Acceptance and Commitment Therapy For Insomnia - A Session-By-Session Guide (Feb 22, 2024) - (3031507096) - (Springer) - Springer (2024)

Renatha El Rafihi-Ferreira Editor
Acceptance and
Commitment
Therapy
for Insomnia
A Session-By-Session Guide
Acceptance and Commitment Therapy
for Insomnia
Renatha El Rafihi-Ferreira
Editor
Acceptance and Commitment

Therapy for Insomnia
A Session-By-Session Guide
Editor
Department of Clinical Psychology
Universidade de São Paulo
São Paulo, São Paulo, Brazil
ISBN 978-3-031-50709-0 ISBN 978-3-031-50710-6 (eBook)

https://doi.org/10.1007/978-3-031-50710-6
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Foreword
Healthy sleep is an essential pillar of good mental and physical health. Chronic lack
of sleep or disturbed sleep is associated with multiple adverse health outcomes
including increased risks for depression, hypertension, and premature cognitive
impairments. Sleep problems also produce major consequences on occupational
health and increase both absenteeism and presenteeism at work, as well as increased
risks of accidents on the road and at work.
In this 24/7 society with constant pressure to perform and produce, it is no sur-
prise that insomnia is the most prevalent of all sleep disorders, affecting at least 10%
of adults on a chronic basis and another 20–30% occasionally. These prevalence
rates increased by at least twofold during the COVID-19 pandemic. Persistent
insomnia affects all segments of the population, including children, teenagers,
adults, and elderly people. It is especially prevalent among people with mental
health problems, particularly among those with mood and anxiety disorders, in
patients with medical problems such as chronic pain, and in individuals with atypi-
cal work schedules such as shift workers. Given its high prevalence and impact,
there is a definite need for effective insomnia therapies.
The most widely used and readily accessible treatment for insomnia is medica-
tion. Many people do not even seek professional help for this problem, but instead
go to their drug stores and buy all sorts of highly advertised over-the-counter prod-
ucts of unknown risks and benefits. When a patient sees a healthcare professional
for insomnia, usually a family doctor, a sleeping pill is often the only recommenda-
tion made to the patient, either because of lack of time or lack of knowledge about
other effective therapies for insomnia.
Cognitive behavioral therapy is now recognized by several professional and
sleep organizations around the world as the first-line therapy for insomnia. When a
patient has the great fortune to find a therapist with CBT-I expertise, this is like win-
ning a lottery. Indeed, there is now solid evidence that CBT-I is not only effective
for improving sleep, but it also produces clinically meaningful daytime benefits, and
may even prevent depression in at-risk individuals. Of course, not all patients with
chronic insomnia respond or remit with standard CBT-I, and there is a need for
alternative, evidence-based, therapies.
v
vi Foreword
Acceptance and Commitment Therapy for Insomnia: A Session-by-Session

Guide, by Renatha El Rafihi-Ferreira and colleagues, provides a welcome addition
to the insomnia treatment literature. ACT is part of the third-wave cognitive behav-
ioral therapies which has proven effective for several psychological problems. In
this book, Professor El Rafihi-Ferreira and her colleagues have very nicely crafted
ACT for patients with insomnia disorder. The book is well organized with a step-by-
step treatment protocol complemented by “real-world” case studies illustrating the
effective use of ACT in clinical practice. It provides a clear description of the theo-
retical framework of ACT, along with its key concept of psychological flexibility
and underlying processes of acceptance, cognitive “defusion”, and mindfulness, to
name a few. The book is also packed with clinically useful information about the
assessment and differential diagnosis of insomnia and a description of the more
standard behavioral and cognitive procedures for treating insomnia.
This treatment manual provides a novel approach that is likely to be a useful
guide for any clinicians working with patients who suffer from chronic insomnia,
either as the primary problem or comorbid with other mental or medical problems.
ACT can be used as a stand-alone treatment or it can be combined with the more
standard behavioral (stimulus control, sleep restriction, relaxation) and cognitive
procedures (cognitive restructuring). Acceptance and Commitment Therapy for
Insomnia is definitely a value-added, hands-on resource for any behavioral sleep
medicine specialist and psychotherapist working with insomnia patients.
Professor of Psychology and Canada Research Charles M. Morin

Chair in Behavioral Sleep Medicine
Université Laval,
Quebec City, QC, Canada
Preface
This book was written to prepare clinical psychologists for the growing demand for
effective insomnia treatment options. Within this context, the book addresses the
theoretical model of Acceptance and Commitment Therapy (ACT) for the treatment
of insomnia.
Insomnia is associated with numerous harms, a fact that reinforces the need for
evidence-based treatments, especially those that do not require the use of medica-
tions. Cognitive Behavioral Therapy for Insomnia (CBT-I) is the treatment of
choice; however, there are patients who have difficulties in adhering to some thera-
peutic components (stimulus control and sleep restriction), while others are refrac-
tory to this modality. Another important aspect is the plurality of individuals and
that not all of them identify with the same therapeutic approach; hence, more options
other than CBT-I are needed.
Recently, the application of ACT to treat insomnia has shown effective results
and may provide another approach to deal with the cognitive components involved
in sleep difficulties. ACT represents a change in the insomnia paradigm that could
improve the effectiveness of treatment because it does not focus exclusively on
sleep problems and symptom control, but also on the patient as a whole in an attempt
to enhance quality of life and psychological flexibility, reducing the severity of
insomnia. ACT can be applied in conjunction with behavioral therapy components
that are associated with better insomnia treatment outcomes, such as stimulus con-
trol and sleep restriction. This modality can also be applied as monotherapy in
patients who are resistant to behavioral components such as stimulus control and
bedtime restriction.
The primary goal of ACT is the development of psychological flexibility, which
can be achieved through the processes of acceptance, cognitive defusion, being
present, self as context, values, and committed action. This book on ACT is divided
into five parts, each consisting of three to five chapters.
The first part “Sleep and Insomnia” is dedicated to the understanding of normal
sleep, changes in sleep patterns throughout life, sleep architecture, sleep functions,
consequences of sleep deprivation, and the definition and classification of the differ-
ent subtypes of insomnia, all of them part of psychoeducation. This part also
vii
viii Preface
discusses comorbidities of insomnia, differential diagnoses, and hypnotic depen-

dence and withdrawal. The part is divided into five chapters: (1) Chapter 2: Sleep
and Its Functions; (2) Chapter 3: Effects of Sleep Deprivation; (3) Chapter 4:
Insomnia; (4) Chapter 5: Insomnia: Its Comorbidities and Differential Diagnosis,
and (5) Chapter 6: Hypnotic Dependence and Withdrawal.
The second part “Assessment of Insomnia” covers the assessment process of
insomnia. In this part, the initial interview, the use of retrospective measures for
patient assessment and the use of prospective measures for follow-up of the thera-
peutic process are discussed. The part is divided into three chapters: (1) Chapter 7:
Initial Interview in the Therapeutic Setting; (2) Chapter 8: Evaluation and
Retrospective Measurements, and (3) Chapter 9: The Role of Actigraphy and Sleep
Diaries in Assessing Sleep in Adults with Insomnia.
The third part “Behavioral Treatment for Insomnia” deals with behavioral treat-
ment options for insomnia and is divided into three chapters: (1) Chapter 10: Sleep
Hygiene; (2) Chapter 11: Stimulus Control Therapy for Insomnia, and (3) Chapter
12: Sleep Restriction.
The fourth part “ACT for Insomnia” explains the theoretical model of ACT and
the concept of psychological flexibility and its six processes (acceptance, cognitive
defusion, mindfulness, self as context, values, and committed action) and provides
a brief review of the evidence on ACT-based therapy for insomnia. A model of a
flexible ACT protocol for insomnia (ACT-I) using resources such as metaphors,
mindfulness exercises, and poetry is presented. The therapeutic processes of this
ACT protocol for insomnia are also discussed. The chapters that make up this part
are: (1) Chapter 13: Acceptance and Commitment Therapy; (2) Chapter 14:
Evidence of Acceptance and Commitment Therapy-Based Therapies for Insomnia;
(3) Chapter 15: A Session-by-Session Guide for Acceptance and Commitment
Therapy for Insomnia, and (4) Chapter 16: ACT Therapeutic Processes in the ACT-I
Protocol.
The fifth and last part of this book “Application of ACT-I and ACT-BBI-I” is
dedicated to examples of clinical cases in which the ACT protocol for insomnia was
applied in different modalities: group format, individual format, and use of behav-
ioral components for insomnia management. This part is divided into three chap-
ters: (1) Chapter 17: Case Example: Application of ACT-I in a Group Intervention;
(2) Chapter 18: Case Example: Application of ACT-I in an Individual Intervention,
and (3) Chapter 19: Case Example: Application of ACT-BBI-I in an Individual
Intervention.
São Paulo, Brazil Renatha El Rafihi-Ferreira

Contents
1 Introduction�� 1
Part I Sleep and Insomnia

2
Sleep and Its Functions�� 9
Andrea Cecilia Toscanini and Rosa Hasan
3
Effects of Sleep Deprivation�� 19
4 Insomnia�� 31
Israel Soares Pompeu de Sousa Brasil and
5
Insomnia: Its Comorbidities and Differential Diagnosis�� 43
Daniel Guilherme Suzuki Borges
6 Hypnotic Dependence and Withdrawal �� 51
Israel Soares Pompeu de Sousa Brasil and Rosa Hasan
Part II Assessment of Insomnia

7
Initial Interview in the Therapeutic Setting�� 71
Ila Marques Porto Linares and Renatha El Rafihi-Ferreira
8
Evaluation and Retrospective Measurements �� 81
Ila Marques Porto Linares and Marwin do Carmo
9 The Role of Actigraphy and Sleep Diaries in Assessing
Sleep in Adults with Insomnia�� 93
Maria Laura Nogueira Pires
ix
x Contents
Part III Behavioral Treatment for Insomnia

10 Sleep Hygiene �� 107
Renatha El Rafihi-Ferreira and Andrea Cecilia Toscanini
11
Stimulus Control Therapy for Insomnia�� 113
Maria Laura Nogueira Pires and Ksdy Maiara Moura Sousa
12 Sleep Restriction�� 119
Silvia Gonçalves Conway and Bárbara Araújo Conway
Part IV ACT for Insomnia

13 Acceptance and Commitment Therapy �� 139
Michaele Terena Saban-Bernauer and Roberta Kovac
14 Evidence of Acceptance and Commitment Therapy-Based
Therapies for Insomnia �� 147
Léo Paulos-Guarnieri, Ila Marques Porto Linares,
and Renatha El Rafihi-Ferreira
15 A Session-by-Session Guide for Acceptance and Commitment
Therapy for Insomnia�� 161
16
ACT Therapeutic Processes in the ACT-I Protocol�� 193
Part V Application of ACT-I and ACT-BBI-I

17
Case Example: Application of ACT-I in a Group Intervention �� 209
18 Case Example: Application of ACT-I in an Individual
Intervention�� 235
Ila Marques Porto Linares
19
Case Example: Application of ACT-BBI-I in an Individual
Intervention�� 247
Renatha El Rafihi-Ferreira and Ila Marques Porto Linares
Index�� 259
About the Authors
Daniel Guilherme Suzuki Borges Daniel G. Suzuki Borges is attending physician at Sleep
Group at Hospital of Clinics – University of Sao Paulo. Residency: Psychiatry University of Sao
Paulo – USP (2015), Sleep Medicine: University of Sao Paulo – USP (2016). MD University of
Sao Paulo – USP (2011). Certifications: Board Certification: Psychiatry, Brazilian Medical
Association (2016), Sleep Medicine, Brazilian Medical Association (2017).
Bárbara Araújo Conway Psychologist with expertise in Sleep Psychology. Master’s student in
the Graduate Program in Psychiatry at the Faculty of Medicine of the University of São Paulo
(FMUSP), with a scholarship from the State of São Paulo Research Foundation (FAPESP).
Volunteer psychologist at the Sleep Outpatient Clinic of the Institute of Psychiatry (ASONO) and
the Sleep Outpatient Clinic of the Division of Neurological Clinic, both at Hospital das Clínicas da
FMUSP (HCFMUSP).
Silvia Gonçalves Conway Clinical psychologist by Universidade de São Paulo (USP). Specialist
in non-pharmacological intervention for Post-Traumatic Stress Disorder and sleep disturbs.
Certified in Sleep Psychology by Associação Brasileira do Sono (ABS) and Sociedade Brasileira
de Psicologia. Master in Science by Universidade Federal de São Paulo (UNIFESP). Member of
the Sleep Department and coordinator of Sleep Psychology course at Instituto de Psiquiatria da
USP. Founding partner of AkasA – Formação & Conhecimento. Meditation practitioner and stu-
dent since 2002. Pathwork® facilitator. USP – University of São Paulo. Associação Brasileira do
Sono – Brazilian Sleep Association. Sociedade Brasileira de Psicologia – Brazilian Psychological
Society. Universidade Federal de São Paulo – Federal University of São Paulo. Instituto de
Psiquiatria da USP – Psychiatry Institute of Clinical Hospital from University of São Paulo.
Israel Soares Pompeu de Sousa Brasil Title of specialist in Neurology and Sleep Medicine by
the Brazilian Academy of Neurology/Brazilian Medical Association (ABN/AMB). Attending phy-
sician of the Neurology Residency Program at Instituto de Assistência Médica do Servidor Público
Estadual de São Paulo (IAMSPE), São Paulo-São Paulo, Brasil. Collaborating physician from the
sleep clinic at Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da
Universidade de São Paulo (IPq-HCFMUSP).
Marwin do Carmo Ph.D. student in Psychology at the University of California, Davis. MSc. in
Psychiatry at University of São Paulo (USP) – São Paulo, Brazil. Bachelor in Psychology at
Universidade do Estado do Rio de Janeiro (UERJ) – Rio de Janeiro, Brazil. mmcarmo@
ucdavis.edu.
xi
xii About the Authors
Renatha El Rafihi-Ferreira Professor at the Department of Clinical Psychology at the

Institute of Psychology at the University of São Paulo. Advisor at the Graduate Program in
Clinical Psychology at the University of São Paulo. Support from the FAPESP Young Researcher
Program (2018/19506-5) to conduct research on behavioral therapy for insomnia. Psychologist.
Master in Behavior Analysis from the State University of Londrina (UEL). PhD and Post-
Doctorate in Clinical Psychology from the University of São Paulo (USP). Certified in Sleep
Psychology by the Brazilian Association of Sleep and the Brazilian Society of Psychology.
[email protected].
Rosa Hasan MD, Neurologist and specialist in Sleep Medicine. Director of the Sleep Laboratory
and Sleep Outpatient Clinic at the Psychiatry Institute of the Hospital das Clínicas of the Medical
School of the University of São Paulo.
Roberta Kovac PhD in Clinical Psychology (USP) and Master in Experimental Psychology:
Behavior Analysis (PUC-SP). Academic Director, professor and advisor at Instituto Par Educação
(former Centro Paradigma de Ciências do Behavior). Coordinator of the research laboratory
RFTAC (Theory of Relational Frames applied to the clinic) also at Instituto Par. Member of the
Brazilian Association of Behavioral Sciences (ABPMC) and the Association for Contextual
Behavioral Sciences (ACBS). Past President of the ACBS Chapter – Brazil. He works mainly in
the clinical area, in contextual behavioral therapies and in teaching, training therapists and
researchers. Author of several articles and book chapters related to Behavior Analysis and
Contextual Behavioral Sciences.
Ila Marques Porto Linares Graduation in Psychology (UFSCar), Master in Neurology (USP),
PhD in Mental Health (USP), Pos Doctoral in progress (USP), Specialization in Clinical
Behavioural Analysis (Núcleo Paradigma), Certified in Sleep Psychology by the Brazilian Sleep
Association and the Brazilian Society of Psychology. Volunteer psychologist at the sleep outpa-
tient clinic at Instituto da Criança, Hospital das Clínicas, Faculty of Medicine, University of São
Paulo (HC-FMUSP).
Léo Paulos-Guarnieri PhD student in Psychiatry at the Faculty of Medicine of the University of
São Paulo (USP) – São Paulo, Brazil, with research support from the São Paulo State Research
Support Foundation (FAPESP) [grant #2023/06859-5]. Bachelor in Psychology at the Pontifical
Catholic University of São Paulo (PUC-SP) – São Paulo, Brazil.
Maria Laura Nogueira Pires Psychologist, Master in Psychobiology and PhD in Sciences from
the Departament of Psychobiology at Universidade Federal de São Paulo-Unifesp. FAPESP fund-
ing post-doctoral fellowship at the Sleep and Mood Disorders Laboratory at Oregon Health &
Science University (OHSU, USA). Board certified in sleep psychology by the Brazilian Sleep
Association-ABS and Brazilian Society of Psychology-SBP. Former professor of psychology at
public university (Universidade Estadual Paulista-Unesp), now work in private sector with sleep
psychology and actigraphy (LP Actigrafia & Sono). [email protected]
Michaele Terena Saban-Bernauer Master in Experimental Psychology and specialist in

Behavior Analysis, professor and coordinator of the ACT course at Hospital das Clínicas,
Faculty of Medicine, University of São Paulo. Author of the book “Introduction to Acceptance
and Commitment Therapy”, and co-author of the book “Third Generation Behavioral
Therapies”, “The Treatment of Chemical Dependence and Cognitive Behavioral Therapies”,
among others of the ACT Brazilian literature. Founding President of the Brazilian Association
About the Authors xiii
for Contextual Behavioral Science – ACBS Brasil, and was part of the founding board of the
ACBS Foundation.
Ksdy Maiara Moura Sousa Psychologist, specialists in Neuropsychology from the Neurological
Institute of São Paulo. Master and PhD in Sciences with an emphasis on Medicine and Sleep
Biology by the Department of Psychobiology at the Universidade Federal de São Paulo.
Pedagogical coordinator of the neuropsychology course at Nepsi MG, Sleep Psychologist certified
by the Associação Brasileira do Sono, researcher at the Universidade Federal de São Paulo.
Andrea Cecilia Toscanini Graduated in Biomedicine and Medicine, area of expertise “Sleep
Medicine”. PhD concluded in 2005 Medical School of University of São Paulo (FMUSP),
researcher since then in basic and clinical area. At the moment, works as a physician at the sleep
clinic at the Institute of Psychiatry at the Hospital das Clínicas at FMUSP. andrea.toscanini@
uol.com.br
Chapter 1
Introduction
1.1 Why to Use Acceptance and Commitment Therapy

for Insomnia?
Chronic insomnia is associated with clinical and psychiatric health problems and is
a burden on the healthcare system (Hargens et al., 2013; Hertenstein et al., 2019;
Laugsand et al., 2011). CBT-I is recognized as the treatment of choice for insomnia,
with several studies supporting its effectiveness (Riemann & Espie, 2018; Van
Straten et al., 2018). CBT-I is a directive and structured treatment that consists of
behavioral and cognitive techniques (Morin et al., 2006). The behavioral strategies,
which include sleep hygiene, stimulus control, sleep restriction, and relaxation,
focus on behaviors and habits that contribute to good sleep quality. The cognitive
therapeutic strategy is cognitive restructuring, which involves refuting and restruc-
turing dysfunctional beliefs about sleep (Harvey et al., 2014).
Although studies have reported positive results, CBT-I does not lead to remission
of insomnia disorder in 20–25% of patients with insomnia without comorbidities
(Morin et al., 2006) and in approximately 60% of patients with psychiatric or medi-
cal comorbidities (Wu et al., 2015). Furthermore, adherence to stimulus control and
sleep restriction techniques is difficult for many individuals (Harvey & Tang, 2003).
Considering that some individuals do not respond to traditional CBT-I approaches
and that adherence remains difficult for many individuals, a modified treatment may
be useful to enhance the effects of existing insomnia treatments and to improve
outcomes in a larger number of individuals. In addition, the effect sizes of CBT for
insomnia are less representative than for other psychological complaints (Harvey &
Tang, 2003). The combination of these factors justifies the need for new therapeutic
modalities for insomnia.
R. El Rafihi-Ferreira (*)
Department of Clinical Psychology, University of São Paulo, São Paulo, Brazil
e-mail: [email protected]
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 1

R. El Rafihi-Ferreira (ed.), Acceptance and Commitment Therapy for Insomnia,
https://doi.org/10.1007/978-3-031-50710-6_1
2 R. El Rafihi-Ferreira
The need for new therapeutic modalities is supported by the following factors:
(a) pre-sleep cognition is associated with insomnia and arousal; (b) thought sup-
pression strategies increase the levels of pre-sleep cognitive activity and arousal,
and (c) CBT-I primarily uses thought control strategies for the management of pre-
sleep cognitive activity. It is, therefore, plausible to argue that the reduced effect
sizes associated with CBT-I may be in part due to the use of thought control strate-
gies. Thus, interventions that do not focus on control, such as those using accep-
tance and mindfulness, may be able to effectively address pre-sleep cognition and
related arousal (Espie et al., 2006).
Within this context, over the last decades, third-wave behavioral therapies have
proposed a different approach to private events (thoughts and feelings). Unlike cog-
nitive therapy, which involves refuting beliefs and thought content, contextual ther-
apies focus on context and are more concerned with the function of a behavior
rather than modifying its content. Third-wave therapies include ACT, functional
analytic psychotherapy (FAP), dialectical behavior therapy (DBT), and mindfulness-
based therapies. Taylor et al. (2015) evaluated the effect of third-wave therapies for
insomnia and concluded that these therapies demonstrate efficacy and effectiveness
in treating insomnia, particularly mindfulness-based therapies. In the book
Mindfulness-Based Therapy for Insomnia Ong (2016) introduces mental health
practitioners to an evidence-based treatment: mindfulness-based therapy for insom-
nia (MBTI). Although third-wave therapies show some similarities, their theoretical
basis is different. This book focuses on ACT.
1.2 Acceptance and Commitment Therapy for Insomnia
ACT is a behavioral therapy based on functional contextualism, a philosophy that

seeks to predict behavior accurately and thoroughly, and on the relational frame
theory (RFT), an accurate and empirically sound post-Skinnerian assumption of
language and cognition (Barbosa & Murta, 2014). The central goal of ACT is the
development/enhancement of behavioral and psychological flexibility, that is, the
ability to contact the present moment more fully as a conscious human being and,
based on what the situation offers, to change or persist in behavior in order to serve
valued ends (Hayes et al., 2003). This therapeutic modality involves the clarification
of personal values and value-based action planning. As such, ACT links processes
of acceptance and mindfulness to processes of commitment and behavior change
(Hayes & Strosahl, 2004). Psychological flexibility is established through six core
ACT processes: acceptance, cognitive defusion, being present, self as context, val-
ues, and committed action (Luoma et al., 2007).
The six ACT processes are overlapping and interrelated, and their aim is to
develop psychological flexibility. The core principles of ACT can be applied to dif-
ferent problems and can be useful for treating insomnia, as many people with
insomnia have difficulty controlling their sleep problems since they struggle to fall
asleep (Dalrymple et al., 2010).
1 Introduction 3
Regarding control strategies for insomnia, Espie et al. (2006) point out that the
process of falling asleep is relatively automatic and can be inhibited by focused
attention and repeated attempts to fall asleep. The intense effort of trying to fall
asleep, as well as trying to control the insomnia, actually exacerbates and further
worsens sleep difficulties. According to Hayes et al. (2006), many strategies that
focus directly on solving the problems end up becoming the problem, that is, by
trying to control the symptoms, they become even more central, salient, and
influential.
According to Lundh (2005), the process of acceptance proposed by ACT can
reduce the effort to fall asleep, increasing acceptance of physiological and mental
arousal, in addition to the commitment proposed by this modality that includes the
planning of value-based actions. Espie et al. (2006) highlight that insomniacs often
place an exacerbated value on sleep problems and eventually leave aside other
aspects of their lives.
Considering this paradigm, a treatment that goes beyond the sleep complaint
may be an effective strategy (Hertenstein et al., 2014) since the focus shifts from
symptom control to acceptance of the feelings and thoughts associated with it
through value-based actions. ACT is thus an appropriate intervention for the treat-
ment of insomnia since it does not focus on a single symptom but on improving
overall quality of life (Hayes et al., 2012).
Within the context of insomnia, the clinician simultaneously addresses the pro-
cesses of acceptance, defusion, being present, and self as context through the use of
metaphors for mindfulness and meditation, in which the patient is invited to observe
his/her relationship with sleep (e.g., the fear of not being able to sleep, daytime
tiredness, thoughts like “my day will be ruined if I don’t sleep tonight,” “what will
happen if I can’t sleep”) without judgment in order to promote a posture of impartial
observer in relation to these experiences without changing their content. In parallel,
the patients’ values are explored in different domains (professional, personal, and
family, among others) and compared with their current choices in order to plan
actions based on values and not on avoidance of experiences. For example, by ques-
tioning their values, patients may discover that they are devoting little time to the
personal domain in order to avoid experiences of frustration and thereby increase
their workflow, which may compromise their quality of sleep and quality of life. In
an attempt to avoid pain, the individual often makes choices based on avoidance
rather than values. ACT applied to insomnia does not focus exclusively on the sleep
complaint but rather on the patient as a whole person and on the different domains
that encompass his/her experiences.
Studies using the ACT conceptual model for insomnia have reported favorable
results. A recent systematic review (Paulos-Guarnieri et al., 2022) on the level of
evidence and characteristics of interventions using ACT for insomnia indicated ben-
eficial effects on sleep and insomnia symptoms. ACT can be applied as monother-
apy (ACT-I) or in combination with the behavioral components of stimulus control
and sleep restriction (ACT-BBI-I). According to the authors of the review, ACT-
BBI-I can improve adherence to stimulus control and sleep restriction techniques
(Paulos-Guarnieri et al., 2022). In a randomized controlled trial, El Rafihi-Ferreira
et al. (2021) reported that ACT-BBI-I was as effective as CBT-I in treating patients
with chronic insomnia. In addition, the use of ACT-BBI-I increased sleep efficiency
and reduced sleep onset latency, nocturnal awakenings, and insomnia symptoms.
This modality also improved anxiety and psychological flexibility and reduced
sleep-related dysfunctional beliefs.
Studies investigating ACT as monotherapy for the treatment of insomnia are still
incipient. Recently, El Rafihi-Ferreira et al. (2022) compared the efficacy of ACT as
monotherapy and CBT-I for the treatment of insomnia. The results showed that both
treatment modalities significantly reduced the severity of insomnia. The proportion
of treatment responders was higher in the CBT-I group than in the ACT-I group
(64.7% versus 50.0%, respectively). Six months later, additional improvements
were observed in the ACT-I group, while there was a reduction in the treatment
response in the CBT-I group (58.8% versus 55.6%, respectively). The results sug-
gest a better short-term response for CBT-I, while the response to ACT-I is slower
but more sustained, with better long-term results. Since this was the first study com-
paring CBT-I versus ACT as monotherapy for insomnia, the results have important
clinical implications. Because many individuals have difficulty adhering to stimulus
control and sleep restriction, ACT-I may be a viable option for people resistant
to CBT-I.
Preliminary data from an ongoing randomized clinical trial (El Rafihi-Ferreira
et al.) have demonstrated favorable outcomes of ACT for insomnia, with a signifi-
cant reduction in insomnia severity and a parallel decrease in the scores assessing
depression, beliefs about sleep, and non-acceptance of sleep problems.
ACT represents a shift in the insomnia paradigm that can improve therapeutic
effectiveness because it does not focus exclusively on sleep problems and symptom
control, but also on the patient as a whole in an attempt to enhance quality of life
and psychological flexibility, reducing the severity of insomnia. ACT for insomnia
has beneficial effects on sleep and insomnia symptoms and can be applied in differ-
ent formats and with different intervention components. The use of ACT for insom-
nia can be divided into two categories: ACT-I (i.e., ACT as monotherapy for
insomnia) and ACT-BBI-I (i.e., ACT plus behavioral components of stimulus con-
trol and sleep restriction).
Although the empirical support for ACT-based interventions in treating insomnia
is not the same as that for established treatments (i.e., CBT-I), the former can serve
as an alternative treatment for insomnia and contribute to the building of a process-
based approach.
References
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1 Introduction 5
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Part I
Sleep and Insomnia
Chapter 2
Sleep and Its Functions
The classic definition of sleep is generally based on physiological characteristics

observed in mammals, including decrease in muscle activity, reduced response to
external stimuli, closed eyes, lower respiratory rates, typical body position and
characteristic brain wave architecture evaluated by polysomnography (Zielinski
et al., 2016) (see Table 2.1).
REM and NREM Sleep
Normal human sleep comprises two states: REM (Rapid Eye Movement) and
NREM (Non-Rapid Eye Movement) that cyclically alternate during a period of
sleep (Fig. 2.1), with the larger proportion of REM sleep occurring in the second
half of this period.
Sleep alterations are common as an individual ages, considering that sleep is a
dynamic state (Ohayon et al., 2004). Therefore, newborns have approximately 50%
REM sleep that reduces to 20–25% at 2 years old, maintaining this percentage
throughout adulthood, and possibly reducing again after age 60 (Lenehan et al.,
2023). Conversely, the opposite occurs with NREM sleep slow waves which are not
present at birth but appear during the first 2 years of life. These slow waves reduce
Sleep is the intermediate state between wakefulness and death;

wakefulness being regarded as the active state
of all the animal and intellectual functions,
and death as that of their total suspension (Macnish, R. (1830). The Philosophy of Sleep.
W. R. McPhun.).
A. C. Toscanini (*)
Institute of Psychiatry, School of Medicine, University of São Paulo, Sao Paulo, Brazil
e-mail: [email protected]; [email protected]
R. Hasan
Institute of Psychiatry, School of Medicine, Hospital das Clínicas, FMUSP, Sao Paulo, Brazil

10 A. C. Toscanini and R. Hasan
Table 2.1 Physiological characteristics of wakefulness, NREM and REM

Wakefulness NREM REM
Fine motor activity Decrease in motor activity Muscle atony
Open eyes Closed eyes Closed eyes (movement)
Response to environmental Reduced response to Reduced response to
stimuli environmental stimuli environmental stimuli
Varied body positon Typical body position Typical body position
Varied respiratory rates Regular respiratory rate Varied respiratory rates
Wakefulness
REM
REM
N1
NREM N2
N3
NREM
● ● ● ● ● ● ● ● ●
22h 23h 0h 1h 2h 3h 4h 5h 6h 7h
Fig. 2.1 Schematic progression of sleep stages across a single night
by around 40% during adolescence compared to previous years and continue to

reduce until old age, curiously, more so in men than in women.
Besides age and sex, other factors alter sleep in a predictable way, such as pre-
morbid sleep history, circadian rhythm, chronotype, temperature, environmental
conditions, medications, and other substances potentially being used, clinical or
psychiatric disorders, and other sleep disorders.
Sleep–Wakefulness Cycle Regulation
The two-process sleep–wakefulness cycle regulation, proposed tree decades ago,
postulate that are two different mechanisms: homeostatic and circadian acting in
opposition and synchronization throughout the 24-hour cycle (Borbély et al., 2016)
(Fig. 2.2).
The “S” process is expressed as sleep drive that exponentially increases during
wakefulness and abruptly decreases during sleep. During the increase in the “S”
process, there is an accumulation of sleep-promoting substances in the central ner-
vous system, such as adenosine, which would be eliminated during sleep. The “C”
or circadian process, on the other hand, involves 24-hour biological rhythms, self-
sustaining and synchronized with environmental cues (zeitgerbers) such as the
light-dark cycle, meals, physical activity, and social commitments. This process is
controlled by the circadian timing system located in the suprachiasmatic nucleus
(Achermann and Borbély, 2017).
2 Sleep and Its Functions 11
Fig. 2.2 The two-process sleep–wakefulness cycle regulation model. (Modified from Borbély
(1982) and from Daan et al. (1984))
Legend for Fig. 2.2: Sleep propensity, reflected by the homeostatic process S,
builds up during wakefulness and declines during sleep. The two thresholds (T1 and
T2) delimiting S are modulated by a circadian process (C). A circadian pacemaker
entrained by external Zeitgebers generates or synchronizes various physiological
circadian oscillations. The masking effect in this context is considered as the over-
ruling by external factors of the expression of the endogenous rhythm. Behavior or
more specifically the local use of brain centers as induced, for example, by a learn-
ing task might have an impact on the local sleep homeostatic drive (e.g., Huber
et al., 2004). External circumstances also affect the final output of these two pro-
cesses to define our specific sleep–wake behavior (Schmidt et al., 2007).
2.1 Sleep Functions
Humans spend roughly one-third of their lives sleeping, and other animals sleep even
more (Cirelli and Tononi, 2008). Despite how much time is spent in this offline state,
why we sleep remains a mystery. There are various candidate answers related to the
immune system, hormonal systems, thermoregulatory systems, and basic metabolic
processes, as sleep is essential for all these bodily functions. Although the entire
body benefits from sleep (Knutson et al., 2007), the most immediate, detrimental,
and unavoidable consequences of sleep loss impact the brain and the various cogni-
tive functions it supports (Zamore and Veasey, 2022). This insight has led some
researchers to conclude that “sleep is of the brain, by the brain, and for the brain.”
Far from the arduous task of dealing with all sleep functions, here we highlight
some important ones in the social context we live in and closely related to sleep
disorders that are highly prevalent in our population.
2.1.1 Central and Autonomic Regulation of Cardiovascular

and Respiratory Functions
Because of the close neurohumoral coupling between central structures and cardio-
respiratory function, a special coordination exists between heart rhythm, arterial
blood pressure, coronary artery blood flow, and ventilation. Sleep states exert a
major impact on cardiorespiratory function, and non-rapid eye movement (NREM)
sleep is associated with relative autonomic stability and functional coordination
between respiration, pumping action of the heart, and maintenance of arterial blood
pressure. During rapid eye movement (REM) sleep, surges in cardiac-bound sym-
pathetic and parasympathetic nerve activity provoke accelerations and pauses in
heart rhythm, respectively (Harper et al., 2012).
In general, the autonomic stability of NREM sleep, with hypotension, bradycar-
dia, and reduced cardiac output and systemic vascular resistance, provides a rela-
tively salutary neurohumoral background during which the heart has an opportunity
for metabolic restoration. REM sleep can disrupt cardiorespiratory homeostasis,
due to its characteristics explained above. Furthermore, accessory and upper airway
muscles diminish activity (REM atonia) while neurons serving the principal dia-
phragmatic respiratory muscles are spared the generalized inhibition. Cardiac effer-
ent vagus nerve tone generally is suppressed during REM sleep, and the highly
irregular breathing patterns can lead to lower oxygen levels (Mancia, 1993).
An important consideration in preserving circulatory homeostasis during sleep is
coordination of control over two systems: the respiratory system, essential for oxy-
gen exchange, and the cardiovascular system, for blood transport. The coordination
of two motor systems, one for somatic musculature and the other for autonomic
regulation is a unique task during sleep.
2.1.1.1 Immune System Regulation and Maintenance
Over the last 15 years, research following a system approach of neuroimmunology

has accumulated surprisingly strong evidence that sleep enhances immune defense,
in agreement with the popular wisdom that “sleep helps healing.”
Life is organized in rhythms. A multi-oscillatory system with cellular clocks in
many, if not all cells of the organism which are synchronized by a hypothalamic
pacemaker, the suprachiasmatic nuclei, regulates the circadian (∼24 h) rhythm of
body functions and behavior. The sleep–wake cycle can be regarded as the most
prominent manifestation of the circadian rhythm.
The nocturnal sleep period in humans is characterized by a profound downregu-

