This article was downloaded by: [88.8.89.

195]
On: 24 October 2014, At: 12:37
Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954
Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Scandinavian Journal of Behaviour
Therapy
Publication details, including instructions for authors and
subscription information:
http://www.tandfonline.com/loi/sbeh19
An Integrative Model for the
Analysis and Treatment of Insomnia
Lars-Gunnar Lundh
a
a
Department of Psychology , Stockholm University ,
Stockholm, Sweden
Published online: 05 Nov 2010.
To cite this article: Lars-Gunnar Lundh (2000) An Integrative Model for the Analysis and
Treatment of Insomnia, Scandinavian Journal of Behaviour Therapy, 29:3-4, 118-126, DOI:
10.1080/028457100300049737
To link to this article: http://dx.doi.org/10.1080/028457100300049737
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information
(the Content) contained in the publications on our platform. However, Taylor
& Francis, our agents, and our licensors make no representations or warranties
whatsoever as to the accuracy, completeness, or suitability for any purpose of the
Content. Any opinions and views expressed in this publication are the opinions and
views of the authors, and are not the views of or endorsed by Taylor & Francis. The
accuracy of the Content should not be relied upon and should be independently
verified with primary sources of information. Taylor and Francis shall not be liable
for any losses, actions, claims, proceedings, demands, costs, expenses, damages,
and other liabilities whatsoever or howsoever caused arising directly or indirectly in
connection with, in relation to or arising out of the use of the Content.
This article may be used for research, teaching, and private study purposes.
Any substantial or systematic reproduction, redistribution, reselling, loan, sub-
licensing, systematic supply, or distribution in any form to anyone is expressly
forbidden. Terms & Conditions of access and use can be found at http://
www.tandfonline.com/page/terms-and-conditions
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
3
7

2
4

O
c
t
o
b
e
r

2
0
1
4

An Integrative Model for the Analysis and
Treatment of Insomnia
1
Lars-Gunnar Lundh
Department of Psychology, Stockholm University, Stockholm, Sweden
The present paper describes an integrative cognitive-behavioural model for the analysis
and treatment of insomnia. According to the theoretical model, insomnia is the result of
an interaction between sleep-interfering processes (e.g. various kinds of arousal, and
processes whereby various stimuli, behaviours and cognitive activities lead to arousal)
and sleep-interpreting processes (sleep-related beliefs, attributions, attitudes, etc.). It is
argued that insomnia involves various combinations of such processes, and that treatment
should be based on a cognitive-behavioural analysis of how these processes combine in
each particular case of insomnia. The treatment model focuses both on a reduction of
sleep-interfering arousal processes (e.g. by replacing willful goal-directed control
strategies with skills of mindful observation and acceptance) and on a modification of
sleep-interpreting processes (by means of behavioural experiments and psychoeducative
interventions). Key words:Insomnia, Cognitive-behaviour therapy.
Correspondence address: Lars-Gunnar Lundh, Department of Psychology, Stockholm University,
S-106 91 Stockholm, Sweden. Tel:

46-8-163916. Fax:

46-8-166236.
E-mail: llh@psychology.su.se
I
nsomnia, defined as difficulty in initiating or maintaining sleep (American Sleep Disorders
Association, 1997), is a common complaint that is reported by up to 1015% of the population
(e.g., Bixler, Kales, Soldatos, Kaley, & Healy, 1979; Ford & Kamerow, 1989) and that can persist
relatively unchanged over many years (Mendelsohn, 1995). There are a number of psychological
treatment methods that have demonstrated various degrees of effectiveness in the treatment of
insomnia, like stimulus control, sleep restriction, and various kinds of relaxation methods (for
reviews of existing psychological treatments of insomnia and their effects, see Lundh, 1998, and
Murtagh & Greenwood, 1995). The effects, however, are far from optimal, and there is a need for
the development of more effective treatments.
Although there has been a steady growth of insomnia research during the last decades, however,
very little has happened with regard to new treatment methods. The empirically most well-
validated treatment is still the stimulus control procedure that was introduced by Bootzin (1972).
Although a number of therapists (e.g. Espie & Wicklow, in press; Morin, 1993; Sanavio, 1988)
have added cognitive models and techniques to the treatment of insomnia, there is still no
empirical evidence that cognitive methods confer any advantage, as compared with stimulus
control treatment. In the present paper a new but still not empirically tested approach to the
analysis and treatment of insomnia is described. This is an approach which (a) integrates basic
empirical findings in terms of a theoretical model of insomnia as an interaction between sleep-
interfering processes and sleep-interpreting processes (Lundh & Broman, 2000); and (b) draws on
1
This is a modified version of a paper that was presented at the International Congress of Cognitive
Psychotherapy in Catania, Italy, 23 June, 2000.
SCANDINAVIAN JOURNAL OF BEHAVIOUR THERAPY VOL 29, NO 3-4, PAGES 118126, 2000
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
3
7

