is also director of the Insomnia and Behavioral Sleep Medicine Program.

foreword	p. ix
introduction	p. 1
the scope of the insomnia problem	p. 5
What is Insomnia?	p. 7
Insomnia is More Common Than You Think	p. 8
How Do You Know if You Have Depression or Anxiety?	p. 8
Is Your Insomnia Affecting Your Depression, Anxiety, or Chronic Pain Problem?	p. 15
When to Treat Insomnia That Coexists with Other Disorders	p. 17
Summing Up	p. 18
learning about your sleep	p. 19
Assessing for Insomnia and Other Sleep Disorders	p. 19
Keeping a Sleep Log	p. 26
Summing Up	p. 30
Understanding insomnia and Your Sleep System	p. 33
What Causes Insomnia?	p. 33
How Does Sleep Work?	p. 36
Other "Sleep Thieves"	p. 44
Summing Up	p. 45
sleep-incompatible behaviors: tools for change	p. 47
Sleep-Incompatible Behaviors	p. 48
Some Specific Sleep-Incompatible Behaviors	p. 49
Taking Action	p. 57
Summing Up	p. 62
optimizing your sleep system by changing your habits	p. 63
Optimizing Your Sleep Driver System	p. 64
Irregular Rise Time	p. 69
When it's Difficult to Stay Awake Until Your Scheduled Bedtime	p. 70
Taking Action	p. 72
Summing Up	p. 81
quieting your mind: tools for change	p. 83
The Importance of Thoughts	p. 83
The Overactive Mind and Strategies for Change	p. 84
Taking Action	p. 95
Summing Up	p. 99
when thinking about sleep gets in the way of sleep	p. 101
Thoughts, Feelings, and Behaviors: How Changes in One Area Affect the Others	p. 101
Tools for Changing Your Way of Thinking	p. 104
Taking Action	p. 122
Summing Up	p. 126
issues with substances and medications	p. 127
Alertness-Promoting Factors	p. 128
The Paradoxical Effects of Alcohol	p. 129
Sleep Medications	p. 130
Substance Use as a Potential Safety Behavior	p. 132
What about Medications for Other Conditions?	p. 133
Taking Action	p. 134
Summing Up	p. 138
when things get in the way of treatment	p. 139
What Do You See as Barriers to Treatment?	p. 139
Possible Challenges in Implementing Change	p. 142
Taking Action	p. 153
Summing Up	p. 156
appendix: resources	p. 157
Resources for Insomnia	p. 158
Self-Help Books for Depression	p. 159
Self-Help Books for Anxiety	p. 159
Self-Help Books for Chronic Pain	p. 161
Resources for Quitting Smoking	p. 162
Resources for Communicating Needs in a Relationship	p. 162
references	p. 163
Table of Contents provided by Ingram. All Rights Reserved.

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Modern society often dictates long hours, packed schedules, and less time to sleep and to unwind. To “stay ahead” in their work lives, North Americans don’t take as many vacations as they used to, which is unfortunate, because in a fast-paced and busy life, taking time to unwind and recharge your battery is more important than ever. So it’s understandable that insomnia is the number-one health problem in Western societies (Canals et al. 1997). Sleep requires disengaging from the bustling environment around us, and stress interferes with this process. Stress can come in many forms, possibly arising in the context of a major life event, such as taking a new job, becoming a parent, or ending a relationship. It’s no surprise that these stressful situations are often associated with difficulty sleeping. In addition, the experience of disturbed sleep is itself a source of stress that tends to further prolong the problem. That is, when you have difficulty sleeping, you begin to worry about being able to sleep at night and being able to function the next day, and that worry makes it more difficult to sleep. When sleep difficulties persist and lead to daytime problems, such as irritability, depressed mood, difficulty concentrating, or fatigue, the sleep problem often calls for a medical diagnosis of insomnia.

More often than not, insomnia occurs along with other health problems, most commonly depression, anxiety, and chronic pain conditions. Each of these three problems can cause you considerable personal suffering, not to mention the cost of medications and visits to the doctor’s office. The suffering and societal costs are even higher when you have insomnia along with depression, anxiety, or chronic pain, a kind of insomnia calledcomorbidinsomnia. Yet until recently, doctors didn’t usually treat comorbid insomnia, because they assumed that it was merely a symptom of the other health problem and would go away when the other problem was treated. However, untreated comorbid insomnia often doesn’t get better even after the other condition is adequately treated (Carney et al. 2007), and untreated insomnia can make the other condition worse or interfere with its treatment (Carney et al. 2007; Buysse et al. 1999). For example, when treated for their coexisting depression, people with insomnia don’t improve as much as those without sleep difficulties (Buysse et al. 1999). For reasons like this, the National Institutes of Health (NIH), the leading health-research funding agency in the United States, recently released a statement that urges doctors to treat the insomnia that occurs along with another conditions (National Institutes of Health 2005).