lation of the two stress systems, the hypothalamus–pituitary–adrenal (HPA) axis
and the sympathetic nervous system (SNS), with a concomitant drop in blood levels
of cortisol, epinephrine, and norepinephrine. In contrast, mediators serving cell
growth, differentiation, and restoration like the pituitary growth hormone (GH) and
prolactin and the pineal hormone: melatonin. This hormone shows a steep increase
in their blood levels during the night, when humans sleep (Haus, 2007; Reis et al.,
2011). In parallel, increases of leptin that is released by adipocytes are assumed to
prevent sleep-disturbing feelings of hunger during this time (Baccelli et al., 1969).
Despite their very different cellular sources, GH, prolactin, melatonin, and leptin
exert remarkably synergistic actions on the immune system. They are pro-
inflammatory signals that support immune cell activation, proliferation, differentia-
tion, and the production of pro-inflammatory cytokines like interleukin (IL)-1,
IL-12, tumor necrosis factor (TNF)-α, and of Th1 cytokines like interferon (IFN)-γ
(Hattori, 2009; Kelley et al., 2007; Radogna et al., 2010). In contrast, cortisol and
catecholamines generally suppress these immune functions in an anti-inflammatory
manner (Elenkov et al., 2008), although some specific aspects of immunity may be
supported by these signals.
On this background, numerous experiments have shown a consistent and intrigu-
ing pattern of endocrine and immune rhythms reflecting an “inflammatory peak”
during nocturnal sleep whereas wakefulness is associated with prevalent anti-
inflammatory activity (Lange et al., 2010; Scheff et al., 2010). In addition to the
effects of hormones and danger signals, immune rhythms are regulated by intrinsic
cellular clocks.
What triggers pro-inflammatory cytokine production throughout the body with
the beginning of the rest period? Neuroendocrine rhythms with the prevalent release
of pro-inflammatory hormones and a suppression of anti-inflammatory hormones
during the early SWS-rich portion in combination with endogenous and exogenous
danger signals throughout the active wake period and the intrinsic clock gene activ-
ity synergistically impact immune and nonimmune cells to boost immune activation
during the rest period. This pro-inflammatory function of sleep can be beneficial.
Thus, sleep after vaccination can enhance the subsequent adaptive immune
response like an adjuvant. How does sleep affect immunity during a genuinely
ongoing immune response? There are a few studies that investigated the effects of
sleep on the response to vaccinations used as an experimental model of infection.
Intriguingly, these studies consistently demonstrate that sleep enhances the adaptive
immune response against the invading antigen. Compared with subjects who stayed
awake during the night after a single vaccination against hepatitis A in the morning
before, subjects who regularly slept on this first night after vaccination, 4 weeks
later, displayed a twofold increase in antigen-specific antibody titres (Lange, 2003).
The proportion of pro-inflammatory and Th1 cytokine (IL-2, IFN-γ, TNF-α) pro-
ducing T cells was also profoundly reinforced by sleep. Importantly, these immuno-
enhancing effects of sleep were still present at a one-year follow-up, indicating that
sleep in enhancing the initial formation of an adaptive immune response also
supports the long-term maintenance of the antigenic memory, a function hallmark-

ing the immune system.
Collectively, these findings provide strong evidence for the notion that processes
of immune activation and proliferation involving pro-inflammatory signals, antigen-
presenting cells (APC), naïve and central memory T cells in lymph nodes are timed
to the resting period. The reason for this timing is not clear. However, inflammation,
if present during waking, causes malaise, fatigue, immobility, pain, and other
aspects of sickness behavior that are incompatible with the demands of mental and
physical activity required during the day.
Hence, confining major immunological response to sleep time seems reasonable
(Petrovsky, 2001). In addition, immune activation, especially protein synthesis and
cell proliferation, needs energy, and the endocrine changes during sleep allow for
the allocation of energy-rich fuels like glucose from insulin-dependent tissues (e.g.,
muscle) to the immune system (Straub et al., 2010). Finally, inflammation leads to
oxidative stress and cell injury that are efficiently counteracted by melatonin scav-
enging free radicals and by hematopoietic stem cells providing cellular supply.
These may be just some reasons favoring the sleep period as suitable time for initiat-
ing adaptive immune responses and associated pro-inflammatory activity.
2.2 Thermoregulation and Energy Conservation
Core body temperature (CBT) comprises the temperature of the brain and the
abdominal cavity, and is regulated between thermoeffector thresholds, which are
subject to circadian oscillations (Kräuchi, 2007). Circadian rhythms in mammals
are generated by the self-sustaining central pacemaker located in the suprachias-
matic nuclei (SCN) of the hypothalamus and are usually coupled to the 24-hour
solar day mainly synchronized by light (Moore and Danchenko, 2002).
The regulation of CBT results from the concerted action of the homeostatic and
circadian processes. In humans, the daily decline of CBT in the evening results from
a regulated decline in the thermoregulatory thresholds of heat production and heat
loss; the inverse happens in the morning.
Under resting conditions, about 70% of heat production depends on the meta-
bolic activity of inner organs, whereas body heat loss is initiated by heat redistribu-
tion from the core to the shell through blood flow to the distal skin regions (Kräuchi,
2007). Thermoregulatory distal skin blood flow is regulated by the autonomic ner-
vous system by constriction or dilation of arteriovenous anastomoses.
Nocturnal secretion of melatonin, which is under control of the SCN, plays a
crucial role in the endogenous downregulation of CBT in the evening. Administration
of melatonin in the afternoon, when endogenous melatonin levels are low, provokes
exactly the same thermophysiological effects, as observed naturally in the evening
(Kräuchi et al., 2006). Whether melatonin induces distal vasodilation in humans by
acting directly on blood vessel receptors, indirectly through modulation of sympa-
thetic nerve activity, or both, remains to be determined. In addition, both subjective
ratings of sleepiness and the level of activity in the electroencephalogram (EEG)

theta and alpha rhythms as an objective outcome of the sleep–wake state are
increased (Kräuchi et al., 2006).
Moreover, it is noteworthy that rise in melatonin secretion in the evening belongs
to a well-orchestrated circadian physiological regulation controlled by the SCN,
which in turn downregulates CBT, increases sleepiness, and promotes sleep. The
most evident explanation for whether and why the sleep regulatory and thermoregu-
latory systems are interrelated is that “sleep is for energy conservation” (Berger,
1984). All species sleep or rest when their energy expenditure is low. Rest or quiet
wakefulness is a prerequisite for sleep in all species.
2.3 Memory Processing
Humans can learn, store, and remember various types of information in different
ways and for variable periods of time, from conscious acquisition strategies to inci-
dental detection of environmental events.
Long-term memories in humans may further belong to multiple systems, primar-
ily delineated between declarative and nondeclarative memories. Declarative mem-
ory further comprises semantic and episodic memory components. Semantic
memory is the receptacle for our general knowledge about the world, regardless of
the spatiotemporal context of knowledge acquisition. Conversely, episodic memory
refers to the system that stores events and information along with their contextual
location in time and space. On the other hand, distinctive features of nondeclarative
memories are that they are not easily accessible to verbal description and can be
acquired and reexpressed implicitly. It means that our behavioral performance can
be affected by the new memory even if we are not necessarily consciously aware
that new information has been encoded or is retrieved.
Importantly, memory abilities aggregated under the nondeclarative label also
include skills, habits, priming, and conditioning.
Scientific evidence suggests two main models:
(a) Sleep and associated processes of brain plasticity (Maquet et al., 2003) are
major players in time-dependent processes of memory consolidation, acting as
key constituents in the chain of transformations that help integrate information
for the long term. According to the dual-process hypothesis, REM and NREM
sleep act differently on memory traces depending on the memory system or
process to which they belong.
(b) Memory processing during sleep takes place in a sequential manner whereby
particular transitions from one sleep state to another each handle particular
aspects of memory consolidation (Stickgold et al., 2000).
Both approaches assume that it is sleep on the first post-training night that is
important for memory consolidation. On the other hand, during wakefulness, pro-
cesses of memory consolidation have also been observed, and for this reason it is
inappropriate to claim that only sleep may achieve the necessary conditions to con-
solidate novel memories in the nervous system (Peigneux, 2006; Brown and
Robertson, 2007; Robertson et al., 2004).
In addition to the sleep functions mentioned here, the importance of sleep is pres-
ent in endocrine physiology (affecting activity of the hypothalamic-pituitary axes,
carbohydrate metabolism, appetite regulation, and the hormone control of blood
pressure and body-fluid balance), in motor and sensory processing, and in as many
as other systems as those that may appear in our organism. It should be remembered
that the most studied and didatic way to learn about the functions of sleep is simply
to verify the effects of its deprivation.
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Chapter 3
Effects of Sleep Deprivation
Sleep is a vital biological function, so its existence is conditioned to a series of

mechanisms inherent to life itself, its evolution and maintenance. The need to quan-
tify the necessary sleep time to keep our body functioning properly is the subject of
numerous studies and represents more than simply “hours of sleep” for adequate
physical and mental functioning, there is an important political and economic
impact directly and indirectly caused by sleep deprivation (Hafner et al., 2017).
The American Academy of Sleep Medicine (AASM) and the National Sleep
Foundation (NSF) recommend that school-age children should receive at least
10 hours of sleep daily while the minimum requirement for adults is 7–8 hours. The
reality, however, is that large proportions of the population are sleeping far less than
these recommended minimums. Population-based studies indicate that nearly 30%
of American adults report sleeping an average of six or fewer hours per night, while
69% of high school students report having an average of less than 8 hours of sleep
on school nights (CDC, 2009).
Previous research has shown that sleeping patterns are related to quality of life
(QoL) and that key aspects are the time when individuals sleep, sleep duration, and
sleep quality. People who obtain sufficient high-quality sleep at proper times were
found to have better general health and overall quality of life. By contrast, individu-
als who sleep too much or sleep poorly exhibit diminished quality of life (Kudrnáčová
& Kudrnáč, 2023).
In recent decades, studies have shown an important association between sleep
duration and mortality risk, finding the lowest risk among those individuals who
A. C. Toscanini (*)
Institute of Psychiatry, Faculty of Medicine, University of São Paulo, Sao Paulo, Brazil
R. Hasan
Institute of Psychiatry, Hospital das Clínicas, FMUSP, Sao Paulo, Brazil

sleep between 7 and 9 hours/night (Vgontzas et al., 2010). In the United States,
sleep deprivation is directly associated with 5 of the 15 leading causes of death
(Kochanek et al., 2014).
Sleep deprivation is a global and growing problem in modern society, largely
attributed to the 24/7 social pattern in which we live, where there are long working
hours and “virtually” 24 hours of wakefulness. Currently, the main cause of exces-
sive daytime sleepiness is chronic sleep deprivation. Studies around the world indi-
cate rates of 2.5–26% of the population with excessive daytime sleepiness (Hayley
et al., 2014; Bixler et al., 2005).
Insufficient sleep was reported by 23%, 12%, and 9% in representative surveys
from Japan, Sweden, and Finland, respectively. In 2008, the Centers for Disease
Control (CDC) examined data from over 400,000 subjects throughout the USA and
found that 11.1% reported that they had had insufficient rest or sleep every day dur-
ing the preceding 30 days (Ford et al., 2015).
Sleep deprivation may be a result of behavior which may range from a person’s
decision to restrict sleep time, even unconsciously, in pursuit of other activities or
consumption of stimulants such as coffee and tea close to bedtime. The disruption
of sleep cycles is commonly seen among shift workers and frequent business travel-
ers. The growing levels of stress and unrealistic targets and time pressures at work-
places have an adverse impact on sleep. Sleep deprivation is also becoming very
common among school-age children and adolescents as their schedules and demands
are preventing them from having sufficient sleep, although it is recommended these
groups should try to sleep more than adults (Chattu et al., 2018).
According to the International Classification of Sleep Disorders (ICSD),
“Insufficient sleep syndrome occurs when an individual persistently fails to obtain
the amount of sleep required to maintain normal levels of alertness and wakeful-
ness. The individual is chronically sleep deprived because of failure to achieve nec-
essary sleep time due to reduced time in bed.”
3.1 Consequences of Insufficient Sleep Syndrome (ISS)
In general, the most prevalent consequences of insufficient sleep (low performance,

cognitive changes, and drowsiness) are largely unrecognized and not valued, many
of them being confused with overworking, mood swings, tiredness, or even aging.
When it comes to children, this may present as low school performance, irritability,
and impairment of social activities (Kohyama et al., 2018).
ISS can lead to serious consequences for all the systems present in our organism,
affecting the physiological homeostasis in each one of them. However, cognitive
impairment, obesity, hypertension, and insulin resistance are the most pronounced,
a decrease in immune function and an increase in inflammatory markers are also
observed, in addition to the dysregulation of several hormones, including sexual and
thyroid axes (Table 3.1) (Aldabal & Bahammam, 2011).
3 Effects of Sleep Deprivation 21
Table 3.1 Summary of the major adverse effects of insufficient sleep

Complications Effects
Daytime sleepiness Inadvertently fall asleep during sedentary activities, such as
meetings, reading, watching television or movies, or while driving
and increased risk for motor vehicle accidents
Emotional disturbances Results in a more negative mood, with reduced optimism and
sociability
Complaints of pain were also observed
Worsens mood states in healthy adolescents, with females having
heightened vulnerability
Effects on functions of the Cognitive impairment, prefrontal cortex dysfunction, Novelty
brain detection, a mechanism that involves the frontal lobes, gets
negatively affected
Memory disorders
Effects on the structure of Reduction of cells in the dentate gyrus of the hippocampus
the brain Structural changes in the cortical neurons
Degeneration of locus ceruleus neurons
Effects on body weight Weight gain during insufficient sleep reverses when normal sleep
is resumed
Decrease of appetite-suppressing hormone leptin while levels of
ghrelin, a hunger
Glucose metabolism Glucose tolerance test shows a pre-diabetic state in otherwise
normal persons
Changes in insulin sensitivity and body weight
Increased insulin resistance in diabetes
Cardiovascular system Hypertension, arrhythmia, oxidative stress, endothelial
dysfunction, inflammation, and metabolic disorder in coronary
heart disease patients
Coronary heart disease
Reproductive system Impairment of sperm health
Genes linked with immune Fraternal twins have shown that resiliency and vulnerability to
and inflammatory processes sleep loss are highly heritable
Variant in the ABCC9 gene that explains approximately 5% of the
variation in sleep duration
Genetic polymorphisms related to orexin signaling are important
for predicting an individual’s vulnerability to overeating and
gaining weight when sleep deprived
Circardian rhythms Reduction in circardian transcripts in whole blood
Immune system, Decrease antibody production following influenza vaccination
inflammation, and infection Dampened the normal circadian T-cell function and regulation
Associated with a 1.39 relative risk of developing pneumonia
Alterations in interleukin 6 and tumor necrosis factor alpha
Leading to cardiovascular disease, insulin resistance, and
osteoporosis
Table 3.1 shows a summary of the major adverse effects of insufficient sleep
(Chattu et al., 2018).
Depending upon chronicity and extent of sleep loss, individuals with this condi-
tion may show irritability, concentration and attention deficits, reduced vigilance,
distractibility, reduced motivation, anergia, dysphoria, fatigue, restlessness, lack of

coordination, and malaise. Secondary symptoms may become the focus of the
patient, serving to obscure the primary cause of the difficulties. Psychologically and
somatically normal individuals who chronically obtain less sleep than they physio-
logically require typically experience daytime sleepiness. Situational factors such
as demands of the family and work schedule may make it very difficult to obtain
adequate sleep (Sateia, 2014).
In humans, sleep is responsible for orchestrating our metabolism during a third
of our lives. For this reason, it would be impossible to cite “all” the consequences of
its deprivation, but it is certainly possible to group some of them. Thus, in a didactic
and modest way, there are three groups of alterations frequently found in sleep-
deprived patients:
1. Mental health impairment: cognition and mood.
2. Metabolic alterations.
3. Immune function and inflammatory response modifications.
3.1.1 Mental Health Impairment: Cognition and Mood
Sleep deprivation (SD) is one of the reasons for the etiopathogenesis of various
neurological disorders, and it impairs long-term potentiation and brain-derived neu-
rotrophic factors and is linked to dementia and cognitive decline (Bishir et al.,
2020). SD also causes accumulation or misfolding of proteins and its role in neuro-
degenerative diseases like Alzheimer’s Disease (Wang & Holtzman, 2020),
Parkinson’s Disease (Dong et al., 2019), and cerebral stroke (Novati et al., 2011) is
well documented. SD is associated with an imbalance in the immune axis leading to
increased release of cytokines, autoimmune diseases (multiple sclerosis) (Kaminska
et al., 2011), and glioma (Lee et al., 2004). In summary, it is apparent that SD plays
a role in adversely modulating several key proteins and cellular/molecular cascades
in various neurological disorders (Table 3.2). Based on the data gathered from lit-
erature and clinical studies on SD, it is apparent that the impact is enormous and
profound and needs urgent attention.
In the field of psychiatry, it is believed that most psychiatric disorders can be
aggravated, if not precipitated, by sleep deprivation, and we have to remember that
in addition to traditional sleep deprivation (the imposition of a routine that provides
fewer hours of sleep), there are unwanted conditions that also reduce total sleep
time, such as insomnia, and lead to the same consequences as sleep deprivation itself.
Anxiety disorders are commonly seen in primary care settings where patient
complaints of sleep problems are often prominent.1 Sleep disturbances are included
among the diagnostic features of generalized anxiety disorder (GAD), separation
1
Sleep difficulties and sleep deprivation can lead to worsening of anxiety symptoms, including
panic attacks, in patients with panic disorder.
Table 3.2 Sleep deprivation and neurological disorders associated

References
Alzheimer’s disease (AD) Wang and Holtzman, Neuropsychopharmacology 2020
Ramanathan et al., Frontiers in aging neuroscience 2015
Lucey et al., Neurology 2018
Parkinson’s disease (PD) Currie et al., Neurology 1997
Dong et al., Frontiers in neuroscience 2019
Multiple sclerosis (MS) Rudick and Goelz, Experimental cell research 2011
Papantoniou et al., Occup and environmental medicine 2019
Chalah and Ayache, J of inflammation research 2018
Stroke Baumann et al., Sleep 2006
Gao et al., Sleep 2010
Huntingtons’s disease (HD) Essa et al., Neurotoxicity research 2019
Herzog-Krzywoszanska and L. Krzywoszanska, Frontiers in
psychiatry 2019.
Learning and cognition McDermott et all, The J of neurosciences 2003
impairment Hagewoud et al., J sleep research 2010
Epilepsy M. Steriade, Trends in neurosciences 2005
Lanigar and Bandyopaghyay, Missouri medicine 2017
Staniszewska et al., Neuropsychitric disease 2017
Glioma Hardeland and Pandi-Perumal, Nutrition and metabolism 2005
Jung and Ahmad, Cancer research 2006
Bieganska et al., J of molecular neuroscience 2012
Autism spectrum disorders Buckley et al., Archieves of pediatrics 2010
(ASD) National Sleep Foundation, 2019
Neuropathic pain Kundermann et al., Pain research and management 2004
Onen et al., Brain research 2001
Murk et al., Neuropsychobiology 2002
anxiety disorder, and post-traumatic stress disorder (PTSD). Polisomnography stud-

ies of anxiety disorders indicate that there are abnormalities in initiating and main-
taining sleep and in sleep stage distribution. Sleep difficulties and sleep deprivation
can lead to worsening of anxiety symptoms, including panic attacks, in patients with
panic disorder (Roy-Byrne et al., 1986).
Mood disorders are the second-most common category of psychiatric disorders
after anxiety disorders (Kessler et al., 2005). Subjective sleep complaints are some
of the most consistent symptoms associated with major depression. Disruption of
typical sleep patterns (insomnia or hypersomnia) is a diagnostic criterion for depres-
sive episodes in the Diagnostic and Statistical Manual of Mental Disorders (DSM5)
(Kessler et al., 2005). Sleep has been studied more extensively in patients with
depression than in those with any other psychiatric disorder, and in addition to the
subjective reports, objective, robust, and relatively specific changes in sleep archi-
tecture have been identified as correlates with the underlying neurobiology of
depression. On the other hand, sleep deprivation, alone or in combination with phar-
macological treatment, and as part of a chronotherapy package, is potentially used
for people with major depressive episodes; however, the evidence base is still con-
flicting (Mitter et al., 2022).
A range of sleep and circadian disturbances are prominent features of bipolar

disorder. Sleep disturbance persists during the interepisode period; up to 70% of
adults with bipolar disorder report clinically significant sleep disturbance between
episodes (Harvey et al., 2005). There is also evidence that sleep disturbance can
precede the onset of the disorder by several years. Sleep disturbances during mood
episodes and interepisode periods of bipolar disorder may include insomnia, hyper-
somnia, reduced sleep need, delayed sleep phase, and irregular sleep patterns. More
specifically, insomnia is highly prevalent in bipolar disorder. As many as 100% of
people with bipolar disorder report experiencing insomnia while depressed
(Nofzinger et al., 1991), and 55% report having insomnia during the interepisode
period. Reduced need for sleep is often exhibited during mania and mixed episodes
and is characterized by a decrease in total sleep time. Furthermore, people with
bipolar disorder are more likely to report circadian dysfunction, such as a delayed
sleep phase preference, compared with healthy individuals. All these conditions
converge in a decrease in total sleep time, and literature does not clarify the cause-
consequence relationship clearly.
Up to 70% of children with ADHD have been reported to have mild to severe
“sleep problems” (Sung et al., 2008). In terms of adult ADHD, there are no epide-
miologic studies that investigate subjective sleep complaints, but sleep disturbances
are also considered to be common in adults with ADHD (Philipsen et al., 2006). The
most recent meta-analysis on sleep disturbances in ADHD, which focused on chil-
dren and adolescents (Cortese et al., 2009), found significantly more sleep problems
in children with ADHD than in healthy controls without ADHD based on subjec-
tively rated sleep items, including bedtime resistance, sleep-onset difficulties, night
awakenings, difficulties with morning awakenings, sleep-disordered breathing, and
daytime sleepiness and, compared with controls, children with ADHD had less total
sleep time based on actigraphy.
3.1.2 Metabolic Alterations
Metabolism is defined as the whole range of biochemical processes that occur

within a living organism. It constitutes the two processes of anabolism (build up)
and catabolism (break down). It is believed that during normal sleep, the metabolic
rate reduces by around 15% and reaches a minimum in the morning in a standard
circadian pattern (Goldberg, 1988). Although impact of sleep on glucose regulation
has been known and studied for some time, metabolic dysregulation with sleep loss
has only recently been understood. Studies done by Hampton et al. revealed that
when subjects were made to simulate shift work, it resulted in alterations in post-
prandial glucose and lipid metabolism (Hampton et al., 1996).
The mechanism of sleep deprivation causing metabolic dysregulation may be
multifactorial. Changes in hormonal secretion profile as discussed above may have
profound effect on glucose regulation (Scheen et al., 1996). Sympathetic stimula-
tion has been shown to occur with sleep deprivation (Vgontzas et al., 2004) and
might contribute to the metabolic dysregulation. The third possible mechanism is

inflammation. Experimental sleep deprivation has been found to alter immune
response and increase proinflammatory markers such as IL-6, TNF-α, and PCR
(Meier-Ewert et al., 2004).
Epidemiological data increasingly suggests that short sleep duration or chronic
partial sleep deprivation may increase the risk of type II diabetes. A Swedish study
with more than 2000 people followed for over 10 years revealed that short duration
of sleep (<5 hours) and difficulty in initiating and maintaining sleep were associated
with higher incidence of diabetes in men (but not in women) even after adjusting for
confounding factors (Mallon et al., 2005). In another study by Yaggi and colleagues,
a large cohort of men without diabetes at baseline was followed for more than
15 years in a longitudinal study. Subjects who self-reported less than 6 hours of
sleep were twice as likely to develop diabetes (Yaggi et al., 2006). Although epide-
miological studies do not establish causality, these studies are consistent with the
physiological data discussed earlier.
More than two dozen epidemiological studies from around the globe looking at
sleep deprivation and BMI in humans have shown association between decreased
obesity and an increase in sleep duration. These studies, however, do not establish a
causal relationship. Few studies revealed a U-shaped curve with lowest mean BMI
associated with 7.7 hours/night (Taheri et al., 2004; Cournot et al., 2004). Apart
from cross-sectional studies, there have been around nine prospective/longitudinal
studies in adults and children, eight of which have shown similar findings of sleep
deprivation and a higher prevalence of obesity (Patel et al., 2006; Lumeng et al.,
2007). Epidemiological data is suggestive of weight gain with sleep deprivation
though a few studies have also noted weight gain with prolonged sleep. Based on
data on sleep duration and weight, sleep hygiene counseling could form an impor-
tant tool in management of obesity (Sharma and Kavuru, 2010).
Mechanistically, sleep and circadian rhythm exert considerable influences on
hormones involved in appetite regulation and energy metabolism. As such, data
from experimental sleep deprivation in humans demonstrate that insufficient sleep
induces a positive energy balance with resultant weight gain, due to increased
energy intake that far exceeds the additional energy expenditure of nocturnal wake-
fulness, and adversely impacts glucose metabolism (Duan et al., 2023).
3.1.3 Immune Function and Inflammatory Response
The role that sleep plays in the maintenance and function of the immune system has
not been completely elucidated. Some studies have shown that sleep deprivation can
have important effects on immune function, levels of cytokines, and inflammation
markers, also decreasing the function of NK cells, T lymphocytes, and monocytes.
This is consistent with evidence accumulated in recent years, which show that sleep
increases defense immunity by several mechanisms, among others, the increase in
Fig. 3.1 Main cytokines and hormones presented and regulated during normal sleep. In orange
boxes those that increase during sleep, and in green boxes those that decrease. (Adapted from
Rico-Rosillo and Vega-Robledo, 2018)
immunological memory and the proinflammatory, and activating functions that

develop during this time (Fig. 3.1) (Rico-Rosillo and Vega-Robledo, 2018).
Repeated partial sleep deprivation for several days produces an increase in the
production of C-reactive protein (PCR) (Grandner et al., 2013), IL-6 (Ferrie et al.,
2013), TNF (Chennaoui et al., 2011), and IL-1β (Frey et al., 2007), which persists
even after a full night’s sleep recovery. These molecules activate NF-κB, the key
transcriptional control pathway in the inflammatory signaling cascade. Sleep distur-
bance, possibly through effects on inflammation, may contribute to the development
of chronic inflammatory diseases (Kinucan et al., 2013). Studies carried out on
people who sleep less than 5 hours show that they have a greater risk of presenting
cardiovascular events (Sabanayagam et al., 2011), with a linear relationship between
the duration of sleep and the possible risks (Chien et al., 2010). They suggest that
the duration of optimal sleep is between 7 and 8 hours.
In addition to the alterations exposed here, there are certainly other physical and
mental conditions modulated by sleep deprivation. However, besides the impact on
health, it is necessary to remember the economic and social impact that sleep depri-
vation entails, considering that it is the most prevalent sleep disorder in the world.
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Chapter 4
Insomnia
Israel Soares Pompeu de Sousa Brasil and Renatha El Rafihi-Ferreira
4.1 Insomnia: A Multiple Condition
Insomnia is the most common sleep disorder in the general population (Schutte-
Rodin et al., 2008). But what are we talking about exactly: The complaint? The
symptom? Or the disorder? Do these phenomena refer to the same patient profile or
do their characteristics lead to differences in terms of evolution and prognosis?
Hence, one of the main challenges involving insomnia today is how to delineate
universal concepts for such a multifaceted condition.
Nosologically, insomnia has been included in more and more categories over
time. It can be evaluated as a symptom (when it is part of the presentation of other
diseases, for example, major depression), as a disorder (when it becomes a syn-
dromic condition with its own course and prognosis), or even denominating dis-
eases such as fatal familial insomnia (Poon et al., 2021). Despite so many features,
it is as a disorder that insomnia demonstrates all its strength; the investigation of
insomnia disorder facilitates the understanding of its pathophysiology and repercus-
sions on the patient’s life and it is, therefore, the chosen condition in studies on
insomnia. Within this context, insomnia disorder is defined as a persistent difficulty
with sleep initiation, duration, consolidation, or quality that occurs despite favor-
able circumstances and opportunities to fall asleep, resulting in daytime impair-
ments (American Academy of Sleep Medicine, 2014). Its chronic and recurrent
nature is one of the characteristics that reinforce the concept of a disorder within the
insomnia spectrum.
I. S. P. de Sousa Brasil (*)

Institute of Medical Assistance to State Civil Servants of São Paulo (IAMSPE),
São Paulo, Brazil
R. El Rafihi-Ferreira

32 I. S. P. de Sousa Brasil and R. El Rafihi-Ferreira
Previous versions of the International Classification of Sleep Disorders (ICSD)

distinguished between primary (and its subtypes: psychophysiological, idiopathic,
associated with inadequate sleep hygiene, and paradoxical) and secondary insomnia
(when associated with a comorbidity). The current version of the ICSD no longer
differentiates the different types of insomnia and combines all of them in a single
entity—the aforementioned insomnia disorder. In addition to reflecting observa-
tions made in clinical practice, that is, patients hardly fit into a single category, this
apparent simplification also reinforces the importance of the syndromic diagnosis of
insomnia as an entity that requires specific assessment and treatment. Nevertheless,
remembering these subdivisions can be useful in the etiological investigation of
insomnia (Hasan & Brasil, 2019).
Assessing the course of a patient’s complaint of sleep difficulty can be the key to
determining not only the classification of insomnia as a symptom or disorder but
also the clinical and environmental factors that explain its occurrence. It is not rare
that the conversion of a symptom into insomnia disorder occurs along a continuum
that involves the outbreak of a precipitating factor and the progressive development
of poor habits and dysfunctional beliefs about sleep that will perpetuate the disrup-
tion promoted by that factor, as proposed by Spielman’s theoretical model (Spielman
et al., 1987). At this point, the focus of attention of insomnia is no longer the altera-
tion that caused the sleep difficulty (e.g., pain, anguish, or dyspnea) but sleep itself,
which is intrinsically unstructured in the patient’s view (Espie et al., 2006). This
degeneration process may not necessarily last 3 months, the interval suggested by
the diagnostic criteria for insomnia disorder (see below), but much less; the patient
may already require a more robust therapeutic approach within a few weeks, as
recommended for cases of the disorder (Perlis et al., 2022).
The above considerations highlight the complexity of insomnia whose manifes-
tation is specific for each patient. The full understanding of this condition requires
the specialist to consider temporal, emotional, cognitive, and environmental factors
of the insomnia patient, which form the basis of a more assertive and effective
treatment.
4.2 Epidemiological Characteristics
Both clinical practice and research confirm that insomnia is the most common sleep
disorder in the population. However, a more precise epidemiological notion of this
problem is still difficult to obtain because of the already-mentioned nosological
variability of the condition (Poon et al., 2021). More detailed studies indicate a
global prevalence of 30% to 35% of insomnia symptoms and of 3.9% to 22.1% of
4 Insomnia 33
insomnia disorder (American Academy of Sleep Medicine, 2014). The annual inci-
dence can reach 7–15% (Morphy et al., 2007). Unlike initiating sleep and early
morning awakening, the difficulty staying asleep seems to be the most common
complaint among individuals with insomnia, as demonstrated by an European group
(Ohayon & Reynolds, 2009).
Complaints of insomnia are more common among women and older adults,
especially when accompanied by other medical and psychiatric comorbidities or by
substance/medication use. Female predominance is reflected by a female/male ratio
of 1.4 for insomnia symptoms and of 2.0 for insomnia disorder (Singareddy et al.,
2012); hormonal and psychosocial factors are usually related to this female pre-
dominance (Johnson et al., 2006). The higher prevalence in older age groups can be
explained by the greater sleep fragmentation found in this population and by the
higher frequency of comorbidities and medication use (Ohayon et al., 2004).
The environmental dimension of insomnia is illustrated by the higher prevalence
of cases in lower socioeconomic strata, among retired and unemployed individuals,
and among widowers and divorced/separated individuals. This scenario also reflects
the impact of the association with psychiatric disorders such as anxiety and depres-
sion. Mental health is so intrinsically linked to sleep that it is not surprising that
depressive and anxiety disorders are the most common comorbidities in patients
with insomnia; these disorders maintain a bidirectional relationship of cause and
consequence, influencing both the development and the prognosis of each condition
(Hertenstein et al., 2018).
4.3 Diagnostic Criteria
Defining a clinical entity based on diagnostic criteria must consider fundamental

features of the disease that differentiate it from other diseases and, at the same time,
are sensitive so that the condition does not pass unrecognized. This definition is
especially difficult in the case of insomnia, given its aforementioned nosological
multiplicity. It is no coincidence that such criteria have changed over the years and
should continue to change as new perspectives emerge.
The Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fifth
edition, was the first manual that combined all insomnia variants in a single diagno-
sis, that is, insomnia disorder (American Psychiatric Association, 2013). It can be
further divided into different types according to specifications associated with
comorbidities (psychiatric condition, clinical comorbidity, other sleep disorder) and
course (episodic: 1 to 3 months; persistent: more than 3 months; recurrent: 2 or
more episodes per year). The criteria of the DSM-V are given in Box 4.1.
Box 4.1: Criteria of the DSM-V

A. Dissatisfaction with sleep quantity or quality, associated with one (or
more) of the following symptoms:
1. Difficulty initiating sleep.
2. Difficulty maintaining sleep, characterized by frequent awakenings or
problems returning to sleep after awakenings.
3. Early morning awakening with difficulty returning to sleep.
B. The sleep disturbance causes clinically significant impairment in social,
occupational, educational, academic, and behavioral functioning or any
other important area.
C. The sleep difficulty occurs at least three nights per week.
D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. Insomnia is not better explained by or does not occur exclusively during
the course of another sleep disorder (narcolepsy, breathing-related sleep
disorder, circadian rhythm disorder, parasomnia).
G. Insomnia is not attributable to the physiological effects of a substance
(e.g., a drug of abuse and a medication).
H. A mental disorder or medical condition does not adequately explain the
predominant complaint of insomnia.
The third edition of the ICSD (ICSD-3), published in 2014 and revised in 2023
(ICSD-3R), followed the pattern established by the DSM-V and also proposed a
single diagnosis of chronic insomnia disorder (American Academy of Sleep
Medicine, 2014). This manual also mentions other varieties based on time course
(short-term; other insomnia disorder). It is worth mentioning that criteria for behav-
ioral insomnia of childhood have also been incorporated into the classification of
insomnia disorder. The complaint of “non-restorative sleep” was eliminated as a
diagnostic criterion from both the DSM-V and the ICSD-3R because of its subjec-
tive nature, the lack of specificity (much more frequent attribution to other diseases
such as sleep apnea and fibromyalgia), and the lack of association with more objec-
tive markers. The criteria of the ICSD-3R are given in Box 4.2.
4 Insomnia 35
Box 4.2: Criteria of the ICSD-3