2
4

O
c
t
o
b
e
r

2
0
1
4

new treatment models that have developed recently within cognitive-behaviour therapy in terms
of

mindfulness (Linehan, 1993; Teasdale, 1999a,b) and

acceptance (Hayes, Strosahl, &
Wilson, 1999).
Sleep-interfering processes
In a recent theoretical review of the empirical research on insomnia (Lundh & Broman, 2000) it
was suggested that different varieties of insomnia involve various combinations and interactions
of two kinds of processes, which were referred to as sleep-interfering processes and sleep-
interpreting processes.

Sleep-interfering processes is a name for all kinds of arousal that
interfere with sleep, and the various kinds of processes that lead to such an elevated arousal. In
particular, the work by Bonnet and Arand (1992, 1994, 1995, 1996, 1997, 1998) has demonstrated
that persistent insomnia is characterized by a higher baseline level of physiological arousal, as
measured by metabolic rate (whole body oxygen use) not only during the night but also at all
measurement points during the day. Their conclusion is that these patients suffer from a general
disorder of hyperarousal that is responsible for both daytime symptoms and nocturnal poor sleep.
This is important for at least two different reasons: firstly, it reminds us that insomnia is not only a
matter of nigh-time functioning, but also a matter of daytime functioning. Secondly, it suggests
that reduced arousal should be one focus of insomnia treatment.
How the elevated arousal should be reduced must rest on an adequate understanding of what
causes this arousal in each particular case of insomnia. An elevated arousal may be due to a
number of different things. What is needed, therefore, is a functional analysis of the conditions for
arousal in each individual i.e. what kinds of external events, internal experiences, behaviours and
cognitive activities lead to a sleep-interfering arousal?
What causes the sleep-interfering arousal?
The frequency and intensity of arousing events in the persons life may obviously play a role in
the causation of a sleep-interfering arousal. There is evidence that stressful life events often
precede the onset of insomnia (e.g. Healey et al. 1981). Temporary forms of insomnia may be
caused almost entirely by such external stressful events, and if there is too much stress in a
persons life this may lead to consistent sleep problems. In that case, life-style changes may be
called for to reduce the degree of external stress.
Internal experiences may also cause arousal. Rachman (1980), for example, suggested that
insomnia may appear as the result of an insufficient

emotional processing of stressful life
events. Memories of traumatic events which are not sufficiently emotionally processed, for
example, may intrude into a persons experience and cause a sleep-interfering arousal. All kinds
of standing worries and concerns may also lead to an elevated level of arousal. As argued by
Spielman and Glovinsky (1991), an individual who has some outstanding concern, and attaches
great risk to leaving this concern unattended, is likely to respond with increased wakefulness to
stimuli which are associated with this concern. To the extent that a persons sleep-interfering
arousal is due to cognitive intrusions of traumatic memories, or other kinds of emotional concerns
and worries, treatment should include a focus on emotional processing of these concerns.
Another factor that must be reckoned with is arousal-generating aspects of the individuals
behaviour and cognitive activity. Bootzin and Nicassio (1978) argued that insomniacs often
engage in various kinds of sleep-incompatible behaviours like reading, eating, watching TV,
thinking about problems, etc. in bed. With regard to behaviours like reading, watching TV, etc. in
bed, however, Lundh, Lundqvist, Broman, and Hetta (1991) found no evidence that insomniacs
engage in these behaviours more than others do. There is also reason to question the idea that these
behaviours are necessarily sleep-interfering on the contrary, a number of people use reading and
watching TV in bed as efficient ways of relaxing and falling a sleep. What seems to be more
VOL 29, NO 3-4, 2000 Analysis and treatment of insomnia 119
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
3
7

