Self-management of severe predormital insomnia

1. Behav. Tkcr. 6 .Erp. Ps,hiat.

Vol. 8, pp. 57-63. Pcrgamo

Res,.

L9?7. Ftmted in Great Britain.

SELF-MANAGEMENT OF SEVERE PREDORMITAL INSOMNIA KENNETH

R. MITCHELL*

Student Counselling

and RONALD G. WHITE

and Research Unit. University

of New South Wales

Summary-The present study examined the separate and cumulative effects of progressive muscle and mental relaxation training and cognitive control procedures for reducing pre-sleep tension and intrusive cognitions. Ten subjects were assigned to groups which focused on either separate or combined training in muscle and mental relaxation. followed by training in cognitive control procedures. Three other subjects were trained only in the cognitive control procedures. The findings indicated that muscle relaxation reduced the taiget pre-sleep tension but did not decrease pre-sleep intrusive cognitions. The addition of mental relaxation further reduced pre-sleep tension, and also decreased intrusive cognitions. The effects of cognitive control procedures were similar to those of mental relaxation. Reductions in both pre-sleep tension and intrusive cognitions were followed by significant reductions in latency to sleep onset. which was found to have been maintained at follow-up 4 months later.

intrusive cognitions. Following the findings of Lader and Matthews (1971) which indicated considerable dissociation between physical and mental states of tension and arousal, and the suggestion by Borkovec et al. (1975). the present study explored the effects of reductions in both physical and mental tension, as well as pre-sleep intrusive cognitions on latency to sleep onset. Further, the success of behavioral selfmanagement as a means of training individuals to cope with migraine headaches (Mitchell and White, in press) prompted the application of this approach to the problem of predormital insomnia. Because evidence has emerged which suggests that the self-recording and/or self-monitoring of one’s own behavior can be a reactive measure which leads to behavior change on the part of the recorder without the addition of further treatment (Kazdin, 1974). the present study also examined the reactive effects of self-recording and self-mcnitoring on latency to sleep onset. In summary, the present study explored: (a) the combined effects of muscle relaxation, mental relaxation and cognitive control procedures on pre-sleep tension, pre-sleep intrusive cognitions, and latency to sleep

Predormital insomnia, where the onset to sleep is delayed, is undoubtedly the most common form of sleep disturbance. Recent applications ‘of hypnosis (Stanton, 1975), muscle relaxation (Botkovec. Kaloupek and Slama, 1975) and combinations of muscle relaxation and desensitization (Steinmark and Borkovec, 1974) to the problem of insomnia have been successful in reducing the latency to sleep onset. The tat-get of treatment in these studies has typichlly been the reduction of physical tension by training clients either to relax their muscles before going to bed or to focus their pre-sleep attention on relaxation. However, although past studies have reported significant reductions, these reductions have not resulted in latency to sleep onset periods comparable with that of the noninsomniac population (Haynes, Follingstad and McGowan, 1974). To account for these findings Borkovec et al. (1975) suggested that in addition to physical and mental tension, presleep intrusive cognitions such as ‘racing thoughts’, worry and specific anxieties may also contribute to insomnia as measured by latency to sleep onset. To date, however, investigators have not measured reports of changes in either pre-sleep tension levels or ‘Requests for reprints should be addressed New South Wales, P.O. Box I, Kensington,

to Kenneth R. Mitchell, Student Counselling N.S.W. 2033. Australia. 57

and Research Unit, University

of

55

KENNETH

K. MITCHELL

onset. (b) the short-term, separate effects of muscle and mental relaxation, (c) the effects of training in cognitive control procedures independent of relaxation training, and (d) the effects of self-recording and selfmonitoring.

