Cognitive Topics — free cognitive behavioral therapy for insomnia, CBTi

COGNITIVE Topics:

· Sleep and Insomnia Information

· Progressive Muscle Relaxation

· Sleep Related Thoughts

Sleep and Insomnia Information Topic

Sleep helps your memory.
Sleep helps your brain function. Sleep helps you organize, make decisions, pay attention, use judgement, be motivated and control emotions.
Sleep helps you have energy.

Sleep is driven by the circadian rhythm and periods of not sleeping. The circadian rhythm is the cycle of being awake during the daylight and ready for sleep at night. Periods of not sleeping causes sleepiness and drives the body to want to sleep again.

Sleep Stages:

Non-REM Sleep: There are three categories of Non-REM sleep including N1, N2, N3. Non-REM sleep happens first when you go to sleep. N1 is the transition from being awake to falling asleep. If you wake up from N1 you may not realize you were asleep (but you were!). N3 sleep is deep sleep. N3 is the most difficult sleep stage to wake up from. If you wake out of N3 sleep you will feel groggy.
REM Sleep: We dream during REM sleep. Our temperature goes up during REM sleep. REM sleep is the last part of the sleep cycle. When you wake up during or after REM sleep you will be somewhat groggy but less so than waking up from N3 sleep.

Sleep Cycles: One complete sleep cycle is going through Non-REM sleep and then REM sleep. One sleep cycle is 1.5 to 2 hours long. You have a few sleep cycles per night. It is normal to briefly wake up after a sleep cycle and then easily fall back to sleep.

Adults start with Non-REM sleep for 1 hour and then go to REM sleep for 30 to 60 minutes. Adults should try to sleep about 7 to 8 hours per night.

Sleep inertia is feeling groggy after waking up. It is the feeling that it is difficult to wake up and you want to fall back asleep. This is a normal transition from sleeping to being awake. Sleep inertia goes away with time, usually 20 to 40 minutes.
It is normal to feel somewhat sleepy and groggy after first waking up. If your alarm goes off why you are in N3 deep sleep you may feel sleepier. If your alarm goes off after you finished REM sleep or you are in N1 sleep you may feel less groggy when you wake up. It is normal to feel somewhat groggy when you first wake up and each morning may vary somewhat.

What happens to your brain when you do not sleep well? Chronic sleep loss impacts the following parts of the brain the most.

Prefrontal Cortex. This is the area for complex thinking, organizing, decision making, attention, judgement and motivation.
Amygdala. This is the area for emotional control.
Striatum. This is the area for control of behavior.

When you lose sleep, it is difficult to get things done. When you lose sleep, you can feel irritable and frustrated. When you lose sleep, you can feel your emotions are more difficult to control. When you lose sleep, you can have worse memory, judgement, motivation and balance in thinking.

Dr. Spielman talked about the steps involved that lead to insomnia in his 1986 paper.
Insomnia happens because of three “p” words.

Predisposing
Precipitating
Perpetuating

A person with insomnia is predisposed to get insomnia. This predisposition may be from genetics inherited from biological parents. This predisposition may be from life experiences that disrupted the circadian rhythm or ideal hormone levels. A person with insomnia likely had a precipitating event that caused the insomnia to start. This could be a positive or negative event. It could be related to personal health or life events. For example, pain from breaking a leg, being pregnant or the parent of a new baby, changing jobs, moving, hearing sad news or happy news can all change sleep for a short time. These can precipitate insomnia and make insomnia start happening. A person with chronic insomnia has perpetuating factors that prevent normal sleep from returning. Perpetuating factors may be napping during the day to catch up on sleep, spending too much time in bed while awake, going to bed or waking up at irregular times or starting to depend on using sleeping pills or substances.

Source: Spielman, A. Assessment of Insomnia. Clinical Psychology Review. 1986; volume 6:11-25.

Sleep Information WORKSHEET

What are three things that sleep helps us with?

What do you enjoy most about sleeping?

What is the stage of sleep that you may not realize you were even asleep?

What stage of sleep is deep sleep?

What stage of sleep is dream sleep?

What stage of sleep is the most difficult to wake up out of?

What is sleep inertia?

How does sleep inertia go away?

How long is the sleep cycle for an adult?

How long should most adults sleep each night

What do you struggle with the most when you have one night of bad sleep?

What do you struggle with the most when you have many nights of bad sleep?

Progressive Muscle Relaxation Topic

Having insomnia is stressful. It can cause negative thoughts about sleep. Having negative thoughts about sleep and makes it more difficult for insomnia to go away.

What are your thoughts about sleep? Does thinking about sleep cause stress? Do you have negative thoughts about insomnia that quickly jump into your mind?

Having negative thoughts about insomnia makes the problem worse. You have to push yourself to stop negative thoughts and start positive thinking. This can be very challenging.

Stress is linked to muscle tension. Progressive muscle relaxation is an exercise to calm the body and calm the mind. The goal of progressive muscle relaxation is to create a calm body and a calm mind. Progressive muscle relaxation helps you fall asleep. Progressive muscle relaxation was first proposed by Dr. Edmund Jacobson in 1908. Dr. Jacobson outlined the procedure for progressive muscle relaxation in his 1924 paper titled The Technic of Progressive Relaxation. Progress muscle relaxation is applied to many areas including sleep and insomnia.