2
4

O
c
t
o
b
e
r

2
0
1
4

unambiguously sleep-interfering, however, is the tendency to lie in bed and think about problems.
Rumination about past events, and worrying about the future are two kinds of cognitive activities
that seem to be prevalent among insomniacs and that may serve as sleep-interfering arousal
processes (Lundh et al., 1991).
Moreover, one important kind of sleep-interfering arousal among many insomniacs seems to be
due to their tendency to ruminate and worry about their sleep and sleeplessness, and the potential
consequences of insufficient sleep, and to try to control their thought processes in order to fall
asleep. Harvey (in press) administered a revised version of Wells and Davies (1994) Thought
Control Questionnaire to both insomniacs and good sleepers, and found that insomniacs generally
reported more of meta-cognitive thought control strategies, in particular thought suppression,
reappraisal and worrying. In a second study, Harvey (2000) let the participants select the thought
most likely to dominate their pre-sleep cognitive activity, and randomly allocated them to either a
thought suppression condition or a non-suppression condition. The former group were instructed
to suppress the self-selected thought during the pre-sleep period, whereas the latter group were
instructed not to control their thoughts. The results showed that the participants instructed to
suppress estimated their sleep onset latency to be longer and their sleep quality to be poorer than
participants given non-suppression instructions. Harvey, like Espie and Wicklow (in press),
suggests the possibility that any active control strategy mechanism may be maladaptive and that
the process of sleep should involve minimal effort. As she points out, this also questions the
training in thought-stopping that is sometimes included in treatment packages for insomnia
without any empirical support for its efficacy. Since thought stopping is essentially a form of
thought suppression, it may well turn out to have negative effects on sleep.
Replacing wilfulness with mindfulness
It should be noted that a common denominator to most empirically validated psychological
treatments of insomnia stimulus control, sleep restriction and various forms of relaxation
training is that they all, in various ways, counteract the pattern of lying in bed thinking
(including the kind of thinking involved in meta-cognitive thought control strategies). Stimulus
control therapy (Bootzin, 1972) requires the insomniac not to remain in bed if he/she cannot fall
asleep; sleep restriction (Spielman, Caruso, & Glovinsky, 1987) reduces the time spent awake in
bed and thereby also the opportunities for thinking in bed; and relaxation (e.g., Woolfolk &
McNulty, 1983) involves a focus on body sensations or mental images instead of verbal thought
processes. With regard to stimulus control treatment which is generally seen as the treatment of
choice for insomnia it may be asked the following question: if the main thing is to prevent
thinking, worrying and ruminating in bed, is it then really necessary to get out of bed if one cannot
fall asleep?
Another possibility is to let the client engage in an exercise of mindfulness at regular intervals
while lying awake in bed. Preliminary evidence (Lundh, unpublished data) indicates that at least
some clients may benefit from a

mindfulness exercise in which they are instructed to observe,
each 5 minutes, various aspects of their cognitive and emotional state. In this exercise, the client is
instructed to (1) name in a few words the kinds of thoughts that he or she had during the past 5
minutes, and (2) to make a number of ratings on a scale from 0 to 3 of (a) how easy or difficult it
was to remember these thoughts, (b) the degree to which he/she tried to control these thoughts,
and (c) his/her actual emotional state (degree of arousal, tension/worry, anger/annoyance,
sadness/depression, tiredness/sleepiness and pleasant relaxed feeling). The rationale for this
exercise is that it represents a kind of cognitive activity (mindful observation of the here-and-now)
that is incompatible with cognitive processes of worrying and rumination.