Criteria A–F must be present:
A. The patient reports, or caregivers observe, one or more of the following
characteristics:
1. Difficulty initiating sleep.
2. Difficulty maintaining sleep.
3. Waking up earlier than desired.
4. Resistance to going to bed on appropriate schedule.
5. Difficulty falling asleep without parent or caregiver intervention.
B. The patient reports, or caregivers observe, one or more of the following
difficulties related to nighttime sleep:
1. Fatigue/malaise.
2. Attention, concentration, or memory impairment.
3. Impaired social, family, occupation, or academic performance.
4. Mood disturbance/irritability.
5. Daytime sleepiness.
6. Behavioral problems (e.g., hyperactivity, impulsivity, aggression).
7. Reduced motivation/energy/initiative.
8. Proneness for errors/accidents.
9. Concerns about or dissatisfaction with sleep.
C. The reported sleep/wake complaints cannot be explained by inadequate
opportunity (i.e., enough time is allotted for sleep) or inadequate circum-
stances (i.e., the environment is safe, dark, quiet, and comfortable)
for sleep.
D. The sleep disturbance and associated daytime symptoms occur at least
three times per week.
E. The sleep disturbance and associated daytime symptoms have been pres-
ent for at least 3 months.
F. The sleep disturbance and associated daytime symptoms are not solely
due to another current sleep disorder, medical disorder, mental disorder,
or medication/substance use.
The latest version of the International Classification of Diseases (ICD-11), which

came into effect in 2022, also follows the precepts determined by the aforementioned
manuals, with codes for three modalities: chronic insomnia disorder, short-term
insomnia disorder, and insomnia disorders, unspecified (World Health Organization,
2018). This classification also allows characterization based on their severity, with
codes for mild, moderate, and severe insomnia. Although the ICD-11 determines the
threshold of 3 months for characterizing chronic insomnia, it does not specify a mini-
mum frequency of symptoms per week (as occurs in the other manuals).
4.4 Etiological Factors of Insomnia
Insomnia is often explained from different pathophysiological perspectives, reflect-

ing its multifaceted nature. When understood as a sleep continuity disorder linked
to psychological, cognitive, and functional repercussions, insomnia may be consid-
ered to involve different mechanisms in different contexts.
From an anatomophysiological point of view, it is still difficult to specify how
insomnia emerges. The hypervigilant state, a phenomenon considered to be the
underlying clinical condition of patients with insomnia, has been illustrated by sev-
eral studies, which indicate possible mechanisms for this pattern: hyperactivation of
the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system, dys-
function of homeostatic sleep regulatory mechanisms, and circadian alterations
associated with the sleep-wake cycle, among others (Coelho & Rizzo, 2019).
Recently, polymorphisms in genes related to stress reactivity and neuronal excit-
ability that could be linked to insomnia disorder have been described (Ban et al.,
2011; Jansen et al., 2019). Nevertheless, none of these findings fully explains the
entire cascade involved in the genesis of insomnia, nor do they help to effectively
understand the development of the disease in each patient.
Theoretical models have been developed in recent decades in an attempt to
explain key points in the course of insomnia that could contribute to the investiga-
tion and treatment of patients. These models are much more useful and didactic than
previous ones in the clinical approach to insomnia. The behavioral model proposed
by Spielman and collaborators (1987) is the oldest, most articulated, and most cited
regarding the etiology of chronic insomnia. Also known as the 3P model, it postu-
lates that predisposing, precipitating, and perpetuating factors are involved in the
genesis of insomnia (Conway et al., 2019).
Predisposing factors refer to factors that increase vulnerability to developing
insomnia, such as old age, female gender, an irregular sleep–wake cycle, a hyperalert
condition, a personal and/or family history of insomnia, and the presence of psychi-
atric comorbidities (anxiety and/or depression) (Rafihi-Ferreira & Soares, 2012;
Spielman et al., 1987). Insomnia is commonly precipitated by stressful events, for
example, the diagnosis of an illness, unemployment, divorce, interpersonal con-
flicts, difficulties at work, and financial losses. These factors contribute to the devel-
opment of short-term insomnia (Conway et al., 2019; Spielman et al., 1987). The
factors that perpetuate insomnia are related to behaviors that prolong the duration of
this condition. Spending excessive time in bed and taking daytime naps can lead to
an irregular sleep–wake cycle. Furthermore, if the bed or the room becomes a place
for carrying out daily activities like studying, working, eating, watching TV, or
using cell phones, tablets and notebooks, the reflex conditioning involving bed-
relaxation-sleep will be broken. In addition to inadequate behaviors for good quality
sleep, patients may have erroneous and dysfunctional beliefs regarding sleep (“if I
don’t sleep 8 hours per night, I will have countless damages to my health”; “if I
don’t sleep well tonight, I won’t be able to study tomorrow”; “my insomnia is the
4 Insomnia 37
result of some chemical dysfunction”). These beliefs function as mediators of

insomnia, contributing to its perpetuation (Graci, 2005; Paltiel & Greenwald, 2008).
In general, a set of factors is associated with the development of insomnia. The
constant interaction between biological, behavioral, and environmental factors of
the individual must be considered to understand the etiology of insomnia (Rafihi-
Ferreira & Soares, 2012). Within this context, predisposing, precipitating, and per-
petuating factors can interfere with the homeostatic process and increase arousal
and alertness, resulting in insomnia (Berger, 2009).
4.5 Clinical Presentation
Clinical manifestations can be as varied as the factors that modulate the presentation
of insomnia, so that each patient becomes the bearer of his own characteristics and
course. This variability encourages the discussion about the delimitation of new
phenotypes of the disease (see below). Nevertheless, it is possible to identify ele-
ments that are commonly found in cases of insomnia and that would help with the
recognition of the condition. For didactic purposes, the clinical presentation of
insomnia can be divided into daytime and nighttime symptoms, as shown in
Table 4.1.
It can be noted that insomnia disorder is a 24-h condition, affecting the individual
in physical, psychological, and functional domains, although nocturnal phenomena
are the defining factors of the disease. The difficulty in initiating and maintaining
sleep is the trigger for a series of symptoms that simultaneously cause and perpetu-
ate the condition. The patient develops irritability and anguish in the face of the
obstacle, which can give rise to the feeling of impotence and hopelessness.
Ruminating thoughts is a phenomenon that permeates this whole scenario and is a
major barrier to the process of falling asleep. The hyperarousal state probably even
modulates the perception of time, which helps explain the fact that many individuals
with insomnia underestimate their sleep time, reaching extremes as in cases of poor
sleep perception (or paradoxical insomnia). This negative context usually occurs in
Table 4.1 Clinical Daytime symptoms Nighttime symptoms

characteristics of insomnia Fatigue Ruminating thoughts
Irritability Somatic symptoms
Anxiety Irritability
Somatic symptoms Anxiety
Excessive concern about sleep Hyperalertness
Depressive mood
Malaise
Cognitive symptoms
Excessive sleepiness
the supposed sleep environment—the bed, which involuntarily transforms it into a

scenario of conflict and agony, with persistence of symptoms.
The individual with insomnia shows during the day many of the consequences of
a bad night’s sleep, although there is a wide variation in these symptoms among
patients. Fatigue, tiredness, malaise, and irritability can be cited. Anxious, depres-
sive, and cognitive symptoms (e.g., difficulty concentrating and forgetfulness) are
common and usually have a great functional impact, affecting the individual in the
family, occupational, and academic spheres, among others. The risk of errors and
accidents is increased and there is great loss of quality of life (Ohayon & Reynolds,
2009). It must be noted that a proportion of this population does not experience
excessive sleepiness, reflecting the hyperarousal state that is so typical of this condi-
tion. Individuals with insomnia who are drowsy may not rarely exhibit reduced
objective total sleep time; in addition, they may have other sleep disorders, a fact
reinforcing the importance of paying attention to this symptom since it indicates a
more severe condition and poor prognosis (Vgontzas & Fernandez-Mendoza, 2013).
4.6 Phenotypes of Insomnia
Diseases characterized by a broad spectrum of symptoms are usually divided or

categorized for better identification and even for more specific treatments. This
requirement perfectly applies to insomnia but its categorization is still incipient, a
fact that can probably be explained by the phenomenological complexity of the
disease.
A priori phenotypic classification of a disease based on its clinical presentation
and/or associated etiological factors is common. This applies to insomnia, for which
subdivisions based on its possible causes are available but were abandoned by the
latest editions of clinical manuals, as reported earlier, while classification based on
clinical presentation, which is more practical and simpler, has been maintained (see
Table 4.2).
It must be noted that the classification based on sleep duration is more recent;
although not yet used by clinical manuals, it has been gaining prominence. This
classification is derived from studies that demonstrate a more severe condition and
worse prognosis in insomnia patients with short sleep duration (Vgontzas &
Fernandez-Mendoza, 2013; Vgontzas et al., 2013). The definition of short sleep
duration is still imprecise and should consider objective sleep time (determined by
objective methods such as actigraphy and polysomnography) and recommendations
of ideal sleep duration for each age group. Different cut-off points are reported in
the literature, although a cut-off of 6 h predominates (Vgontzas & Fernandez-
Mendoza, 2013).
Certainly, the classifications mentioned above are still far from encompassing all
dimensions of insomnia, especially those related to cognition, mood, family history,
patient experience, personality, sleep architecture, genetics, and neuroimaging.
These gaps may suggest the need for establishing new phenotypes that, in turn,
4 Insomnia 39
Table 4.2 Already applied Etiology:

phenotypic classification of
Idiopathic/primary insomnia
insomnia
Psychophysiological insomnia
Insomnia associated with poor
sleep hygiene
Paradoxical insomnia
Insomnia associated with mental
disorders
Behavioral insomnia of childhood
Insomnia associated with medical
conditions
Physiological insomnia
Insomnia associated with substance
use or withdrawal
Clinical presentation:
Time of night
Initial insomnia
Maintenance insomnia
Terminal insomnia (early morning
awakening insomnia)
Course
Acute
Recurrent
Chronic
Duration of sleep
Short sleep duration
Normal sleep duration
permit to improve the way insomnia is assessed and treated. New models are being
published and seek greater validation, such as the model proposed by Blanken et al.
(2019) that delimits phenotypes based on life history and on affective and personal-
ity traits, and models based on genetic analysis (Stein et al., 2018; Hammerschlag
et al., 2017).
4.7 Conclusions
–– Insomnia is a multifaceted condition that manifests differently in different

patients.
–– Insomnia is an extremely common complaint in health services today and should
be duly recognized and assessed.
–– Insomnia disorder affects the individual globally, with a great impact on function
and quality of life.
–– Characterization of the patient with insomnia regarding clinical presentation and

factors that modulate the condition is important. The determination of new phe-
notypes of insomnia depends on these features and should guide the treatment.
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Chapter 5
Insomnia: Its Comorbidities
and Differential Diagnosis
Daniel Guilherme Suzuki Borges
5.1 Introduction
Insomnia is a prevalent medical complaint that often coexists with other illnesses
such as psychiatric disorders, neurological and medical conditions (see Boxes 5.1
and 5.2). Its diagnosis remains essentially clinical, but eventually complementary
exams (e.g., labs, polysomnography, and actigraphy) are necessary when there are
suspicions of concomitant medical conditions (Schutte-Rodin et al., 2008; Riemann
et al., 2017).
The health provider should perform a thorough clinical interview and examina-
tion to assess both physical and mental health to address this disorder (Bonnet et al.,
2014). The aim of this evaluation is to help identify comorbidities that may be con-
tributing to the insomnia and eventually exclude medical and psychiatric conditions
that may mimic it. These factors prevent patients from receiving proper treatment.
5.2 Comorbidity
Comorbidity is the term when at least two distinct diseases or disorders occur in the
same patient at same time. Previously, insomnia was regarded as an accessory
symptom rather than a disease itself, and it is no longer considered “primary” or
“secondary” (depending on the presence or not of a comorbid disturbance). Its rela-
tionship with other illnesses is generally complex, and it is not clear if insomnia
would remit once the related condition is solved (NIH, 2005).
D. G. S. Borges (*)
Institute of Psychiatry, Faculty of Medicine, University of Sao Paulo (FMUSP),
Sao Paulo, SP, Brazil

44 D. G. S. Borges
Box 5.1: Common Medical Conditions Comorbid with Insomnia

–– Neurology: e.g., restless legs syndrome, stroke, Alzheimer disease,
Parkinson disease, epilepsy, chronic pain disorders, traumatic brain injury,
peripheral neuropathy, neuromuscular disorders.
–– Cardiology: e.g., congestive heart failure, angina pectoris, cardiac
arrhythmias.
–– Pulmonology: e.g., sleep apnea, asthma, emphysema, chronic bronchitis.
–– Gastrointestinal: e.g., gastroesophageal reflux disease, peptic ulcer dis-
ease, cholelithiasis, irritable bowel syndrome.
–– Genitourinary: e.g., urinary incontinence, benign prostatic hypertrophy,
interstitial cystitis.
–– Gynecology: e.g., menopause, pregnancy.
–– Endocrinology: e.g., hypothyroidism, hyperthyroidism, diabetes mellitus.
–– Musculoskeletal: e.g., rheumatoid arthritis, osteoarthritis, fibromyalgia,
disc herniation
Adapted and modified from Schutte-Rodin et al. (2008)
Box 5.2: Common Psychiatric Disorders Comorbid with Insomnia

–– Mood disorders: e.g., major depressive disorder, bipolar mood disorder,
cyclothymia dysthymia.
–– Anxiety disorders: e.g., generalized anxiety disorder, panic disorder,
posttraumatic stress disorder, obsessive compulsive disorder, phobias.
–– Psychotic disorders: e.g., Schizophrenia, schizoaffective disorder,
substance-induced psychotic disorders.
–– Others disorders: e.g., attention-deficit/hyperactivity disorder, adjust-
ment disorders.
Given these facts, the preferred term is “comorbid insomnia” (APA, 2013;
AASM, 2014), for example, comorbid insomnia with depressive disorder, comorbid
insomnia with obstructive sleep apnea (COMISA), comorbid insomnia with chronic
pain, and comorbid insomnia with substance use disorders, etc. The new status
comes as a need to emphasize that insomnia should be given more attention inde-
pendently of the co-occurring condition. The “secondary insomnia” approach may
promote inadequate treatment when assuming the therapeutic of comorbid condi-
tion is sufficient to resolve its sleep problem.
As persistent or residual insomnia may represent a risk factor, and a poor predic-
tor for several medical and psychiatric conditions (Hertenstein et al., 2019), both
insomnia and the concomitant conditions must be assessed and treated. In addition,
5 Insomnia: Its Comorbidities and Differential Diagnosis 45
insomnia may be associated with new onset or relapse from major depressive disor-
der, as well as anxiety disorders, substance use disorders, etc.
If left untreated, insomniacs may misuse medications or alcohol to help them fall
asleep and deal with anxiety, or even consume psychostimulants (e.g., caffeine) to
alleviate fatigue or somnolence. This pattern of substance abuse may lead to a sub-
stance use disorder in addition to worsening insomnia (Hertenstein et al., 2019).
Regarding general medical conditions, short-sleep duration insomnia (objec-
tively measured sleep time < 6 h) has been shown to represent a significant risk
factor for numerous cardiovascular diseases (Fernandez-Mendoza, 2017), including
hypertension, coronary artery disease, stroke, etc.
Therefore, it is fundamental that comorbid conditions be adequately diagnosed
and treated for a successful treatment plan (Sateia et al., 2017). Consider medical or
specialized referral (neurology, pneumology, ENT, psychiatry, pediatrics, sleep
medicine) for a joint assessment and treatment of patients with insomnia problems.
5.3 Differential Diagnosis
5.3.1 Acute Insomnia
Acute insomnia is a common reaction to any significant (positive or negative) life

status changes, just as stressful events, diseases, anticipatory anxiety, job promo-
tion, marriage, birth of children, etc. (APA, 2013; AASM, 2014). The condition
usually remits spontaneously in a few days or weeks, and symptoms are not fre-
quent enough to meet the three-month duration criteria for chronic insomnia
disorder.
Some individuals will develop maladaptive patterns of thought and behavior that
will eventually result in the development of a chronic insomnia disorder.
5.3.2 Short Sleepers
Some individuals require relatively little sleep and have no daytime repercussions
and symptoms (APA, 2013; AASM, 2014). They have no difficulties in falling or
staying asleep, but may be worried about their sleep duration. Some of them may try
to spend more time in bed, creating anxiety and conditioning that can make sleep
difficult and shorter.
It is a long time characteristic remoting from childhood persisting through life-
time. If its amount is below what is expected for each age group, a “short sleeper”
phenotype should be suspected (see Table 5.1).
46 D. G. S. Borges
Table 5.1 Summary of sleep Age group Mean duration (hours)

duration expected during Newborn 14–17
lifespan
Infant (4–11 months) 12–15
Toddler (1–2 years) 11–14
Preschool (3–5 years) 10–13
School age (6–13 years) 9–11
Teenager 8–10
Adult 7–9
Older adult 7–8
Adapted and modified from Hirshkowitz et al. (2015)
5.3.3 Sleep Deprivation
Sleep deprivation refers to a persisting reduction in the sleep hours required for
optimal functioning, usually an amount of time below the recommended for the age
group (APA, 2013; AASM, 2014).
Individuals may experience daytime sleepiness, fatigue, reduced performance,
memory and concentration deficits, increased risk of accidents, as well as detrimen-
tal effects on psychological and physical health. However, some people may not
have clear daytime consequences or may have little perceived mild symptoms.
It is not easy to determine the sleep need of an individual. One method to assess
this aspect could be by evaluating sleep during long periods of free time (e.g., vaca-
tions). Other approach involves determining how long a person would sleep if left
to awaken spontaneously on a regular basis, including weekends and holidays. On
this case, the individual must report no fatigue, somnolence, or sleep rebound.
5.3.4 Circadian Rhythm Sleep–Wake Disorder
It occurs due to desynchrony and incompatibility between the required or desired

social agenda in relation to the endogenous sleep–wake rhythm (APA, 2013; AASM,
2014). Because of this, individuals may experience insomnia, daytime sleepiness,
or both.
The amount of sleep is normal in periods when individuals have the opportunity
to sleep freely, for example, during vacations. These patients tend to remain asymp-
tomatic and without daytime impairment in such occasions. The specific patterns
vary according to the underlying disorder:
–– Delayed sleep–wake phase disorder (DSPD): This condition results in delayed
sleep onset, rarely occurring before midnight. Sleep onset insomnia often occurs
due to the disparity between the endogenous sleep rhythm and desired or
a cceptable social schedule. Sleep deprivation on workdays and rebounds on days

off are commons feature.
–– Advanced sleep–wake phase disorder (ASPD): It manifests as advanced sleep
onset, so patients complain of somnolence early in the evening. Sleep offset
arises prior to scheduled time and patients cannot get back to sleep, but its
amount is normal.
–– Irregular sleep–wake rhythm disorder (ISD): In ISD, there are polyphasic sleep
spread across the 24-hour day. Therefore, sleep and wake times are erratic
throughout the day. It’s a common feature in advanced neurodegenerative disor-
ders (e.g., Alzheimer disease, Parkinson disease).
–– Non-24-hour sleep–wake rhythm disorder or free-running: Patients with this
condition cannot synchronize their sleep with the external 24-hour day. Sleep
onset and cessation happen later and later each day (or the opposite), so there are
alternating periods of insomnia, excessive sleepiness, or both, with a short
asymptomatic period.
–– Shift work disorder: It occurs in shift workers with an irregular sleep and wake
schedule. People usually complain of insomnia, excessive daytime sleepiness, or
both (Fig. 5.1).
Fig. 5.1 Schematic representation of the major CRSD. Black bars represent sleep periods
48 D. G. S. Borges
5.3.5 Restless Legs Syndrome
It is a common sleep-related movement disorder characterized by an unpleasant

or uncomfortable urge to move the legs. It generally occurs during periods of
inactivity, particularly in the evenings, and is transiently relieved by movement
(APA, 2013; AASM, 2014) and eventually spreads to other body parts such as
the arms.
Because of this characteristic of nocturnal appearance or worsening, patients
often complain of sleep onset insomnia and, occasionally of night awakenings.
However, an urge to move the legs and any accompanying unpleasant leg sensa-
tions are features that differentiate this affection from the insomnia disorder.
5.3.6 Sleep Apnea
Most sleep apnea patients (or bed partners) report loud snoring, respiratory pauses
during sleep and excessive daytime sleepiness (APA, 2013; AASM, 2014). Many of
these individuals may complain of fragmented sleep, difficulty of maintaining it,
and of not being restorative.
5.3.7 Substance/Medication-Induced Insomnia
There are evidences from anamnesis, physical examination, or laboratory findings

of substance/medication capable of producing insomnia (APA, 2013; AASM,
2014) (see Box 5.3) by its use, intoxication or after withdrawal. Here are some
examples:
–– Alcohol has a short-lived sedative effect in the first half of the night, followed by
sleep disruption in the second half. During its withdrawal, there are disrupted
sleep continuity and an increased amount and intensity of REM sleep (usually
associated with vivid dreaming).
–– Abrupt discontinuation of chronic sedative, hypnotic, or anxiolytic use can lead
to withdrawals but more commonly rebound insomnia (exacerbation of insomnia
upon drug discontinuation).
–– Caffeine, cocaine, and psychostimulants (e.g., methylphenidate, amphetamines)
usually produce insomnia in a dose-dependent manner, with some individuals
presenting with daytime sleepiness related to withdrawal. Tobacco also has a
psychostimulant effect, and some individuals may experience nocturnal awaken-
ings caused by craving.
Box 5.3: Common Contributing Medications and Substances to

Insomnia
–– Antidepressants: e.g., fluoxetine, paroxetine, sertraline, citalopram, escita-
lopram, fluvoxamine, venlafaxine, desvenlafaxine, duloxetine, moclobemide.
–– Stimulants: e.g., caffeine, methylphenidate, d-amphetamine, lisdextroam-
phetamine, ephedrine, cocaine.
–– Decongestants: e.g., pseudoephedrine, phenylephrine, phenylpropanolamine.
–– Narcotic analgesics: e.g., oxycodone, codeine, propoxyphene.
–– Cardiovascular: β-Blockers, α-receptor agonists and antagonists, diuret-
ics, lipid-lowering agents.
–– Pulmonary: theophylline, albuterol.
–– Alcohol.
5.3.8 Hypomania/Mania
Hypomania and mania are hallmarks for bipolar disorder. One common feature is
the decreased need for sleep (APA, 2013). In these particular cases, patients report
a fully refreshed sleep despite its shortening.
Abnormally elevated, expansive, or irritable mood are hallmarks to diagnose
hypomania and mania. It may be accompanied by disinhibited and impulsive behav-
iors, engagement in excessive activities, and even features not perceived as prob-
lematic like increased productivity.
5.3.9 Anxiety Disorders
The individuals with psychophysiological insomnia have significant anxiety and

fear of the sleeping process (initiating, performance, arousals, duration, and quality)
and imagined (often catastrophizing) daytime repercussions (APA, 2013; AASM,
2014). These cause heightened bodily and cognitive arousals and specifically focus
on sleep, unless insomnia is a comorbid condition.
5.4 Conclusions
–– Insomnia is highly comorbid with medical and psychiatric conditions. Although

its diagnosis is clinical and medical referral is frequently necessary.
–– There are medical conditions or disorders that may mimic insomnia.
–– It is essential to recognize and treat comorbid conditions for a successful insom-
nia therapy.
50 D. G. S. Borges
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orders (3rd ed.). American Academy of Sleep Medicine.
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it’s importance for health and prevention. Current Opinion in Psychiatry, 30(1), 56–63.
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meta-analysis. Sleep Medicine Reviews, 43, 96–105.
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NIH State-of-the-Science Conference Statement. (2005). Manifestations and management of
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13(2), 307–349.
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insomnia in adults. Journal of Clinical Sleep Medicine, 4(5), 487–504.
Chapter 6
Hypnotic Dependence and Withdrawal
Israel Soares Pompeu de Sousa Brasil and Rosa Hasan
6.1 Hypnotics: A Story About Dependence
Insomnia is one of the most reported conditions in clinical practice and usually has
substantial physical and psychological implications for patients (Avidan &
Neubaner, 2017). Studies rank insomnia among the ten neuropsychiatric conditions
that cause the most suffering around the world, a fact that helps explain its great
treatment appeal (Collins et al., 2011). Motivated by this urgency, drug therapy with
hypnotics emerged as a practical and immediate solution to the problem. However,
what came next turned out to be something as or even more harmful than the disease
itself—hypnotic dependence.
The title of the first “hypnotic drug” used in clinical practice can be attributed to
a barbiturate, barbital, introduced in 1903, followed by phenobarbital in 1912
(Lader, 1991). Its spectrum of action was expanded by anticonvulsant and anxio-
lytic functions, which gave rise to other barbiturates over subsequent years. It did
not take long for the first cases of dependence and overdosing to appear and benzo-
diazepines (BZDs) became the hypnotic drug class of choice. The first BZD, chlor-
diazepoxide, discovered in 1955 was followed by diazepam in 1963 (Lader, 1991).
Today, there are more than 30 BZD derivatives, a number that indicates the absolute
success of this drug class (Soyka, 2017). The number of people in the United States
who received a BZD prescription increased by 67% between 1996 and 2013
(Lembke et al., 2018). Furthermore, most users were found not to take the medica-
tion as prescribed by the doctor or even to misuse it, a phenomenon that is more
I. S. P. de Sousa Brasil (*)

Institute of Medical Assistance to State Civil Servants of São Paulo (IAMSPE),
Sao Paulo, Brazil
R. Hasan
Institute of Psychiatry, Hospital das Clínicas, FMUSP, Sao Paulo, Brazil

52 I. S. P. de Sousa Brasil and R. Hasan
common among young people between 18 and 25 years of age (Maust et al., 2019).
The number of deaths from overdose involving BZDs consistently increased
between 1999 and 2015 (Lembke et al., 2018); this fact has an even greater impact
and becomes more complex by observing that opioid overdose deaths involve many
individuals who also use BZDs (Jones & McAninch, 2015). Once it realized the
extent of the catastrophe, in September 2020, the American health regulatory
agency, the Food and Drug Administration (FDA), recognized that BZDs are associ-
ated with a risk of abuse, addiction, and other harmful effects (U.S. Food and Drug
Administration, 2020).
Corroborating the maxim that history tends to be cyclical, a new drug class was
launched on the market in the early 1990s with the promise of becoming a safer
alternative to BZDs: the selective GABAA complex agonists, or more popularly
known as “Z-drugs” (e.g., zolpidem, zaleplon, zopiclone, and eszopiclone). In fact,
prescriptions of these new drugs are progressively replacing those of BZDs, with a
30-fold increase in the number of these prescriptions between 1993 and 2007
(Moloney et al., 2011), once again determining their space in the drug market.
However, what has also been noticed is that many of the harmful effects of BZDs
that led to the growth of the new class are also being documented among users of
Z-drugs, with reports of tolerance, abstinence, cognitive effects, an association with
accidents, and dependence (Schilano et al., 2019).
Once again, mankind is cornered and overcome by drugs that have not yet man-
aged to produce the much-desired “perfect sleep”, the holy grail of sleep pharma-
cology in clinical practice. Indeed, people continue to suffer from the side effects of
these drugs and do not realize that, in fact, sleeping requires “getting back to basics”.
For this process to unravel, it is necessary to understand what, in fact, is happening
today regarding these drugs, especially BZDs and Z-drugs.
6.2 General Concepts
6.2.1 Hypnotic Drugs and the GABA Receptor Complex
There are several commercially available drugs with hypnotic effects, although
many of them have no formal indication for treating insomnia. The hypnotic effect
can be due to different mechanisms depending on the medication used, and it is not
uncommon that the same drug produces such effect through multiple and intricate
pathways. For example, sedative antidepressants usually facilitate sleep due to their
action on different neurotransmitters, but especially by antagonizing histaminergic
pathways. The action of hypnotic drugs most associated with dependence (BZDs
and Z-drugs), however, is based on another site: the GABA receptor complex.
Gamma-aminobutyric acid, or GABA, is one of the main inhibitory neurotrans-
mitters in the central nervous system. It acts on receptors located on the presynaptic
and postsynaptic membranes of neurons (GABA receptors), facilitating the opening
of local chloride channels that results in hyperpolarization and consequent inhibi-
tion of neural transmission (Engin et al., 2018). These receptors have a complex
6 Hypnotic Dependence and Withdrawal 53
conformation in the membrane (hence the name GABA receptor complex). They
are composed of several protein subunits that determine different types of com-
plexes. BZDs and Z-drugs bind at specific sites between the α and γ subunits of
GABAA receptors (they have no effect on GABAB receptors), acting as allosteric
modulators that modify the conformation of the receptor in order to facilitate the
opening of chloride channels and thus potentiate the inhibitory effect of GABA
(Miller & Aricescu, 2014).
The different patterns of the GABAA complex (which, as mentioned, are deter-
mined by the combination of subunits) show a varied distribution throughout the
brain. Activation of a specific pattern of the GABAA complex mediates the different
clinical effects of BZDs: for example, the action on α1 subunits is associated with a
sedative effect and action on α2 and α3 subunits with an anxiolytic effect. Z-drugs
differ from BZDs exactly in terms of this feature: these drugs act more selectively,
especially in complexes with α1 subunits, which are more associated with a hypnotic
effect (Sanna et al., 2002). This is exactly why Z-drugs do not exert some of the
clinical effects observed for BZDs, such as anxiolytic and anticonvulsant effects.
In general, BZDs show good absorption and strong protein binding and are lipo-
philic (Griffin et al., 2013). Most BZDs are metabolized in the liver via microsomal
oxidation or demethylation, followed by glucuronidation. Since some BZDs already
possess a hydroxyl group (such as lorazepam and oxazepam), they are metabolized
directly by glucuronidation and have a shorter half-life. Cytochrome P450 3A4
(CYP3A4) is involved in the metabolism of BZDs and its inhibition by other drugs
can slow down the process and promote accumulation of these drugs. In addition,
many BZDs have active metabolites, which further prolong the effect of the drug
(Peng et al., 2022). Thus, the half-life of BZDs is highly variable and this fact must
be considered in the clinical management of patients. These drugs may have a short
half-life (such as triazolam, lorazepam, alprazolam, and bromazepam) or a longer
half-life (such as diazepam, clobazam, and clonazepam) (Soyka, 2017).
In view of their anxiolytic, hypnotic, myorelaxant, and anticonvulsant effects,
BZDs are useful in different clinical scenarios and are commonly indicated for the
treatment of anxiety disorders and for the management of withdrawal syndrome
such as alcohol withdrawal (Baldwin et al., 2013). The safety of BZDs is not well
established when used for more than 4 weeks (Lader, 2011), and dependence has
been shown to develop in half of the patients who use these drugs for more than
1 month (de las Cuevas et al., 2003). There are many side effects that can limit the
use of BZDs (e.g., lethargy, dizziness, excessive sleepiness, stupor, cognitive defi-
cits) and are often associated with accidents and falls (Gustavsen et al., 2008;
Wagner et al., 2004). The concomitant use of opioids potentiates all of these effects
and should be avoided. The prescription of BZDs to older adults must be discour-
aged since this population is known to be more susceptible to these risks (Berrymen
et al., 2012). Z-drugs are specifically indicated for the treatment of insomnia but are
also not formally approved for long-term use. This class has been found to have the
same disadvantages as BZDs in terms of side effects and the development of toler-
ance and dependence (Schilano et al., 2019), although the level of evidence is not
the same as that established for BZDs.
6.2.2 Mechanisms of Tolerance and Dependence
The physiological basis of the dependence process involves the mesolimbic reward
system. Drugs that promote the release of dopamine in this area are potential causes
of addiction (Lüscher & Ungless, 2006; Saal et al., 2003). Studies have shown that
BZDs bind to GABAA receptors on interneurons in the ventral tegmental area which,
in turn, triggers the activation of dopaminergic neurons (Tan et al., 2010).
Physiological dependence on BZDs may even occur after a few weeks of use
(Gerada & Ashworth, 1997).
Substance dependence comprises different clinical conditions that determine and
characterize the pathophysiological process. Phenomena such as drug tolerance
(loss of effect of the substance at a defined dose or the need to increase the dose to
obtain the same effect), rebound (recurrence of the original symptoms at greater
intensity after discontinuation of the drug), and withdrawal syndrome (a set of
symptoms that occur after cessation or dose reduction of a substance) corroborate
the diagnosis.
Tolerance to the hypnotic effects of BZDs appears to be more pronounced than
tolerance to their anxiolytic effects (American Psychiatric Association, 1990). Drug
tolerance can be mediated by different, not yet well-established, mechanisms such
as alterations in the expression of GABAA complex subunits, compensatory activity
of other neurotransmitter pathways, and less effective opening of the chlorine chan-
nels of the complex (Allison & Pratt, 2003; Bateson, 2002). Rebound involves
symptoms that can be confused with withdrawal symptoms: these symptoms are
usually new to the patient and include anxiety, agitation, insomnia, and sensory
(e.g., paresthesia, tinnitus) and motor (e.g., tremor, spasms) alterations, in addition
to more severe conditions such as epileptic seizures and delirium (Soyka, 2017).
Withdrawal is due to the disinhibition of glutamatergic pathways, previously inhib-
ited by the GABAergic effect of BZDs (Peng et al., 2022). Studies also suggest the
contribution of other factors such as downregulation of BZD receptor sites in the
GABA receptor complex, increased calcium flux, and elevated serotonergic activity
(Baldwin, 2022). Withdrawal symptoms tend to occur earlier with the use of short
half-life BZDs (within 2 to 3 days after discontinuation) compared to BZDs with a
longer half-life (within 5–10 days) (Soyka, 2017); these symptoms usually start
gradually, reach a peak, and subside slowly over a total period of less than 4 weeks
(Baldwin, 2022).
6.2.3 Diagnostic Criteria
Many terms have been used to better characterize the phenomenon of dependence,
which help delimit its different domains. Phenomena such as tolerance and with-
drawal syndrome are usually listed as criteria that confirm the diagnosis.
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) employed the classification of “abuse” and “dependence” in which the
first highlights social aspects (impairment of interpersonal relationships and legal
problems) and the second emphasizes clinical aspects. The subsequent edition
(DSM-V), in turn, eliminated this division and implemented the concept of sub-
stance use disorder, defined by 11 criteria (see Box 6.1). The severity of the condi-
tion is assigned based on the number of criteria met (2–3 criteria: mild; 4–5 criteria:
moderate; 6 or more criteria: severe).
Box 6.1: Diagnostic Criteria for Substance Use Disorder According to

DSM-V (American Psychiatry Association, 2013)
Substance use disorder
A problematic pattern of substance use leading to clinically significant impair-
ment or distress, as manifested by at least two of the following criteria that
must occur for a minimum period of 12 months:
• The substance is often taken in larger amounts or over a longer period
of time than was intended.
• Persistent desire or unsuccessful efforts to reduce or control use of the
substance.
• A great deal of time is spent in activities related to obtaining, using, or
recovering from the effects of the substance.
• Craving, strong desire, or urge to use the substance.
• Recurrent use of the substance resulting in failure to fulfill roles at
home, work, or school.
• Continued use of the substance despite persistent or recurrent social or
interpersonal problems caused or exacerbated by its effects.
• Giving up or reducing important social, occupational, or recreational
activities due to use of the substance.
• Continued use of the substance even in situations in which it poses risks
to physical integrity.
• Use of the substance is continued despite knowledge of having a persis-
tent or recurrent physical or psychological problem that tends to be
caused or exacerbated by this use.
• Tolerance, defined as a markedly reduced effect with continued use of
the same amount of the substance and/or the need for progressively
larger amounts of the substance to achieve the same degree of
intoxication.
• Withdrawal, as expressed by withdrawal syndrome characteristic of the
substance used and/or use of the substance or a similar one to avoid
withdrawal symptoms.
On the other hand, the 10th and the new 11th edition of the International
Classification of Diseases (ICD-10 and ICR-11, respectively) adopted the expres-
sion “substance dependence” to designate this condition (see Box 6.2), in addition
to establishing another clinical scenario, which would be hierarchically inferior and
clinically milder than that of dependence—“harmful substance use” (ICD-10) or
“harmful pattern of substance use” (ICD-11). Both classifications identify cases in
which the substance causes damage to the user’s health but no dependence relation-
ship has yet been established. The latest edition adds that such harm may also be
suffered by another person related to the patient (World Health Organization, 2018).
Box 6.2: Diagnostic Criteria for Substance Dependence According to

ICD-10 and ICD-11
ICD-10:
The diagnosis of dependence should be made if three or more of the follow-
ing criteria have been experienced or exhibited during the previ-
ous year:
• A strong desire or sense of compulsion to take the substance.
• Difficulties in controlling substance-taking behavior in terms of initia-
tion, termination, or levels of use.
• A physiological withdrawal state when substance use has ceased or
been reduced, as evidenced by the characteristic withdrawal syndrome
for the substance, or use of the same substance (or a closely related one)
with the intention of relieving or avoiding withdrawal symptoms.
• Evidence of tolerance such that increasing doses of the psychoactive
substance are required to achieve effects originally produced by
lower doses.
• Progressive neglect of alternative pleasures in favor of psychoactive
substance use: increased amounts of time necessary to obtain or take the
substance or recover from its effects.
• Persisting with substance use despite clear evidence of overtly harmful
consequences, such as liver damage due to heavy drinking or depressive
mood states consequent to periods of excessive consumption.
ICD-11:
The diagnosis requires 2 or all 3 criteria described below to be present simul-
taneously in the individual and to occur repeatedly over a period of at least
1 year, or continuously over a period of at least 1 month:
• Loss of control over substance use—in terms of the onset, volume, cir-
cumstances, or termination of use—often, but not necessarily, accom-
panied by a subjective sensation of craving or urge to use the substance.
• Substance use becomes an increasing priority in life such that it takes
precedence over other interests or pleasures, daily activities, responsi-
(continued)
Box 6.2 (continued)

bilities, or personal and healthcare. It assumes an increasingly central
role in the individual’s life and relegates other areas to a secondary
plane. Substance use often persists despite the occurrence of problems.
• Physiological phenomena (indicative of neuroadaptation to the sub-
stance) manifested as: (1) tolerance; (2) withdrawal symptoms after
cessation or reduction in the use of the substance, or (3) repeated use of
the substance (or a pharmacologically similar one) to prevent or allevi-
ate withdrawal symptoms. These symptoms must be characteristic for
that substance and must not simply reflect a hangover effect.
6.3 Hypnotic Dependence
6.3.1 Epidemiology
Epidemiological data on hypnotic dependence are heterogeneous. The factors

responsible for this variation include the diagnostic criteria chosen in each study,
the geographic region studied, and the substances chosen for evaluation. In general,
the use of BZDs increases with advancing age and is more frequent among women
(Petitjean et al., 2007). A German population study used the abuse and dependence
classification according to the DSM-IV criteria and found a prevalence of 0.8% for
abusive use of sedatives in both sexes. The prevalence of dependence was 1.4%
among men and 1.3% among women. A prevalence of sedative abuse of 1.1% has
been reported in the United States (Huang et al., 2006). A retrospective study found
that BZD use was twice as prevalent in women as in men (Olfson et al., 2015).
The following risk factors for developing BZD dependence have been described
in the literature (Kan et al., 2004):
–– A low educational level.
–– Prescription at a young age.
–– Belonging to ethnic minority groups.
–– Presence of more severe depressive and anxiety symptoms.
–– A history of alcoholism and dependence on other substances.
–– Characteristics of BZD use: higher dosage, short half-life option, and concomi-
tant use of other psychotropics (Okumura et al., 2016).
Patients with dependence syndrome tend to adopt certain patterns of behavior
that have been documented from clinical experience and may even help identify
these cases. These behavioral patterns include the following (Soyka, 2017):
–– Anxiety symptoms between doses.
–– Frequent return to appointments for prescription renewal.
–– The patient himself/herself increasing the dose.
Table 6.1 Clinical presentation of hypnotic withdrawal

