Insomnia and Anxiety (Series in Anxiety and Related Disorders) (34 page)

your upper face. Let your eyebrows drop and feel the tension releasing for those muscles.

Continue to relax those muscles in your face and when they feel as relaxed as the muscles

in your arms and hands signal me as before (after a 30–40 relaxation cycle the 7 sec. ten-

sion and 30-40 sec. relaxation cycle is repeated).

Now you should focus your attention on the muscles in the central part of your face. You

will tense these muscles by squinting your eyes as tightly as you can and simultaneously

wrinkling your nose. OK tense your central face muscles now. Notice how the tension feels

as you do that. Feel the tightness (7 sec. pause). Now relax the muscles in the center of your

face and notice how it feels to release the tension. Continue to relax these muscles and

when they feel as relaxed as the muscles in your upper face signal me as before (after

30–40 sec relaxation phase the 7 sec. tension and 30-40 sec. relaxation cycle is repeated).

Now focus your attention on the muscles in your lower face. You will tense these muscles by

biting down hard and, at the same time, pulling back the corners of your mouth. OK, tense

those muscles now. Feel the tightness as you do that (7 sec. pause). Now relax those muscles

in your lower face and notice the difference between tension and relaxation. Continue to relax

your lower face and signal me when those muscles feel as relaxed as the other muscles in

your face (after 30-40 sec. of relaxation, the tension-relaxation cycle is repeated)”.

Now focus on the muscles in your neck. You will tense these muscles by pulling

your chin toward your chest and at the same time keep it from touching your chest.

OK tense your neck now. Notice how it feels to tense your neck (7 s). Now relax

your neck. Notice how relaxation feels and how different it is from tension. As before,

when your neck feels as relaxed as your face muscles, signal me with your finger

(after 30–40 s of relaxation, the tension-relaxation cycle is repeated).

“We will now consider the muscles in your upper torso. You will tense these muscles by

pulling your shoulder blades together. Ok, tense these muscles now. Notice how they feel

when you tense them (7 sec delay). Now relax those muscles. Let go of all of the tension

and notice how different that feels. As before, when your upper torso feels as relaxed

PMR Treatment Outline

129

as your neck muscles, signal me with your finger (after 30-40 sec. of relaxation, the

tension-relaxation cycle is repeated).

Now turn your attention to the muscles in your abdomen. You will tense these muscles by

making your stomach as hard as you can make it. Notice how tight that feels as you tense

your stomach (7 sec. pause). Now relax your stomach. Notice the difference between

tension and relaxation as you let go of the tension in your stomach. When your stomach

feels as relaxed as your upper torso, signal me with your finger (after 30-40 sec, of relax-

ation the tension-relaxation cycle is repeated).

Now we will focus on the muscles in your dominant leg. To begin, focus your attention

on the muscles in your upper leg. You will tense these muscles by trying to straighten your

leg and at the same time trying to bend your leg at the knee. Your leg should not move, but

you should feel tension as a result of the opposing muscles working against each other. OK

tense your upper leg now. Notice the tightness in your leg muscles as you do that (7 sec.).

Now release the tension in your upper leg. Notice how different your leg feels as you relax

it. Let it relax very deeply and when it feels as relaxed as your stomach signal me as before

(after 30-40 sec. of relaxation patter the tension-relaxation cycle is repeated).

We will now focus on the muscles in your dominant calf. You will tense these muscles by

pulling your toes toward your head. OK, tense your calf now and notice how it feels when

it is tense (7 sec.). Now relax your calf and notice how different that feels from being tense.

When your calf feels as relaxed as your upper leg, signal me as before (after 30-40 sec. of

relaxation the tension-relaxation cycle is repeated).

Now we will move to your dominant foot. You will tense the muscles in your foot by pointing

and curling your toes as you turn your foot inward. OK tense your foot now. Notice how it

feels to tense your foot (7 Sec.). Now relax your foot and notice how different it feels from

tensing your foot. Let it relax very deeply and when it feels as relaxed as your calf signal

me as before (after 30-40 sec of relaxation the tension-relaxation cycle is repeated)”.

At this point, the above three paragraphs are repeated with the nondominant upper

leg, calf, and foot in sequence to conclude the exercise. After the exercise is con-

cluded, there should be an inquiry into any difficulties encountered in following any

of the instructions. Also, the patient should be asked about such common side effects

as floating sensations, disorientation, muscle twitches, restlessness, etc experienced

during the session. Discussing that these side effects are usually transient can provide

assurance that with continued practice such side effects will subside. However,

if there are any bothersome or anxiety-provoking side effects, these should be

discussed at length and the therapist should decide whether PMR training should

be continued. If there was a favorable PMR response during the session, it is often

helpful to provide a recording of the exercise to assist home practice efforts. An actual

recording of the PMR training session can be made for this purpose, or the patient

can be referred to one of the many recordings that are commercially available.

Whatever home aids are used, the person should be instructed to practice the initial

PMR exercise one time each day at least 2 h before bedtime.

At the second PMR session, there should be an inquiry into adherence to home

practice instructions. Those reporting adherence difficulties should be provided in-

session assistance in problem-solving their difficulties. Specifically, those with

adherence difficulties should be assisted in identifying barriers to adherence and in

determining a time each day when they might most easily engage in the exercise.

130

9 Other Issues in Managing the Sleep of Those with Anxiety

Once these issues are addressed, the patient should be guided through the same

16-muscle exercise presented during session 1.