In that vein, this book describes an effective insomnia treatment calledcognitive behavioral therapy(CBT). Some readers might be familiar with CBT for other mental disorders, such as depression, anxiety disorders, and eating disorders. They all share common principles but use some problem-specific techniques. CBT for insomnia has been tested in many studies, and the results show that CBT is an effective treatment, just as effective as taking sleep medications (Smith et al. 2002). Most important, when people are followed for a period after the end of treatment, the sleep improvements seen at the end of treatment last longest in those treated with CBT (Edinger et al. 2001; Morin et al. 1999). We highlight this information because it’s very relevant to the insomnia that occurs in the context of another medical or mental condition, which is our focus. In people who have both insomnia and depression:

Whether your treatment involves antidepressant medication or psychotherapy, insomnia remains a significant issue for about half of those who recover from depression (Carney et al. 2007).
Having insomnia increases your risk of developing depression in the future (Ford and Kamerow 1989).

Taking these facts together, we can conclude that an insomnia treatment with longer-lasting effects will also have a more favorable effect on depression.

The approach we describe in this book provides practical advice in enough detail to allow you to apply it to your situation. Because we have written this CBT self-help workbook for people who have insomnia along with another condition, we provide specific suggestions for issues related to experiencing insomnia along with another health problem. Let’s continue with our example of insomnia occurring with depression. Some of the CBT recommendations aren’t easy to follow and might seem particularly difficult to those who also have depression. For instance, CBT recommends that people get out of bed shortly after waking up in the morning. This recommendation is challenging for many people with depression, because they often find it difficult to get started in the morning. Therefore we give specific suggestions on how to overcome this challenge. We also discuss tools to manage the high levels of anxiety that are common to many people with depression, anxiety, and pain. We also provide methods for dealing with common daytime consequences of poor sleep, such as low energy, trouble concentrating, and irritable mood. Again, this is very important in the context of depression, because low energy, poor concentration, and irritability are also symptoms of depression. Our approach also emphasizes the importance of the mind in insomnia and offers many practical suggestions for dealing with an overactive mind or anxiety-provoking thoughts. People with insomnia often complain of having a “noisy mind” at night, particularly those who are more anxious than average or describe themselves as “perfectionists.” We recognize that each person is unique and faces different challenges when being treated for insomnia, and we hope you’ll find that this approach fits your particular set of challenges.

Quiet Your Mind and Get to Sleepprovides strategies to overcome the insomnia that occurs with other conditions. Each chapter focuses on providing sleep-related information, self-tests, and simple worksheets to help you enact changes in thoughts or behaviors known to perpetuate insomnia. Each treatment recommendation is made in the context of understanding what’s going on in the accompanying disorder. As such, this book is for anyone who has ever struggled with insomnia and for those who love them.

You may be wondering whether you can use this book if you’re taking medication, and the short answer is yes. This approach is effective even when you’re taking medication for sleep, pain, anxiety, or depression. You may have read that some antidepressant medications cause insomnia as a side effect. This may happen with certain antidepressant medications, but it’s not very common. You may wonder whether you should discontinue antidepressant medications just in case they’re causing the insomnia. If insomnia emerges as a side effect of an antidepressant medication and it doesn’t go away in a few weeks, your prescribing physician will likely offer an alternative antidepressant medication because people react differently to these medications. Don’t stop taking prescribed medications without first consulting with the physician who prescribed them. Stopping medications abruptly and without guidance can be very uncomfortable and sometimes dangerous. Stopping sleep medications can result inrebound insomnia, which is caused by stopping the medication and doesn’t necessarily reflect your underlying sleep patterns. If you stopped taking prescribed medication for depression or anxiety, this condition could worsen, making it difficult for you to follow the sleep treatment we offer. Besides, even if you believe that a medication has a negative impact on your sleep quality, it’s unlikely that your insomnia would resolve the moment you stopped taking it. You can discuss with your physician any concerns you might have about your medications. If you have pain, anxiety, or depression, continue to get treatment for these conditions. In all likelihood, it will be easier for you to follow the instructions for the insomnia treatment described in this book when your pain, depression, or anxiety is under control.

Our approach doesn’t require that you stop whatever therapy you’re currently receiving. In fact, we hope that if you have a coexisting condition, you’re getting treatment and your treatment provider is available to assist you with using the strategies in this book. We believe that the best approach to treating insomnia in the context of another condition is to treat both conditions. Making health-related changes can be quite demanding, and how you decide to make such changes is a personal choice. While we’ve written the sleep strategies so that you can use them on your own, you may wish to enlist the help of a sleep specialist in your area. By providing information about sleep and helpful exercises, this book will offer you an opportunity to take control of your insomnia. We hope you’ll discover that making small changes in the way you approach sleep will give you the sleep you dream about!