Mindfulness may defined as a meta-cognitive activity of observing ones own cognitive and
emotional processes, without trying to control or change these processes (e.g. Linehan, 1993;
Teasdale, 1999a,b). Mindfulness, therefore, implies acceptance (e.g. Hayes et al., 1999).
120 Lundh SCAND J BEHAV THER
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
3
7

2
4

O
c
t
o
b
e
r

2
0
1
4

Wilfulness, on the other hand, may be seen as the opposite of

mindfulness, in the sense that it
implies attempts to control and change events attempts that may be highly adaptive in dealing
with the external world, but that are often futile when it comes to dealing with cognitive and
emotional processes (Linehan, 1993; Hayes et al., 1999). The above-mentioned

mindfulness
exercise may, for example, lead the client to experience that he/she has sometimes great
difficulty recalling the major kinds of thoughts during the past minutes which may serve as a
stimulus for paying more attention to ones thoughts during the next 5 minutes. This is one of the
ways in which this exercise can set the stage for the gradual learning of a more mindful meta-
cognitive activity.
At the same time, all the above-mentioned methods (i.e. not only various kinds of relaxation
and stimulus control methods, but also the mindfulness exercise) suffer from one potential
weakness, since they can be drawn into potentially self-defeating attempts to fall asleep by means
of wilful efforts i.e. they may all be used as techniques for the explicit purpose of falling asleep.
It may be argued that wilful efforts in themselves tend to cause an increased arousal. All kinds of
wilfulness, by definition, involve the creation of a tension between the persons present state and a
desired goal-state a tension which is released when this goal-state is reached. Such goal-directed
activities are adequate in many different contexts, when we are faced with various kinds of
problems that have to be solved. However, if the goal that is to be reached requires a relaxed state,
then wilful efforts will be inadequate, and may even make it more difficult to reach the goal.
Paradoxically, therefore, if a person tries to relax in order to fall asleep, or tries to follow various
kinds of stimulus control rules in order to fall asleep, this may in fact create a tension or arousal
that makes it more difficult to fall asleep! Moreover, if a person fails to reach the desired goal, he
or she may become frustrated and irritated in a way that increases tension and arousal even more,
and makes it even more difficult to fall asleep. In the insomnia literature, this kind of phenomenon
is sometimes referred to as

trying too hard to fall asleep.
One way of counteracting wilfulness in treatment is to use

counter-demand instructions
(Steinmarck & Borkovec, 1974) as part of the rationale, i.e. to instruct the patient that no
improvement is to be expected during the first weeks of treatment. Most importantly, however, the
patient may be instructed that treatment is a matter of learning new skills which is a process that
takes time and not a matter of finding techniques that can be used instantly to fall asleep.
The more the client copes with problems by means of such wilful goal-directed strategies, the
more indicated is also the use of a more basic training in

mindfulness or

acceptance, i.e. an
attitude that involves a mindful observation of ones present state (bodily sensations, sense
impressions, feelings and thoughts, as they come and go) without any wish to change these. That
is, the purpose is simply to observe how it feels to be just here and now, not only in the sleep
situation but also in other areas of life. This kind of skills training is used in Linehans (1993)
Dialectical Behaviour Therapy, in Hayes et al.s (1999) Acceptance and Commitment Therapy
(ACT) and in Teasdales (1999a) Mindfulness-based Cognitive Therapy.
Insomnia vs sleep deprivation
All the negative psychological factors that have been mentioned so far represent forms of
potentially sleep-interfering processes. What remains to clarify empirically is the relative
contribution of these various processes to problems of insomnia. At the same time, it is important
to note that insomnia cannot be a matter only of such sleep-interfering processes, since in that case
insomnia would be more or less equivalent to insufficient sleep, or sleep-deprivation. However,
there is strong evidence that insomnia is clearly separate from sleep deprivation. Daytime
sleepiness is generally considered the most reliable indicator of insufficient nocturnal sleep. An
important thing about the daytime functioning of insomniacs, however, is that they complain more
of fatigue or tiredness than of daytime sleepiness. Insomniacs often report that they cannot fall
asleep during the day even if they try, and a typical statement of patients with persistent insomnia
VOL 29, NO 3-4, 2000 Analysis and treatment of insomnia 121
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
3
7