Anxiety Tremor Epileptic seizures
Depression Sweating Hyperacusis
Irritability Nausea/vomiting Photophobia
Delirium Agitation Sleepiness
Depersonalization Dyspnea Dysesthesia
Derealization Headache Cognitive deficits
Sleep disorder Tachycardia Involuntary movements
–– “Doctor shopping” (visiting different doctors to obtain multiple prescriptions)

–– Use of hypnotics during the day.
–– Belief of the necessity of BZD use for daily activities.
–– Reporting loss of prescription.
–– Keeping pills close by for “emergencies”.
Withdrawal symptoms are diverse and may vary among patients (see Table 6.1).
It should be noted that the symptoms are not specific; depending on the context, it
is prudent to investigate other causes of these symptoms. Differential diagnoses
include hypoglycemia, stroke, electrolyte changes, and intoxication by other sub-
stances (Soyka, 2017).
6.3.2 Treatment
There are no straightforward or objective answers as to how to treat dependence

syndrome or substance use disorder. No universal guidelines are available.
Therapeutic alternatives are varied and each patient may require a specific manage-
ment; thus, treatment should be individualized. However, there are some consensual
recommendations that can guide patient management. In general, treatment covers
different aspects. Care should include the adoption of measures even before the
diagnosis of dependence, at the time of prescription of the hypnotic. Once the diag-
nosis is established, treatment can be divided into three pillars: gradual discontinu-
ation of the drug, treatment of withdrawal symptoms, and a psychotherapeutic
approach (see Fig. 6.1).
The recommendations for each item are described in the following sections.
6.3.2.1 Hypnotic Discontinuation
Once the diagnosis of dependence on a hypnotic drug (generally a BZD or Z-drug)

is established and a harmful context for the patient has been determined, it is neces-
sary to define the best strategy in order to dismantle this scenario. Before starting
this process, it would be useful to reflect on the disease that led to the use of the
medication in order to identify new therapeutic approaches for its resolution.
Fig. 6.1 Summary of recommendations for the approach to hypnotic dependence
Different clinical factors, ranging from the drug taken by the patient and the
duration of its use to the patient’s psychic profile, must be considered when defining
the best discontinuation strategy. For this very reason, there is no single protocol
that could universally be recommended. Several studies using different approaches
to BZD withdrawal have been published, including a Cochrane review (Darker
et al., 2015) that found different levels of evidence for each of these strategies.
From a practical point of view, the first factor to be defined in the process of
hypnotic discontinuation is the need for institutionalization (hospitalization or a day
hospital regimen) (Peng et al., 2022). More severe cases of dependence may be bet-
ter managed in a more controlled environment. The following characteristics sug-
gest this management (Miller et al., 2018):
–– A history of unsuccessful attempts to discontinue the drug.
–– Use of very high doses (>100 mg diazepam or equivalent per day).
–– High risk of seizures or other withdrawal complications.
–– Other concomitant substance use disorders.
–– Decompensated clinical or mental health comorbidities.
Institutionalization allows the simultaneous use of several approaches, a more
accurate and careful dose titration of the drug, and prompt management of any
complication.
There is consensus (with a high level of evidence) that slow and gradual with-
drawal from hypnotics is one of the pillars of dependence treatment (Soyka, 2017).
Its aim is to minimize the risk of complications during discontinuation, such as
epileptic seizures and withdrawal symptoms. Several dose reduction schemes have
been published; in practice, what will determine the speed of dose reduction is the
patient’s ability to tolerate the symptoms. Schemes can range from a 50% reduction
in the BZD dose weekly to a 10–25% dose reduction every 2 weeks (Soyka, 2017).
A total withdrawal period of 4 to 6 or 4 to 8 weeks seems to be sufficient in most
cases and care should be taken not to prolong this period too much (Lader
et al., 2009).
It is relatively common in clinical practice to switch the BZD used to another
BZD with a longer half-life (clonazepam or diazepam) as part of the withdrawal
strategy. This approach enables slower titration (as occurs when a drop formulation
is used), which would reduce the risk of developing withdrawal symptoms. However,
judging by studies in the literature, there is no clear evidence that this strategy
results in good outcomes (Ashton, 2002). If the patient is using several BZDs, there
is good evidence that conversion to a single BZD with a longer half-life can indeed
be beneficial during the withdrawal period (Soyka, 2017).
Many patients who are dependent on hypnotics also use opioids. It is recom-
mended that the dose of the opioid used be maintained during BZD discontinuation
in order to minimize the risk of developing withdrawal symptoms (Lintzeries &
Nielsen, 2010).
6.3.2.2 Pharmacological Treatment
There are no formally recommended medications (or approved by the FDA) for the
specific treatment of hypnotic dependence syndrome or its withdrawal symptoms
(Peng et al., 2022). Thus, pharmacological treatment becomes empirical and symp-
tomatic. Many studies have evaluated some of these medications; however, the level
of evidence is low and they are used off-label.
Anticonvulsants and mood stabilizers are often used for withdrawal treatment,
especially from alcohol (Barrons & Roberts, 2010). However, the level of evidence
is much lower for hypnotics. Carbamazepine/oxcarbazepine is a widely cited option
(Lader, 2014); gabapentin and pregabalin are also listed but with far fewer studies
(Mariani et al., 2016). The anxiolytic effect of these drugs may be useful in these
cases. There are also protocols for the use of phenobarbital as prophylaxis of epilep-
tic seizures in rapid BZD discontinuation regimens during hospitalization (Kawasaki
et al., 2012). There is no evidence on the benefit of lithium, buspirone, or proprano-
lol (Baandrup et al., 2018).
The medication may also be directed toward the treatment of sleep disorders,
although an abrupt change of BZD is not recommended. Antidepressants with a
hypnotic effect (e.g., trazodone, doxepin, mirtazapine), which facilitate sleep due to
their predominantly antihistamine action, are recommended. Other antidepressants
(such as serotonin reuptake inhibitors) may be used to treat anxiety symptoms.
Studies have reported some improvement in sleep with melatonin (Baandrup et al.,
2018) and flumazenil (Faccini et al., 2016) but, in general, the effect is still
questionable.
6.3.2.3 Psychological/Behavioral Approach
Many types of behavioral or psychotherapeutic approaches have been studied. In

fact, several models of structured intervention exist that range from short to long
follow-up periods depending on the patient’s needs and profile. In general, the
objectives are to facilitate discontinuation of the hypnotic drug, to manage the with-
drawal status, and to address both the underlying disorder and mental health comor-
bidities that the patient may have (Baldwin, 2022; Lader et al., 2009).
Psychoeducation is generally the first approach used (Ten Wolde et al., 2008).
Presentations, texts, or letters addressed to the patients that contain information
about the condition and its causes, symptoms, consequences, and treatment can
provide the stimulus and initial motivation that would encourage the patient to
engage in weaning from the hypnotic. Simple measures such as the doctor sending
a letter to the patient encouraging treatment can have a positive prognostic effect (de
Gier et al., 2011), although it is important to concomitantly invest in other approaches
(Mugunthan et al., 2011).
Motivational interviewing is a counseling method that is often used in substance
dependence treatments, although evidence on its use in cases involving hypnotics is
still very limited. The method seeks to encourage patients to reassess their situation,
analyzing the advantages and disadvantages of their behavior. By targeting the
capacity to change and the expectation of improvement, motivational interviewing
induces behavioral changes that may be useful for the progression of treatment
(Miller & Rollnick, 2012).
Cognitive behavioral therapy (CBT) is considered the gold standard treatment
for chronic insomnia disorder (Trauer et al., 2015). Although the degree of effec-
tiveness is not the same, this therapy is also important for the management of BZD
dependence (Lader et al., 2009). Among psychotherapeutic approaches, CBT has
the largest number of studies in the literature and the highest level of evidence; it is
also the most used approach (Darker et al., 2015). The aims of CBT are to address
new behavioral repertoires, to manage dysfunctional beliefs about the condition,
and to teach how to deal with expectations. For this purpose, CBT comprises differ-
ent techniques that include relaxation exercises, simulations of risk scenarios, and
problem-solving approaches. Measures that are usually adopted in CBT for insom-
nia disorder, such as sleep hygiene, stimulus control and bedtime restriction, can
also be applied to these patients (Morin et al., 1994). Analysis of the evidence in the
literature suggests that the therapeutic success of CBT for BZD dependence is still
not guaranteed. Within this context, one study with a 15-month follow-up demon-
strated that the efficacy of a controlled protocol of hypnotic withdrawal was supe-
rior to a usual approach combined with CBT (Voshaar et al., 2003). A review
reported only a short-term beneficial effect, with the observation of a good response
after 3 months when combined with gradual discontinuation of the hypnotic drug,
but not after 6 months (Darker et al., 2015).
Acceptance and commitment therapy (ACT) is relatively new and part of the
third wave of behavioral therapies. Its use in patients with chronic insomnia disor-
der has not been extensively documented in the literature but the results are
promising (Lappalainen et al., 2019; Paulos-Guarnieri et al., 2022; El Rafihi-

Ferreira et al., 2020; El Rafihi-Ferreira et al., 2022). The level of evidence on the use
of ACT in patients with hypnotic dependence is even lower but a pilot trial has sug-
gested a good response. The study found a reduction in the mean number of BZD
pills and Z-drugs taken per day among patients treated with CBT combined with
elements of ACT, in addition to a reduction in the number of hypnotic drug users
after 6 months (Chapoutot et al., 2021).
Several other techniques can be employed, although their level of evidence is
very limited. Group, couple, or family therapies are also suitable models.
Psychodynamic and psychoanalytical approaches can be useful and tend to focus on
the tolerance of negative emotions, problem-solving strategies, and the sense of
frustration that permeates the state of substance dependence (Soyka, 2017).
6.3.3 Prognosis
In general, the prognosis of patients after treatment of hypnotic dependence is rela-

tively good (Soyka, 2017). However, short-term outcomes can be very variable and
long-term outcomes are poorly documented (Baldwin, 2022). Studies suggest that
two-thirds of patients are able to remain BZD free soon after treatment but only
one-third remain abstinent in the long term (Voshaar et al., 2006). The impact of
simple measures such as psychoeducation on the prognosis of many of these patients
should be highlighted. Studies report discontinuation of BZD use in 20–49% of
patients who received this intervention (Voshaar et al., 2003; Bashir et al., 1994;
Cormack et al., 1994).
The following factors have been reported to reduce the success of withdrawal
(Schweizer et al., 1998; O’Connor et al., 1999, 2004):
–– Clinical comorbidities: more severe symptoms of anxiety and depression, per-
sonality traits such as neuroticism, a diagnosis of panic disorder, and concomi-
tant use of alcohol.
–– A low socioeconomic level.
–– Greater pharmacological complexity: higher dose of the hypnotic, prolonged
duration of treatment, very fast discontinuation, and use of a short half-life BZD.
Withdrawal-associated psychological symptoms may persist in some patients
even after 5 years (Golombok et al., 1987). Post-acute withdrawal syndrome is the
term designated by some authors to refer to prolonged withdrawal symptoms that
can include headache, paresthesia, anxiety, depression, and motor signs such as
tremor and spasms (Ashton, 1991). These are more complex cases and there are no
recommendations for specific formal treatment, with the same measures as men-
tioned above being used (Miller et al., 2018). Resolution of these symptoms is usu-
ally observed within 6–12 months but they may also persist for years in some cases
(Cosci & Chouinard, 2020).
The risk of relapse or return to misuse of hypnotic drugs must be considered and
monitored. Data on this phenomenon are limited but some predictive factors have
been reported (Voshaar et al., 2003, 2006; Morin et al., 2005; Mol et al., 2007):
–– Previous use of high BZD doses (>10 mg of diazepam or equivalent per day).
–– Persistent insomnia.
–– Self-perception of greater disease severity.
–– Daily consumption of alcohol.
–– Craving for BZD.
It should also be remembered that, in many cases, the use of BZDs is facilitated
and/or perpetuated by socioeconomic factors that may not have subsided after dis-
continuation (unemployment, mourning, financial difficulties, abusive relation-
ships), a context that also facilitates the return to hypnotic use (Baldwin, 2022).
6.3.4 Prevention
Knowing the complexity of hypnotic dependence, its harmful effects and treatment,
preventive measures are urgently needed. A systematic review identified factors that
can be fundamental for this process and highlighted that measures need to be imple-
mented at all levels of care (Sirdifield et al., 2017). At the primary level, the aim is
to avoid, if possible, the prescription of BZDs, especially to risk groups such as
older adults (Schwitz, 2021). If prescribed, it is always necessary to determine the
duration of medication use (which should be as short as possible), avoiding a sig-
nificant dose increase. One may even suggest transient discontinuation during treat-
ment, if clinically and pharmacologically possible. Risk factors for dependence in
these patients must be identified and addressed, such as psychiatric comorbidities,
chronic pain (which may be related to concomitant opioid use), alcohol abuse, sleep
disorders, and risky personality traits for the condition (Sirdifield et al., 2017).
During follow-up, automatic prescription renewal of these drugs must be
restricted or avoided. Integrated information systems and clinical audits carried out
by care services can be useful to identify possible deviations and inappropriate pre-
scriptions. Education campaigns and meetings on the topic among health profes-
sionals are equally important (Smith & Tett, 2010).
The patient, who is the target of all attention, must be monitored continuously
from the time the hypnotic is prescribed to the post-treatment phase regarding use
of the drug, possible side effects, changes in the clinical condition, and possible
outcomes. Patients must have easy access to the healthcare service in order to ensure
their safety and make them feel welcome.
6.4 Conclusions
–– The excessive use of hypnotic drugs has been a matter of concern over the last
century and has persisted until today because of the false promise of an immedi-
ate solution to sleep disorders, which are increasingly more common.
–– Hypnotic drugs, especially BZDs and Z-drugs, have many adverse effects,
including the risk of falls, cognitive alterations, and respiratory depression,
which can culminate in the phenomena of tolerance and dependence.
–– Dependence syndrome or substance use disorder associated with hypnotic drugs
is a complex, heterogeneous clinical condition with an uncertain prognosis.
Measures preventing the misuse of BZDs and Z-drugs should be implemented at
all levels of healthcare.
–– There are no universal guidelines for the treatment of hypnotic dependence but
consensus recommendations exist that should guide patient management.
Different clinical factors must be considered when determining the best treat-
ment for the patient.
–– The treatment generally consists of three pillars: gradual discontinuation of the
hypnotic drug, the use of other drugs to relieve withdrawal symptoms, and a
psychotherapeutic approach, with CBT being the technique with the highest
level of evidence in the literature.
–– Patient care comprises the period from before the prescription of BZD or Z-drug
to follow-up after discontinuation in order to establish an objective and accurate
treatment, in addition to monitoring complications and/or relapse of the disorder.
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Part II
Assessment of Insomnia
Chapter 7
Initial Interview in the Therapeutic Setting
Ila Marques Porto Linares and Renatha El Rafihi-Ferreira
Satisfactory therapeutic results depend on a careful assessment that considers the

client as a whole. Thus, the first step in starting an intervention is to assess the com-
plaint and gather the variables that may be associated with its development and
maintenance. The data collection process begins with the initial contact with the
client. Based on the collected information, it is then possible to formulate the case.
These points are discussed in this chapter, which also explores elements present in
the first therapeutic contact such as format and environment for conducting the
interview and treatment, the professional qualified to apply ACT, clinical interview,
determination whether the client is a candidate for ACT-based therapies, course of
treatment, and other treatment options, if necessary.
Case Formulation
The process of case formulation in ACT is essential for the development of inter-
vention strategies that meet the needs of each client. ACT is an approach that is
based on functional contextualism; therefore, the case formulation in ACT consists
of analysis of the complaints reported by the client considering not only the fre-
quency and type of the complaint but above all its function, context, and history.
Functional contextualism views events as continuous actions of the organism
within a historically and situationally defined context and aims to predict and influ-
ence these events. The philosophical perspective on functional contextualism is the
pragmatic and functional view of radical behaviorism, emphasizing the functional
analysis of behavior as the main methodological tool (Hayes et al., 2006; Oshiro &
Ferreira, 2021). Based on its theoretical foundation and psychotherapeutic model,
I. M. P. Linares (*)
Faculty of Medicine, University of São Paulo, São Paulo, Brazil

72 I. M. P. Linares and R. El Rafihi-Ferreira
ACT does not consist of a combination of procedures and techniques but determines
parameters for explanation, intervention, and evaluation of its clinical
effectiveness.
Case formulation using a contextual approach considers functional analysis, the
identification of processes, intervention planning, and assessment (Ferreira, 2021).
The aim of case formulation is to identify relationships between events that occur in
the environment and actions of the organism. Investigation of the function of behav-
ior is the main target of case formulation. In this analysis, the antecedents and con-
sequences of which the behavior is a function are sought in the environment. In
other words, all behavior must be analyzed considering the context in which it
occurs. To investigate the function of a behavior, the occasion when the response
occurs is identified, that is, the antecedent, the response, and subsequent conse-
quences. During treatment by the clinician, assessment and intervention are inter-
twined processes that occur throughout the therapeutic process. Case formulation
provides the basis for treatment planning. Identification of the variables of which
the behavior is a function is the key step in case formulation.
Case formulation in ACT is structured using the model of psychological flexibil-
ity. This model was described in the chapter “Acceptance and Commitment Therapy”
of this book. Based on the delimitation of the complaint reported by the client, we
seek to identify how the complaint is connected to psychological inflexibility pro-
cesses (experiential avoidance, cognitive fusion, dominance of the conceptualized
past and future, self as content, lack of values, and inaction) and psychological flex-
ibility (acceptance, cognitive defusion, contact with the present moment, self as
context, values, and committed actions) (Ferreira, 2021; Sandoz, 2021).
The first step in the formulation or conceptualization of a case is to gather infor-
mation about the client such as his/her life story, complaint, and expectations. The
data collection or evaluation process, which includes the initial interview, is essen-
tial to obtain detailed information about the complaint and its context. Based on the
case formulation, treatment planning is performed, which requires structuring inter-
ventions, the format and frequency of sessions, and therapeutic directions. It is
worth noting that treatment planning comprises the strategies and techniques that
will be used throughout the intervention.
The process of case formulation and treatment planning in ACT for insomnia
complaints does not differ from the case formulation for other complaints described
above. In the context of insomnia, careful data collection is necessary and must
include objective information on sleep patterns such as sleeping and waking times,
time needed to fall asleep, time in bed, and the number and duration of awakenings.
These data can be collected based on retrospective and prospective measurements
using questionnaires, diaries, and actigraphy. A complete description of these mea-
surements can be found in the chapters “Evaluation and Retrospective Measurements”
and “The role of actigraphy and sleep diaries in assessing sleep in adults with
insomnia” of this book. In addition to the information about the sleep complaint,
data on the individual’s context, including how he/she relates to the insomnia com-
plaint and his/her thoughts and feelings, as well as life values, goals, and psycho-
logical processes that interfere with the pursuit of these values, are collected.
7 Initial Interview in the Therapeutic Setting 73
To understand the complaint of insomnia, the professional must investigate the

function of the complaint within the individual’s context and to what extent the six
processes of psychological inflexibility (experiential avoidance, cognitive fusion,
dominance of the conceptualized past and feared future, self as content, lack of
values, and inaction) are responsible for maintaining the complaint. Next, once the
clinician understood what triggered and might be perpetuating insomnia, the profes-
sional is able to better structure the treatment plan and to select strategies and tech-
niques that will be implemented throughout the intervention. During therapy,
behavior change occurs based on the progression of the six processes of psychologi-
cal flexibility. It should be noted that a direct relationship and interconnection exist
between assessment, case formulation, and treatment. Thus, neglecting or reducing
the relevance of each of these steps will compromise the effectiveness of the pro-
posed treatment.
7.1 Format and Environment for Conducting the Interview

and Treatment
The format of the interview and treatment of the sleep complaint can be face-to-face
or virtually, individually and in groups, since many studies on CBT-I have con-
firmed the effectiveness of different formats (Boness et al., 2020). It is worth noting
that virtual therapy will permit access to specialized professionals. Although there
are no studies that compared online versus face-to-face application of ACT, which
does not permit to state categorically how the format interferes with the outcome,
studies using different intervention formats with favorable results are available (e.g.,
individual or group modalities, remote, face-to-face, or self-administered) (Paulos-
Guarnieri et al., 2022).
Regarding the therapeutic environment, regardless of the treatment modality
adopted, it is important that its structure and conditions provide sufficient comfort,
safety, and acceptance. In a virtual environment, the clinician must guide clients to
look for a reserved space so that they have privacy to talk about their issues without
being interrupted; good quality internet and a screen with an adequate size that
allows to visualize psychoeducation and session activities that often require screen
sharing are necessary. In a physical environment, the clinician can use a space with
a table, blackboard or notebook for psychoeducation and armchairs for the client,
professional, and a family member who may accompany the client to a session.
The clinical environment can be located in a sleep center or in an independent
clinic/office. Offices within a sleep center complex can provide access to a multidis-
ciplinary team of sleep physicians, neurologists, and psychiatrists. Affiliation of the
clinic with a sleep center or association can facilitate client access. The aim of dis-
seminating ACT for insomnia is to make the treatment accessible in private clinics
and in public health institutions, including primary care and health services and
psychology teaching schools at universities, among others.
Whether in a virtual or physical environment, the clinician must reserve a space

to store client records, questionnaires, scales, and materials used in the session.
7.2 Qualified and Appropriate Professional to Apply

ACT-Based Therapies for Insomnia
The best qualified professional to apply ACT-based therapy for insomnia is a psy-
chologist trained in ACT who has in-depth knowledge of sleep and its intervention
strategies in order to ensure that a duly prepared person with a theoretical and prac-
tical basis performs the interventions. It is, therefore, extremely important that pro-
fessionals invest in their training in terms of both knowledge about sleep and
contextual approaches. The therapist’s training must consider the constant updating
of the scientific literature in the area. In addition to theoretical updates, supervision
is essential to improve the quality of clinical care, especially for beginners. Contact
with the multidisciplinary team that attends the population with sleep problems is
important and can contribute to the evolution of cases.
7.3 First Contact with the Client
The first contact with the client is a critical moment in the establishment of a bond
between the professional and client and consequently in the continuation of psycho-
therapeutic follow-up. Establishing a therapeutic bond is also important for the cli-
ent to feel comfortable in reporting the necessary information and thus to enable
data collection, as well as case formulation and development of a treatment plan.
Some therapist behaviors can favor establishment of the bond, such as an empa-
thetic and understanding attitude, non-judgmental acceptance, authenticity, self-
confidence, flexibility, commitment, tolerance, and interest. Gestural behaviors,
maintaining eye contact, verbalizing thoughts and feelings, a non-directive attitude,
and occasional guidance are also important elements that should be included in the
therapist’s repertoire (Bandeira et al., 2006).
It is important that the therapist takes care in building this bond, which will con-
tribute to greater adherence and more effective results regarding the client’s com-
plaint. Also seeking to establish a good therapeutic relationship and to gather
information for case formulation, clinicians must observe their own reactions dur-
ing the initial interview and throughout the therapeutic process. Within this context,
thoughts, feelings, associations, memories, and physical sensations experienced
during contact with the client can be relevant data. It is during the first meeting that
the professional informs the client about the rules and conditions of therapy, includ-
ing confidentiality, schedules, absences, session replacement, and session fee.
7.4 Clinical Interview
The diagnosis of insomnia is essentially clinical and requires a careful anamnesis.

The initial clinical interview or anamnesis is composed of several elements, includ-
ing the client’s identification (name, age, sex, marital status, profession, religion),
cultural and contextual aspects, main complaint (onset of symptoms and triggering
and perpetuating factors), personal and family history, medications used, and clini-
cal and psychiatric history. In the field of sleep, the clinical interview also needs to
contain some specific elements in order to obtain relevant information for under-
standing the current presentation.
Therapist
When did this problem start?
Was there a time when insomnia was significantly less pronounced?
Does your insomnia have the same intensity, frequency, and duration as when
it started?
Do you recognize the complaint or does your partner recognize it?
Other sleep disorders
Other sleep disorders whose symptoms resemble those of insomnia, but arise
from another cause, must be ruled out. These conditions include obstructive sleep
apnea, restless legs syndrome, circadian rhythm disorders (phase advance and
delay), insomnia secondary to medication use, and poor sleep hygiene.
Therapist
Do you snore at night?
Do you have any type of sleep-related discomfort other than insomnia?
Nocturnal symptoms
Symptoms as difficulty falling asleep, nocturnal awakenings, early morning
awakening, and perception of poor sleep quality can occur alone or simultaneously.
Additionally, the progression of symptoms and their duration, frequency, and sever-
ity are also part of this evaluation step.
Therapist
Have you been feeling sleepy during the day?
Do you fall asleep easily during the day?
Daytime impairments
According to the International Classification of Sleep Disorders (AASM, 2014),
symptoms such as fatigue, malaise, impairment in attention, concentration or mem-
ory, daytime sleepiness, proneness for errors and accidents, mood disturbance,
social and vocational dysfunction, and reduced motivation make up the diagnosis of
insomnia.
Therapist
Are the negative impacts of the problem broadening or restricting your life?
Are you finding yourself less attentive or struggling to memorize information
that you used to be able to memorize before?
Daytime routine
Considering that sleep is a 24-hour activity, it is necessary to obtain information
about daytime habits, work and/or study routine and hours, practice of physical
activity (time, frequency, and type of exercise), and napping. It is also extremely
important to investigate the use of stimulants such as caffeine and eating habits,
including the times and type of food usually consumed.
Therapist
What activities do you usually perform during the day?
What time do you eat your meals?
At what time of day do you perform physical activity?
Sleep routine
Regarding sleep routine, investigation of the sleeping environment is necessary,
that is, the conditions of the room (luminosity, noise, temperature). It is also impor-
tant to identify everything the client does before going to sleep, including activities
that take place in the bed/room such as reading and use of electronic devices. The
presence of animals in the bed and whether alcohol is consumed close to bedtime
must also be investigated.
It is also important to assess which client behaviors are perpetuating factors of
insomnia, that is, behaviors that may contribute to the maintenance of insomnia
such as going to bed earlier than recommended, napping during the day, increased
use of stimulants and use of an inappropriate type/amount, and avoidance of physi-
cal activity.
The combination of retrospective and prospective measurements is fundamental.
These measurements are part of the initial assessment (see chapter “Evaluation and
Retrospective Measurements”) and substantially contribute to the direction of deci-
sions and evaluation of the effectiveness of the intervention during the course of
treatment.
Therapist
What time do you sleep and wake up during the week and on weekends?
How long does it take you to fall asleep after going to bed?
How long does it take you to get up after waking up?
What activities do you perform before going to bed? What effects do these
activities have on your sleep?
In case you use a hypnotic drug to sleep, what is the dosage, amount, and type
of medication?
What do you do to try to improve insomnia and what are the effects of these
behaviors?
What thoughts about sleep and insomnia run through your head throughout
the day and night?
What do you do when you wake up in the middle of the night?
In addition to the questions suggested in this chapter, the professional can use the
retrospective and prospective measurements described in the next chapters, which
provide data and information that will help with the clinical interview and the
understanding of the case.
7.5 Determination if the Client Is a Candidate

for ACT-Based Therapies for Insomnia
The association between psychological inflexibility and sleep problems suggests

that psychological inflexibility contributes to the maintenance of insomnia (Daly-
Eichenhardt et al., 2016). Most of the insomnia-associated problems are related to
the attempt to control symptoms and to an exaggerated effort to fall asleep. ACT-
based interventions can be useful to reduce the effort to fall asleep by accepting
physiological and bodily arousal. These therapies may also increase adherence to
stimulus control and sleep restriction techniques, which aim to increase the willing-
ness to experience short-term discomfort produced by behavioral techniques
(Dalrymple et al., 2010).
Thus, treating insomnia using an ACT-based intervention is indicated for any
population, that is, there are no populations for which ACT for insomnia could be
harmful. Regarding this theoretical approach, from the time that a certain complaint
produces suffering for the individual, it must become a therapeutic target.
7.6 Course of Treatment
ACT can be applied as monotherapy or in combination with stimulus control and

time-in-bed restriction techniques. For this purpose, the sessions should involve the
revision of tasks and of the sleep diary, psychoeducation about sleep, and behavioral
strategies, as well as the development of psychological flexibility based on the six
processes of ACT.
The ACT protocol for insomnia generally comprises 4–14 weeks, with a duration
of 60–120 min per session (Paulos-Guarnieri et al., 2022). It is important to mention
that ACT addresses complaints beyond sleep; thus, the number of sessions is not
necessarily tied to a fixed protocol and it is up to the clinician to determine the num-
ber of sessions based on the case formulation. Performing assessments throughout
the intervention is important so that the therapist obtains elements as to how the
intervention affects sleep and the relationship that the client has with sleep.
7.7 Determination of Other Treatment Options, If Necessary
The set of techniques that compose the CBT-I protocol have the greatest empirical
support for the treatment of insomnia and are a treatment option for clients with this
complaint. Recently, third-generation behavioral therapies such as mindfulness-
and ACT-based therapies have also provided beneficial results. If the combination of
these therapies does not show benefits, it is important to reassess the variables
involved in the maintenance of the complaint.
The duration of treatment varies from individual to individual and more complex
cases may require a longer duration, with results being obtained in the medium and
long term. In all cases, an inter- and multidisciplinary approach is recommended
along with behavioral therapies for insomnia. Therefore, referral to sleep science
professionals, such as a sleep physician in cooperation with a psychologist, is nec-
essary. In cases in which pharmacotherapy is indicated by the sleep physician, non-
pharmacological interventions in combination with the medication are recommended.
In addition to the psychotherapeutic approach, other interventions such as physical
activity and Tai Chi that have shown benefits for insomnia can be part of the list of
multidisciplinary care and can contribute positively to quality of life and sleep
(Yang et al., 2012; Irwin et al., 2014).
7.8 Conclusion
ACT represents a shift in the insomnia paradigm since it does not focus solely on
the sleep complaint and symptom control but on the client as a whole. Hence, the
focus of ACT is to promote psychological flexibility and quality of life. To intervene
in these aspects and in the variables directly related to sleep, the clinician must
invest in the initial contact with the client, exploring the individual’s life history and
the context of his/her interaction with the complaint. The initial interview is
extremely important since case formulation and therapeutic management will be
established based on the collection of initial information. Therefore, a careful
assessment of the case will improve the therapeutic process.
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Chapter 8
Evaluation and Retrospective
Measurements
Ila Marques Porto Linares and Marwin do Carmo
8.1 Assessment Strategies for Insomnia
Assessment is essential to clinical practice and should be implemented at different

stages throughout insomnia treatment. The assessment must take place before start-
ing treatment for diagnostic purposes; to identify predisposing, precipitating, and
perpetuating factors and to survey the harm associated with insomnia. It is also
necessary to evaluate during the treatment to examine the course of the implemented
intervention and, after the treatment, to reveal the results obtained with the interven-
tion and provide data that support its effectiveness. In this sense, the assessment
serves as a compass to guide clinicians in making decisions.
Pre- and post-treatment assessments of insomnia can be performed retrospec-
tively and prospectively. The retrospective format uses instruments that collect com-
plaints and markers within a time interval before the assessment, that is, the presence
of markers and complaints in recent months. The prospective format refers to the
daily estimates that occur during a specific period, such as using a sleep diary
throughout the intervention.
Although there is no standardized assessment format for complaints related to
insomnia, like any investigative process, it must be composed of different tools to
better track possible elements that outline the complaint in question. Thus, in addi-
tion to anamnesis or clinical history, questionnaires, and scales about sleep specific
to insomnia and other possible clinical conditions and self-registration usually make
up for sleep assessment.
Clinical history characterizes the complaint, whether insomnia is related to dif-
ficulties initiating or maintaining sleep, early awakenings, and mixed conditions.
Additionally, it seeks to understand the impacts and losses resulting from insomnia
and its course, whether continuous, intermittent, or progressive. Comorbidities,
I. M. P. Linares (*) · M. do Carmo

Faculty of Medicine, University of São Paulo, Sao Paulo, Brazil

82 I. M. P. Linares and M. do Carmo
different clinical conditions, medications, day and night activities, pre-sleep rou-
tine, diet, quality of life, and sleep-wake schedules are also essential elements that
should be surveyed (Schutte-Rodin et al., 2008).
Measurement scales for assessing insomnia should not be used as the sole diag-
nostic criteria. Nonetheless, the data obtained using these tools can contribute to this
investigation. The remainder of this chapter describes some scales used to assess the
severity of insomnia, sleep quality, and general sleep complaints. Scales that inves-
tigate chronotypes and other sleep disorders can also be helpful tools at the begin-
ning of an investigative process (the scales described here do not exhaust instruments
available in the literature). A summary of the instruments presented in this chapter
is displayed in Table 8.1.
8.1.1 A Note on Validity1
It is beyond the scope of this chapter to delve into the theoretical and technical
aspects of psychological measurement, as they are thoroughly covered in books
such as Borsboom (2005). However, it is important to note that when choosing a
measurement tool for clinical practice, especially in high-stake settings, it is crucial
to exercise caution and thoughtfulness in the selection process. Despite the simplic-
ity and practicality of self-report instruments, it is not sufficient to simply create or
translate items on the fly to have a valid tool. Instead, there should be evidence that
the instrument can effectively measure the intended construct, as defined by
Cronbach and Meehl (1955) as construct validity. Furthermore, it is essential to note
that validity is not obtained through a single quantitative index but rather through
the accumulation of evidence from various sources that justify the test’s uses and
interpretations (American Educational Research Association, American
Psychological Association, & National Council on Measurement in Education
[AERA, APA, and NCME], 2014).
Unfortunately, not all scales published in scientific journals have undergone rig-
orous construct validation (Flake et al., 2017). Clinicians must make well-informed
decisions when choosing a measurement tool by thoroughly examining the chosen
instrument. Moreover, it helps to clearly understand the construct you want to assess
and its relationship to other variables. To aid in this process, we suggest considering
the following points, inspired by Flake and Fried’s (2020) questions to increase
transparency and avoid questionable measurement practices.
1. Determine whether the authors have clearly defined the measured construct and
all relevant variables and processes.
1
Note that the scales presented in this chapter were not selected because of their validity evidence
quality but by popularity or innovation in clinical and research settings. Readers should judge
the quality matter on their own.
8 Evaluation and Retrospective Measurements 83
Table 8.1 Instruments for assessment of sleep and complementary variables

Number Validation
Test Reference Assesses of items Components sample
Sleep assessment instruments
Insomnia Severity Bastien Patient’s 7 Unidimensional Adults
Index (ISI) et al. perception of (36–52 years)
(2001) their insomnia with insomnia
complaints
Pittsburgh Sleep Buysse Sleep quality 19 Subjective sleep Adults
Quality Index et al. quality, sleep (24–83 years)
(PSQI) (1989) latency, sleep with and
duration, habitual without sleep
sleep efficiency, problem
sleep disturbances, complaints
use of sleeping
medications, and
daytime
dysfunction.
Epworth Johns Level of 8 Unidimensional Adults
Sleepiness Scale (1992) daytime (36–52 years)
(ESS) sleepiness or with and
sleep without sleep
propensity disorders
Stanford Hoddes Sleepiness 7 Unidimensionala Adults over
Sleepiness Scale et al. 18 years old
(SSS) (1972)
Dysfunctional Morin Beliefs, 16 Consequences of Adults
Beliefs and et al. attitudes, insomnia; Worry (20–71 years)
Attitudes About (2007) expectations, about sleep; sleep with insomnia
Sleep Scale evaluations, expectations; symptoms
(DBAS-16) and medication
attributions
about sleep
Sleep Problem Bothelius Acceptance in 8 Activity Adults (mean
Acceptance et al. insomnia engagement and age of 42 years
Questionnaire (2015) willingness and SD = 15)
(SPAQ) with insomnia
complaints
Sleep Acceptance Rafihi- Sleep 6 Avoidance and Adults
Scale (SAS) Ferreira acceptance distress (18–59 years)
et al. with and
(2023) without
insomnia
complaints
Sleep-Related Ree and Safety 32 Unidimensionalb Adults
Behaviours Harvey behaviors in (18–63 years)
Questionnaire (2004) insomnia with and
(SRBQ) without
insomnia
complaints
(continued)
Table 8.1 (continued)

