Quiet Your Mind and Get to Sleep Solutions to Insomnia for

Those with Depression, Anxiety, or Chronic Pain

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 Publisher’s Note
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However,
the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the
information in this book and make no warranty, express or implied, with respect to the contents of the publication.
The authors, editors, and publisher have exerted every effort to ensure that any drug selection and dosage set forth in this text are
in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research,
changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is
urged to check the package insert for each drug for any change in indications and dosage and for added warnings and
precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication may have Food and Drug Administration (FDA) clearance for
limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each
drug or device planned for use in their clinical practice.
Distributed in Canada by Raincoast Books
Copyright © 2009 by Colleen E. Carney and Rachel Manber
New Harbinger Publications, Inc.
5674 Shattuck Avenue Oakland, CA 94609
www.newharbinger.com
Cover design by Amy Shoup; Text design by Tracy Carlson; Acquired by Jess O’Brien; Edited by Nelda Street
All Rights Reserved

Epub ISBN: 978-1-60882-552-3

The Library of Congress has cataloged the print edition as:
Carney, Colleen.
Quiet your mind and get to sleep : solutions to insomnia for those with depression, anxiety, or chronic pain / Colleen E. Carney
and Rachel Manber.
p. cm.
Includes bibliographical references and index.
ISBN-13: 978-1-57224-627-0 (pbk. : alk. paper)
ISBN-10: 1-57224-627-8 (pbk. : alk. paper) 1. Insomnia--Popular works. 2. Depression--Complications--Popular works. 3.
Anxiety--Complications--Popular works. 4. Chronic pain--Complications--Popular works. I. Manber, Rachel. II. Title.
RC548.C367 2009
616.8’4982--dc22
2009038434
For Shannon and Sydney

—C.E.C.

For Udi, Tali, and Shelly

—R.M.
 Contents
foreword
introduction
1. the scope of the insomnia problem
What Is Insomnia?
Insomnia Is More Common Than You Think
How Do You Know If You Have Depression or Anxiety?
Is Your Insomnia Affecting Your Depression, Anxiety, or Chronic Pain Problem?
When to Treat Insomnia That Coexists With Other Disorders
Summing Up
2. learning about your sleep
Assessing For Insomnia and Other Sleep Disorders
Keeping a Sleep Log
Summing Up
3. Understanding Insomnia and Your Sleep System
What Causes Insomnia?
How Does Sleep Work?
Other “Sleep Thieves”
Summing Up
4. sleep-incompatible behaviors: tools for change
Sleep-Incompatible Behaviors
Some Specific Sleep-Incompatible Behaviors
Taking Action
Summing Up
5. optimizing your sleep system by changing your habits
Optimizing Your Sleep Driver System
Irregular Rise Time
When It’s Difficult to Stay Awake Until Your Scheduled Bedtime
Taking Action
Summing Up
6. quieting your mind: tools for change
The Importance of Thoughts
The Overactive Mind and Strategies for Change
Taking Action
Summing Up
7. when thinking about sleep gets in the way of sleep
Thoughts, Feelings, and Behaviors: How Changes In One Area Affect the Others
Tools for Changing Your Way of Thinking
Taking Action
Summing Up
8. issues with substances and medications
Alertness-Promoting Factors
The Paradoxical Effects of Alcohol
Sleep Medications
Substance Use as a Potential Safety Behavior
What About Medications for Other Conditions?
Taking Action
Summing Up
9. when things get in the way of treatment
What Do You See as Barriers to Treatment?
Possible Challenges In Implementing Change
Taking Action
Summing Up
appendix: resources
Resources for Insomnia
Self-Help Books for Depression
Self-Help Books for Anxiety
Self-Help Books for Chronic Pain
Resources for Quitting Smoking
Resources for Communicating Needs In a Relationship
references
 Foreword
I heard a voice cry, “Sleep no more!
Macbeth does murder sleep,”—the innocent sleep;
Sleep that knits up the ravell’d sleave of care,
The death of each day’s life, sore labour’s bath,
Balm of hurt minds, great nature’s second course,
Chief nourisher in life’s feast.
—Shakespeare, Macbeth