METHOD Subjects Thirteen male college students and staff aged 19 to 28 yr (mean 23.1) were medically diagnosed as suffering from chronic predormital insomnia. The average duration of the problem reported by the subjects was 1.9 yr (minimum 1.2 yr). None of the subjects reported less than 60 min to sleep onset latency, or the presence of eyestrain, vegatative, visceral or other physical disorders known to influence the latency period to sleep onset. Drugs prescribed for the control of insomnia were phased out under medical supervision prior to the first contact. Self-recording At first contact, subjects were instructed to complete, upon awakening each morning, four daily sleep indices for the duration of the the follow-up period. Two study, including IO-point rating scales obtained information on the targets pre-sleep tension and pre-sleep TABLE

1. Means

and RON.ALD G. WHITE

intrusive cognitions. The remaining indices \vere the estimated number of minutes taken to fall asleep (latency to sleep onset) and a lo-point rating scale measuring satisfaction with sleep. No rationale for either insomnia or its relief were discussed and the subjects were requested to return after 3 weeks of selfSubjects were then randomly recording. assigned to one of three conditions: (a) incremental self-management (N = 5, ISM), (b) accelerated self-management (N = 5. ASM). and (c) delayed partial self-management (N = 3, DPSM). Se!f+norritoring At the second contact. all subjects were provided with the same rationale for predormital insomnia (Mitchell and White, 1975) which explained that their difficulties in getting to sleep were due to a combination of two types of pre-sleep incompatible behaviors: physical and mental tension and/or an overactive and preoccupied mind. Following the work of Steinmark and Borkovec (1974) which showed that differential subject expectation was associated with differential change in latency to sleep onset irrespective of treatment technique. a uniformly high demand positive instruction set was introduced which emphasized that all subjects would reduce their latency to sleep onset by recognizing,

of targets and outcome measures for all groups post self-recording

Croup and period

T3rgcts

and self-monitoring

Outcomes

Weeks Pre-sleep tension*

Pre-sleep intrusive cohmitions*

hlinutcs to SleCp onset

Post-sleep Utisfactiont

/S,ZI (hi = 5) Self-recording Self-monitoring

3 2

8.4 8.3

9.5 9.0

89 81

0.2 0.6

A.s+f (N = 5) Self-recording Self-monitoring

3 2

8.1 8.1

9.3 9.1

83 80

0.5 0.8

DfJSl%f (N = 3) Self-recording Self-monitoring

3 2

1.9 8.0

9.4 9.4

85 78

0.7 1.1

*High scores indicate high pre-sleep tension and intrusive cognitions. tLow scores represent low satisfaction with sleep.

SELF-MANAGEMENT

OF SEVERE

monitoring and recording the details of those events in their daily lives which made them anxious and worried. One hour of tense. training was then focused on identifying and discriminating between the overt and covert antecedents of pre-sleep incompatible behaviors. Each subject was provided with self-monitoring sheets and was instructed to return after 2 weeks. Table 1 presents the sleep behavior patterns of all groups following the self-recording and self-monitoring phases of the study. All groups reported high scores on both the targets of pre-sleep tension and intrusive cognitions as well as extremely poor scores on both outcome measures, latency to sleep onset and post-sleep satisfaction. Incremental

self-management training The rationale for insomnia and the high demand positive instructions were restated prior to the initial training session in behavioral self-management. The five subjects were trained in three stages. Each stage comprised a time period in which the particular selfmanagement skill was taught followed by a time period in which they practised the skill in their daily life, The purpose of these intervening practice periods was to allow for assessment of the separate effects of muscle relaxation, mental relaxation and cognitive control procedures on both targets and outcome by controlling any delayed practice effects. The first stage of training involved instruction in progressive muscle relaxation, by audiotape (Mitchell and White, 1975) in four sessions (3 x45 min, and 1 x 20 min), spaced over a 2-week period. Each subject muscle \vas then requested to practice relaxation three times daily for the following 3 weeks. and to focus on reducing the targets, pre-sleep tension and pre-sleep intrusive cognitions. There was no contact with the subjects during this three week practice period. The second stage, also two weeks, involved four sessions of audiotape instruction in mental

PREDORMITAL

59

INSOMNIA

relaxation (4 x 45 min). Each subject was trained to mentally project himself into a calm scene in which he visualized himself engaging in a variety of relaxing and sedative activities. Training was again followed by three weeks of mental relaxation practice in combination with progressive muscle relaxation. No contact with the subjects occurred during this 3-week application period. In the final 3-week stage of training, subjects listened to three 30-min audiotapes (Mitchell and White, 1975) on which instruction in the procedure and application of five cognitive control techniques was presented. They included three techniques for the control of worry (thought stopping, time out from worry, experiential focusing) and two for the management of fears and anxiety (selfdesensitization, rational thinking). The aim covert was to increase self-control by conditioning behaviors incompatible with presleep intrusive cognitions. Each subject was requested to practice the cognitive control procedures, pre-bedtime and pre-sleep, and to continue their relaxation practice for the next occurred with the 2 Lveeks. No contact investigators during this 2-week practice period.