Number Validation
Psychological and psychiatric instruments
Acceptance and Bond et al. Psychological 10 Unidimensional Adults over
Action (2011) flexibility 18 years old
Questionnaire-II across six
(AAQ-II) samples
Brief Experiential Gámez Experiential 15 Behavioral Undergraduate
Avoidance et al. avoidance avoidance, distress students,
Questionnaire (2014) aversion, psychiatric
(BEAQ) procrastination, outpatients, and
distraction/ community
suppression, adults (age
repression/denial, range of
and distress 18–62 years)
endurance
Multidimensional Grégoire Psychological 24 Flexibility and Adults with a
psychological et al. flexibility and inflexibility mean age of
flexibility (2020) psychological 34.2 (SD =
inventory inflexibility 12.4)
(MPFI-24)
Beck Anxiety Beck et al. Anxiety 21 Somatic symptoms Adults with an
Inventory (BAI) (1988) severity and subjective average of
anxiety and panic 35 years with
symptoms affective and
anxiety
disorders
Beck Depression Beck et al. Depression 21 Unidimensional College
Inventory (BDI-II) (1996) severity students and
adult and
adolescent
psychiatric
outpatients
Depression Lovibond Depression, 14 Depression, Adult
Anxiety Stress and anxiety, and anxiety, and stress psychiatric
Scales (DASS-21) Lovibond stress outpatients and
(1995) and nonclinical (age
Antony range of
et al. 18–65 years)
(1998)
The Hospital Zigmond Anxiety and 14 Anxiety and Outpatients
Anxiety and and Snaith depression depression with ages
Depression Scale (1983) between 16 and
(HADS) 65 years
(continued)
Table 8.1 (continued)

Number Validation
Patient Health Kroenke Depression 9 Unidimensional Adults
Questionnaire et al. severity (18 years or
(PHQ) (2001) older), primary
care and
obstetrics-
gynecology
patients
a
MacLean et al. (1992) suggested a two-factor structure for the SSS, although their analysis was
conducted using a modified version of the scale
b
Ree and Harvey (2004) did not attempt to find a factorial structure in their paper, so the one-
dimensionality of the scale was untested
2. Evaluate the quality of the validity evidence provided and consider its applica-
bility in a specific context.
3. Verify that the instrument appears to measure what you intend to measure, as
measures with the same construct name may assess different constructs.
4. Although different versions of the same scale may seem to tap the same con-
struct, differences in item wording, the number of items, or the response format
may convey distinct information.
5. Review the scoring rules provided by the authors and exercise caution if an inter-
pretation of the scores is not provided. Usually, the authors suggest how the
responses should be scored, such as summing the raw scores, averaging the total
score over the number of items, calculating separate component scores, or calcu-
lating a standardized score.
6. If modifying an existing scale, ensure that there is a justification for doing so and
be aware that any further interpretation will have only qualitative value.
It is also important to note that when using an existing psychological instrument
in a distinct context from its original development, it is vital that studies attest to the
construct’s existence and similarity in the new context (Flake et al., 2017). This
process, known as cross-cultural adaptation, requires more than simply translating
the test items and instructions. Herdman et al. (1998) proposed a model that assesses
five types of equivalence in a cross-cultural adaptation study: conceptual equiva-
lence, item equivalence, semantic equivalence, operational equivalence, and mea-
surement equivalence. The absence of such equivalence evidence seriously threatens
the scale validity.
8.2 Sleep-Related Assessment
8.2.1 Sleep Assessment Instruments
–– Insomnia Severity Index (Bastien et al., 2001): The Insomnia Severity Index (ISI)
is a self-reported questionnaire used to measure the severity of insomnia symp-
toms. It consists of seven items that assess the individual’s difficulty initiating
sleep, difficulty maintaining sleep, early morning awakening, dissatisfaction
with sleep, perception of sleep problems by others, impairment of daytime func-
tioning, and the degree of distress caused by insomnia. Each item is rated on a
scale of 0 (no problem) to 4 (very severe problem). The total score ranges from
0 to 28, with scores greater than or equal to 15 indicating the presence of clini-
cally significant insomnia: absence of insomnia (0–7); sub-threshold insomnia
(8–14); moderate insomnia (15–21); and severe insomnia (22–28). The ISI is a
widely used tool in both research and clinical settings to evaluate the severity of
insomnia and monitor changes in symptoms over time.
–– Pittsburgh Sleep Quality Index (Buysse et al., 1989): The Pittsburgh Sleep
Quality Index (PSQI) is a self-reported questionnaire used to measure an indi-
vidual’s sleep quality and patterns. It consists of 19 items that assess 7 compo-
nents of sleep quality: subjective sleep quality, sleep latency, sleep duration,
habitual sleep efficiency, sleep disturbances, use of sleeping medication, and
daytime dysfunction. Each component is scored on a scale of 0 to 3, and the total
score ranges from 0 to 21. Scores greater than or equal to 5 indicate poor sleep
quality, and scores higher than 11 indicate a possible sleep disorder. Examples of
questions from the Pittsburgh Sleep Quality Index (PSQI) include the following:
(1) During the past month, how long (in minutes) has it usually take you to fall
asleep each night? (2) During the past month, how many hours of actual sleep
did you get at night? (3) During the past month, how would you rate your sleep
quality overall? (4) During the past month, how often have you taken medicine
to help you sleep?
8.2.2 Sleepiness and Fatigue Instruments
–– Epworth Sleepiness Scale (Johns, 1992): The Epworth Sleepiness Scale (ESS) is
a self-reported questionnaire used to measure an individual’s level of daytime
sleepiness. It consists of eight items that assess the likelihood of dozing off or
falling asleep in different situations, such as sitting and reading, watching televi-
sion, or sitting inactive in a public place. Each item is rated on a scale of 0 (would
never doze) to 3 (high chance of dozing), with higher scores indicating greater
daytime sleepiness. The total score ranges from 0 to 24, with higher scores indi-
cating more severe daytime sleepiness.
–– Stanford Sleepiness Scale (Hoddes et al., 1972): The Stanford Sleepiness Scale
(SSS) is a seven-point subjective measure of the perception of sleepiness, with
each level representing a different degree of sleepiness. The levels range from 1
(Feeling active and vital, awake) to 7 (No longer fighting sleep, sleep onset
soon). It is a momentary assessment scale and can detect sleepiness as it waxes
and wanes over a day.
8.2.3 Sleep Cognitions and Sleep-Related

Behavior Instruments
–– Dysfunctional Beliefs and Attitudes About Sleep Scale (Morin et al., 2007): The
Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS-16) measures
sleep-disruptive cognitions, such as beliefs, attitudes, expectations, evaluations,
and attributions. Its 16 items were derived from the original 30-item scale and are
rated on an 11-point scale ranging from 0 (strongly disagree) to 10 (strongly
agree). Similar to the original version, the DBAS-16 assumes a four-factor struc-
ture: (a) consequences of insomnia, (b) worry about sleep, (c) sleep expectations,
and (d) medication. Examples of items are as follows: (1) When I sleep poorly on
one night, I know it will disturb my sleep schedule for the whole week. (2) Without
an adequate night’s sleep, I can hardly function the next day. (3) I have little
ability to manage the negative consequences of disturbed sleep. (4) I am worried
that I may lose control over my abilities to sleep.
–– Sleep Problem Acceptance Questionnaire (Bothelius et al., 2015): The Sleep
Problem Acceptance Questionnaire (SPAQ) is a self-assessment tool designed to
evaluate individuals’ acceptance of their sleep issues. As a relatively new mea-
sure, it comprises eight items that assess two factors—Activity Engagement and
Willingness. Activity Engagement pertains to the extent of an individual’s persis-
tence in carrying out routine activities despite dissatisfaction with their sleep
quality. On the other hand, Willingness captures the individual’s ability to give
up the struggle to control and overcome sleep problems. Each item is rated on a
7-point Likert scale, with 0 indicating “Disagree” and six signifying “Completely
agree.” The total score ranges from 0 to 48, with Willingness items scores being
reversed. A higher score implies a lower acceptance of sleep problems. The
SPAQ can provide insight into how acceptance of sleep problems may affect
treatment outcomes and overall quality of life. The SPAQ includes items such as
(1) Although things have changed, I am living a normal life despite my sleeping
problems. (2) My life is going well, even though I have sleeping problems. (3) I
need to concentrate on getting rid of my sleeping problems. (4) It’s important to
keep on fighting these sleeping problems.
–– Sleep Acceptance Scale (Rafihi-Ferreira et al., 2023): The Sleep Acceptance
Scale (SAS) is a brief self-assessment tool for adults to measure their acceptance
of sleep problems. It comprises six items, rated on a scale that ranges from 1
(never) to 7 (always), where higher scores indicate lower acceptance of sleep

problems. The questionnaire is divided into two dimensions: Avoidance (two
items) and Distress (four items). Some of the SAS items are as follows: (1) I
avoid making plans or doing things I enjoy or need to do because of my sleep. (2)
The thought of going to sleep makes me uneasy. (3) I have negative feelings
towards my sleep. (4) I am scared of not being able to fall asleep.
–– Sleep-Related Behaviours Questionnaire (Ree & Harvey, 2004): The Sleep-
Related Behaviours Questionnaire (SRBQ) is a self-report measure comprised of
32 items assessing safety and avoidance behaviors related to sleep problems.
Each item is rated on a scale of 0 (Almost never) to 4 (Almost always), where
higher scores indicate a greater frequency of sleep-related safety behaviors. The
following items are a sample of the behaviors to cope with tiredness or improve
sleep assessed by the SRBQ: (1) I spend time considering ways to improve sleep.
(2) I reduce my expectations of what I can achieve. (3) I give up trying to work.
(4) I keep busy to stop thinking about my sleep.
8.2.4 Complementary Instruments for Psychological

and Psychiatric Assessment
Psychological and psychiatric aspects, such as anxiety and depression, are recur-
rently present in the diagnosis of insomnia, acting as part of the cause or by-product
of the sleep disorder in question. Therefore, to effectively assess insomnia, it is
important to investigate impairments associated with daytime functioning and other
relevant factors related to the reported sleep complaint. The following instruments
are presented as examples. We describe tools to assess anxiety, depression, and ACT
processes, such as psychological inflexibility, flexibility, and acceptance. However,
it should be noted that they do not encompass the entirety of the literature; for
example, measures such as the State-Trait Anxiety Inventory (STAI) and the Quality
of Life Scale (SF-36) are not mentioned.
8.2.4.1 Psychiatric Instruments
–– Beck Anxiety Inventory (Beck et al., 1988): The Beck Anxiety Inventory (BAI) is
a self-report inventory that assesses the severity of anxiety symptoms in adults.
The inventory consists of 21 items, each of which asks the individual to rate the
intensity of a specific symptom or feeling of anxiety during the past week on a
4-point scale (0–3) where 0 = not at all, 1 = mildly, 2 = moderately, 3 = severely.
The items assess common anxiety symptoms such as numbness or tingling, trem-
bling hands, fear of dying, and indigestion. The total score ranges from 0 to 63,
with higher scores indicating greater severity of anxiety symptoms. The BAI
manual recommends the classification of anxiety levels as minimal anxiety (0 to
7), mild anxiety (8 to 15), moderate anxiety (16 to 25), and severe anxiety
(26 to 63).
–– Beck Depression Inventory (Beck et al., 1996): Similar to the BAI, the Beck
Depression Inventory (BDI) is also a 21-question multiple-choice self-report,
rated on a Likert scale from 0 to 3, using the same anchors. The BDI is designed
to assess the severity of depression symptoms in individuals older than 13 years.
Its total score ranges from 0 to 63, with higher scores indicating greater severity
of depression symptoms. A recommended cut-off point is 0–13 for minimal
depression, 14–19 for mild depression, 20–28 for moderate depression, and
29–63 for severe depression. The items assess symptoms such as sadness, pes-
simism, loss of pleasure, and suicidal thoughts.
–– Depression Anxiety and Stress Scales (Lovibond & Lovibond, 1995; Antony
et al., 1998): The Depression Anxiety Stress Scales (DASS) is a set of three self-
report measures designed to measure the three related negative emotional states
of depression, anxiety, and stress. Each of the three scales contains 14 items,
rated on a four-point Likert scale from 0 (did not apply to me at all) to 3 (applied
to me very much or most of the time), in which respondents rate the frequency
and severity of psychological distress experienced in the last week. The DASS is
also available in a shorter version with 21 items, referred to as DASS21, that
assesses the same constructs but with seven items per scale. The DASS was
developed with nonclinical samples with participants 17 or older. The following
items are a sample of each DASS scale: I found it hard to wind down (stress), I
was aware of dryness of my mouth (anxiety), and I couldn’t seem to experience
any positive feeling at all (depression).
–– Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983): The Hospital
Anxiety and Depression Scale (HADS) is a self-reported questionnaire used to
measure anxiety and depression symptoms. It consists of 14 items, seven assess-
ing anxiety symptoms and the other seven assessing depression symptoms. All
its 14 items refer exclusively to the emotional state and do not reflect somatic
symptoms. Participants rate each item on a 4-point Likert scale, with higher
scores indicating greater symptom severity. The global score in each subscale
ranges from 0 to 21, and scores greater or equal to 9 may reveal the presence of
anxiety/depression. Two Depression items are I still enjoy the things I used to
enjoy, and I have lost interest in my appearance, whereas two Anxiety items are
Worrying thoughts go through my mind and I feel tense or “wound up.”
–– Patient Health Questionnaire (Kroenke et al., 2001): The Patient Health
Questionnaire (PHQ) is a self-reported questionnaire used to assess the severity
of depression symptoms over the last 2 weeks. Each of its nine items assesses a
specific symptom of depression, such as loss of interest or pleasure, feelings of
hopelessness, and difficulty sleeping. Items are rated on a 4-point Likert scale
(0 = Not at all, 4 = Nearly every day), with higher scores indicating greater
symptom severity. The suggested classification of depression severity based on
the total score is 0–4 = None-minimal, 5–9 = Mild, 10–14 = Moderate, 15–19
Moderately Severe, and 20–27 = Severe. The items request the respondent to rate
the frequency of problems such as Little interest or pleasure in doing things,

Feeling tired or having little energy, or Trouble concentrating on things.
8.2.4.2 Psychological Instruments
–– Acceptance and Action Questionnaire-II (Bond et al., 2011): The Acceptance

and Action Questionnaire-II (AAQ-II) is a self-report measure that assesses an
individual’s level of psychological flexibility. The measure comprises ten items,
rated on a 7-point Likert scale (1–7) where one represents “never true,” and seven
represents “always true.” The items are designed to assess an individual’s ability
to accept painful experiences, memories, feelings, and worries without getting
caught up in them and to take action that is consistent with their values. The
scores for each question are then added together to obtain a total score. A higher
total score indicates a lower level of psychological flexibility. It should be noted
that the AAQ-II has a unidimensional structure, meaning that it only yields gen-
eral scores and does not provide specific scores for different dimensions of psy-
chological flexibility.
–– Brief Experiential Avoidance Questionnaire (Gámez et al., 2014): The Brief
Experiential Avoidance Questionnaire (BEAQ) is a measure of experiential
avoidance assessing avoidance of pain, uneasiness, effort, upset, unpleasantness,
discomfort, emotions, painful emotions, feelings, bad feelings, upsetting feel-
ings, fear/anxiety, unpleasant memories, and doubts in 15 items. The items are
rated using a 6-point Likert scale from 1 (strongly disagree) to 6 (strongly agree).
It was developed as a brief alternative to the Multidimensional Experiential
Avoidance Questionnaire (MEAQ; Gámez et al., 2011) to be used in situations
where the length of the 62-item version could be an issue. The brief version was
shown to replicate the good psychometric properties found in the MEAQ.
–– Multidimensional Psychological Flexibility Inventory Short Form (Grégoire
et al., 2020): The Multidimensional Psychological Flexibility Inventory
(MPFI-24) is a self-reported assessment tool that evaluates psychological flexi-
bility and psychological inflexibility. It was first conceived with 60 items (Rolffs
et al., 2016) and later adapted as a 24-item scale to help clinicians and research-
ers assess the full complexity of the Hexaflex model with a shorter but compre-
hensive tool. The MPFI-24 has two general factors of flexibility and inflexibility,
each assessing 12 distinct processes.
8.3 Conclusion
As previously described, qualitative and quantitative methods for assessing sleep,

such as scales, questionnaires, and sleep self-reports, are very important for direct-
ing clinical interventions. Endorsing their relevance are the low cost, their
non-invasive nature, and the possibility of detailing the complaint. However, the
choice of elements that compose the assessment requires analysis of what is sought
to be investigated in each case; therefore, an individualized view of each patient is
essential. In this sense, it is necessary to understand why, for what, and how to use
assessment instruments.
It is worth mentioning that scales, questionnaires, and self-registration also have
limitations, such as the lack of continuity, recall bias, subjectivity, and lack of well-
validated measures. In turn, objective tools such as actimetry offer greater precision
in the data collected; however, they cost significantly more and require professional
specialization. Additionally, in isolation, these assessment tools are insufficient to
understand the variables that precipitate and perpetuate insomnia.
Finally, developing more assessment tools can improve and optimize the process
of understanding the sleep pattern, diagnosing possible disorders, and enhancing the
accuracy of the choice of intervention based on a particular complaint. In any case,
these tools only contribute to the data collection, which must be duly analyzed by
the clinician.
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Chapter 9
The Role of Actigraphy and Sleep Diaries
in Assessing Sleep in Adults with Insomnia
Maria Laura Nogueira Pires
9.1 Actigraphy: Basic Concepts
When individuals are awake, they are frequently moving. When individuals are
sleeping, movements are almost absent and they are characterized by low level of
activity. Actigraphy is a technology that allows the objective quantification of move-
ment level continuously over time by means of acceleration sensors built in a small
watch-like device called actigraphy. The device is frequently worn on the wrist
while the person behaves in its natural environment over an extended period of
days, as one week or even longer depending on the clinical.
In an updated report by the American Academy of Sleep Medicine, actigraphy in
patients with insomnia showed to be consistent with polysomnography and more
sensitive than sleep logs which supported its use in insomnia evaluation (Smith
et al., 2018). The experts recognize that, although objective monitoring is not
required in daily practice, actigraphy may be a useful tool in various clinical con-
texts, such as differential diagnosis from suspect case of circadian rhythm sleep
disorders or paradoxical insomnia, in order to objectively evaluate treatment
response and when self-records are unreliable or burdensome.
9.2 Actigraphy: Basic Technological Features
There are several types of commercial monitors available on the market and Fig. 9.1
show an actigraphy by Condor Instruments which record motion in three axes (x-,
y-, and z-axis are illustrated in Fig. 9.1). Current models of monitors are equipped
M. L. N. Pires (*)
São Paulo, Brazil

94 M. L. N. Pires
Fig. 9.1 Actigraphy model

by Condor Instruments.
(Source: Author)
with memory with the ability to record motor activity over extended periods of time,
such as weeks and months. Movement data are saved after they are processed with
filters to remove the gravity bias on each axis and raw accelerometer output is
expressed in arbitrary units referred to as “counts”. The activity counts are usually
stored in 1-min epochs and a reader device is used to transfer data from actigraphy
to computer for analysis using the manufacture’s software algorithm.
Most actigraphy devices have an event marker button on their surface and patients
can be instructed to press it to inform when specific events happened during the day
such as to mark bedtime, wake time and night awakenings (Fig. 9.1). The event
marker is thought to have higher accuracy than the sleep diary since the last requires
the patient to check the time and remember it in the following morning. Light sen-
sors are also available in current models and can be used to identify light exposure
levels during the day and night (Fig. 9.1).
9.3 Clinically Relevant Actigraphic Measures
The inference of sleep and wakefulness states from the activity is done using an
algorithm available in proprietary software. The Cole–Kripke (Cole et al., 1992) is
a well-established and validated algorithm used to score actigraphy data collected in
the adult population and it classifies each epoch as “sleep” or “wake” based on
activity counts of that epoch of interest and nearest epochs.
It is from the rest period segment (the sleep period) that the proprietary-automated
software derives multiple sleep variables corresponding to the measurements
9 The Role of Actigraphy and Sleep Diaries in Assessing Sleep in Adults with Insomnia 95
Fig. 9.2 Example actogram of a patient with insomnia. The record was made with ActTrust actig-
raphy (Condor Instruments) and analyzed with ActStudio software. (Source: Author)
obtained by polysomnography, the gold standard of sleep assessment (Fekedulegn

et al., 2020). The software automated identification of the start and end of the rest
interval, however, may be imprecise since it is based solely on activity data. It can
be improved by manual adjustments made by the scorer using the light sensor and
the event button (Ancoli-Israel et al., 2015). The end points of the rest interval can
be more accurate when manually demarcated by the abrupt and sustained changes
in activity levels (when the wearer lie down in bed attempting to sleep and when he
gets out of bed to start the day) and light exposure (lights are turned off/turned on)
combined with the time stamps from the event button signalizing the patient’s inten-
tion to sleep or when he gets out of bed to start the day (see Fig. 9.2). Supplemental
information can also be obtained from sleep diary and questions about non-wear
periods, bedtime and get up time and day issues (e.g., if it was a typical day/night or
not) can assist the scorer to data editing, such as manual trimming, defining rest
interval, and excluding off-wrist periods from analyses.
Actigraphic estimates have been used to objectively assess the multi-dimensional
construct of “sleep health” (Chung et al., 2021), including sleep timing (when
patient typically had his major sleep episode), duration (how long the patient sleep
during the day), regularity (day-to-day variability in sleep timing and/or sleep dura-
tion), efficiency (sleep quality), and alertness/sleepiness (wakefulness during day-
time). Definitions of the main sleep and rhythmicity variables derived from
actigraphy are shown in Box 9.1 together with their proposed cutoff values (Natale
et al., 2014; Fekedulegn et al., 2020; Chung et al., 2021).
96 M. L. N. Pires
Box 9.1: Definitions of the Main Actigraphic Variables and Proposed

Cutoff Values
1) Sleep timing
When the patient typically sleeps?
Variables
Bedtime: hour and minute when the patient lies down in bed with the
intention of sleeping and turns the light out.
Get up time: hour and minute when the patient gets out of bed to start
the day.
Time in bed (TIB): time from bedtime to get up time.
2) Sleep duration and efficiency (quality)
Does the patient have difficulty falling asleep? Does the patient have
difficulty to maintain sleep, with frequent and/or long awakenings?
There is a significant variability in awakenings from night to night?
Does the patient spend too much time in bed relative to time spend
sleeping? There is sufficient total sleep time?
Variables
Sleep onset latency: time between bedtime and sleep onset, usually
defined as the first epoch scored as asleep by the algorithm. Cutoff
value: less than 15 min.
Total sleep time (TST): time scored as sleep during time in bed (TIB
minus sleep latency + WASO). Cutoff value: 6–8 h/night.
Sleep efficiency: proportion of time in bed spent asleep (TST/TIB,
expressed as %). Cutoff value: greater than or equal to 85%.
Wake after sleep onset (WASO): time spent awake between sleep onset
and sleep offset. Cutoff value: equal or less than 20 min.
3) Sleep regularity and rhythmicity:
There is a significant variability in bedtime/wake time from one day to
another?
Variables
Sleep onset and offset regularity: standard deviation calculated across
days of less than 30 min.
Sleep duration regularity: standard deviation calculated across days of
less than 60 min.
Interdaily stability (IS): estimates the stability of the rest-activity rhythm
across days. Scores range from 0 to 1, and higher values indicate better
synchronization and a more stable rhythm.
(continued)
Box 9.1 (continued)

4) Alertness/sleepiness
Naps can be defined as sleep intervals longer or equal to 20 min in dura-
tion within a 24-h day. Are naps frequent? How long they usually last?
Do they typically occur at certain time during the day or they are more
frequently on weekends? Is there an association between naps and noc-
turnal sleep quality or duration?
Variables
Frequency of days napped; frequency of naps on a given day(s) or week,
duration, and timing (evening and/or day).
Source: Author
9.4 Actogram
An actogram is the graphic representation of the activity over time and Fig. 9.2
shows the sleep pattern of a 60-year-old patient. Consecutive days are plotted on the
vertical and time of day is plotted on the horizontal axis. Sleep was assessed with
the ActTrust actigraphy (Condor Instruments) and analyzed with ActStudio soft-
ware, Cole-Kripke algorithm. The patient wore the actigraphy on the nondominant
wrist for 8 consecutive days. He was instructed to press the event button when get-
ting into bed with the intention to sleep, when got up in the morning, and during the
watch removal. The end points of the nocturnal rest interval were manually selected
taking in account data from activity and light sensors and event marker. Each verti-
cal line indicates the activity level on the 1-minute epoch (higher the activity level,
higher the amplitude of the line). Nocturnal rest intervals are identified in light blue
and segments of watch removal in purple color.
Visual inspection of this recording shows a stable timing of sleep periods and
sleep interrupted by awakenings. No naps. His usual bedtime is 22:08 (SD of
18 minutes; ranging from 21:32 to 22:34), he had no difficulty in falling asleep, tak-
ing an average of 7 min to fall asleep, and wake time is typically at 05:46 (SD of
17 minutes; ranging from 05:23 to 06:15), with a mean time in bed of 07:38. The
interdaily stability index (IS) was 0.62, indicating stability of the sleep-wake cycle.
However, sleep was characterized by activity of high amplitude and fragmented
by awakenings (mean WASO of 58 minutes, ranging from 00:39 to 01:26), average
sleep efficiency of 85% (ranging from 79% to 90%), and total sleep time of 06:29
(SD of 27 minutes, ranging from 05:51 to 07:30).
Together, these findings are compatible with low day-to-day variation in sleep
duration and timing, adequate sleeping time and insomnia characterized by difficul-
ties of maintaining sleep and low sleep quality.
98 M. L. N. Pires
9.5 Clinical Actigraphy Report
The clinical actigraphy report is the document that describe the patient’s character-
istics, reasons for the exam, technical specifications, and data interpretation. When
actigraphy is used for clinical purposes as assessing sleep of patients with insomnia
(and other sleep disorders), the report should ideally be elaborated and signed by
health professionals who have qualification in mental health care, such as psycholo-
gists and physicians, with expertise in sleep science and tools for insomnia diagno-
sis and evaluation. Basic reporting guidelines for actigraphy report is shown in
Box 9.2.
Box 9.2: Basic Guidelines for Elaborating an Actigraphy Report

1) Identification and reasons
–– Patient data: name, sex, age; local.
–– Identification of the requesting professional; reasons for the examina-
tion (complementary to the diagnosis, treatment planning, follow-
up, etc.)
–– Identification of the health professional who analyzed the record.
2) System information
–– Actigraph manufacturer and model; software used; scoring algorithm.
3) Data collection and processing
–– Site of use: dominant/nondominant wrist.
–– Record duration: start and end date; number of days analyzed; number
of days excluded from analysis and reasons.
–– Quality of the record: removals from the device, presence of events that
influenced the quality of the record, technical failures of the device,
presence of artifacts.
–– Description of data cleaning/editing.
4) Scoring procedures
–– Procedure for determining rest intervals (manual and/or automated by
the software).
–– Definition of sleep and circadian measures and cutoff values, when
applicable (bedtime, wake time, time in bed, sleep onset latency, WASO,
sleep efficiency, total sleep time, and interdaily index).
5) Analysis
–– Description of results by measures of central tendency (mean; median)
and variability (standard deviation; range); when necessary, consider
separated analyzes for work and non-working days.
(continued)
Box 9.2 (continued)

–– Inform main findings in light of the reasons for the examination and
patient specificities; duration, quality, and regularity of sleep; daytime
activity pattern and rhythmicity; additional considerations; limitations.
–– Summary.
Source: Author
9.6 Instructions for Use
The overall quality of the exam depends heavily on the instructions given to the
patient. The starting point is to explain, in clear and context-appropriate language,
the general technical aspects of actigraphy and the objectives of the exam. A basic
characteristic to be clarified is that it is fundamentally a device equipped with an
accelerometer that will measure movements during continuously and with that it
will be possible to estimate the timing, duration, and quality of sleep and the sleep
pattern across consecutive days.
The patient should be instructed to wear the device on the nondominant wrist,
like a watch, in a comfortable way, without looseness or tightness. The precautions
to be taken are the same as with any watch and, as they are expensive equipment,
care must be taken to ensure that they are not damaged or lost. Thus, patients should
be instructed not to use the device in risk situations such as during vigorous activi-
ties as is the case of running, gym training, and similar situations.
Most devices are water resistant. Thus, the patient must be aware that it is okay
to use it during everyday activities such as washing hands or while showering.
However, if the device is not waterproof, it must be removed in case of immersion,
as is the case of swimming pools, bathtubs, and similar situations.
Current devices have light and body temperature sensors. In these cases, the
patient must be informed that the light sensor will help to know the pattern of light
exposure throughout the day. As the light sensor is located on the external surface of
the device, it is important to guide the patient to avoid covering it with clothing. The
body temperature sensor, in turn, is located at the bottom, in contact with the skin,
with no need for specific guidance beyond explaining its function.
Some models have an event button on their surface that, when pressed, makes a
mark in the record. This functionality is valuable to inform the moments that certain
events happen during the day (bedtime, wake time, naps, medication time, etc.).
Instructions should be provided in writing so that the patient can refer to them when
needed. Finally, it is important to guide how to proceed in case of doubts (Box 9.3).
100 M. L. N. Pires
Box 9.3: Basic Instructions on How to Wear an Actigraphy

Actigraphy is an easy way to know the pattern and quality of your sleep.
The actigraph is a device that measures movement and you should wear it on
your nondominant wrist like a watch, day and night, for _____ days.
The actigraph wristband should fit snugly around the wrist, without being
loose or tight.
The device is water-resistant, so it doesn’t matter if it gets wet when you wash
your hands or while showering. But it must be removed when you go
swimming or bathing.
This device is expensive. Be careful not to lose it and do not use it in places
where there is such a risk.
Remove the device during vigorous physical activity such as jogging, sports,
or when going to the gym.
On the surface of the device there is a sensor that measures the ambient light.
Avoid covering the sensor with clothing. You can pull or fold the sleeve.
When to push the button?
The actigraph has a button on its surface and when pressed it makes a mark on
the record. Press the button:
1. When to go to bed, turn off the light and try to sleep.
2. Upon waking up in the morning and getting out of bed.
3. When napping.
If you forget to press the button, don’t worry. Press the button on the next
occasion.
If you have any questions, please contact: ______________
Source: Author
9.7 Sleep Diaries
Sleep diaries have been extensively used as a valuable and low-cost tool in research
and clinical practice to gather subjective sleep to help with diagnosis and treatment of
insomnia. The use of smartphone is now widespread and this paved the way for elec-
tronic sleep diaries. Digital sleep diaries have gained popularity over the pen-and-
paper diaries: they are less time-consuming for filling, the format prevent input errors,
data from several days or weeks are calculated automatically by the application (app),
and the clinician have access to visual representation of data which facilitates an accu-
rate interpretation of the patient’s sleep. Nowadays there is a variety of apps options
in the market (i.e., Apple Store and Google Play Store), but models that do not display
the sleep estimates to users (patients) seems to be preferred for use in clinical settings.
In order to help with sleep monitoring, a standardized sleep diary, termed
Consensus Sleep Diary (CSD), was suggested by an international panel of insomnia
experts (Carney et al., 2012). The expanded version of the CSD also asked the
patient to give his best estimate about how long did he sleep. Although the CSD
generates two different total sleep time values, indicated by the patient and calcu-
lated, total sleep time has been shown to be a more accurate measure to distinguish
patients with insomnia from normal sleepers when indirectly calculated from a set
of items (time in bed, sleep onset latency, wake after sleep onset, and terminal awak-
ening) rather by a single item (Natale et al., 2015). However, there may be clinical
situations where comparisons between values can be useful as in case of patients
who have difficulties in identifying their own sleep pattern.
Initially developed to be used in clinical research with adults with insomnia at
Institute of Psychiatry, University of São Paulo, Brazil (Renatha Rafihi-Ferreira,
personal communication), a digital sleep diary based on CSD from Condor
Instruments (Condorinst.com) also have additional items about naps, use of sleep-
ing medication and if a given day is working day or not that is highly useful for
clinical purposes (Fig. 9.3 and Table 9.1).
Fig. 9.3 Screenshot of digital sleep diary from Condor Instruments. (Source: Author)
102 M. L. N. Pires
Table 9.1 Digital sleep diary by Condor Instruments: items, response format, sleep diary variables
calculations and cutoff values proposed by Natale et al. (2015)
Sleep diary items Response format
1. What day are we talking about? Month/day/year
2. In total, how long did you sleep last night? hh:mm
3. What time was your final awakening? hh:mm
4. What time did you get out of bed for the day? hh:mm
5. What time did you get into bed? hh:mm
6. What time did you try to go to sleep? hh:mm
7. How long did it take you to fall asleep? hh:mm
8. How many times did you wake up, not counting your Number
final awakening?
9. In total, how long did these awakenings last? hh:mm
10. How satisfied are you with your sleep? Rating scale ranging from “little” to
“much”
11. How many times did you nap or doze yesterday? Number
12. How long did the naps or dozes last? hh:mm
13. Did you take any medication(s) to help you sleep? Number
14. If so, list medication(s), dose, and time taken Free text
15. Is today a working day (work, study, etc.)? No/yes
16. Do you have anything to say? Free text
Sleep diary variables calculations and cutoff values Diary item
A) Time in bed (TIB) Item 4–6
B) Sleep onset latency (SOL) Item 7
Cutoff value: ≤ 16 min
C) Wake after sleep onset (WASO) Item 9
D) Terminal awakening (TWAK) Item 4–item 3
E) Total sleep time—Calculated (TSTc) TIB minus –(SOL + WASO + TWAK)
F) Sleep efficiency—Calculated (SEc) (TSTc/TIB)*100
Cutoff value: 87.5%
Source: Author
It should be kept in mind that there may be circumstances where a paper-based

sleep diary is still the best option, or the only one. Table 9.2 shows an example of a
sleep diary for recording time in bed, sleeping difficulties, presleep activities, fac-
tors disturbing sleep, and the patient’s perception of restorative sleep.
Table 9.2 Example of paper-based sleep diary

Day 1 Day 2 Day x
dd/mo dd/mo dd/mo
Write down the date and day of the week ........ ........ .......
1. What time did you get out of bed for the hh:mm hh:mm hh:mm
day?
2. What time did you turn off the light and try hh:mm hh:mm hh:mm
to sleep last night?
3. Did you have difficult falling asleep last ( ) no ( ) no ( ) no
night? ( ) yes ( ) yes ( ) yes
4. Did you have difficult staying asleep last ( ) no ( ) no ( ) no
night? ( ) yes ( ) yes ( ) yes
5. Did you wake up earlier than planned and ( ) no ( ) no ( ) no
you were unable to fall back to sleep? ( ) yes ( ) yes ( ) yes
6.What activities you did during the two ( ) alcohol ( ) alcohol ( ) alcohol
hours before going to sleep last night? Tick ( ) caffeine ( ) caffeine ( ) caffeine
all that apply ( ) heavy meal ( ) heavy meal ( ) heavy meal
( ) exercise ( ) exercise ( ) exercise
( ) other:.......... ( ) other:.......... ( ) other:..........
7. What activities you did shortly before ( ) paper ( ) paper ( ) paper
turning off the light and trying to sleep last reading reading reading
night? Tick all that apply ( ) cell phone ( ) cell phone ( ) cell phone
( ) computer ( ) computer ( ) computer
( ) work/study ( ) work/study ( ) work/study
( ) watch TV ( ) watch TV ( ) watch TV
( ) sleeping ( ) sleeping ( ) sleeping
med med med
() () ()
other:........... other:........... other:...........
8. Did you nap yesterday? Tick all that apply ( ) no nap ( ) no nap ( ) no nap
( ) morning ( ) morning ( ) morning
nap nap nap
( ) afternoon ( ) afternoon ( ) afternoon
nap nap nap
( ) night nap ( ) night nap ( ) night nap
9.Was your sleep disturbed last night? Write
down the mental/physical/environmental
reasons (noise, brightness/temperature,
snoring, pain, nightmare, stress, worries,
anxiety, restlessness, etc.)
10. How rested did you feel when you get up 1 = not at all 1 = not at all 1 = not at all
and start the day? 2 = a little bit 2 = a little bit 2 = a little bit
3 = somewhat 3 = somewhat 3 = somewhat
4 = very much 4 = very much 4 = very much
5 = completely 5 = completely 5 = completely
Source: Author
104 M. L. N. Pires
9.8 Final Considerations
Actigraphy and sleep diaries have been proven as useful tools in clinical practice for
longitudinal assessment of sleep in patients with insomnia with benefits for diagno-
sis formulation and monitoring treatment response. The choice should rely on the
balance between several factors including patient’s preference, less cumbersome
alternative, patient’s ability to give accurate information and costs.
References
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The SBSM guide to actigraphy monitoring: Clinical and research applications. Behavioral
Sleep Medicine, 13(Suppl 1), S4–S38.
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Morin, C. M. (2012). The consensus sleep diary: Standardizing prospective sleep self monitor-
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health in a diverse, aging adult cohort: Concepts, advances, and implications for research and
intervention. Sleep Health, 7, 699–707.
Cole, R. J., Kripke, D. F., Gruen, W., Mullaney, D. J., & Gillin, J. C. (1992). Automatic sleep/wake
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Part III
Behavioral Treatment for Insomnia
Chapter 10
Sleep Hygiene
Renatha El Rafihi-Ferreira and Andrea Cecilia Toscanini
10.1 Sleep Environment
The bedroom, that is, the environment where individuals sleep, must be their place
of physical and emotional recovery. Therefore, factors such as comfort, lighting,
temperature, and sounds and noise must be considered when preparing the sleeping
environment. Box 10.1 reports guidelines that address these factors.
Box 10.1 Guidelines on the Sleep Environment