2
4

O
c
t
o
b
e
r

2
0
1
4

is that

I am tired, but not sleepy. On the Multiple Sleep Latency Test (MSLT), which is the most
commonly used objective test of sleepiness, numerous studies have failed to find objective
evidence of sleepiness in insomniacs (Seidel et al., 1984). Chambers and Keller (1993) refer to
these patients as

alert insomniacs. Moreover, when insomniacs are sleep deprived this does not
lead to an increase in the symptoms that are typical of insomnia, but to symptoms of sleep
deprivation, e.g. increased sleepiness (Bonnet &Arand, 1998). Whereas insomnia is characterized
by increased arousal, as measured e.g., by electrodermal activity (Broman & Hetta, 1994;
Lichstein & Fanning, 1990; Waters, Adams, Binks, & Varnado, 1993), sleep deprivation is
characterized by decreased arousal (Bonnet & Arand, 1996; McCarthy & Waters, 1997).
In order to explain these findings, we have to posit an important role also for cognitive sleep-
interpreting processes i.e. cognitive processes which influence how insomniacs perceive and
think about their sleep and about the causes and effects of their sleep pattern. Such sleep-
interpreting processes are essentially involved in the very definition of insomnia, since the
diagnosis of insomnia is made on the basis of the subjective complaint of insomnia, whether this is
corroborated by objective evidence in the sleep laboratory or not.
Sleep-interpreting processes

Sleep-interpreting processes is a label for all kinds of cognitive processes that affect how we
perceive, interpret, evaluate and think about sleep and sleep problems. Since insomnia is defined
in terms of subjective sleep complaints (and not in terms of objective sleep recordings), sleep-
interpreting processes by definition are essentially involved in insomnia. This is seen, for
example, in the fact that there is a subcategory of insomnia that involves only subjective sleep
complaints but no objectively verifiable sleep deficits this variety of insomnia has been
variously referred to as

subjective insomnia and

sleep state misperception. However, even in
most other varieties of insomnia there is a discrepancy between subjective sleep complaints and
objective sleep recordings; it is well documented that most insomniacs tend to overstimate their
sleep latency, and underestimate their total sleep time, in comparison with objective sleep
recordings, and in comparison with normal sleepers who do not show this kind of discrepancy
(Edinger & Finns, 1995; Coates et al., 1982). The reasons for this discrepancy are not entirely
clear, but empirical research indicates that degree of arousal may influence the degree of this
discrepancy (Bonnet & Arand, 1994), possibly because time perception is influenced by degree of
arousal.
The role of sleep-related beliefs, attributions and standards
The category of dysfunctional sleep-interpreting processes also include unrealistic beliefs about
the need to sleep. Chambers and Keller (1993) have hypothesized that many insomniacs are, in
fact, short sleepers who mistakenly believe that they need more sleep than they actually do.
Research by Morin, Stone, Trinkle, Mercer, and Remsberg (1993) also shows evidence that
insomniacs hold stronger beliefs than good sleepers about the detrimental consequences of
insomnia on physical and mental health, and stronger attributions of mood disturbances and lack
of energy to poor sleep. Here, psychoeducational interventions are called for, in order to inform
the client, for example, that we tend to compensate for sleep loss during the following nights, at
least with regard the most valuable forms of sleep (i.e. delta sleep and REM sleep).
Exposure to sleep deprivation may also be therapeutic, since this may serve to correct
exaggerated beliefs about the detrimental consequences of poor sleep with regard to daytime
functioning. Treatments like stimulus control and sleep restriction initially often involve an
element of sleep deprivation, since both of these treatments lead to a decrease in the time spent in
bed; what these treatments lack, however, is a cognitive conceptualization of sleep deprivation in
terms of behavioural experiments with the explicit purpose of testing sleep-related beliefs.
122 Lundh SCAND J BEHAV THER
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
3
7

2
4

O
c
t
o
b
e
r

2
0
1
4

Further, since the interpretation of ones sleep functioning essentially involves an evaluation in
terms of