The importance of sleep has been recognized for centuries. Sleep was
understood by Shakespeare to heal emotional and cognitive distress (“knits
up the ravell’d sleave of care,” “balm of hurt minds”) as well as physical
aches and pains (“sore labour’s bath”). Today’s researchers have confirmed
the central role that sleep plays in almost every aspect of human life,
including regulating emotion; reducing stress, worry, and irritability;
consolidating memories; improving cognitive performance; reducing pain;
strengthening the immune system; and reducing daytime fatigue and
sleepiness. In today’s twenty-four-hour, seven-day-a-week world, sleep
disturbance is a common problem. For many people, this leads to chronic
insomnia. Because of the central role that sleep has in emotional, cognitive,
and physical functioning, problems in these other areas may develop or be
made worse when sleep is disturbed.
The authors of this workbook, Drs. Colleen Carney and Rachel Manber,
are experienced sleep clinicians who are among the world’s leading
researchers examining the treatment of insomnia in people who have
additional emotional, cognitive, or physical problems. This workbook is
unique among books available in providing the knowledge and skills to
treat insomnia in ways that promise to produce the full range of benefits to
those with depression or pain or other problems along with insomnia.
Is there evidence that treating sleep will improve other problems such
depression or pain? The answer is a resounding yes, and Drs. Carney and
Manber have published the watershed studies that have provided that
evidence. Their book is a comprehensive, integrative approach to cognitive
behavioral therapy for insomnia. One of its best features is the many self-
assessments to guide the reader in applying the treatment recommendations.
This reflects an active learning perspective that will help the reader truly
master the skills and strategies.
It is ironic that society’s increasing recognition of the importance of
sleep may make the treatment of insomnia more difficult. As is made clear
in the workbook, people with sleep disturbances often have unrealistic
expectations about sleep and exaggerated concerns about the effects of even
a single night of poor sleep. A central aspect of the workbook is to teach
skills to help identify expectations that are not realistic and to help
substitute alternative statements and actions. Those with insomnia put
pressure on themselves to sleep better. As the workbook chapters point out,
this can often lead to behaviors that make better sleep less likely.
Instead, we need to recognize that sleep is indeed important, as
Shakespeare recognized, but that sleep cannot be forced to occur. The
solution is to engage knowledge and skills that allow for sleep. The authors
have struck just the right balance between the importance of sleep and the
methods for improving sleep in this outstanding workbook.
—Richard R. Bootzin, Ph.D.
professor and director, Insomnia Program
Departments of Psychology and Psychiatry
University of Arizona
Tucson, Arizona
 introduction
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 called
comorbid insomnia. 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 called
cognitive 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 Sleep provides 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 in rebound 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!
 Chapter 1

the scope of the insomnia problem

Retired CEO Garry came to the sleep clinic because he was having
trouble falling asleep. He would toss and turn for an hour or two
before finally being able to fall asleep, a problem that began when he
was in college. He’d tried a variety of different sleeping pills over the
years but continued to have trouble sleeping. In recent years, he’d
taken to drinking a martini every evening to help him “unwind.” He
usually began feeling sleepy by around 11:00 p.m., which was when he
headed upstairs to bed. However, as soon as he got into bed, he felt
wide awake. He tossed and turned, and after a while thought, “Ugh,
it’s happening again; how long can this go on?” After enduring almost
an hour of frustration about being unable to fall asleep, he would take
a sleeping pill or drink more alcohol, and finally fall asleep between
12:30 and 1:00 a.m. Once asleep, he slept fine but would wake up and
get out of bed between 7:00 and 8:00 a.m., feeling as if his head were
“clogged up.” This had gone on several times a week for much of his
adult life. Having had anxiety problems for as long as he could
remember, Garry believed that his insomnia and anxiety were linked.
He recalled that the insomnia first began in college, when he
experienced anxiety before taking e­ xaminations. As we talked about
his anxiety, he realized that he became worried in a variety of
situations. He also worried that his insomnia would make him
susceptible to a serious illness.
A senior in college, Frank began waking up in the middle of the night
last winter, and would then be awake for hours. At first, this wasn’t
much of a problem, because he could take an afternoon nap and feel
better for the rest of the day. Lately he found that despite feeling very
tired, he couldn’t sleep when he lay down for a nap. He started feeling
down and was no longer excited about things he used to enjoy, such as
jogging, playing Frisbee, and doing his schoolwork. Feeling bad about
himself, he withdrew from his friends and began skipping classes.
Sometimes he slept in and showed up late to classes. He even had to
ask for extensions for some of his course work. He went to see a doctor
 at the student health clinic and was prescribed antidepressant
medication. When the doctor asked him if he had ever been depressed
before, Frank realized that he probably had been depressed in high
school too. The antidepressant medication helped his mood
significantly, but his insomnia continued. He became quite concerned
that unless he started sleeping better, the depression would return. He
believed that getting his sleep pattern back on track was the key to
graduating.
A schoolteacher, Barbara had experienced problems falling asleep and
waking up multiple times in the middle of the night. She was diagnosed
with fibromyalgia several years ago, and still suffered with it. Her pain
and fatigue fluctuated in severity, but even when these symptoms were
under control, she continued to have problems sleeping. She tended to
take over an hour to fall asleep and wake up two hours later with
difficulty returning to sleep. After a few bad nights, her pain would
increase. She became very frustrated because each of the sleeping
medications that initially had been effective stopped working. In an
attempt to get more sleep, she started going to bed earlier than usual
and resting in the morning hours, but nothing seemed to help.
The three people in these case scenarios had something in common:
they all experienced insomnia along with another health-related condition.
Garry suffered from anxiety, Frank had a history of depression, and Barbara
struggled with chronic pain. This chapter will provide you with a
description of insomnia as well as the disorders that commonly co-occur
with insomnia, including depression, anxiety, and chronic pain. We’ll
outline the common symptoms of these disorders and discuss how insomnia
impacts these conditions when they coexist with insomnia.

what is insomnia?
What problems in the people you just read about (whose names have been
changed to protect their privacy) characterize them as having insomnia? We
all experience sleep disruption from time to time, but when should we seek
treatment? Usually, a person seeks treatment when the problem becomes
persistent and has a significant impact on daytime functioning, which is
how doctors distinguish between having difficulty sleeping and having an
actual insomnia-disorder diagnosis. Generally, insomnia is disturbed sleep