Comfort
The bedroom should be comfortable, making it a sleep sanctuary. Thus, the room should
be clean, airy, and organized. All these recommendations should be adapted to each
patient’s socioeconomic reality.
• The mattress needs to be suitable for the patient’s needs and medical conditions such
as pain, rheumatological diseases, or any other clinical or orthopedic condition.
• Bed linens must also provide comfort and must be appropriate for seasonal
temperatures.
• Pillow height should be equal to the distance from neck to shoulder in order to ensure
that the spine is aligned during sleep.
Lighting
(continued)
Department of Clinical Psychology, University of São Paulo, Sao Paulo, Brazil
A. C. Toscanini
Sleep Ambulatory (ASONO) at the Clinics Hospital of the University of São Paulo,
Sao Paulo, Brazil
108 R. El Rafihi-Ferreira and A. C. Toscanini
Box 10.1 (continued)

The sleep environment must be bright and airy during the day and dark at night.
• To keep the room dark, blackout curtains and a closed door can help maintain
adequate lighting. When adjusting room light is not possible, sleep masks could be an
effective option to reduce light exposure.
• The use of electronic devices such as cell phones, tablets, notebooks, computers, and
TVs before going to bed should be discouraged. Light emission, especially blue light,
from the screen of these devices can compromise sleep onset latency. Thus, we
recommend avoiding their use at least 1 hour before going to bed and preferentially
keep them out of the bedroom.
Important: If the person commonly gets up during the night, night lights may be used to
avoid accidents.
Temperature
The room should have a pleasant temperature to avoid thermal discomfort during sleep.
High or very low temperatures compromise central thermoregulation that occurs during
sleep, triggering nocturnal arousals that could result in sleep fragmentation with daytime
and nighttime consequences. Hence, precautions are necessary such as the use of
appropriate pajamas for the season and expected temperature, as well as appropriate bed
linens. If there is disagreement between bed partners, separate bedding is an option,
keeping the global temperature neutral in the case of air conditioning, a fan, or similar.
Sounds and noise
A quiet environment contributes to the quality of sleep. Sounds and noises can cause
microarousals with daytime consequences. Closing the door and wearing earplugs can
help maintain silence.
10.2 Eating Habits
Food and substance consumption can also affect sleep. Guidelines on eating habits
and substance use are shown in Box 10.2.
10 Sleep Hygiene 109
Box 10.2 Food Consumption and Substance Use Guidelines

Food
• Going to bed after overeating or feeling hungry can interfere with adequate rest.
Choose a light dinner and easily digestible foods such as fruits and cereal bars before
going to bed.
• Hard-to-digest or high-fat foods may be associated with circadian rhythm disruptions.
Trying to sleep after eating large portions of fatty foods can be uncomfortable and
also interfere with rest. Excess protein, especially red meat, can slow digestion and
consequently compromise the rapid response to sleep. Thus, avoid high-fat and
hard-to-digest foods at dinner.
Fluids
• Although water consumption is always encouraged, drinking water before going to
bed can increase nocturnal awakenings due to the need to go to the bathroom. Thus,
reduce fluid intake 1–2 hours before going to bed.
Stimulants
• Nicotine is a stimulant that compromises sleep quality. Avoid smoking at night and
nicotine consumption at least 4–6 hours before going to bed.
• Caffeine acts on the central nervous system, remaining in the body for a few hours,
and promotes a state of mental alertness and influences psychomotor and cognitive
performance. Products containing caffeine can increase sleep latency causing
difficulty in initiating and maintaining sleep, compromising overall sleep quality.
Thus, avoid the consumption of caffeinated products at least 6 hours before going to bed.
Products containing caffeine include coffee, soft drinks, and chocolate. Caffeine is also
present in white tea, yellow tea, green tea, black tea, and other dark teas. Hence, choose a
relaxing beverage before going to bed.
Alcohol
• Avoid consuming alcohol, especially at night. Although alcohol causes muscle
relaxation, which can lead to a feeling of sleepiness, its activity on the central
nervous system is stimulating and can inhibit an adequate sleep rhythm. Alcohol
consumption before going to bed is associated with fragmented sleep, including
microarousals during the night.
10.3 Routine
Daytime routine is key to achieve quality sleep. The activities we perform during
the day can also influence our night. Therefore, having regular times for these activ-
ities is fundamental and helps our body to understand that the time for relaxation
will come soon. Routine guidelines are presented in Box 10.3.
Box 10.3 Daytime Routine Guidelines

Regular schedules
• Consistent bedtime and wake-up times contribute positively to circadian rhythm
regularity. Set the alarm to go off at the same time every day, preferably including
weekends.
• Eat meals at the same times and also have regular schedules for work, study, and other
activities.
• Perform mental and physical activities on a regular basis.
Physical activity
• Practice physical activity preferably in the morning (except if you have a late
chronotype). Physical activity induces an increase in cortisol secretion. Thus, in the
morning, it can favor a state of alertness to spend the day without sleepiness.
However, physical activity close to bedtime can affect the ability to fall asleep. Avoid
exercising during the hours before going to bed.
Sunlight
• Sunlight is an important regulator of the biological clock and we can use it to our
advantage if we regularly expose ourselves to light in the morning. Therefore, reserve
at least 30 minutes daily for sun exposure in the morning.
Naps
• Daytime naps can lower sleep pressure by delaying the nighttime sleep schedule.
Hence, avoid daytime napping. Staying awake throughout the day can make it easier
to fall asleep at night.
10.4 Sleep Ritual
A sleep ritual consists of a set of activities that precede sleep and should be com-
posed of elements that give you pleasure and peace of mind. The activities must
occur every day so that the body understands that it is time to sleep based on these
activities. It is important that the pre-sleep ritual starts about 40–60 minutes before
bedtime and that it occurs in the same order. The activities that make up the pre-
sleep ritual should be calm and relaxing and should be finalized in the bedroom. An
example of a pre-sleep ritual is taking a shower, putting on pajamas, having a cup of
tea, disconnecting from daily activities, and reading. Box 10.4 lists some guidelines
on pre-sleep activities, that is, the sleep ritual.
10 Sleep Hygiene 111
Box 10.4 Sleep Ritual Guidelines

Pre-sleep activities
• A warm to hot shower 1 hour before going to bed can favor sleep since it provides a
temperature that contributes to the process of falling asleep.
• It is important that the pre-sleep ritual excludes stimulating physical and mental
activities. Try to disconnect from daily activities and choose readings not related to
work or study. Dedicate yourself to reading poetry, novels, fiction, or other content
that encourages relaxation. Give preference to physical books. Electronic books must
not be part of the pre-sleep routine and must be kept at a distance!
• Hearing classical music or sounds of nature can help with the relaxation process.
10.5 Worries
Worries and problems before going to bed can affect the process of falling asleep.
Therefore, in the case of excessive worries, write them down in a notebook. Transfer
worries, anguish, and thoughts to the paper. This can help to “empty the mind”.
Identify what bothers you when you go to bed and, if possible, write it down on a
piece of paper to deal with those thoughts, problems, and worries only on the next
day. Box 10.5 shows a model of a thought diary.
Box 10.5 Thought Diary

Write in this space your thoughts, feelings, or worries. For this, answer the following
question “What bothers you when go to bed?”
To-do-list for the next day:
• 1
• 2
• 3
• 4
• 5
Thoughts on the day gone by
Thoughts about problems
Random thoughts
Fear of not being able to sleep
Vent in your diary
In conclusion, the elements of sleep hygiene can be addressed in a psychoeduca-

tion session and can be discussed during the course of the intervention. It is impor-
tant to mention that, due to individual variability, not all guidelines have the same
impact on different patients. The guidelines must be personalized considering
demand, context, and individual characteristics of the patient.
Bibliography
Perlis, M. L., Aloia, M., & Kuhn, B. (2011). Behavioral treatment for sleep disorders: A compre-
hensive primer of behavioral sleep medicine. Elsevier.
Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. (2005). Cognitive behavioral treatment of
insomnia: A session-by-session guide. Springer.
Chapter 11
Stimulus Control Therapy for Insomnia
Maria Laura Nogueira Pires and Ksdy Maiara Moura Sousa
11.1 The Falling Asleep Process
Recognizing that sleep is not a behavior but a state of the organism leads behavior
analysts to focus on the transition from waking to sleep. As conceptualized by
Bootzin (1972), falling asleep is an operant behavior that is reinforced by sleep.
Under this perspective, sleep initiation is a behavioral chain that is under control of
various discriminative stimuli, including interoceptive stimuli such as sleepiness
and reduced mental alertness, proprioceptive cues such as sleeping posture, and
external cues such as pre-bed preparation behaviors that signal that a reinforcer,
sleep, is available.
The period of behavioral quietude that precedes sleep onset—low physiological
and mental arousal—is the consummatory response for sleep, and when it is under
appropriate stimulus control (e.g., dark and quiet room, comfortable temperature
and bedding clothes, bedtime routine), the transition into sleep is highly likely to be
short and smooth.
Motivating operations will affect the value of sleep as a reinforcer. The sleep-
wake cycle is understood to be regulated by the interaction of two biological mecha-
nisms known as a homeostatic factor (Process S), which posits that the pressure to
sleep increases with the time awake, and a circadian factor (Process C), which posits
that there is a time of day that the probability to fall asleep is higher (Borbely, 1982).
In this context, motivating operations that alter the motivational state toward sleep,
M. L. N. Pires (*)
Private Practice in Sleep Psychology, Sao Paulo, Brazil
K. M. M. Sousa
Private Practice in Sleep Psychology, Sao Paulo, Brazil
SleepUp Tecnologia em Saúde, Sao Paulo, Brazil
114 M. L. N. Pires and K. M. M. Sousa
such as a consistent sleep-wake schedule, an appropriate time of day for trying to

sleep, and enough time awake since previous sleep, will facilitate the falling asleep
process by increasing the reinforcement value of sleep and the emission of the sleep
consummatory response (Blampied & Bootzin, 2013).
Classical conditioning can also play a role in insomnia when cues associated
with pre-bed activities or the bedroom become associated with negative emotions
such as anxiety, worries, and frustration about not falling asleep. Under these cir-
cumstances, a conditioned response of arousal is elicited, and the sleeping process
is disrupted. This explains why insomniacs may fall asleep easily in other places
than the bedroom, such as on a couch, chair, or even away from home (Bootzin &
Nicassio, 1978).
The perspective of falling asleep as an operant behavior that is reinforced by
sleep and, as such, must be under the control of discriminative stimuli is the basis of
stimulus control therapy for insomnia, an effective treatment for insomnia as a
stand-alone treatment or when associated with other interventions (Bootzin
et al., 1991).
11.2 Stimulus Control Therapy for Insomnia
The stimulus control therapy for insomnia involves five orientations (Bootzin et al.,
1991), and the choice of strategy to be carried out is part of the psychoeducation
process that seeks to teach the patient the relationship between the applied method
and the objectives to be achieved. Below are the main guidelines given to the patient
during the psychotherapeutic process:
1. Go to bed only when sleepy: This instruction aims to help the patient identify
signs that he is drowsy and, therefore, increase the chance of falling asleep
quickly when he goes to bed. It is common for insomniacs to report tiredness and
go to bed without sleep, either because they believe they need to sleep at a cer-
tain time or because they believe they need to be in bed for sleep to come. Thus,
this guidance should be directed to the patient who is going to bed without sleep
and is waiting for sleep to arrive in bed. These habits can often lead to feelings
of frustration or anxiety, increase alertness, and make it difficult to fall asleep.
When we guide the patient to go to bed only when they feel sleepy, this ensures
that excessive time in bed and anxiety about falling asleep are reduced, favoring
a quick onset of sleep.
2. Getting out of bed when unable to sleep: Patients are advised to get out of bed if
they cannot sleep after 20 or 30 minutes by going to another part of the house,
avoiding activities that wake them up, and returning to bed only when sleepy.
This guideline can be used both for sleep onset and for patients who usually
wake up in the middle of the night and are no longer able to fall asleep. The
11 Stimulus Control Therapy for Insomnia 115
mechanism here is the same as mentioned above, as the time spent in bed without
sleeping can be a factor in maintaining wakefulness due to the hyperalert state
generated.
3. Using the bed only for sleeping or sexual activity: This instruction aims to asso-
ciate the bed with sleeping behavior and thus facilitate the onset of sleep. This
instruction should be given when the patient uses the bed for activities other than
sleep, such as watching television, eating, working, using electronic devices,
making plans, or solving problems. In this case, there may be an aversive condi-
tioning between the sleeping environment and the bed, as it turns out to be a
place of stress, tiredness, anxiety, and wakefulness.
4. Have a regular wake-up time, regardless of the number of hours slept: The pur-
pose of this instruction is to strengthen the regularity of the sleep rhythm. Many
patients usually extend their time in bed with the intention of restoring nighttime
sleep. This behavior, which is more commonly observed on weekends, leads to
irregularities in schedules, making it difficult to fall asleep. Regularity in sleep-
ing and waking times facilitates the process of falling asleep.
5. Avoid daytime naps: Naps lasting 30 minutes or more can lead to impairments in
daytime functioning and alteration of the circadian rhythm, impairing the onset
of nocturnal sleep. Therefore, patients should be instructed to avoid napping dur-
ing the day, and, if this is not possible, this nap should last approximately
20 minutes. Naps should be avoided at night since they can impair the sleeping
process.
Some adaptations are necessary for specific cases, in particular the guidance on get-
ting out of bed and the bedroom, which should be adapted for the elderly, patients
using hypnotics, and patients who share the sleeping environment or live in environ-
ments with low privacy.
Sleep undergoes changes in its structure, course, and duration throughout devel-
opment. Elderly people tend to have a shorter and more fragmented sleep time, with
an increase in the time awake after sleeping, to nap more during the day, often in
places outside the bedroom, and to sleep and wake up earlier (Cooke & Ancoli-
Israel, 2011; Hughes & Martin, 2022).
Several factors may be involved in the association between bed and sleep in the
elderly. The aging process can be associated with the presence of chronic diseases
such as cardiovascular changes, depression, neurodegenerative diseases and insom-
nia (Edwards et al., 2010; Fillenbaum et al., 2000). Elderly people can also have low
mobility and frailty, as well as being bedridden or living in long-term institutions.
Also, the instruction for the elderly to get out of bed if they are not sleepy can lead
to changes in their caregivers’ sleep. Thus, it is important to choose safe alternatives
that patients with limited mobility and increased risk of falling can do in bed instead
of struggling to sleep (Hughes & Martin, 2022). Also, the chronic use of sedative
hypnotics is frequent among patients with insomnia, with a North American esti-
mate indicating that half of the patients use sleep medication for a period longer
116 M. L. N. Pires and K. M. M. Sousa
than 2 years (Kaufmann et al., 2018). It is well recognized that sedative hypnotics
are associated with dependence and a range of important adverse effects that include
the risk of falls and fractures. The counter control technique can be useful for these
patients. This technique involves keeping the patient in bed when awake during the
night with relaxing activities unrelated to falling asleep. Instead of trying to fall
asleep or worrying about the consequences of not sleeping well, the patient is moti-
vated to read, meditate, and listen to quiet music, among other activities (Bootzin &
Epstein, 2000; Hughes & Martin, 2022).
Stimulus control technique can also be challenging for the patient who lives in a
house with little private space preventing him from using the bedroom only for
sleep and sex. Based on the literature (Bootzin & Epstein, 2000; Hughes & Martin,
2022; Simpson & Manber, 2022), some suggestions for adaptations for this and
other situations are shown in Table 11.1.
Table 11.1 Conventional and adapted stimulus control instructions

Conventional
strategy Adapted strategy Indications
Leave the bed/ Older people and users of sedative-hypnotic If there is a risk of falling
bedroom if drugs and/or physical limitations
unable to fall Consider the counter control strategy to that restrain the individual
asleep within reduce the risk of falling. getting out of bed by
20 minutes themselves and safely.
Avoid naps Older people Elderly people who nap in
Naps should be limited to 30 minutes and places other than their
taken in a sleeping environment with open sleeping environment, such
windows and natural light. Incorporate as on the couch or armchair
strategies to increase alert activities. while watching TV.
Examples of such activities include walking
outside, standing at regular intervals, or
engaging in social interactions such as
playing cards with others.
Users of sedative-hypnotic drugs Patients using sedative
Avoid the use of hypnotics during daytime hypnotic during naps.
naps, as this is the first step in tapering off
medication.
Go to bed only Users of sedative-hypnotic drugs
when sleepy Instruct the patient to take the medication
30 minutes or immediately before going to
bed.
Use the bed only Older people Older adults that are used to
for sleep and sex Avoid staying awake while in bed during the sleep in other places than
day; avoid sleeping in places other than bed. bed, such as a sofa or chair.
Individuals that share the sleeping Where the sleeping
environment or live in a single-room house accommodation is not
Consider an additional mattress; consider individual; there is no room
room dividers, folding screens or curtains. division to add privacy.
Source: Authors
11 Stimulus Control Therapy for Insomnia 117
When approaching patients with insomnia, it is necessary to clarify and understand

how the maladaptive behaviors that interfere with the process of falling asleep were
established. Any behavior change requested from the patient must be systematically
monitored and followed up until the objectives are achieved. Furthermore, the
implementation process of the behavioral stimulus control strategy must be based
on a detailed assessment of important variables such as the patient’s motivation, the
patient’s understanding of the method, the patient’s context, including their living
conditions, the feasibility of carrying out the activity in their own environment, and
even the presence of social support as such from their family members.
References
Blampied, N. M., & Bootzin, R. R. (2013). Sleep: A behavioral account. In APA handbook of
behavior analysis, Vol. 2: Translating principles into practice (pp. 425–453). American
Psychological Association. https://doi.org/10.1037/13938-017
Bootzin, R. (1972). Stimulus control treatment for insomnia. Proceedings of the American
Psychological Association, 1972, 395–396.
Bootzin, R. R., & Epstein, D. R. (2000). Stimulus control. In K. L. Lichstein & C. M. Morin (Eds.),
Treatment of late-life insomnia (pp. 167–184). Sage Publications, Inc.
Bootzin, R. R., & Nicassio, P. M. (1978). Behavioral treatments for insomnia. Progress in Behavior
Modification, 6, 1–45. https://doi.org/10.1016/B978-0-12-535606-0.50007-9
Bootzin, R. R., Epstein, D., & Wood, J. M. (1991). Stimulus control instructions. In Case studies in
insomnia (pp. 19–28). Springer US. https://doi.org/10.1007/978-1-4757-9586-8_2
Borbely, A. A. (1982). A two process model of sleep regulation. Human Neurobiology, 1, 195–204.
Cooke, J. R., & Ancoli-Israel, S. (2011). Normal and abnormal sleep in the elderly. Handbook of
Clinical Neurology, 98, 653–665. https://doi.org/10.1016/B978-0-444-52006-7.00041-1
Edwards, B., O’Driscoll, D., Ali, A., Jordan, A., Trinder, J., & Malhotra, A. (2010). Aging and
sleep: Physiology and pathophysiology. Seminars in Respiratory and Critical Care Medicine,
31(5), 618–633. https://doi.org/10.1055/s-0030-1265902
Fillenbaum, G. G., Pieper, C. F., Cohen, H. J., et al. (2000). Comorbidity of five chronic health
conditions in elderly communityresidents: Determinants and impact on mortality. The Journals
of Gerontology Series A: Biological Sciences and Medical Sciences, 55(2), M84–M89. https://
doi.org/10.1093/gerona/55.2.M84
Hughes, J. M., & Martin, J. L. (2022). CBT-I for older adults. In Adapting cognitive behavioral ther-
apy for insomnia (pp. 347–366). Elsevier. https://doi.org/10.1016/B978-0-12-822872-2.00005-0
Kaufmann, C. N., Spira, A. P., Depp, C. A., & Mojtabai, R. (2018). Long-term use of benzodiaz-
epines and nonbenzodiazepine hypnotics, 1999–2014. Psychiatric Services, 69(2), 235–238.
https://doi.org/10.1176/appi.ps.201700095
Simpson, N., & Manber, R. (2022). CBT-I in patients who wish to reduce use of hypnotic medica-
tion. In Adapting cognitive behavioral therapy for insomnia (pp. 437–456). Elsevier. https://
doi.org/10.1016/B978-0-12-822872-2.00014-1
Chapter 12
Sleep Restriction
Silvia Gonçalves Conway and Bárbara Araújo Conway
12.1 Introduction
Sleep Restriction Therapy (SRT) is an established treatment for insomnia that has
been used in clinical practice for over 30 years (Maurer et al., 2021). It was first
described and tested in 1987 by Spielman and colleagues (1987a). It is commonly
delivered as part of a multicomponent cognitive-behavioral therapy for insomnia
(CBT-I) but has also been linked to beneficial effects as a stand-alone intervention
(Edinger & Means, 2005; Buysse et al., 2011). It has been shown to be the most
effective technique to reduce insomnia symptoms and to consolidate sleep (Epstein
et al., 2012; Kalmbach et al., 2019). The theoretical perspective of SRT derives from
circadian sleep–wake concepts and physiologic sleep–wake regulation models,
which postulate that regular sleep schedule and full wakefulness throughout day and
evening reinforce circadian sleep–wake rhythm and potentialize homeostatic drive
for sleep. Its goal is sleep consolidation and abolition of arousal during sleep period.
Figure 12.1 illustrates the sleep model proposed by Borbély and Achermann
(1999), Borbély et al. (2016). SRT is a structured and standardized protocol that
involves restricting and regularizing a patient’s time in bed to prime and strengthen
it. The protocol reviews weekly progress and promotes adjustment on the sleep
schedule to match it with sleep needs. The time in bed restriction in a regular sched-
ule is a way to anticipate and sustain the sleep deprivation effects, potentiating the
sleep drive and reflecting on an alleviation of sleep efforts. The results achieve the
diminishing cognitive and physiological arousal and enhance the consolidation and
predictability of sleep.
S. G. Conway (*) · B. A. Conway

Psychiatry Institute, Faculty of Medicine at the University of São Paulo, São Paulo, Brazil
e-mail: [email protected]; [email protected]
120 S. G. Conway and B. A. Conway
Fig. 12.1 Borbély sleep modelBorbély sleep model (1999, 2016) posits two processes involved in
sleep homeostasis: Sleep Process and Circadian Process. Sleep Process (red line) represents the
homeostatic sleep drive, which increases the longer a person is awake. Circadian Process (blue
line) involves timing information, derived from the suprachiasmatic nucleus (SCN). Mediated by
zeitgebers, mainly light, meal, and sleep schedule, the SCN synchronizes with the daylight and
stimulates arousal networks that promote and sustain wakefulness, modulating the enhancement of
performance and alertness. When the sun goes down, the weakening of light information triggers
melatonin production and secretion, which is believed to decrease the alerting signal from the SCN
and synchronize the tendency of sleeping with the night, when the circadian drive exhibits its oscil-
latory output in opposite direction from the day, favoring the homeostatic sleep drive to be
expressed and discharged, represented by the scratched line. (Source and adaptation: Borbély and
Achermann (1999), Borbély et al. (2016))
12.2 Habits and Behaviors Associated to Sleep Homeostatic

Drive Dysregulation
Pre-sleep anticipatory anxiety is a common feature of insomnia patients. The focus

on sleep became the axis of patients’ attention during day and night. Caffeine con-
sumption, for example, is commonly used to contour sleep deprivation effects, as
well as alcohol consumption is adopted by some patients to induce sleep. During the
night, insomnia behavior usually comprehends excessive time in bed, irregular
sleep–wake schedule, control of clock timing during sleep time, concern about the
harmful effects of sleep deprivation, and a set of inadequate tasks and behaviors
undertaken inadvertently in an awake mode in bed.
The alteration of sleep schedules used to be adopted as an ineffective coping
strategy to obtain more sleep, that is, a way to offer more opportunity of time to
sleep: going to bed earlier, canceling morning appointments and or implementing
naps during the day—all behaviors adopted to try to compensate sleep deprivation
effects of previous insomnia nights or to avoid it in hypothetical awakenings that
can occur in the following sleep period. This endeavor is related to the sleep loss
complaint hyper focus that grounds an obsessive behavior of sleep searching, offer-
ing more opportunity to repair or alleviate the tiredness from sleep loss. These
behaviors impair the nocturnal sleep pattern, increase the sleep effort, decrease the
sleep efficiency, and enhance the cognitive and physiological arousal, reinforcing
12 Sleep Restriction 121
the cognitive vicious cycle of insomnia, including pre-sleep anticipatory anxiety,

concerns about harmful effects of sleep deprivation on daily activities, interpersonal
relationships, and health damages in the long term.
Insomnia disorder does not begin instantly. In most cases, the first symptoms are
closely related to problems in real life. It is anguish in the form of insomnia. As long
as the symptoms persist, the difficulties with sleep can complicate, becoming the
focus of a patient’s attention. That is the changing point, when the person abandons
the core of the problem and tries desperately to recover the sleep loss by a series of
strategies throughout day and night.
Figure 12.2a illustrates the sum of these strategies transformed on a strength
resistance against sleep. That’s why people with insomnia disorder usually experi-
ence a series of poor nights of sleep followed by a good and satisfactory night of
sleep, after which the series of poor nights begin again and so on (Fig. 12.2b). It
illustrates the strong power of the vicious cycle of insomnia against the homeostatic
sleep drive. As long as the sequence of poor nights of sleep happens, the sleep depri-
vation increases, enhancing the sleep homeostatic drive. When it exceeds the sleep
resistance condition of insomnia, the sleep pressure imposes a full night of recovery
sleep. However, as soon as the sleep homeostatic drive is discharged, the condi-
tioned behaviors and beliefs around insomnia play its strength, intercepting the
natural expression of sleep–wake cycle and the insomnia nights return as protago-
nist (Fig. 12.2c). That is, although there is preservation of sleep physiology condi-
tions, the psychological conditions make resistance against it—such as unconscious
resistance, fears of sleep loss consequences, and obsessive thoughts and behaviors
in search of recovery sleep loss or contour tiredness.
Insomnia disorder does not begin abruptly, nor will it disappear magically. The
compendium of CBT-I techniques, as well as other psychological approaches, such
as Acceptance Commitment Therapy (ACT), aims to crack and melt each one of the
sleep resistance elements. SRT targets some of these sustaining factors, mainly
excessive time in bed and disorganized sleep schedule, but it also addresses exces-
sive concern about the harm caused by sleep deprivation the next day and pre-sleep
anticipatory anxiety. SRT anticipates and sustains the expression of the homeostatic
sleep drive power. The effects surpass the physiological response to sleep depriva-
tion, such as the organization of sleep schedules and the consolidation of sleep.
They also extend to psychological aspects associated with insomnia, including pre-
sleep arousal (Maurer et al., 2022), which leads to a reduction in the frequency and
intensity of fear-related thoughts, control behaviors, and pre-sleep expectations
(Fig. 12.2d). This indicates that when combined, all strategies mutually reinforce
one another.
12.3 Sleep Restriction Therapy Components and Efficacy
SRT is composed of two central behavioral techniques that aim to reduce variability
in sleeping time and wakefulness during sleep period:
Fig. 12.2 Insomnia resistance drive versus homeostatic sleep drive

Orange arrow represents the insomnia resistance to sleep. Blue arrow represents the homeostatic
sleep drive. The dimension of each arrow represents the strength of resistance or drive. Orange
square represents an insomnia night. Blue square represents a restful night. Each little orange
arrow exhibited on Figure (a) illustrates each one of the strategies that patients usually adopt to
contour sleep deprivation or to control sleeping, such as caffeine consumption during the day, or
alcohol during the night; clock watch all over night; canceling commitments at the end or at the
beginning of the day to guarantee sleep; time in bed extension to compensate for sleep deficits, etc.
The sum of these behaviors become a strength that makes resistance against sleep, being repre-
sented by the large orange arrow, consolidating the difficulties with sleep as an insomnia disorder.
Figure (b) illustrates the typical sleep pattern of insomnia: a sequence of poor nights of sleep fol-
lowed by a good and satisfactory night of sleep, after which the series of poor nights begin again
and so on. Figure (c) illustrates the strength fight between the insomnia resistance drive and
homeostatic sleep drive. As the resistance to sleep plays its strength night by night, the homeostatic
sleep drive grows each night, becoming strong enough to impose over the psychological resistance,
that is when the insomnia pattern gives in and the patient experiences a restful night. The dashed
line represents the homeostatic sleep drive increase tendency. As soon as the sleep homeostatic
• Time in Bed Regularization (TBR): patients are asked to keep a fixed bed and
rise time.
• Time in Bed Restriction (TIBR): patients are asked to keep a fixed sleep period.
The sleep period is defined based on the total sleep time (TST) estimates informed
by a self-reported sleep diary. It represents the opportunity for sleep that should be
reduced in accordance with the current exercise of sleep. Bed and rise time will be
defined according to the sleep period definition and patient routine. The coupled
reference values (bed and rise time that fits the sleep period) are nicknamed as
“sleep window,” which will be gradually adjusted to reach the need for sleep of each
patient. The full application and adjustments of SRT are better described, step by
step, on the “Sleep Restriction Therapy application: step by step” topic.
SRT efficacy shows reduction on sleep onset latency (SOL) and wake after sleep
onset (WASO) and improvement on sleep efficiency (SE) in the short term (Miller
et al., 2014; Maurer et al., 2021; Belfer et al., 2021) and better outcome on the
Insomnia Severity Index (Maurer et al., 2021), with no effects for TST. Even though
insomnia patients complain of insufficient sleep time, it is not usual to observe that.
What happens is that they have a poor sleep experience when they often try to
recover from sleep loss by spending a longer TIB. This behavior yields too much
effort to get and/or resume sleep. The avoidance of sleep deprivation and its conse-
quences stress the patient, potentializes the attention over sleep and perpetuates
insomnia in the long term, leading to poor sleep efficiency, not very well consoli-
dated and, very often, sleep misperception. That is why the effects of SRT are not
necessarily a huge increment in TST, but a change in sleep pattern that is correlated
to an increased sleep depth (Belfer et al., 2021), improving and correcting the per-
ception of sleep that leads to an improvement of patients’ satisfaction.
Maurer et al. (2020) dismantled SRT and compared sleep measures between
TIBR (+ sleep hygiene) versus TBR (+ sleep hygiene). Based on self-reported sleep
diaries and actigraphy, they demonstrated that TIBR technique shows better sleep
outcomes than TBR when taken isolated on SOL, WASO, SE in the short and long
terms. Moreover, TIBR technique promoted improvement in sleep-related quality
of life in the long term. Even though weaker, TIBR also demonstrated better sleep
outcomes by polysomnography than TBR (Maurer et al., 2020). It highlights TIBR
as the key component of SRT intervention. The fit of sleep ability onto sleep oppor-
tunity is the principal factor to enhance the sleep homeostatic drive. As the sleep
efficiency is achieved in accordance to the stabilization of sleep ability, periods of
sleep opportunity are extended (titration) in order to reach sleep needs (Fig. 12.3).
Among insomniacs, it is very difficult to maintain a good sleep efficiency when it is
Fig. 12.2 (continued) drive is discharged, the insomnia sleep pattern returns by its conditioned
behaviors and consolidated beliefs. Figure (d) illustrates SRT effects: as soon as the sleep window
is implemented, the homeostatic sleep drive is anticipated, exerting its strength. As the sleep win-
dow keeps steady, the homeostatic sleep drive keeps its fast expression night by night, provoking
the weakening of the insomnia resistance. Night after night, each element of resistance gets
weaker, diminishing the pre-sleep anticipatory anxiety and concerns around insomnia. This pro-
cess facilitates the return of restful sleep till the settling of insomnia disorder
Sleep
Sleep Need
Opportunity
mismatch
Sleep Ability
Efficient Sleep Inefficient Sleep
Fig. 12.3 Sleep opportunity extension impairs sleep efficiencySleep opportunity restriction aligns
with sleep opportunity and sleep ability, leading to efficient sleep. The overabundance of sleep
opportunity in a scenario of low sleep ability produces poor sleep efficiency and perpetuates
insomnia in the long term. (Figure source: Belfer et al., (2021))
given an overabundance of sleep opportunity. The amount of it, more than the tim-
ing, determines the response (Maurer et al., 2020; Belfer et al., 2021). Nevertheless,
worse sleep quality has also been associated with irregular bedtimes (Kang & Chen,
2009), which regularization corroborates to the reduction of daytime sleepiness and
SE increment (Manber et al., 1996). So, sleep opportunity applied in a regular
schedule potentializes sleep drive and sleep–wake circadian rhythm, both involved
in sleep homeostasis. For that, it is recommended to implement both strategies
together, seven nights a week with only small variations over successive weeks of
treatment, well described on the following topic.
12.4 Sleep Restriction Therapy Application: Step by Step
SRT initiates with the definition of sleep window: sleep opportunity in accordance
to sleep ability defined based on a regular bedtime. The initial amount of sleep
restriction is determined based on an individual’s TST extracted from at least
2 weeks of self-report sleep diaries and, eventually, actigraphy register. Usually, the
beginning of SRT application promotes the greatest restriction of sleep opportunity,
that is expected to enhance sleep drive and stabilize sleep ability during the bedtime
period. Improved sleep can take days to manifest, as homeostatic sleep drive builds
(Fig. 12.4). The titration of sleep opportunity consists of a slow process used to
increase it as sleep is consolidated and becomes more efficient. It depends on the
match of: (a) the stabilization of sleep inside the sleep window; (b) with at least 90%
of SE (85% for the elderly); and (c) patient’s reports of insufficient TST. This report
means, as expected, that the sleep ability achieved the sleep opportunity in a stable
Fig. 12.4 (continued) oriented not to sleep before or after the sleep window: 7 h of sleep opportu-
nity to happen between 00 and 7 AM. The conditioned sleep pattern persists as the homeostatic
sleep drive builds. For that, improved sleep can take days to manifest. Responses to SRT may vary
from faster SOL (c), lower WASO (d), diminishing the frequency of nocturnal awakenings (e) or
mixed responses such as is described, usually accompanied by better sleep satisfaction
Fig. 12.4 SRT effects on a schematic example of difficulty in initiating and maintaining sleep
Red dash corresponds to the bed and rise time, respectively. Blue blocks correspond to sleep bouts.
Blue dash corresponds to the sleep window. (a) illustrates a typical night of a patient with difficulty
in initiating and maintaining sleep, in which the sleep opportunity (total time in bed = 10 h) is very
superior to the total sleep time (7 h) that usually happens in four bouts of sleep. (b) The sleep
window was defined based on sleep diaries collected by 2 consecutive weeks and the patient was
way, evidencing that sleep opportunity falls short of satisfying sleep needs and that
more sleep time is requested.
SRT applications used to last over 8 weeks. In order to promote adjustments on
sleep needs and to avoid prolonging eventual sleep deprivations that encompass the
setting of the sleep window, it is recommended to apply SRT during consecu-
tive weeks.
The sleep diary should be completed as long as the insomnia treatment lasts. It
consists of a fundamental tool to define the sleep window, points the adjustments
needed on it, as well as to suggest situations, behaviors, and beliefs that can inter-
fere with sleep expression and pattern. For example, a worse sleep period linked to
bad news received during the workday, linked to the care of a sick son during the
night, followed by higher consumption of alcohol, etc. Moreover, SRT titration
depends on sleep diary reports. It could be completed by caregivers if the patients
are physically or cognitively incapable of completing a sleep diary. Sleep diary is
well described in Chap. 9.
12.5 How to Define a Sleep Window?
As shown on Fig. 12.4, SRT involves prescribing a sleep window that matches
patient-reported sleep duration to a fixed sleep period in a fixed bedtime. The sleep
duration is obtained by the average of the TST self-reported on the last 2 weeks of
sleep diaries. This reference corresponds to the patient’s sleep ability. If the sleep
ability is happening late at night (increased SOL—initial insomnia) and/or with
awake periods during sleep period (increased WASO—maintenance insomnia) and/
or early morning awakening (terminal insomnia) with SE minor or equal to 80%, it
means that the opportunity to sleep is overabundant and must be adjusted to a nar-
row period according to the real sleep ability of the patient. After defining the sleep
period, patients are asked to define a fixed bed and rise time that should be followed
seven nights a week. For that, the daily routine should be investigated in order to
consider the time that the patient arrives at home—what he does till the time he
decides to lie down, if and how he relaxes, the period of the day he feels more alert
and more tired or drowsy, what makes him wake up, what time he should leave
home on workdays, etc. This investigation aims to understand routine and circadian
preferences, eventually proposes adjustments on it, and helps define bed and rise
times that fits better with circadian rhythms, sleep needs, and routine. The bed and
rise time also has to consider the sleep pattern description, for example: if the patient
has an increased SOL and reports feeling alert when lying down, it is recommended
to fix the beginning of the sleep window at the time he reports starting sleep time;
on the other hand, if sleep is well consolidated until 4:30 AM, becoming fragmented
after that, it could be suggested to consider the rise time at 4:30 AM.
Consider the following example to illustrate the SRT application step by step:
James (male, 41 years old) complains about difficulties in initiating and maintain-
ing sleep. He reported as always having more nocturnal habits that conflicts with
the early work time. Since the time to wake up should be at a maximum of 7 AM,
he decided to sleep earlier than his preference in order to have more sleep oppor-
tunity. In the beginning of his work life, he started having trouble in initiating
sleep. As he assumed more responsibilities in work, he began to experience dif-
ficulties in maintaining sleep. It started 10 years ago, exactly when he was pro-
moted as manager. As the insomnia symptoms intensified, James became more
concerned with the amount of sleep he was able to get and, in order to guarantee
sleep time and ease the sleep deprivation, he decided to extend the sleep period
to 8 AM and go to bed earlier (at 10 PM), turning off all the lights and forcing
relaxation in order to get to sleep. He reported being very disappointed with
himself because he is always late to work, tired, and afraid of losing control over
work performance. Moreover, he avoids social meetings to preserve these sleep
habits. He filled up 2 weeks of sleep diaries, which sleep measures averages are
shown in Table 12.1.
As shown in Table 12.1, James’ sleep ability is happening late at night (increased
SOL—initial insomnia) and with awake periods all night long (increased WASO—
maintenance insomnia) with SE equal to 70%. As the frequency of nocturnal awak-
ening is three times per night, it means that the sleep ability used to occur in four
bouts of sleep comprehending 7 h of TST. Figure 12.4a illustrates the schematic
sleep pattern of James. The sleep period should be defined according to TST. In this
case, a sleep period of 7 h. The investigation of James’ circadian preferences and
routine demonstrated that the later he lies down, the easier he could initiate sleep.
Moreover, he referred to having a sensation of deepest sleep at the last bout of sleep,
after 3 or 4 AM. However, he should leave home for work at 7:40 AM, meaning the
need to get up at 7 AM. Discussing the many pros and cons of evening and morning
routine, James decided to fix bedtime between 00 AM to 7 AM. That is the James’
sleep window: a sleep period of 7 h fixed to occur only between 00 AM to 7 AM.
After defining the sleep window, patients are oriented to respect it seven nights a
week and to avoid napping during daytime or in the evening. The sleep window
defines the period that the patient can go to sleep, not before or after that. Moreover,
they are oriented to follow sleep hygiene orientations, avoiding use of electronic
equipment that emits light (mobile, tablet, television, computer) at least 1 hour
Table 12.1 James’ sleep Sleep measure Value