good or

bad, it follows that a persons sleep-interpreting processes always imply the
existence of some kind of personal standards for what constitutes a sufficiently good sleep. The
same applies to the insomniacs daytime functioning. The diagnosis of insomnia requires that the
patient experiences negative daytime consequences of his or her poor sleep, either in the form of
fatigue, performance impairment or mood disturbance, and that this causes significant impairment
in social or occupational functioning, and/or marked distress. What counts as acceptable
performance, and what counts as significant impairment in social or occupational functioning,
however, is always relative to some kind of standard. This means that the nature of these personal
standards may have an important role for the persons appraisal of his/her sleep and daytime
functioning; people with harsh personal standards may have less tolerance for the negative
consequences which follow from a bad nights sleep, and will therefore have a lower threshold for
complaining of insomnia. The more perfectionistic these standards are, the less tolerance may be
expected for temporary fluctuations in sleep time and sleep quality. It may therefore be expected
that degree of perfectionism with regard to sleep and daytime functioning may influence the
insomnia patients perception and cognitive appraisal of his or her quality of sleep and daytime
functioning. The empirical evidence here points to a clear association between perfectionism and
insomnia (Lundh, Broman, Hetta, & Saboonchi, 1994). If perfectionistic standards play an
important role for a persons sleep complaints, they may need to be addressed by means of
cognitive techniques and behavioural experiments.
Finally, beliefs about how to influence sleep may play an important role in a persons way of
handling his or her sleep problems. A person with strong beliefs in the power of willfulness, for
example, may be expected to become a victim more easily to the trap of

trying too hard to fall
asleep. To the extent that this is the case, the persons beliefs in this area may need to be focused
on.
Applying the ACT model to insomnia
In Hayes et al.s (1999) Acceptance and Commitment Therapy (ACT), the therapist begins the
process by focusing on three primary questions: (1) What does the client want? (2) What has the
client tried? and (3) How has that worked? That is, one of the first goals in the initial assessment
phase is to enumerate all of the various methods that the client has used and how they have
worked. According to Hayes model, this often leads to the identification of a class of futile
control strategies, i.e. various methods for wilful goal-directed change that have not worked an

unworkable change agenda. The next goal is then to introduce an alternative to these wilful
control strategies, which Hayes refers to in terms of

willingness or

acceptance. This kind of
approach may, in fact, be very suitable in the treatment of insomnia, since sleep problems
represent a paradigm example of a problem where wilful change strategies are bound to fail. This
means that the assessment of insomnia should include a detailed review of all kinds of techniques
that the client has tried in order to improve his or her sleep. This will most probably lead to an
identification of a class of wilful goal-directed strategies that have not worked very well, and
which can be the starting-point for looking at alternatives that involve less of wilfulness and more
of acceptance.
Some case studies with insomnia patients (Lundh, unpublished data) indicate that this theme
may be approached in a psychoeducational format, with

socratic questions and experiential
exercises, in order to establish the following points: (1) although wilful goal-directed strategies
are highly valuable and useful in many contexts, sleep is not such a context, since sleep is not
under voluntary control. (2) Wilful goal-directed strategies with regard to sleep may lead to an
increased tension and arousal which interferes with sleep, since such wilful goal-directed
activities tend to create tension, whereas sleep is facilitated by relaxation. (3) Sleep is facilitated
VOL 29, NO 3-4, 2000 Analysis and treatment of insomnia 123
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
3
7

2
4

O
c
t
o
b
e
r

2
0
1
4

by the letting go of willful goal-directed change strategies with regard to sleep, and an acceptance
that sleep can be allowed to regulate itself.
By means of cognitive methods and exposure exercises, the insomniacs sleep-interpreting
processes may change. To borrow a term from Teasdale (1999a), this kind of change can be
described in terms of the creation of a new

schematic model of sleep and sleep problems. This
new schematic model of insomnia will involve something like the following perspective on sleep:
(1) sleep fluctuates as the result of various kinds of external and internal events (stressful events,
emotional concerns, etc.). (2) Sleep is not under voluntary control, and there are no techniques
that can be used efficiently in order to fall asleep, so these fluctuations have to be accepted. (3) A
sleepless night is no catastrophe.