Accelerated self-management

training

These subjects were given the same rationale, training and practice instructions as incremental self-management (ISM) subjects except that the training for muscle and mental relaxation were combined and taught in a single 4-week instruction period followed by IHV>3-week periods of application. No contact occurred with subjects during the two practice periods. At the end of the second 3-week period, instructions and practice in the five cognitive control procedures were carried out as for the ISM subjects. Delayed partial self-management

training During the lo-week relaxation training and practice periods of incremental self-management (KM) and accelerated self-management (ASM). these subjects were instructed to

cognitions

cognitions

cognitions

latency to sleep sleep satisfaction

Tension intrusive

latency to sleep sleep satisfaction

Tension intrusive

latency to sleep sleep satisfaction

Tension intrusive

80 0.8

8.1 9.1

78 1.1

8.0 9.4

81 0.6

8.3 9.0

(2 weeks)

bT*t

Selfhlonitor-

59 2.8

6.0 7.2

14 1.0

14 1.2

8.0 9.5

39 5.4

4.0 6.3

38 5.5

3.9 6.0

25 6.9

3.1 4.0

58 3.4

7.4 7.2

23 6.0

3.8 4.1

Acquisition (3 weeks)

14 1.8

3.4 3.6

47 5.1

5.6 4.9

19 7.0

3.1 3.5

Application (2 weeks)

3. Intrusive cognitions

over all occasions

at this point.

33 5.8

3.8 5.9

Application (3 weeks) (4 weeks)

muscle and mental relaxation

18 0.8

1.9 9.8

8.0 9.7

47 4.1

4.2 1.0

Application (3 weeks)

2. hlental Relaxation

Stage of training

Acquisition (2 weeks)

Self-monitoring (10 weeks)

52 3.2

5.6 1.9

Application (3 weeks)

Progressive Acquisition (4 weeks)

76 1.1

8.0 9.8

64 1.2

1.2 83

Acquisibon (2 weeks)

1. Progressive Muscle Relaxation

*High positive demand instruction set for reduction in latency to sleep onset introduced tUsed as base figure from which mean percentage reductions were calculated.

ASM

DPSM

ISM

Group

TABLE 2. Mean scores for the three groups

9.0 8.5

2.0 2.5

31 6.4

4.7 4.0

15 8.1

2.1 2.3

(16 weeks)

up

Follow

83 -

58 60

40

30 48

17

2:

Mean% reduction post intervention

89

75 73

60 -

41 57

81 -

68 14

Mean% reduction at follow-up

SELF-MANAGEMENT

OF SEVERE PREDORMITAL

continue self-monitoring and to return at times corresponding to the stages of training for ISM. On each of the four occasions they returned. they were assured that eventually there would occur a reduction in latency to sleep onset. At the end of 10 weeks, the DPSM subjects were trained in the same cognitive control procedures as ISM and ASM. This delay procedure was intro&iced for two reasons: firstly, to evaluate the maximum effect of the combination of high demand positive instructions and selfmonitoring on pre-sleep tension and pre-sleep intrusive cognitions, independent of the relaxation training given to ISM and ASM; and secondly, to examine the effects of cognitive control procedures unconfounded by the effects due to muscle or mental relaxation training. Follow-up Four months after the conclusion of the selfmanagement training, all subjects were contacted and requested to return their four daily sleep questionnaires.

RES IJLTS The means and percentage reductions for both the targets and outcomes of selfmanagement training over eight occasions for incremental self-management (ISM) and delayed partial self-management (DPSM) and seven occasions for accelerated self-management (ASM), including post training follow-up, are presented in Table 2. The mean latency io sleep onset for each group were derived from averages of the last week in the period indicated. In accordance with recent findings on self-report behavior (Borkovec et al., 1975; Kazdin, 1974). post self-monitoring scores were used as the baseline from which change and percentage reductions were derived. One-way analyses of variance indicated no differences between groups at the post self-monitoring stage on either pre-sleep tension and pre-sleep intrusive cognitions (Fs< 1.2) or latency to sleep onset

INSOMNIA

61

and post sleep-satisfaction (Fs < 1 .O). The data for each variable in Table 2 were analyzed by the method of planned contrasts and error terms calculated as for a two-factor repeatedmeasures analysis of variance for unequal groups.