measures prior to SRT Initial sleep period 10 PM
intervention
Terminal sleep period 08 AM
Sleep onset latency (SOL) 55 min
Frequency of nocturnal awakenings 3 times a night
Wake time after sleep onset (WASO) 125 min
Early morning awakening (EMA) 15 min
Total sleep time 7h
Total time in bed 10 h
Total awake time (SOL + WASO + 195 min
EMA)
Sleep efficiency 70%
before the beginning of the sleep window and along all sleep period. If they awaken
during the sleep period, they are oriented to leave bed and bedroom (if possible) and
engage in some refreshing activity, such as reading a book, writing personal issues,
painting a mandala, knit, crochet, or any other pleasure activity that does not pro-
voke alertness. These orientations follow the Sleep Hygiene basements and Stimulus
Control Therapy, previously described in Chaps. 10 and 11, respectively.
Attention!
• The sleep diary should be completed as long as the insomnia treatment lasts.
• To define the sleep window, consider collecting at least two consecutive
weeks of sleep diaries.
• To avoid severe drowsiness, the sleep window should never last less
than 5 h.
• Patients should be encouraged not to nap during daytime or in the evening.
• Besides definition of sleep window and how to deal with it, SRT includes
orientations based on sleep hygiene and stimulus control therapy.
12.6 How to Titrate the Sleep Window?
For the following weeks of the treatment, it is advisable to see patients every week.
The adherence to the sleep window may provoke sleep deprivation, especially for
the first and second weeks of the treatment. The weekly segment may offer oppor-
tunities for adjustments, clarifications, and orientations. In terms of SRT, the goal of
the following encounters should be to promote total adherence to the sleep window
in order to make sleep initiation faster (SOL decrease) and sleep consolidated
(decrease in awakenings frequency and in WASO), meaning a better sleep pattern
that achieves patients’ sleep and wakefulness satisfaction. For that, Spielman et al.
(2011) proposed and revised some rules to evaluate sleep measures obtained by the
self-report sleep diary:
• If SE was ≥90% (85% in seniors), sleep window should be increased by
15–30 min.
• If SE was <85%(80% in seniors), sleep window should be reduced by 15–30 min.
• If SE was between 85% and 90%, no changes should be made on sleep window.
Beyond the rules above, in some cases, patients may suffer from severe drowsi-
ness. In such cases, 20 or 30 min should be added to the sleep window in order to
alleviate the effects of sleep deprivation. However, it should be clinical and criti-
cally analyzed, since insomnia patients refer to the sleepiness, tiredness, inattention,
and other immediate sleep deprivation effects to avoid leaving the “comfort zone,”
represented by the challenge of the sleep window strategy.
Improvements in sleep with SRT require ongoing restriction of sleep opportu-
nity. It means that the immediate suspension of restricted sleep opportunity after
SRT provokes a regression of nocturnal sleep efficiency back to baseline (Belfer

et al., 2021).
When patients achieve SE ≥90% and sleep pattern changes to a more consoli-
dated sleep, indicating sleep satisfaction—feeling well throughout the day and not
being vulnerable to insomnia episodes—the SRT should be suspended. Nevertheless,
patients should be oriented to keep the bedtime and rise time defined during the
treatment as the main reference to keep a good sleep homeostasis and a healthy
sleep–wake circadian rhythm.
Back to James’ example, the sleep window was defined as a sleep period of 7 h
fixed to occur only between 00 AM to 7 AM. Table 12.2 synthesizes the sleep win-
dow and the titration segments of SRT. During the session that followed the first
week of SRT implementation (Week 1), James reported difficulty in rising at the
agreed time, arguing tiredness and sleep deprivation. Because of that, he decided by
himself to change the alarm clock to 7:30 AM. As the bedtime was fixed at 00 AM,
even above the pre-sleep anticipatory anxiety, the sleep homeostasis started to play
its strength night after night, turning SOL faster than baseline and diminishing the
awakening frequency (from 2 to 3) and WASO (from 125 to 100 min). TST decreased
from 7 h to 6.5 h because of the persistence of the main insomnia features (awaken-
ings and higher WASO) beneath TIB restriction. The intervention focused on rein-
forcing the principles of sleep homeostasis and James was strongly oriented to
respect the sleep window. For the second week, as he followed the orientations
properly, WASO decreased. The observed increment of SOL was an anxiety answer,
precisely the fear of sleep deprivation effects. Although tired, during this week, he
realized that the respect to the sleep window led to a more consolidated sleep, nur-
turing hopes to get a better sleep pattern in the following weeks. James now adhered
to SRT 100%. From week 3 to 5, as soon as the SRT effects became more promi-
nent, he became more confident, relaxing more day by day, night after night. It
helped him to diminish pre-sleep anxiety, turning faster the SOL (from 40 to 25 min)
and diminishing awakening frequency (from 2 to 1) and WASO (from 80 to 40 min).
These sleep measures reflected on the SE growing (from 68.9% to 82.5%), repre-
senting a growing conquest of sleep consolidation. Although SE was <85%, James
reported increased self-confidence, marked by total adherence to the strategies and
acknowledgment of their effects. Concurrently, features of his insomnia, such as
SOL, awakenings, and WASO, began to subside. This improvement indicates that
there was no need to modify his sleep window. So, the conversion to a better sleep
pattern was proved by week 6 to 8, when faster SOL was consolidated along with
WASO decrement week by week (from 40 to 0 min) and total abolishment of awak-
enings during the night (week 8) and, SE increment (from 82.3% to 93.0%). At the
session that followed the 8th week of treatment, James demonstrated total satisfac-
tion with the results: consolidated sleep pattern, faster SOL, and absence of pre-
sleep anticipatory anxiety. Nevertheless, he reported the need for more sleep,
especially at the end of the sleep period. At week 8, the TST achieved was below
from the one collected at baseline (6h40 versus 7 h, respectively). As SE was 93.0%,
it was proposed an increase of 20 min to the sleep window for the next week.
Considering the work time, James decided to distribute 10 min before and 10 min
130
Table 12.2 James’ sleep window and the titration segments of SRT
References Sleep measure post sleep restriction therapy (week by week)
SM prior Sleep W
to SRT window W1 W2 W3 W4 W5 W6 W7 W8 W9 W 10 11 F-up
Initial sleep period 10 PM 00 AM 00 AM 00 AM 00 AM 00 AM 00 AM 00 AM 00 AM 00 AM 23:50 PM 23:40 PM 23:30 PM
Terminal sleep period 8 AM 7 AM 7:30 AM 7 AM 7 AM 7 AM 7 AM 7 AM 7 AM 7 AM 7:10 AM 7:10 AM 7:15 AM
Sleep onset latency 55 min NA 30 min 40 min 30 min 25 min 25 min 20 min 20 min 20 min 20 min 15 min 20 min
(SOL)
Frequency of 3 NA 2 2 2 1 1 1 1 0 0 0 1
nocturnal awakenings
Wake time after sleep 125 min NA 100 min 80 min 60 min 60 min 40 min 20 min 10 min NA NA NA 2 min
onset (WASO)
Early morning 15 min NA 15 min 15 min 10 min 10 min 10 min 10 min 10 min 10 min 5 min 5 min 5 min
awakening (EMA)
Total sleep time 7h00 NA 6h30 5h00 5h30 5h35 5h55 6h20 6h30 6h40 7h00 7h15 7h30
Total time in bed 10h00 7h00 7h45 7h15 7h10 7h10 7h10 7h10 7h10 7h10 7h25 7h35 7h50
Total awake time 195 min NA 145 min 135 min 100 min 95 min 75 min 50 min 40 min 30 min 25 min 20 min 27 min
(SOL + WASO +
EMA)
Sleep efficiency 70.0% NA 83.9% 68.9% 76.7% 77.9% 82.5% 88.3% 90.7% 93.0% 94.4% 95.6% 95.7%
Subjective sleep 5 NA 4.5 3 4.0 5.0 6.0 6.0 7.0 7.5 8.5 9.0 9.2
quality (0–10)
Legend: SM Sleep measure, SRT Sleep restriction therapy, NA not applicable, W week, min minutes, F-up Follow up (2 weeks after week 9)
S. G. Conway and B. A. Conway
after the bedtime and rise time, defining a new sleep window of 7h20 (between
23:50 PM and 7:10 AM). At week 9, the results observed were a correspondent
increment in TST and SE, with sleep pattern preserved, indicating the possibility to
enhance the sleep window by 10 min more (between 23:40 PM and 7:10 AM). As
James answered well (week 10), with faster SOL, higher SE, reporting much more
relaxed, with no fear about the returning of insomnia symptoms but still needing an
alarm clock to wake up, it was hypothesized that the TST at baseline was below his
real necessity of sleeping time, probably representing a feature of hypervigilance.
For that, it was proposed to increase the sleep window by 15 min. In order to attend
to his routine needs and preferences, it was settled between 23:30 PM and 7:15. At
week 11, TST achieved 7h30 (30 min more than baseline) with sleep consolidated
and SE preserved above 95%. Finally, James reported waking up totally restored,
with no somnolence residue. The suspension of SRT was done with orientations
regarding the importance of sleep hygiene and the bedtime regular habits.
12.7 What to Do When Patients Are Medicated

with Pharmacotherapy Agents to Promote Sleep?
When patients are medicated with sleep inductors, anxiolytic, or other sedative
agents, the treatment length could be prolonged, following the same references and
logic of the procedure defined for 8 weeks. However, it is recommended to first
adjust sleep patterns and only after that dishabituate pharmacotherapy agents, fol-
lowing recommendations and advice by a sleep physician.
12.8 Actigraphy Register—When to Use and When

Not to Use
Actigraphy is a noninvasive and validated method of objectively measuring motor

activity and rest over a period of days to weeks. Through a mathematical algorithm,
these measures can estimate the sleep–wake pattern and rhythm. The International
Classification of Sleep Disorders (American Academy of Sleep Medicine, 2014)
suggests actigraphy to evaluate insomnia and circadian rhythm alterations. As well
described in this chapter and illustrated by Fig. 12.3, insomnia patients tend to
spend long periods of wakefulness in bed, which may compromise sleep estimates
obtained by actigraphy (Rösler et al., 2023). Nevertheless, actigraphy may be con-
sidered for patients who are very resistant to completing a sleep diary or those who
are physically or cognitively incapable to complete a sleep diary. In SRT, the TST
estimated by actigraphy will be adopted to define the sleep window.
In cases of sleep misperception, those who have a huge sleep duration underesti-
mation, the use of actigraphy is controversial. On the one hand, the comparison of
the different amounts of TST (actigraphy versus own perception) may help the
patient to realize his underestimates of TST, demystifying his worse expectations
and equivocal comprehension about his hypothetical poor sleep, providing relax-
ation and better sleep routine. On the other hand, for other patients, the establish-
ment of a sleep window based on TST derived by actigraphy may weaken the
strength of SRT intervention. It happens because sleep misperception is commonly
found on a very fragmented sleep mixed with hypervigilance, meaning a kind of
consciousness state that takes place as long as the sleep period happens, rendering
difficult the perception of sleep and promoting a perception of permanent wakeful-
ness. When actigraphy measures detect a TST almost equal to TIB (e.g., SE ≥90%),
the sleep window based on that will not have the strength to change the sleep pat-
tern, not even the hypervigilance, since TST taken objectively (actigraphy) is much
more extended than that perceived by the patient report. In terms of cognition,
changes will be hardly promoted, since TIB will be maintained almost the same as
before the intervention. In such cases, the subjective TST must be taken into account
in order to promote homeostatic sleep drive and provoke cognitive changes, espe-
cially perception. Consider the following example to illustrate it:
Rachel (female, 48 years, married, advertising professional) complains of insomnia
symptoms for 18 years. She reported a TST of 4 h. She doesn’t refer to sleepiness
during the day and any other symptom of sleep deprivation. However, she reports
difficulties to “turn the mind off” during day and night. As she resisted to com-
plete the sleep diary, arguing anxiogenic effects, actigraphy monitoring over
14 days was offered alternatively. The analysis parameters evidenced a normal
SOL (varying from 20–35 min), TST of 7 h on average, WASO very reduced
(5–15 min) and high SE (~ 90%). The sleep pattern occurs in a unique sleep
bout, however, full of very brief fragmentations. The SRT intervention based on
the TST of 7 hours obtained by actigraphy defined a sleep window of 7 hours,
very proximal to her TIB of 7h45. Since the hypervigilance persisted occurring
in parallel to sleep bout, almost equal to that before SRT intervention, the sleep
misperception persisted, impairing the results in terms of subjective complaints.
After 3 weeks of failure of this strategy, the sleep psychologist decided to reduce
the sleep opportunity. As she reported a subjective TST of 4 h, the professional
decided to be more conservative, as recommended by SRT experts, and asked her
to define a sleep window based on 5 h. The results appeared soon after the last
approach. Rachel described sleepiness and tiredness in the morning, after lunch
and dinner on the days following the new sleep window. Moreover, she began to
report having a restorative sleep, consolidated and deep, nevermore hearing the
noises around the neighborhood. For the following weeks of the treatment, the
sleep psychologist titrated the sleep window as described in this chapter, and
Rachel finished the SRT intervention very satisfied, referring to 7h30 of TST, very
refreshed, with no insomnia symptoms.
Rachel’s example illustrates that even sleep misperception can be corrected by
SRT. Nevertheless, objective measures, such as that obtained by actigraphy, cannot
be taken as reference when there is a huge discordance with subjective measures,
especially when objective WASO is almost absent. It means that hypervigilance

must be abolished and should be a goal of the intervention. Besides relaxation strat-
egies and analytical approach, homeostatic sleep drive plays an important role in
that, helping to promote sleepiness, and so clarifying the real perception of sleep. It
highlights the importance of physiological challenges to promote cognitive change
among insomnia patients with sleep misperception.
12.9 Effect-Size of SRT Intervention and Difficulties

in SRT Adherence
The main effect-size of SRT is sleep deprivation (Kyle et al., 2014; Maurer et al.,
2020, 2021, 2022), especially increased daytime sleepiness, and objective perfor-
mance impairment (Kyle et al., 2014; Maurer et al., 2022) These effects tend to be
more accentuated in the beginning of the treatment (~week 1–3) (Kyle et al., 2014;
Maurer et al., 2022), returning to baseline levels by 3 months (Kyle et al., 2014).
Because of the conditioned sleep pattern, SOL and WASO remain similar in the
early days of SRT implementation, provoking a decrease in TST and sleep depriva-
tion effects as a consequence. Since patients are “prohibited” to compensate for
sleep, the intervention anticipates sleep deprivation, enhancing the sleep drive. This
drive works as a sleep pressure that imposes the SOL abbreviation and fills up the
gap of wakefulness that exists between the fragmented sleep periods, decreasing the
awakenings frequency. See the illustrations in Fig. 12.4. Nevertheless, sleep win-
dow titration will cancel the effect-sizes. As soon as the protocol adjustments pro-
vide TIB extension, soon the TST enhances, gradually reaching the adequate time
of sleep, which in turn diminishes and finally cancels the sleep deprivation effects.
At the beginning of SRT intervention, patients should be warned that their condition
will get worse before it gets better, they will feel more sleep-deprived and tired in
the beginning of the treatment and by the end of it will be feeling more restful and
satisfied about their sleep.
Sleep deprivation effect-size may be worse among those with sleep mispercep-
tion. Some patients with sleep misperception report a TST of less than 5 h, some-
times they affirm to sleep only 3 h every night. In such cases, it is not advisable to
set the sleep window to less than 5 h to avoid subjecting the patient to severe sleep
deprivation. Even so, TIB may be extremely insufficient to recover sleep needs in a
way that sleep deprivation effects may be more pronounced, especially in the next
days following the beginning of SRT implementation. For such cases, it is important
to ask for the sleep diaries between sessions to closely follow the SRT effects and
analyze if there is a need to anticipate the sleep window titration, avoiding perpetu-
ation of severe sleep deprivation, especially if sleep perception and sleep pattern
improved.
Although sleep deprivation effect-size is temporary, it used to be the main factor
for resistance to adhere to SRT. As patients with insomnia usually try to compensate
for the sleep deficits prolonging the time in bed, they hardly believe that the promo-
tion of new habits and behavior in an opposite way could help them. For that, they
may be uncommitted to adhere to the purpose strategies of SRT.
To help adherence, a session of sleep psychoeducation encompassing sleep–
wake physiology and rhythmicity prior to SRT intervention is strongly recom-
mended. When patients understand the principles that substantiate the technique
and the conditioned pattern of behavior that maintain the vicious cycle of insomnia,
they tend to collaborate with the protocol proposals.
Such cases point out that nonpharmacological insomnia intervention, which
includes SRT, is not a simple application of techniques but asks for a wide and deep
domain of psychological knowledge and intervention. Sleep psychologists are pre-
pared to deal with sleep’s physiological, circadian, and psychological aspects often
involved among insomnia patients.
12.10 SRT Indication, Adaptation, and Careful Application
In general, SRT may be indicated for patients with initial, maintenance, or terminal
insomnia (Spielman et al., 2011) that exhibit SE less than 85% (80% in seniors).
Nevertheless, SRT results may be narrow or even useless in some cases of terminal
insomnia or short objective sleep duration phenotype insomnia (TST <6 h), asking
for other approaches to benefit the patient and sleep recovery.
Some patients that complain of insomnia, but do not report daytime impairment
and/or drowsiness, may have enough TST despite a poor pattern or may be hyper-
vigilant. In the first case, especially when patients are non-adherent to SRT strict
protocol, sleep compression should be addressed by a gradual TIB reduction
(Lichstein et al., 2011), respecting sleep schedules regularity in order to slowly
promote a better sleep pattern (consolidated) and to avoid greater sleep deprivation
effects, coping with adherence. In the second case, when the psychological aspects
of hypervigilance are well treated, the patient becomes more relaxed, returning to
report drowsiness as before the insomnia disorder was developed. Hypervigilance is
often associated with short objective sleep duration phenotype insomnia (TST <6 h)
(Vgontzas et al., 2013). Many psychological strategies and methods should be
addressed for such cases, such as mindfulness and ACT. For that, see ACT-I deeply
described in part 4. The same approach could help patients with terminal insomnia
that usually get up as soon as they wake up.
Patients with circadian rhythm disorders, such as advanced or late phase, usually
present social jet lag, complaining of insomnia symptoms. For that, SRT may regu-
larize sleep schedules and promote TST homogeneity between work and free days,
thereby restoring daytime well-being.
Patients with sleep-disordered breathing (SDB) comorbid to insomnia may also
suffer from an intensified sleep deprivation. Although SRT could help to consolidate
the sleep pattern, it will not be enough to promote total sleep satisfaction, since SDB
harms the sleep quality. In such cases, the professional applying SRT must recog-
nize SDB symptomatology, referring the patient to a sleep physician.
Although there is no impediment to SRT intervention in insomnia comorbid to

other conditions, work or health conditions that can be strongly affected and harm-
ful by sleep deprivation effects ask for critical analyses about SRT applicability. Air
traffic controllers, airplane pilots, bus and truck drivers, machine operators in facto-
ries, and others that work within high-risk roles and under absence of surveillance
may be at risk under sleep deprivation caused or potentialized by SRT. Similarly,
patients that suffer from parasomnias, epilepsies, and some severe psychiatric con-
ditions may have the worsening of the condition triggered by the sleep deprivation.
Sleep deprivation effect-size may be worse among those with sleep mispercep-
tion. Some patients with sleep misperception report a TST of less than 5 h, some-
times they affirm to sleep only 3 h every night. In such cases, the sleep window is
not recommended to be less than 5 h. However, some patients even adhering to a
sleep window of 5 h continue to report sleep misperception, complaining of frag-
mentation or even extended awareness periods. In such cases, the sleep window
prescribed should be maintained and relaxation strategies and psychological
approaches should be addressed to decrease hypervigilance. In some rare cases, the
sleep window could be briefly abbreviated. However, it is recommended to do it
with supervision of a sleep psychologist very experienced in SRT management.
Finally, for seniors who live alone, sleep deprivation increases the risk of falling,
asking for an SRT adaptation that offers a cadence on the steps of the process:
TBR → avoidance of naps during the day → TIBR
It is suggested to start the TIBR with a more extended sleep window and be pro-
gressively shortened.
The needs for SRT adaption reinforce the necessity for a wide and deep sleep
knowledge and psychological approaches to be addressed for as long as the non-
pharmacological insomnia interventions lasts.
References
American Academy of Sleep Medicine. (2014). International classification of sleep disorders.

American Academy of Sleep Medicine.
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Part IV
ACT for Insomnia
Chapter 13
Acceptance and Commitment Therapy
Acceptance and Commitment Therapy (ACT) is a psychotherapeutic treatment

approach that is part of contemporary contextual behavioral therapies, also called
3rd wave of Behavioral Therapies (Hayes, 2004). Its philosophical root is Functional
Contextualism, which suggests observing the phenomena in their interaction with
the context. In the case of behavior, the root metaphor of Functional Contextualism
is the observation of action in context (Pepper, 1942), considering the impossibility
of dissociating this relationship (action can only be understood in context, and con-
text is only defined depending on the action) (Biglan & Hayes, 1996). ACT is based
on a theoretical body of Contextual Behavioral Science, which presents models and
theories based on evolutionary science, the principles of behavioral learning and
Relational Frame Theory (RFT), a theoretical approach to language and human cog-
nition (Hayes et al., 2001).
According to its main proponent, ACT addresses human suffering based on a
transdiagnostic model of psychopathology, called psychological inflexibility
(Hayes, 2019). The way language and cognition interact with direct contingencies
can produce an inability to persist or change behavior in the service of long-term
ends (Hayes & Smith, 2005). Thus, the authors define psychological distress as a
corollary of verbal processes, both as a primary source of psychopathology and as
processes that exacerbate the impact of other sources of psychopathology. ACT dif-
ferentiates two types of suffering: the pain that is felt in the lived experience and the
suffering derived from it, which involves thoughts about the pain, remembering,
M. T. Saban-Bernauer (*)
School of Permanent Education, Clinics Hospital, Faculty of Medicine,
University of São Paulo, Sao Paulo, Brazil
R. Kovac
Paradigma Center of Behavioral Science and Technology, Sao Paulo, Brazil
140 M. T. Saban-Bernauer and R. Kovac
fearing that it will happen again, relating to other experiences, deriving new rules
and self-rules, and other cognitive processes that, according to the RFT, imply
trained verbal relations that emerge in a given situation. Pain is lived suffering,
experienced directly from immediate aversive contingencies, and psychological
suffering comes from our ability to relate events.
The proposed treatment for this type of verbal distress, presented by ACT, then
aims to promote psychological flexibility, defined as the “ability to contact the pres-
ent moment more fully as a conscious human being, and to change or persist in
behavior when it serves the purpose ends valued by the individual” (Hayes et al.,
2006, p. 7). In this way, ACT does not have as its primary objective the relief of suf-
fering, but it aims to promote a more meaningful life, even if this implies being open
to challenging feelings, thoughts, sensations, and memories.
The conception of human suffering, according to ACT, is based on the assump-
tion of “the ubiquity of human suffering” (Hooper & Larsson, 2015). Hayes et al.
(1999) open ACT’s landmark book with the sentence: “The most remarkable fact of
human existence is how difficult it is for human beings to be happy” (p. 1). Similarly,
Luoma et al. (2007) argue: “It is impossible to build a human life untouched by suf-
fering” (p. 1).
These statements above illustrate the proposal of ACT and the model of psycho-
pathology that it defends, that suffering is an inevitable product of the experience of
human beings and that the origin of psychological suffering would be in the very
behavior that seems to be exclusively human – verbal behavior (or language and
cognition).
This understanding of human psychological suffering, which has an intervention
and treatment proposal in ACT, is supported by experimental findings and the theo-
retical narrative of the Theory of Relational Frames (Hayes et al., 2001), which
proposes that the central element definer in all human verbal activities is arbitrarily
applicable relational responding (AARR). Relational responding constitutes
responding to a relationship between events, or relating events in certain ways,
based on (arbitrary) social conventions. It is understood that relational responding
impacts the function of basic behavioral processes or, as stated by Hayes, Wilson,
and Barnes-Holmes (2001), “relational responding is operant behavior that affects
the operant learning processes themselves” (p. 45).
According to Dougher (1998), derived relational responding and the transfer of
function resulting from it explain how words and other symbols can come to affect
behavior. According to the author:
(…) words participate in equivalence classes with the events to which they relate in the
world and, in this way, acquire many of the functions of these events. This explains how the
description of eating a sour lemon can elicit salivation or how a warning that a given sub-
stance is poisonous can cause it to be avoided (Dougher, 1998, p. 588).
Hayes et al. (2012) describe how this process of transformation of functions

inherent to language processes can create an expansion of sources of control and
impact on suffering for verbally competent humans:
When nonhumans are exposed to aversive stimuli, they react in a very predictable way.
They engage in avoidance behavior, emit stress-related responses, become aggressive, or
13 Acceptance and Commitment Therapy 141
collapse into a state of immobility. These reactions to aversive events usually have a limited
time and are linked to the presence of conditioned or unconditioned stimuli. Behaviors
related to these situations typically return to baseline levels once the aversive event is
removed and autonomic responses subside. Humans are very different creatures, primarily
because of their ability to engage in symbolic activity. Humans can carry aversive events
with them, create similarities and dissimilarities between events and form relationships
between historical events and current events based on constructed (arbitrary, conventional)
similarities. Humans can create predictions about situations that have not yet been experi-
enced. Humans can respond as if an aversive event were present even though that event
occurred decades ago. The power of the indirect functions of language and cognition cre-
ates the potential for psychological distress in the absence of immediate environmental
cues; however, these are the same cognitive skills that most aid human advancement (Hayes
et al., 2012, p. 17).
Therefore, supported in this understanding of human psychological suffering,

marked by attempts to control private events – feelings, thoughts, body sensations,
and memories to avoid suffering (Hayes & Smith, 2005), ACT presents strategies
and interventions focused on predicting and influencing the events that produce this
suffering, called “Experiential Avoidance.”
Experiential avoidance is initially defined as the “phenomenon that occurs when
a person is unwilling to stay in touch with a particular private experience (body
sensations, emotions, thoughts, memories, behavioral predispositions) and takes
steps to change the form or frequency of these events and the context that caused
them” (Biglan & Hayes, 1996).
In this way, it is understood that psychological suffering occurs when verbal
processes interfere with behavior in a way that is harmful to the individual, in par-
ticular, in an attempt to control the frequency or presence of private events and, by
doing so, produce a restriction or limitation of other aspects of life.
Numerous problems that arise in the clinical context are related to the way the
person tries to control or modify their thoughts (negative, demeaning of themselves,
or catastrophic about the future), their emotions (sadness, anxiety, anger), body sen-
sations, or memories. At the same time, it is known that private experiences are
made up of derived relational repertoire and that relational networks work by addi-
tion and not by subtraction, which makes it clinically impossible to eliminate aver-
sive cognitive and emotional events (Hayes et al., 2012).
From the point of view of ACT, anxiety, depression, and insomnia, among other
forms of psychological suffering, are the products of situations and are not a prob-
lem in themselves. They signal a larger problematic context and a behavioral pattern
of wanting to control the discomfort generated, instead of acting in the original
context of the problem. The intervention proposal on this type of suffering, pre-
sented by ACT, includes changing verbal contexts in such a way that the limitations
imposed by the dominance of verbally established functions and by experiential
avoidance are transformed (Hayes et al. 2012).
According to Hayes et al. (2013), the ACT-based intervention enables the cre-
ation of non-literal, non-evaluative contexts, which reduce unnecessary regulatory
functions of cognitive events and increase contact with the ongoing process (think-
ing, feeling, evaluating, judging, remembering) as opposed to the content of what is
thought, felt, remembered. Included in this intervention are strategies identified as

acceptance, cognitive defusion, contact with the present moment, self as context,
clarification of values and actions committed to them. These six processes are often
illustrated using the image of the “Hexaflex,” a hexagonal shape in which each ver-
tex corresponds to one of the six processes that promote psychological flexibility
(Fig. 13.1)
To illustrate psychological inflexibility and its six processes, consider insomnia
in this prism. Many events can keep us awake at night, as well as thoughts, feelings,
and memories, in the same way, can make falling asleep more difficult. Sometimes,
something reminds us of a bad situation, or recurring thoughts appear and eventu-
ally generate uncomfortable sensations. Hardly a concrete experience is happening
at bedtime, (a fight when you’re about to fall asleep that keeps you up at night, for
example). What happens is suffering arising from verbal behavior: unpleasant
thoughts, feelings, sensations, and memories that we tend to try to control. An
important part of the insomnia process involves thoughts like “I need to stop think-
ing about that,” and “I have to go back to sleep.” To manage distress, we engage in
experiential avoidance responses that serve as distractions from discomfort. They
often work, at least temporarily, but the problem that generated the unpleasant
thoughts and feelings that keep us losing sleep has not been addressed.
In some situations, what we try to do is mentally “solve the problem,” and find a
solution. However, many of the problems that keep us awake at night and that con-
stitute the type of psychological distress described here are “no solution” problems
Fig. 13.1 Hexaflex. (Copyright Steven C. Hayes. Used by permission)

(“I can’t feel this”; “I should have said/done/thought of this sooner”/ “what will
happen if I do X, Y, or Z”) – problems unlikely to be solved lying in bed, at bedtime.
Thus, experiential avoidance responses are like “killing the messenger.” The
messenger appears to warn that the kingdom is at war, and experiential avoidance –
what we do to try to control the discomfort – works like killing the messenger while
the kingdom continues in flames. This is because taking action toward what is
important and making life changes that make it more meaningful requires experi-
encing situations that in the past were challenging, learning to deal with them and
including them in some (productive) way in your experience. How to get through
the war. And this is difficult.
Restoring or cultivating important relationships, changing behaviors, making life
changes, all this evokes many emotions and challenging thoughts. And if the focus
of treatment is to avoid suffering, the patient will avoid making the changes that are
important to them. So the focus of ACT-based intervention, as already mentioned, is
Psychological Flexibility – being psychologically flexible to feel, think, and remem-
ber what comes along in the direction of what is important to you.
During the therapeutic process, the therapist creates alternative verbal contexts,
through experiential exercises, metaphors, and questions to train skills and promote
psychological flexibility (creative hopelessness, acceptance, defusion, mindfulness,
self as context, values, and actions toward them).
In Creative Hopelessness, we investigate the different forms of experiential
avoidance that the client presents and their effect on eliminating/controlling suffer-
ing in the short term – immediate consequences – and in the long term. Generally,
experiential avoidance works in the short term, but as the original problem situation
is not resolved, the feeling or thought returns and there is a need to avoid it again.
This usually generates significant limitations in the person’s life, mainly because it
competes with larger goals. The finding of this pattern generates hopelessness in
trying to control private events, as this attempt to control is not effective in the long
term and generates costs. This step paves the way for the acceptance process.
Acceptance for ACT means experiencing private events openly and non-
judgmentally, in a self-compassionate way. Technically, it is a type of exposure
intervention carried out in a special way, because instead of exposing an anxiogenic
stimulus, it exposes the person to their own anxiety, fear, sadness, or another private
event that is being avoided. This change in focus of the object of exposure (from an
external stimulus to a private event), enables a much broader change, because in
addition to the specific situation in question, other related contingencies, in which
the avoidance of feeling/thought/sensation/memory is present, they will also tend to
be affected. During exposure to the private aversive event, observation and self-care
responses are trained.
Another process related to the management of suffering is cognitive defusion.
This process refers to the ability to observe thoughts as behaviors (and not from the
content they report). Thinking is behaving, emitting sound responses, seeing images,
and establishing relationships between events. Such responses abound in our spe-
cies and like any other behavior, it has its learning history. We learned, in defusion
interventions, to notice that thoughts are learned in our history, that is, for the
discomfort of the type “why do I think these things,” we observe how we learn to
think in certain ways and not in others and to relate in different ways because we
have been taught to do so. When we think, we tend to think that our thoughts are
absolute truths and are reflecting reality. This experience with thinking is useful in
countless situations in which what we think effectively describes the experienced
contingencies. But in several other situations, especially those linked to psychologi-
cal suffering, taking the content of the thought literally can be very paralyzing or
insomnia-provoking (such as “I am a failure, I will never succeed, I have always
been a problem”). The defusion process then involves observing language as behav-
ior and differentiating direct functions (arising from experience) from attributed
ones (evaluations, judgments, and other learned relationships).
The conception of self as context corresponds to another set of relations arising
from language that generates the notion of “I.” The ability to perceive oneself is
typically human and constructed by language. The conception of “I” that ACT trains
is not linked to specific contents of how the person is or is not, thinks or feels, but
rather as the place, the locus where thoughts, feelings, sensations, memories, and
actions occur. A place as a perspective from which the entire experience can be
experienced. This context constitutes a hierarchical relationship in which the “I”
contains private events and actions. This form of self-perception facilitates psycho-
logical flexibility and contact with difficult private content.
Just like the self as a context, the practice of mindfulness is present in all pro-
cesses as a prerequisite. It is the ability to observe without judgment and in an open
way. Mindfulness means the exercise of directing attention. During ACT’s thera-
peutic processes, we train the client to pay attention to the external and internal
environment, as well as their actions and their consequences in the short, medium,
and long terms.
The processes of observation and self-observation, such as the change in the way
of relating to private events, also make it possible to clarify values. This process is
the investigation of what is important to the individual and how they want to be in
the course of their life. This elucidation of values guides the therapeutic process and
becomes its mission – to transform life toward individual values. From these defini-
tions, the client establishes objectives and concrete actions to carry out this new way
of living that is important to them. When carrying out these actions, all other learn-
ing and training processes of psychological flexibility are also put into practice,
with an emphasis on accepting private events that appear in experiences and observ-
ing thoughts as they appear and not based on what is said.
When the client acquires fluency in these processes, the treatment ends.
References
Biglan, A., & Hayes, S. C. (1996). Should the behavioral sciences become more pragmatic? The
case for functional contextualism in research on human behavior. Applied and Preventive
Psychology: Current Scientific Perspectives, 5, 47–57.
Dougher, M. J. (1998). Stimulus equivalence and the untrained acquisition of stimulus functions.
Behavior Therapy, 29(4), 577–591. https://doi.org/10.1016/S0005-7894(98)80018-X
Hayes, S. C., & Smith, S. (2005). Get out of your mind get & into your life. New Harbinger
Publications, Inc..
Hayes, S., Strosahl, K., & Wilson, K. (1999/2012). Acceptance and commitment therapy: An expe-
riential approach to behavior change. The Guilford Press.
Hayes, S., Barnes-Holmes, D., & Roche, B. (2001). Relational frame theory: A post-Skinnerian
account of human language and cognition. Kluwer Academic/Plenum Publishers.
Hayes, S. C. (2004). Acceptance and Commitment Therapy, Relational Frame Theory, and the
Third Wave of Behavioral and Cognitive Therapies. Behavior Therapy, 35(4), 639–665. https://
doi.org/10.1016/S0005-7894(04)80013-3
ment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44, 1–25.
Hayes, S. C., Levin, M., Plumb-Vilardaga, J., Villatte, J., & Pistorello, J. (2013). Acceptance and
Commitment Therapy and contextual behavioral science: Examining the progress of a distinc-
tive model of behavioral and cognitive therapy. Behavior Therapy (44), 180–198.
Hayes, S. (2019). A Liberated Mind: How to Pivot Toward What Matters. New York: Avery.
Hayes, S. C, Wilson, K. G., & Barnes-Holmes, D. Derived Relational Responding as learned behav-
ior. In: Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). (2001). Relational Frame Theory:
A Post-Skinnerian account of human language and cognition. New York: Plenum Press.
Hooper, N., & Larsson, A. (2015). The research journey of acceptance and commitment therapy
(ACT). Palgrave Macmillan. https://doi.org/10.1057/9781137440174
Pepper, S. (1942). World hypotheses: A study in evidence. University of California Press.
Hayes, S. C., Wilson, K. G., & Barnes-Holmes, D. (2001). Derived Relational Responding as
learned behavior. In: Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). Relational Frame
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Chapter 14
Evidence of Acceptance and Commitment
Therapy-Based Therapies for Insomnia
Léo Paulos-Guarnieri, Ila Marques Porto Linares,

and Renatha El Rafihi-Ferreira
A large number of studies are currently investigating the effects of Acceptance and
Commitment Therapy (ACT) interventions on different disorders and conditions.
The website of the Association for Contextual Behavioral Science (ACBS) contains
a list of more than 1000 randomized clinical trials1 and of more than 400 systematic
reviews and/or meta-analyses2 investigating ACT.
Gloster et al. (2020) recently systematized the evidence on ACT in order to eval-
uate the effects of ACT interventions for a variety of conditions, comparing differ-
ent groups. For this purpose, the authors included 20 meta-analysis studies whose
results showed that ACT has benefits for complaints such as depression, anxiety,
substance use, and chronic pain. In addition to reducing these complaints, the stud-
ies have demonstrated beneficial effects for variables such as quality of life,
psychological flexibility, and well-being. ACT was superior when compared with
non-active control groups or with passive interventions. However, there were no
significant differences between ACT and CBT.
The data analyzed by Gloster et al. (2020) can have different implications. The
study suggests that ACT is a viable option for different conditions since it provided
Léo Paulos-Guarnieri receives research support from the São Paulo Research Foundation
(FAPESP) [grant #2020/107486; #2023/06859-5].
1
https://contextualscience.org/act_randomized_controlled_trials_1986_to_present
2
https://contextualscience.org/metaanalyses_and_systematic_scoping_or_narrative_
reviews_of_the_act_evidenc
L. Paulos-Guarnieri (*) · I. M. P. Linares

