Sleep–Wake Disorders Including Insomnia

What Are Sleep Problems?

Symptoms Associated with Poor Sleep and Insomnia

Insomnia disorder is characterized by a complaint of dissatisfaction with sleep quantity or quality, associated with one or more of:

• difficult initiating sleep

• difficulty maintaining sleep

• early-morning awakening with inability to return to sleep

Nightmare disorder is characterized by repeated occurrences of extended, extremely dysphoric, and well-remembered dreams which usually involve efforts to avoid threats to survival, security, or physical integrity. The individual rapidly becomes oriented and alert upon awakening. The dreams are not better explained by the presence of other conditions such as post-traumatic stress disorder.

Psychological Models and Theory of Insomnia

A range of psychological models of insomnia are reviewed in detail in Talbot and Harvey (2010).

Spielman’s Three-P Model of Insomnia (Spielman, Saskin, & Thorpy, 1987)

Spielman’s three-factor model is a diathesis-stress theory that includes predisposing, precipitating, and perpetuating factors influencing insomnia. Perpetuating factors are the typical targets for treatment and include: maladaptive coping skills, and an extension of time in bed. Spielman’s three-P model led to the development of the sleep restriction technique for insomnia.

Bootzin’s Stimulus Control Model of Insomnia (1972)

The stimulus control model of insomnia proposes that the particular response elicited by a stimulus depends upon its conditioning history. Insomnia is said to occur when sleep stimuli (e.g., bed, bedroom, bedtime) are no longer uniquely paired with sleep, but have been paired with other activities (e.g., worrying, being awake, reading). Stimulus control therapy is an effective intervention derived from stimulus control theory.

Espie’s Psychobiological Inhibition Model of Insomnia (2002; Espie, Broomfield, MacMahon, Macphee, & Taylor, 2006)

Espie’s psychobiological inhibition model of insomnia proposes that homeostatic and circadian processes are involuntary and the normal default result is good sleep. Good sleep is maintained by regular sleep habits, sleep-related physiological de-arousal, and sleep-related cognitive de-arousal. According to this model, insomnia is the result of interruptions to or failures of these maintenance processes. An updated version of the model proposes that people can interfere with automatic processes resulting in good sleep by: selectively attending to sleep, explicitly intending to sleep, trying to sleep. Interventions derived from the model target these dysfunctional processes (Espie et al., 2006).

Harvey’s Cognitive Model of Insomnia (2002)

Harvey proposes that insomnia is maintained by a cascade of five critical cognitive processes including: worry (accompanied by arousal and distress); selective attention and monitoring; misperception of sleep and daytime deficits from lack of sleep; unhelpful beliefs; and counterproductive safety behaviors. Treatment interventions for insomnia targets these maintaining mechanisms.

Evidence-Based Psychological Approaches for Working with Insomnia

Evidence-based psychological approaches for working with insomnia include:

• sleep restriction therapy

• stimulus control therapy

• cognitive behavioral therapy for insomnia (CBT-I)

Resources for Working with Sleep–Wake Disorders Including Insomnia

Psychology Tools resources available for working therapeutically with sleep–wake disorders including insomnia include:

• psychological models of sleep–wake disorders including insomnia

• information handouts for sleep–wake disorders including insomnia

• exercises for sleep–wake disorders including insomnia

• CBT worksheets for sleep–wake disorders including insomnia

• self-help programs for sleep–wake disorders including insomnia

References

• Bootzin, R. R. (1972). Stimulus control treatment for insomnia. Proceedings of the American Psychological Association, 7, 395–396.

• Espie, C. A. (2002). Insomnia: Conceptual issues in the development, persistence, and treatment of sleep disorder in adults. Annual Review of Psychology, 53, 215–243.

• Espie, C. A., Broomfield, N. M., MacMahon, K. M., Macphee, L. M., & Taylor, L. M. (2006). The attention-intention-effort pathway in the development of psychophysiologic insomnia: A theoretical review. Sleep Medicine Review, 10(4), 215–245.

• Harvey, A. G. (2002). A cognitive model of insomnia. BehaviourResearch and Therapy, 40(8), 869–894.

• Sheaves, B., Freeman, D., Isham, L., McInerney, J., Nickless, A., Yu, L. M., … & Barrera, A. (2018). Stabilisingsleep for patients admitted at acute crisis to a psychiatric hospital (OWLS): An assessor-blind pilot randomisedcontrolled trial. Psychological Medicine,48(10), 1694–1704.

• Spielman, A. J., Saskin, P., & Thorpy, M. J. (1987). Treatment of chronic insomnia by restriction of time in bed.Sleep, 10(1), 45–56.

• Talbot, L. S., & Harvey, A. G. (2010). Psychological models of insomnia. In M. J. Sateia and D. Buysse (Eds.), Insomnia: Diagnosis and Treatment(pp. 42–49). Boca Raton, FL: CRC Press.