Even if I will get no sleep at all tonight, I will still manage
tomorrow. (4) A poor nights sleep is generally compensated for by deeper and more refreshing
sleep the coming nights. (5) Sleep may be improved by learning new skills and habits, but this is a
process which leads to effects over time, and is not a matter of using techniques in order to fall
asleep.
Within the context of this model, various sleep-facilitating skills can be trained (like relaxation
and mindfulness), and new sleep-facilitating habits and coping techniques can be developed. It is
important, however, that these strategies are used not as means to an end, but in the more
probabilistic spirit of leading to an improved sleep over time.
Summary
In the present paper, the outlines of an integrative cognitive-behaviour treatment for insomnia
have been described. The basic idea is that treatment has to be individualized in terms of the kinds
of sleep-interfering and sleep-interpreting processes that are involved in each particular case of
insomnia. The main innovation in this treatment approach is its focus on meta-cognitive change,
in order to replace wilful control strategies with mindful observation and acceptance with regard
to sleep and pre-sleep processes. It is important to note that the present model is still under
development. So far, various versions of it has been tested in case studies, with promising results.
The model, however, needs to be refined by means of further case studies, before it is formalized
into a manual and is eventually put to the test in a straightforward treatment study.
References
American Sleep Disorders Association (1997). The International Classification of Sleep Disorders.
Diagnostic and Coding Manual Revised. Minnesota: ASDA.
Bixler, E., Kales, A., Soldatos, C. R., Kales, J. D., & Healy, B. (1979). Prevalence of sleep disorders in the
Los Angeles metropolitan area. American Journal of Psychiatry 136, 12571262.
Bonnet, M. H., & Arand, D. L. (1992). Caffeine use as a model of acute and chronic insomnia. Sleep 15,
526536.
Bonnet, M. H., & Arand, D. L. (1994). The impact of level of physiological arousal on estimates of sleep
latency. In R. D. Ogilvie & J. R. Harsh (eds) Sleep Onset: Normal and Abnormal Processes.
Washington, DC: American Psychological Association.
Bonnet, M. H., & Arand, D. L. (1995). 24-hour metabolic rate in insomniacs and matched normal sleepers.
Sleep 18, 581588.
Bonnet, M. H., & Arand, D. L. (1996). The consequences of a week of insomnia. Sleep 19, 453461.
Bonnet, M. H., & Arand, D. L. (1997). Physiological activation in patients with sleep state misperception.
Psychosomatic Medicine 59, 533540.
Bonnet, M. H., & Arand, D. L. (1998). The consequences of a week of insomnia. II. Patients with insomnia.
Sleep 21, 359368.
Bootzin, R. R. (1972). Stimulus control treatment for insomnia. Proceedings of the American Psychological
Association 7, 395396.
124 Lundh SCAND J BEHAV THER
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
3
7