Upon returning for session 3, adherence with home practice of RT should again

be reviewed. Subsequently, the patient should be presented an abridged relaxation

exercise that combines the original 16 muscle groups into 7 larger muscle group-

ings. The PMR instructions for the new groupings are presented below. The thera-

pist should guide through the tension and relaxation of each of these muscle groups

just as was done for the 16-muscle exercise. Once again, it is usually useful to assist

the at-home practice via the use of recorded instructions of this revised exercise.

Muscle group

Tension procedure

Dominant arm

Make fist/press elbow down

Nondominant arm

Make fist/press elbow down

Face

Squint, raise eyebrows, wrinkle nose, bite down, pull mouth back

Neck

Same as for 16 groups

Torso

Pull shoulders back, take deep breath, tighten stomach

Dominant leg/foot

Lift leg and curl toes

Nondominant leg/foot

Lift leg and curl toes

Once this exercise has been presented, the therapist should suggest using relax-

ation skills to combat nocturnal wakefulness. Specifically, the person can attempt

to use their developing relaxation skills to facilitate sleep onset whenever they

experience a prolonged period of wakefulness in bed.

Session 4 should be identical to session three except that the RT exercise will be

reduced to the 4 major muscle groups listed below.

Four muscle groups

Right and left arms/hands

Face/neck muscles

Torso muscles

Right and left legs/feet

Sessions 5 and 6 should be identical to session 4 except the tension component

of the tension-release instructions is dropped from the instructional set. In this

procedure, the therapist only provides instructions to focus on each muscle group,

and then to recall the feelings associated with the release of tension from that

muscle group. Again, 2 presentations of each of the 4 muscle groups are conducted

and each relaxation phase lasts 30–40 s.

Those who manifest excessive bedtime arousal are usually good candidates for

PMR, and those who also show good treatment adherence typically receive some

sleep benefits from this intervention. Generally speaking, those with the types of

anxiety disorders discussed in this text may be considered good treatment candi-

dates. However, it should be remembered that insomnia is often a complex problem

that is perpetuated by a number of cognitive, physiological, and behavioral factors.

Because of this fact, relaxation training may not represent an omnibus treatment

for many people with insomnia. Nonetheless, there may be benefits to combining

Craske’s Nocturnal Panic Protocol

131

relaxation techniques with the other approaches typically included in CBT insomnia

protocols. When employing relaxation therapy as part of a complex, multicompo-

nent insomnia intervention, it may be desirable to use an alternate, less time-intensive

protocol than the PMR instructions presented here. For more information about

those approaches, the reader may wish to consider a number of available texts

largely or specifically devoted to the relaxation therapies (Benson, 1984; Lichstein,

1988; Smith, 1990).

Cognitive Behavioral Treatment of Nocturnal Panic

There is a validated Cognitive Behavioral Therapy treatment available for nocturnal

panic that has shown some impressive improvements in those treated with CBT

relative to a waitlist control group (Craske, Lang, Aikins, & Mystkowski, 2005).

At posttreatment, three quarters of the CBT group reported zero nocturnal panic

attacks and an absence of worry about nocturnal panic. The CBT recipients also

reported decreased severity of their panic disorder and improved sleep satisfaction.

Those in the CBT group evidenced less reactivity on posttreatment anxiety-inducing

laboratory procedures. These improvements were maintained at a 9-month follow-up.

Admittedly, additional randomized controlled clinical trials are needed to validate these

findings but given the promise of this protocol, we provide an overview of it here.

Treatment Approach
: The Craske protocol for nocturnal panic (Craske et al., 2005)

is delivered over approximately 10–13 weeks of hourly sessions

Craske’s Nocturnal Panic Protocol

Session

Content

1

Introduction to panic and anxiety

2

Physiology of anxiety

3

Hyperventilation and breathing retraining

4

Breathing retraining

Cognitive restructuring: overestimates of danger

5

Cognitive restructuring: evaluating consequences

6

Deconditioning

Sensation induction testing

Identification of feared/avoided activities

7

Cognitive restructuring practice

Deconditioning hypothesis testing

Interoceptive exposure

8

Cognitive restructuring practice

Deconditioning: causal analysis

Interoceptive exposure

(continued)

132

9 Other Issues in Managing the Sleep of Those with Anxiety

(continued)

Session

Content

9

Cognitive restructuring practice

Deconditioning: management of intense anxiety

Interoceptive exposure to activities

10

Cognitive restructuring practice

Deconditioning: management of worst panic and

fear of panic

Interoceptive exposure to activities

11

Review and planning for termination

12 and 13

Include progress review sessions at 3 and 6-month

posttreatment

In actuality, much of the treatment of NP is the same as that of PD, although

there are some added sleep-specific psychoeducation and sleep hygiene compo-

nents. Session one provides an overview of what to expect over the course of the

treatment, as well as an introduction to the Cognitive Behavioral model of anxiety.

Patients already have an explanation of panic as sensitivity to physical signs of

fear. As a result, there is an increased attention on physical changes, such that even

small changes in the body that other people would not notice are perceived. Despite

this increased attention, PA sufferers may not be consciously aware that they are

reacting to these small physical symptoms. Attributing negative or catastrophic

meaning to these normal fluctuations increase the likelihood of attentional bias.

The example in the manual is that of being in a large noisy room full of talking

people. When someone mentions your name, you may detect that meaningful bit