Target measures As expected no significant differences were found between groups ISM and ASM at post intervention on either pre-sleep tension (F<0.8) or pre-sleep intrusive cognitions (F<0.9) or at follow-up (FO.29). However, five weeks later at the end of the practice period for mental relaxation training, group ISM reported significant reductions in both pre-sleep tension (5270. P
62

KENNETH

R. MITCHELL

intrusive cognitions, both of which were significant (PcO.01 and PCO.05). No change on either target was reported by group DPSM during this same lo-week period prior to their training in cognitive control procedures, or in the preceding S-week self-recording and monitoring period. The final analyses assessed change in the target pre-sleep intrusive cognitions following the cognitive control acquisition and practice periods and the effect of this change on the target, pre-sleep tension. The findings revealed that although groups ISM and ASM reported further significant reductions in presleep intrusive cognitions during the S-weeks devoted to cognitive control training (30% to 61% and 35% to 60% respectively, Ps 0.71). In contrast, group DPSM reported significant reductions in both pre-sleep tension (0% to 30%, P
and RONALD G. WHITE

was reported by ASM. No significant change was reported by group DPSM (5%, P>O.89) and selffollowing their self-recording monitoring activities corresponding to the lo-week period of relaxation training and application for groups ISM and ASM. Finally no significant change was reported by any group during the initial 5-week self-recording and monitoring periods of the study (see Table 1). Sleep satisfaction. Significant improvements in sleep satisfaction were reported by ISM and ASM post relaxation training (Ps< 0.05), and by all groups at post intervention (ISM and ASM. Ps
SELF-Xl.&N.\GEMENT

OF SEVERE

(DPSM) indicate that training in these procedures alone are effective in reducing intrusive cognitions and pre-sleep tension, latency to sleep onset. This finding suggests that the effect of cognitive control procedures of the effects due to is independent progressive muscle relaxation alone or when combined with mental relaxation. No significant changes were noted in presleep tension, pre-sleep intrusive cognitions, latency to sleep onset, or sleep satisfaction. folloaing the 3-week self-recording period or the 2-week period in which self-monitoring was combined with a high demand positive instruction set. The absence of change in these measures for delayed partial selfmanagement (DPSM), which continued to self-monitor under 3 continuously reinforced high positive demand instruction set for a further lo-week period, supports this finding, but is contrary to the findings of Borkovec cr 111. (1975). and Steinmark and Borkovec (1974). Since these workers did not employ me3sures of pre-sleep intrusive cognitions it is

PREDORMITAL

63

INSOMNIA

impossible to establish whether or not a high demand positive instruction set has potency only in moderate insomnia.

REFERENCES D. G. and Slama K. M. (1975) The facilitative effect of muscle tension-release in the relaxation treatment of sleep disturbance. Bekav. Therapy 6,301-309. Haynes S., Follingstad D. R. and McGowan W. T. (1974) Insomnia: Sleep patterns and anxiety level, J. Psyckosom. Res. 18,69-74. Kazdin A. E. (1974) Reactive self-monitoring: The effects of response desirability. goal setting, and feedback, J. Consult. Clin. Psyckol. 42, 704-716. Lader M. H. and Matthews A. M. (1971) Electramyographic studies of tension. J. Psyckosom. Res. 15,479-486. Mitchell K. R. and White R. G. (Ln press) Behavioral self-management: An application to the problem of migraine headaches. Behavior Therapy. Mitchell K. R. and White R. G. (1975) The Relief of Insomnia. University of Queensland Press, Brisbane. Stanton H. E. (1975) The treatment of insomnia through hypnosis and relaxation. Terpnos Logos 3.4-8. Steinmark S. W. and Borkovec T. D. (1974) Active and Borkovec T. D.. Kaloupek

placebo demand

effects on moderate and positive demand

Psyckol. 83, 157-163.

insomnia under counterinstructions, J. Abnorm.