2
4

O
c
t
o
b
e
r

2
0
1
4

Bootzin, R. R., & Nicassio, P. M. (1978). Behavioral treatments for insomnia. In M. Hersen, R. M. Eisler
and P. M. Miller (eds), Progress in Behavior Modification, Volume 6. New York: Academic Press.
Broman, J. E., & Hetta, J. (1994). Electrodermal activity in patients with persistent insomnia. Journal of
Sleep Research 3, 165170.
Chambers, M. J., & Keller, B. (1993). Alert insomniacs: Are they really sleep deprived? Clinical
Psychology Review 13, 649666.
Coates, T. J., Killen, J. D., George, J., Marchini, F., Silverman, S., & Thoresen, C. E. (1982). Estimating
sleep parameters: a multitrait-multimethod analysis. Journal of Consulting and Clinical Psychology 50,
345352.
Edinger, J. D., & Finns, A. I. (1995). The distribution and clinical significance of sleep time mis-
interpretation among insomniacs. Sleep 18, 232239.
Espie, C. A., & Wicklow, A. (in press). Cognitive therapy for insomnia. In C. Shapiro & E. P. Sloan (eds),
Sleep in Psychiatry. Cambridge: Cambridge University Press.
Ford, D. E., & Kamerow, D. B. (1989). Epidemiologic study of sleep disturbances and psychiatric disorders.
JAMA 262, 14791484.
Harvey, A. (in press). I cant sleep, my mind is racing! An investigation of strategies of thought control in
insomnia. Behavioural and Cognitive Psychotherapy.
Harvey, A. (2000). The attempted thought suppression of pre-sleep cognitive activity in insomnia..
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy. New York:
Guilford Press.
Healey, E. S., Kales, A., Monroe, L. J., Bixler, E. O., Chamberlin, K., & Soldatos, C. R. (1981). Onset of
insomia: role of life-stress events. Psychosomatic Medicine 43, 439451.
Lichstein, K. L., & Fanning, J. (1990). Cognitive anxiety in insomnia: an analogue test. Stress Medicine 6,
4751.
Linehan, M. M. (1993). Cognitive-behaviour treatment for borderline personality disorder. New York:
Guilford.
Lundh, L. G. (1998). Cognitive-behavioural analysis and treatment of insomnia. Scandinavian Journal of
Behaviour Therapy 27, 1029.
Lundh, L. G., & Broman, J. E. (2000). Insomnia as an interaction between sleep-interfering and sleep-
interpreting processes. Journal of Psychosomatic Research 49, 299310.
Lundh, L. G., Broman, J. E., Hetta, J., & Saboonchi, F. (1994). Perfectionism and insomnia. Scandinavian
Journal of Behaviour Therapy 23, 318.
Lundh, L. G., Broman, J. E., & Hetta, J. (1995). Personality traits in patients with persistent insomnia.
Personality and Individual Differences 18, 393403.
Lundh, L. G., Lundqvist, K., Broman, J. E., & Hetta, J. (1991). Vicious cycles of sleeplessness, sleep phobia,
and sleep-incompatible behaviours in patients with persistent insomnia. Scandinavian Journal of
Behaviour Therapy 20, 101114.
McCarthy, M. E., & Waters, W. F. (1997). Decreased attentional responsivity during sleep deprivation:
orienting response latency, amplitude, and habituation. Sleep 20, 115123.
Mendelsohn, W. B. (1995). Long-term follow-up of chronic insomnia. Sleep 18, 698701.
Morin, C. M. (1993). Insomnia. Psychological Assessment and Management. New York: Guilford.
Morin, C. M., Stone, J., Trinkle, D., Mercer, J., & Remsberg, S. (1993). Dysfunctional beliefs and attitudes
about sleep among older adults with and without insomnia complaints. Psychology and Aging 8, 463
467.
Murtagh, D. R. R., & Greenwood, K. M. (1995). Identifying effective psychological treatments for
insomnia: a meta-analysis. Journal of Consulting and Clinical Psychology 63, 7989.
Rachman, S. (1980). Emotional processing. Behaviour Research and Therapy 18, 5160.
Sanavio, E. (1988). Pre-sleep cognitive intrusions and treatment of onset-insomnia. Behaviour Research
and Therapy 26, 451459.
Seidel, W. F., Ball, S., Cohen, S., Patterson, N., Yost, D., & Dement, W. C. (1984). Daytime alertness in
relation to mood, performance, and nocturnal sleep in chronic insomniacs and noncomplaining sleepers.
Sleep 7, 230258.
Spielman, A. J., & Glovinsky, P. B. (1991). Introduction. The varied nature of insomnia. In P. J. Hauri (ed.),
Case Studies in Insomnia. (pp. 118). New York: Plenum Medical.
VOL 29, NO 3-4, 2000 Analysis and treatment of insomnia 125
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
3
7

2
4

O
c
t
o
b
e
r

2
0
1
4

Spielman, A. J., Caruso, L. S., & Glovinsky, P. B. (1987). A behavioral perspective on isomnia treatment.
Psychiatric Clinics of North America 10, 541553.
Steinmarck, S. W., & Borkovec, T. D. (1974). Active and placebo treatment effects on moderate insomnia
under counterdemand and positive demand instructions. Journal of Abnormal Psychology 83, 157163.
Teasdale, J. D. (1999a). Emotional processing, three modes of mind and the prevention of relapse in
depresssion. Behaviour Research and Therapy 37, S53S77.
Teasdale, J. D. (1999b). Metacognition, mindfulness, and the modification of mood disorders. Clinical
Psychology and Psychotherapy 6, 146155.
Waters, W. F., Adams Jr, S. G., Binks, P., & Varnado, P. (1993). Attention, stress and negative emotion in
presistent sleep-onset and sleep-maintenance insomnia. Sleep 16, 128136.
Wells, A., & Davies, M. I. (1994). The thought control questionnaire: a measure if individual differences in
the control of unwanted thoughts. Behaviour Research and Therapy 32, 871878.
Woolfolk, R. L., & McNulty, T. F. (1983). Relaxation training for insomnia: a component analysis. Journal
of Consulting and Clinical Psychology 51, 495503.
126 Lundh SCAND J BEHAV THER
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
3
7

2
4

O
c
t
o
b
e
r

2
0
1
4