Source: Jacobson E. The Technic of Progressive Relaxation. The Journal of Nervous and Mental Disease. 1924;60(6):568-578.

The steps for progressive muscle relaxation are:

Recognize the presence of muscular contraction even if it is very light.
Assess every muscle group of the body for tightness starting with the large muscle groups
Relax each muscle group. This can be done by first tightening the muscle group very tight and then letting go of 100% of the tension.
As a new muscle is relaxed, also relax all the other muscles that have been relaxed up to that point in the exercise.
Continue muscle group relaxation until full relaxation is achieved. This is progressive muscle relaxation.
Once you learn full relaxation you may not need to proceed group by group and can go straight to full relaxation.

Learning the skills for progressive and full relaxation is challenging and important. Learning progressive muscle relaxation takes effort, time and practice.

One example of a progressive muscle relaxation order is below.

Right foot
Left foot + right foot
Right calf + left foot + right foot
Left calf + right calf + left foot + right foot
Right upper leg + left calf + right calf + left foot + right foot
Left upper leg + right upper leg + left calf + right calf + left foot + right foot
Hips + entire right leg + entire left leg + feet
Low back + hips + legs + feet
Mid back + low back + hips + legs + feet
Upper back + mid back + low back + hips + legs + feet
Shoulders + entire back + hips + legs + feet
Right hand + shoulders + back + hips +legs + feet
Left hand + right hand + shoulders + back + hips + legs + feet
Right arm + left hand + right hand + shoulders + back + hips + legs + feet
Left arm + right arm + hands + shoulders + back + hips + legs + feet
Chest + arms + hands + shoulders + back + hips + legs + feet
Neck (front and back) + entire upper body + entire lower body
Face (including the jaw to the forehead) + neck + upper body + lower body
Scalp + face + neck + upper body + lower body
Every muscle in the body at the same time

If you take 15 to 30 seconds to relax each muscle group the entire body relaxation will take 5 to 10 minutes.

You can first add tension. For example, wiggle the toes and then relax. Stretch the legs and then relax. Twist the back and then relax. Shrug the shoulders and then relax the shoulders. Bend the head in each direction and then relax the neck. Tighten the jaw and then relax. Wrinkle the forehead and then relax. Close the eyelids tight and then relax. Smile and then relax. Swallow and then relax.

If you like you can play music during this time. You can place a warm compress on the muscles you are working to relax. You can breathe deeply while relaxing. You can sense your muscles as becoming very heavy and sinking into the bed.

Progressive Muscle Relaxation WORKSHEET

What is the goal of progressive relaxation?

What is the steps for progressive muscle relaxation?

What does it take to learn how to be skilled at progressive muscle relaxation?

What is the order of muscles you would like to use in your progressive muscle relaxation?

Are you open to using progressive muscle relaxation?

What are your thoughts on using progressive muscle relaxation every night for 1 week, 2 weeks, 1 month?

Sleep Related Thoughts

Working on sleep thoughts is unique for each person. It is important to consider what the specific use is for you. Conquering sleep related thoughts is important for success.

Many people with insomnia have concerns on their minds. These may be realistic stress reactions to ongoing problems or exaggerated concerns or imagined crises. Some say the only concern or anxiety is whether or not they will fall asleep or not. This can quickly turn into a vicious cycle of concerns getting in the way of sleeping and then a reinforced belief that sleep will not happen. Anxiety and stress causes more insomnia which causes more stress which causes more insomnia which causes more stress which causes more insomnia and so forth.

It is important to put these thoughts out of the mind and try to turn a thinking mind to a calm mind when it is time to fall asleep. Most of the time the sleep environment is boring for the rest of the senses, no sounds, no lights, no movement and so all of the sudden it is easier to focus on what is going on in the mind and remain involved with the external world in that way. It is important to allow the mind to rest, shut down and drift into sleep. It would be harder to fall asleep in a place with flashing lights, colors, sirens, strong smells, movement. It would be easier to fall asleep in a place that is calm. It would be harder to fall asleep with a mind that is thinking, reviewing, deciding, planning. It would be easier to fall asleep with a mind that is calm. Are there things that cause your mind to be active instead of calm? Does seeing the clock light and time activate you? Does checking your cell phone activate you? Can you change those? Do you have automatic thoughts that are negative about sleep? When you wake up in the middle of the night or early in the morning do you jump to a racing and negative mind? Can you keep your mind calm? Would it help to use progressive muscle relaxation to keep your mind calm? Would it help to say a prayer, song, saying or poem? Would it help think about something boring as a distraction? Would it help to think about the details of a calm place you visit or imagined?

Please think about ways your mind gets activated. Please think of ways you can prevent your mind from becoming over-active. Please think of ways you can calm your mind if it does become overly active. Someone who specializes in providing CBTi may be able to help you work through this complicated topic.

Source: Spielman A., Caruso L., Glovinsky P., A Behavioral Perspective on Insomnia Treatment. Sleep Disorders. 1987;10(4):541-553.