Faculty of Medicine at the University of São Paulo, Sao Paulo, Brazil
148 L. Paulos-Guarnieri et al.
favorable results in different meta-analyses involving different disorders (Gloster

et al., 2020). This scenario also supports the transdiagnostic proposal of ACT (Dindo
et al., 2017; Gloster et al., 2020; Ong et al., 2020), in which psychological flexibility
is an important aspect of health (Kashdan et al., 2010). The proposal of promoting
psychological flexibility expands the notion of mental health beyond the absence of
symptoms by also considering the promotion of quality of life, well-being, func-
tioning, and psychological flexibility (Dindo et al., 2017; Gloster et al., 2020).
The implications of the study by Gloster et al. (2020) are important; however, no
systematic reviews or meta-analyses of ACT focusing on insomnia were available at
the time when that study was published. At present, there are two systematic reviews
on ACT for insomnia and sleep quality (Paulos-Guarnieri et al., 2022; Salari et al.,
2020) and one systematic review with meta-analysis (Ruan et al., 2022). And what
do these studies show?
The review by Salari et al. (2020) evaluated the effects of interventions that used
ACT for insomnia with and without comorbidities, with sleep patterns and sleep
quality as outcomes. Nineteen articles demonstrated a positive and significant
impact of the interventions on insomnia severity, sleep quality, daytime sleepiness,
dysfunctional beliefs and attitudes about sleep, acceptance of sleep problems, and
parameters of sleep efficiency such as sleep latency, wakefulness after sleep onset,
and total sleep time (Salari et al., 2020).
Paulos-Guarnieri et al. (2022) conducted a systematic review on interventions
using ACT for insomnia as the primary outcome. The 11 articles included in the
review reported significant improvements in insomnia severity and sleep parame-
ters, as well as in secondary outcomes such as dysfunctional beliefs and attitudes
about sleep, acceptance of sleep problems, daytime sleepiness, and cognitive sup-
pression (Paulos-Guarnieri et al., 2022). Evaluation of the components of the inter-
ventions suggested that ACT can be applied as monotherapy for insomnia
(Acceptance and Commitment Therapy for Insomnia, ACT-I) or combined with
stimulus control and sleep restriction components (Acceptance and Commitment
Therapy-Based Behavioral Intervention for Insomnia, ACT-BBI-I). Both modalities
produced favorable results in terms of reducing the severity of insomnia (Paulos-
Guarnieri et al., 2022)
Ruan et al. (2022) carried out a systematic review with meta-analysis of random-
ized clinical trials using ACT for insomnia and sleep quality, with the first meta-
analysis of ACT involving these outcomes. Eighteen studies were included.
Meta-analyses were performed to assess the effects of ACT on the sleep and insomnia
of participants and on the sleep of participants with other diseases or conditions. The
results showed that ACT provided better results in terms of reducing insomnia symp-
toms and dysfunctional beliefs and attitudes about sleep when compared with the
waiting-list and psychoeducation control groups. When compared with CBT-I, ACT
did not differ in terms of insomnia severity or sleep diary parameters. At the end, the
authors highlight that, given the limitations in the methodological qualities of the
included studies, caution is necessary when interpreting and generalizing the meta-
analysis results (Ruan et al., 2022). Nevertheless, the authors suggest that ACT could
be an effective approach to treating insomnia and improving sleep quality.
14 Evidence of Acceptance and Commitment Therapy-Based Therapies for Insomnia 149
14.1 Systematization and Synthesis of Reviews on ACT

for Insomnia and/or Sleep Quality
This section systematizes and synthesizes the results of the articles included in the
latest reviews on the topic (Paulos-Guarnieri et al., 2022; Salari et al., 2020; Ruan
et al., 2022), removing duplicate or repeated articles. Although the reviews have
different objectives, as well as different inclusion and exclusion criteria, the infor-
mation of the studies was arranged in tables to show the evidence found so far and
which aspects future studies should explore. Two tables were built for this purpose.
Table 14.1 includes randomized clinical trials and Table 14.2 studies with other
designs. In both tables, the articles were organized according to year of publication,
highlighting whether insomnia was the primary or secondary outcome in the studies
and the general characteristics of the participants.
Table 14.1 Randomized clinical trials

Year Authors Primary outcome Participants
Insomnia as primary outcome
2015 Baik Insomnia Adults
2019 Lappalainen et al. Insomnia Adults
2021 El Rafihi-Ferreira et al. Chronic insomnia Adults
2021 Chapatout et al. Chronic insomnia and hypnotic addiction Adults
2021 Haung et al. Insomnia Elderly adults
2021 Zakiei et al. Insomnia Adults
2022 Chen et al. Insomnia Students
2022a, b El Rafihi-Ferreira et al. Chronic insomnia Adults
Insomnia or sleep quality as secondary outcome
2011 Westin et al. Tinnitus Adults
2012 Hesser et al. Tinnitus Adults
2013 Pelkonen and Puha Chronic sleep problems Adults
2015 Gao and He Tinnitus Adults
2017 Clarke et al. Osteoarthritis Elderly adults
2017 Herbert et al. Chronic pain Adults
2017 Lang et al. Depression and/or anxiety Adults
2018 Simister et al. Fibromyalgia Adults
2018 Mosher et al. Breast cancer Adults
2018 Vethe et al. Chronic fatigue Adults
2018 Wiklund et al. Back, neck and/or generalized pain Adults
2018 Zhang et al. Gynecological cancer patients and partners Adults
2019 Mosher et al. Lung cancer and caregivers Adults
2019 Wells-Di Gregorio et al. Advanced cancer Adults
2020 Davoudi et al. Diabetes and neuropathic pain Adults
2021 Rickardsson et al. Chronic pain Adults
2022 Monfaredi et al. Women in menopause Adults
Table 14.2 Other designs

Year Authors Primary outcome Participants
Insomnia as primary outcome
2010 Dalrymple et al. Chronic insomnia Adults
2014 Hertestein et al. Chronic insomnia Adults
2018 Zetteqvist et al. Chronic insomnia and chronic pain Adults
2019 Khazie and Zakiei Chronic insomnia Adults
2019 Zakiei and Khazie Insomnia Adults
2021 Rollinson et al. Insomnia Adolescents
Insomnia or sleep quality as secondary outcome
2015 Kallestad et al. Chronic fatigue Adults
2017 Farhang et al. Mental disorders Adults
2017 Jacobsen et al. Chronic fatigue Adults
2020 Craner et al. Chronic pain Adults
As can be seen in Tables 14.1 and 14.2, 35 studies on interventions that used
ACT for insomnia and sleep quality were identified among the reviews. Of these, 25
were randomized clinical trials and eight of them used insomnia as the primary
outcome. Ten studies had other designs and six of them had insomnia as the primary
outcome. These divisions were made in order to interpret the data of the reviews
(Paulos-Guarnieri et al., 2022; Ruan et al., 2022; Salari et al., 2020). Based on the
data reported in the reviews, we will discuss different aspects of ACT for insomnia:
(a) the type of outcome (primary or secondary) of insomnia and/or sleep quality in
the studies; (b) ACT modalities used in the interventions; (c) comparisons of ACT
with CBT-I; and (d) how the ACT approach can contribute to the individualization
of interventions.
14.2 Insomnia as Primary or Secondary Outcome
Insomnia was the intervention target in 14 studies; of these, eight were randomized
clinical trials and six had other designs. Another 21 studies measured the effects of
the intervention on insomnia and/or sleep quality, but these outcomes were not the
intervention target. In the studies in which insomnia was not the target of the inter-
vention, the most common primary outcomes were chronic pain (n = 4), cancer
(n = 4), fatigue (n = 3), and tinnitus (n = 3).
To enable interpretation of the impacts of ACT on insomnia, sleep quality, or
sleep parameters, the separation into primary and secondary outcomes is necessary
for two reasons: first, to consider the particularities of each population and, second,
to consider the differences between the protocols used. Studies whose primary out-
come was insomnia involved populations in which complaints of insomnia pre-
dominated and insomnia was even diagnosed. Furthermore, these studies probably
planned the interventions using the sleep topic as the main target. Unlike studies
that had insomnia or sleep quality as secondary outcome, the populations had other
chief complaints and the intervention protocols probably had other targets. For
these reasons, caution is necessary in generalizing the data to other types of popula-
tions or to any protocol using ACT. On the other hand, ACT achieved favorable
results for both patients who were diagnosed with insomnia and patients with symp-
toms of insomnia associated with other conditions. Thus, ACT had benefits regard-
less of whether or not sleep was the main target of the intervention.
The facts that ACT is aimed at developing psychological flexibility, that psycho-
logical inflexibility is transdiagnostic (Levin et al., 2014) and that studies found
improvements in sleep-related outcomes suggest that psychological inflexibility and
flexibility are somehow associated with insomnia and sleep quality. More studies
are needed to safely affirm this statement. Nevertheless, some studies have pointed
in this direction (Daly-Eichenhardt et al., 2016; McCracken et al., 2011; El Rafihi-
Ferreira et al., 2022a; Zakiei et al., 2022), showing relationships of psychological
flexibility or inflexibility with the severity of insomnia.
14.3 ACT Modalities for the Treatment of Insomnia
The study by Paulos-Guarnieri et al. (2022) was the only review that aimed to iden-
tify the strategies employed in each intervention using ACT for insomnia, some-
thing that could be the focus of future studies. The authors suggested two modalities
in which ACT appeared to be used in the context of insomnia, namely, ACT as
monotherapy for insomnia, called Acceptance and Commitment Therapy for
Insomnia (ACT-I), and ACT used in combination with behavioral interventions for
insomnia. (i.e., stimulus control and sleep restriction), called Acceptance and
Commitment Therapy-Based Behavioral Intervention for Insomnia (ACT-BBI-I).
It is interesting to reflect on the composition of the intervention components used
in the studies since different components can provide different results. Knowledge
of the role of each component is also necessary in order to identify the components
related to the effects of the intervention. This recommendation serves both clini-
cians planning individualized treatment for their patients and researchers designing
protocols for intervention studies.
Understanding the roles of the components is not only important for knowing the
effectiveness of ACT for insomnia and sleep quality but also for individualizing
interventions. Below, when we discuss possible directions for ACT research in the
context of insomnia, we will suggest research designs that can contribute to answer-
ing the questions about the individualization of interventions.
14.4 Comparison of ACT and CBT-I
It is interesting to highlight the studies that compared ACT with CBT-I (El Rafihi-
Ferreira et al., 2021, 2022b). These studies revealed no significant differences when
either ACT-BBI-I (El Rafihi-Ferreira et al., 2021) or ACT-I (El Rafihi-Ferreira et al.,
2022b) was compared with CBT-I. The study by El Rafihi-Ferreira et al. (2022b)
found higher treatment response rates in the CBT-I group within 1 week of post-
treatment, while ACT-I resulted in further improvements in outcomes after 6
months. Considering that CBT-I is the recommended first-line treatment for insom-
nia (Edinger et al., 2021) and that not all patients adhere to this therapeutic modal-
ity, these data favor the study and implementation of ACT in the context of insomnia.
The importance of investigating which type of therapy might be more beneficial
for a given patient must be highlighted. Thus, to answer the question “In which con-
texts may ACT be better than CBT for insomnia?” many factors, ranging from the
individual characteristics of the patient to his/her context, must be investigated. For
example, ACT has been shown to be beneficial for patients who are refractory to
CBT-I (Dalrymple et al., 2010; Hertestein et al., 2014) and may contribute to the treat-
ment of patients who, for different reasons, do not adhere or do not respond to CBT-I.
Outcome and process studies are important and should be complementary. While
outcome studies focus on assessing whether a therapy is effective and which therapy
should be applied in a given context, process studies explore the mediating and
moderating factors involved in the success of treatment. Regarding outcome stud-
ies, there is currently much more research on CBT for insomnia than on ACT for
insomnia. Although the effectiveness of ACT for insomnia is being explored in new
studies, additional research is still needed to obtain more answers with greater
potential to generalize the results.
Process studies that explore the mediating and moderating factors of interventions
can increase the accuracy of the results based on characteristics of the individuals’ con-
text and of the individuals themselves. Furthermore, process studies using longitudinal
measures that explore how and when changes occur are needed to understand the mech-
anisms involved in changing the target behavior. Such studies can provide answers to the
following questions: (a) How does each intervention strategy affect sleep and what are
the underlying mechanisms? (b) Which patients with certain characteristics and contexts
could benefit from given interventions and strategies? (c) Which process of psychologi-
cal flexibility and which behavioral strategies are related to the changes?
14.5 Contribution of ACT for the Individualization

of Interventions
How do we know if ACT is the most appropriate therapy for a certain patient? When
should we use ACT-I? When should we use ACT-BBI-I? How do we choose which
processes of psychological inflexibility and flexibility to target? These questions are
difficult to answer and highlight the complexity of a therapeutic process.
ACT is a contextual therapy whose philosophical basis is functional contextual-

ism; hence, identification of the function of behaviors that interact with the histori-
cal and situational context is essential (Hayes et al., 1988; Hayes et al., 2012). For
this purpose, functional analysis is used to identify the processes that are relevant
for the intervention (Ferreira, 2021b). In addition to asking whether the therapeutic
procedures are effective, one question that guides ACT is which processes are
responsible for the changes (Ong et al., 2020). These approaches contribute to the
individualization of cases instead of focusing on strategies for specific diagnostic
disorders.
Based on these considerations, contextual therapies have been moving toward
the process-based therapy (PBT) approach (Ferreira, 2021b; Ong et al., 2020).
Instead of focusing on the investigation of evidence-based procedures, PBT focuses
on evidence-based processes using empirical methods to evaluate pre-established
procedures and outcomes (Hayes & Hoffmann, 2018; Hoffmann et al., 2021; Ong
et al., 2020). Despite their differences, these therapies that make up PBT agree that
clinical evidence must progress toward an understanding of the main processes of
clinical change that are relevant for case formulation (Ferreira, 2021b). Functional
analysis is key to PBT, privileging function over the topography of behavior
(Ferreira, 2021b). The functionally described processes of change consider that it is
not possible to establish a single cause since a dynamic non-linear interaction exists
between many variables. These variables acquire a function within the context in
which they occur. Thus, contextual interventions can confer new functions to the
same events.
For clinicians, it is important to rely on functional analysis in order to identify
target behaviors and the functions of these behaviors for intervention planning
(Ferreira, 2021a). In the context of insomnia, target behaviors would be those that
affect the homeostatic and circadian system (Borbély et al., 2016) and those related
to psychological inflexibility (Hayes et al., 2012). This approach can facilitate case
formulation by contributing to the identification of inflexibility processes related to
elusive experiences and fusions, including insensitivity to the present moment, per-
spective taking, and lack of engagement (Luoma et al., 2017).
For researchers, it is important to identify future topics, for example, which pro-
cesses of psychological inflexibility or flexibility may be risk or maintenance fac-
tors of insomnia. Such information will help in the field to plan prevention and
treatment interventions.
In the case of clinicians, researchers, and individuals who exert both functions, it
is believed that ACT can contribute to the individualization of treatments and in the
quest to understand the relevant processes that affect sleep (Ong et al., 2020; Paulos-
Guarnieri et al., 2022). In the context of insomnia, ACT represents a paradigm shift
since it does not focus solely on reducing the symptoms and severity of insomnia
but rather sees the patient as a whole in an attempt to increase quality of life and
psychological flexibility (Gloster et al., 2020; Paulos-Guarnieri et al., 2022).
14.6 Directions for Future Research
There are different directions for anyone interested in studying ACT in the context
of insomnia, all of them being equally encouraged and important. Different research
questions will lead to different study designs (Kazdin, 2020). The following are
recommended for individuals who seek to evaluate and refine the data on the effec-
tiveness of ACT treatment for insomnia (i.e., ACT-I and ACT-BBI-I): (a) studies
with high methodological quality, preferably randomized clinical trials involving
large populations that evaluate both short- and long-term outcomes with long
follow-ups and compare outcomes with other empirically supported therapies (e.g.,
CBT-I); (b) studies involving populations with not yet studied characteristics (e.g.,
different age groups, patients with comorbidities); (c) studies comparing different
intervention formats (e.g., online versus face-to-face, self-administered versus ther-
apist, group versus individual).
For individuals who seek to better understand how the processes of ACT interact
with the disorder and insomnia symptoms, the following approaches are recom-
mended: (a) studies that investigate the relationship between processes and the
interventions used (e.g., single-subject experimental design); (b) studies that inves-
tigate the relationship of psychological inflexibility or flexibility variables with the
severity of insomnia and/or sleep parameters (e.g., cross-sectional studies, longitu-
dinal studies, moderation, mediation, and network statistical analyses); (c) studies
that identify the role of each component in the intervention (e.g., dismantling stud-
ies); (d) studies that assess predictors of treatment adherence and response; (e) the
use of instruments that adequately measure the ACT processes, including multidi-
mensional instruments (e.g., MPFI; Rolffs et al., 2016, CompACT; Francis et al.,
2016), unidimensional instruments (e.g., PsyFlex; Gloster et al., 2021), or specific
instruments for given processes (e.g., CAQ-8; McCracken et al., 2015, CFQ;
Gillanders et al., 2014, SACS; Zettle et al., 2018, VQ; Smout et al., 2014).
This chapter synthesized the evidence on ACT for insomnia, focusing on the studies
included in the main reviews reported in the literature (Paulos-Guarnieri et al.,
2022; Salari et al., 2020; Ruan et al., 2022). This synthesis permitted to address the
implications and contributions of ACT to the treatment of insomnia, highlighting
insomnia as a target or not of the intervention and showing which ACT modalities
are used in the interventions, their performance when compared to CBT-I, and how
ACT can contribute to the individualization of interventions designed to treat
insomnia and to improve sleep quality. In addition, it is expected that the possible
directions for future research will encourage clinicians and researchers to refine the
interventions and evidence available so far, improving the understanding of the
effectiveness of interventions and focusing on the processes related to the sleep
problems and sleep quality.
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Chapter 15
A Session-by-Session Guide for Acceptance
and Commitment Therapy for Insomnia
This chapter describes an intervention protocol for insomnia complaints based on

Acceptance and Commitment Therapy (ACT). Although it presents a description of
the procedures to be conducted in the session, this protocol does not exclude the
need for functional analysis and case formulation. The aim of functional analysis is
to identify the dependency relationships between the actions of the organism and
antecedent and consequent environmental events. The clinician’s interest lies in
investigating the determinants of the individual’s behaviors.
As a clinical model, case formulation by ACT assumes the identification of pro-
cesses of psychological inflexibility (experiential avoidance, cognitive fusion, dom-
inance of the conceptualized past and future, attachment to the conceptualized self,
lack of values, and inaction) and psychological flexibility (acceptance, cognitive
defusion, contact with the present moment, self as context, values, and committed
actions). Understanding these variables enables more effective therapeutic plan-
ning. Continuous assessment must always be present during this process. In con-
junction with functional assessment, this protocol can be used flexibly, respecting
the specificities of each case.
This insomnia protocol is composed of sleep psychoeducation, ACT-based inter-
ventions, and home activities. For organizational purposes, the set of therapeutic
elements that make up this protocol is divided into six sessions, which can be per-
fectly adapted to a larger or smaller number of sessions at the therapist’s discretion.
The protocol can also be applied in conjunction with stimulus control and sleep
restriction techniques.
The program can be applied in different formats, that is, individual, group, face-
to-face, and online. It is recommended that individual sessions last approximately
50 minutes and group sessions about 120 minutes. The session-by-session protocol
is described below.
15.1 First Session: Building Rapport and Introduction

to Sleep
The focus of the first session is to establish a bond between the therapist and the
client or group members and to provide information about the therapeutic process,
sleep, and insomnia. The interventions used in session 1 are presented in Table 15.1.
1. Presentation of the therapist and client or group members
The therapist starts with their own presentation and asks the client to answer the
following questions: (1) Who am I? (2) What brought me here? (3) What do I
like to do?
2. Presentation of the intervention proposal
The therapist continues with information about the treatment, explaining that the
focus will be on aspects directly related to sleep, such as habits and behaviors, and
indirectly related to sleep, that is, how we deal with the discomforts of life, includ-
ing sleep dissatisfaction.
3. Rules
The therapist explains the rules of confidentiality, schedule, and absences from
therapy. In the case of group intervention, the therapist emphasizes the importance
of confidentiality since the participants may share very delicate and intimate content
and confidentiality may be the only tool to ensure that they expose themselves and
proceed with the vulnerability that ACT promotes.
Table 15.1 Interventions of session 1

Intervention Objectives
Presentation To introduce the therapist and client or group members
To present the intervention proposal
Group/therapy rules To clarify the confidentiality between group members or between the
professional and client
To explain the importance of session attendance
To reinforce commitment to schedules and homework assignments
Wound metaphor To introduce the ACT proposal
To stimulate reflection based on an analogy between the metaphor and
the therapeutic situation
Cartoon dynamics To promote integration between group members or between the
professional and client
To encourage identification with the characters of the cartoon
To discuss the experiences based on the content of the cartoons
Psychoeducation about To teach the patient or group members about sleep and its functions,
sleep effects of sleep deprivation, and insomnia
Homework assignment To develop extra-session therapeutic activities
15 A Session-by-Session Guide for Acceptance and Commitment Therapy for Insomnia 163
4. Wound metaphor
The therapist describes the wound metaphor to the client or group.
Wound metaphor
Let’s address pretty basic issues, including some you might not expect in therapy.
My experience with this approach is that it can put you on a rollercoaster ride. All
kinds of emotions can arise: interest, boredom, anxiety, sadness, doubt, understand-
ing, relief, peace, anguish, discomfort, etc.
It is like treating a wound, procedures that cause even more pain will be needed
so that it stops bleeding. And in the middle of the procedures, you might think that it
was worse to treat it since the pain increased even more. But only by facing the
discomfort of this pain will the wound stop bleeding.
Think about the following situation: Imagine that you have a wound on your
body. This wound hurts and bleeds a lot. If we leave the wound and do not look at it,
it will continue to bleed and hurt. Afraid of feeling even more pain, you may choose
not to treat the wound. However, the wound will continue to bleed.
Whereas if we care for this wound, if we clean it, if we treat it, the wound will
stop bleeding. This process is painful and you have to endure some discomfort since
touching the wound causes pain. It is often necessary to clean, stitch, apply dress-
ings, in short, to treat it. By doing this, the blood ceases.
Depending on the size of the wound, scars will remain and will remind us of the
wound; however, the wound is closed and no longer bleeds.
Source: Metaphor developed by the author of this chapter.
5. Dynamics of integration
Three cartoons that portray different insomnia situations are shown (see Figs. 15.1,
15.2, and 15.3).
In the case of group intervention, different comic strips are given to each small
group. In the group, each participant tells a story about the cartoon. After a few
minutes, each small group shares their stories with the larger group. After all partici-
pants have told their stories, the similarities with the stories themselves are discussed.
Fig. 15.1 Cartoon 1. (Source: Illustration made by the artist Helder Lira, 2023. All rights
reserved ©)
reserved ©)
reserved ©)
In the individual intervention, the client can discuss the cartoons with the thera-
pist, proposing their own stories.
6. Pseudoeducation about sleep
The therapist gives a lecture about sleep to the client or group members, specifi-
cally addressing the following topics: sleep and its functions, effects of sleep depri-
vation, and insomnia. For the preparation of psychoeducation material, the reader
can refer to the first part of this book.
During the presentation, the therapist clarifies any doubts of the client or the
group members.
7. Homework assignment
The homework assignments aim to strengthen what was learned in the session on
extra-session occasions.
The therapist explains the importance of filling out the sleep diary throughout the
therapeutic process and answers any doubts raised by the patient or group members.
The sleep diaries should be filled out daily to monitor treatment progress. A sleep
diary template can be found in Chap. 9 of this book.
15.2 Second Session: Sleep Hygiene and Present Moment
The second session is aimed at educating the client or group members about habits,
behaviors, and activities that can promote quality sleep. In this session, mindfulness
will be practiced using formal and informal exercises. The interventions used in
session 2 are described in Table 15.2.
1. Review of homework
The therapist evaluates the sleep diaries, asks the client or group members about
difficulties in filling out the diary, and clarifies any doubts. Based on the sleep diary
records, the client or group members report the week’s feedback.
2. Psychoeducation about sleep hygiene
The therapist gives a lecture about sleep hygiene to the client or group members,
including the set of habits, behaviors, and activities that promote quality sleep. The
explanation focuses on the five pillars of sleep hygiene: (1) sleep environment; (2) eat-
ing habits and substance intake; (3) routine; (4) sleep ritual; and (5) worries. The reader
can refer to the Chap. 10 of this book to prepare material for psychoeducation. During
the presentation, the therapist clarifies any doubts of the client or group members.
3. Delivery of supporting material (sleep hygiene booklet)
A paper or electronic booklet with information on sleep hygiene is handed out to
the client or group members. This booklet as supporting material aims to strengthen
the absorption of what was learned and of the guidelines given in the psychoeduca-
tion session. Written material allows the client or group members to review the
information provided in the session on extra-session occasions.
A template of the sleep hygiene booklet can be found in the tables of the Chap.
10 of this book.
4. Mindfulness: formal versus informal practices
The therapist explains the concept of mindfulness and mindfulness principles for
insomnia and discusses formal and informal practices.
The concept of mindfulness is defined as staying in the present moment, paying
full attention. Being connected to the present moment helps the individual to assess

Review of homework To review extra-session activities
Feedback on established tasks
Psychoeducation about To inform and guide the client or group members about habits and
sleep – Sleep hygiene activities that promote quality sleep
Supporting material – Sleep To hand out a paper or electronic version of a sleep hygiene
hygiene booklet so that the client or group members can review the
information learned in the session
Mindfulness To explain and show formal and informal mindfulness practices
Body scan (Kabat-Zinn, Mindfulness
1990) To establish contact with the present moment
what the environment offers and to react based on this perspective. Observation of
the present moment focuses on assuming control of the here and now. As a practice,
mindfulness aims to expand our self-awareness about how we connect with what
happens within and around us (Ramos, 2015).
If we are attentive to the present moment, we are better equipped to adequately
respond to what happens around us. We are often caught up in past experiences,
expectations about the future, or our thoughts that distract us from what is taking
place around us.
The relationship with sleep can be addressed based on the seven principles of
mindfulness for insomnia proposed by Ong and Manber (2011): beginner’s mind,
non-striving, letting go, non-judging, acceptance, trust, and patience (see Fig. 15.4).
Mindfulness practices can be formal or informal and both types consist of train-
ing to stay in the present moment.
Formal practices consist of reserving a time of our day to an exclusive mindful-
ness practice such as body scan, which will be described below. On the other hand,
we can practice informal exercises at any time of the day, during daily activities
such as bathing, cooking, eating, walking, and driving. These activities are per-
formed with full attention to senses (touch, smell, taste, vision, hearing), feelings,
and thoughts that we are experiencing in the present moment.
5. Body scan
The therapist applies the body scan practice together with the client or group
members. The practice is described below.
Body scan
Look for a comfortable place, it can be a chair, a sofa, a mattress, whatever you
prefer. Position yourself comfortably. You can choose to remain seated keeping your
spine straight or, if you prefer, you can lie down. If you prefer, close your eyes.
Concentrate on your breathing. Observe your breathing. Feel the air moving in and
out through your nostrils.
The experience of this practice is full attention to different parts of your body.
Direct your attention to your head. Explore the sensations on your scalp, on your
neck until the attention reaches your forehead. Observe if there is any tension, pain,
or discomfort in this region. Contemplate these sensations in a mindful, nonjudg-
mental way. Observe the temperature in this region. And then breathe. Go over your
face, eyes, nose, lips, ears, chin. Perceive whether this region is hot, cold, or has a
mild temperature.
Gradually, pay attention to your neck, working your way up to your shoulders
and shoulder blades. Observe if there is any tension in this region. Breathe and return
your attention to your back, observe the neck region, and go down to the lumbar
region. Is there any discomfort in this region? Is the temperature in this region mild,
hot, or cold?
Slowly direct your attention towards your arms, forearms, wrists, hands, and
fingers. Again, observe if there is any tension in this region.
Observe the sensations in your chest, abdomen, belly. Is there any discomfort?
Slowly move down to the pelvic area, thighs, knee, calf, heel, and toes. Observe if
there are any points of tension or discomfort.
Explore the sensations. Pay attention whether, when you perceive pain or tension
in a specific region of your body, these discomforts change naturally as you notice
(continued)
them. As you breathe with these specific parts of your body, the discomfort
transforms.
Returning your attention to your breathing, say goodbye to this experience. Get
in touch with the sounds of the environment where you are. Slowly move parts of
your body and, when you feel comfortable, you can open your eyes.
Source: Adapted from Kabat-Zinn (1990).
TABLE 14.1 Applying Mindfulness Principles to Sleep
In the spirit of cultivating mindfulness, this program will help guide your personal
inquiry into your own sleep needs and the optimal state of mind for initiation of sleep
(at the beginning or middle of the night). In doing so, bring attention to changing your
relationship to sleep rather than to the amount of sleep you get each night. As you
begin to change this relationship, you might notice an improvement in the quality of
your sleep. Later, you will likely see an increase in the amount of sleep you get. This
approach requires discipline and consistency but follows the principles of mindfulness
discussed in this program.
Beginner’s Mind: Remember that each night is a new night. Be open and try
Something different! What you have been doing to this point is probably not
working well.
Non-striving: Sleep is a process that cannot be forced, but instead should
be allowed to unfold. Putting more effort into sleeping longer or better is
counterproductive.
Letting go: Attachment to sleep or your ideal sleep needs usually leads to
worry about the consequences of sleeplessness. This is counterproductive and
inconsistent with the natural process of letting go of the day to allow sleep to
come.
Non-judging: It is easy to automatically judge the state of being awake as negative
and aversive, especially if you do not sleep well for several nights. However, this
negative energy can interfere with the process of sleep. One’s relationship to sleep
can be a fuitful subject of meditation.
Acceptance: Recognizing and accepting your current state is an important first
step in choosing how to respond. If you can accept that you are not in a state of
sleepiness and sleep in not likely to come soon, why not get out of bed? Many
People who have trouble sleeping avoid getting out of be. Unfortunately,
spending long periods of time awake in bed might condition you to being awake in
bed.
Trust: Trust your sleep system and let it work for you! Trust that your mind
and body can self regulate and self correct for sleep loss. Knowing that short
consolidated sleep often feels more satisfying than longer fragmented sleep can
help you develop trust in your sleep system. Also, sleep debt can promote good
sleep as long as it is not associated with increased effort to sleep.
Patience: Be patient! it is unlikely that both the quality and quantity of your sleep
will be optimal right away.
These are just some ways that the mindfulness principles are related to sleep. you might discover
other connections between these principles and the process of going to sleep or falling back asleep.
We encourage you to explore this for yourself and share your experience throughout this program.
Fig. 15.4 Seven principles of mindfulness for insomnia. (Source: Ong and Manber (2011).
Reprinted with permission from Elsevier)
At the end of the practice, the therapist asks the client or group members for feed-
back on how the experience was.
1. Fill out the sleep diary
The sleep diaries should be filled out weekly to monitor treatment progress. A
sleep diary template can be found in Chap. 9 of this book.
2. Make changes in sleep hygiene
Knowing the habits, activities, and environments that favor sleep, it is now time
to put into practice what you learned in the session on sleep hygiene and make the
necessary changes. To do this, use the guidelines on sleep hygiene that can be found
in the Chap. 10 of this book.
3. Write thoughts/feelings present at bedtime in the thoughts notebook
Writing about personal experiences and worries is a known tool for managing
stress and ruminations, while facilitating the organization of experiences in a narra-
tive. It may also be an extension of sleep hygiene. If you overflow with thoughts/
feelings at bedtime, write them in a notebook. A template of a thoughts notebook
can be found in the Chap. 10 of this book.
4. Practice the body scan mindfulness exercise daily
Practicing mindfulness daily as homework is key to developing and maintaining
the ability to meditate. The body scan practice is described in this chapter.
15.3 Third Session: Creative Hopelessness

and Cognitive Defusion
The third session focuses on the observation of experiential avoidance, that is, cre-
ative hopelessness. In this session, the client or group members will be guided in the
assessment of attempts to control and avoid discomfort. At the same time, they are
invited to observe their thoughts without judging, addressing cognitive defusion.
The interventions used in session 3 are presented in Table 15.3.
The therapist evaluates the sleep diaries and asks the client or group members
about changes made to sleep hygiene and about the body scan practice. The patient
or group members report the week’s feedback. While reviewing the homework
assignment, the therapist asks the client if there have been any changes since the last
session. When giving feedback to the client or group members, the therapist listens
and accepts all of the client’s responses. It is important to create a context of open-
ness and welcoming regardless of the client’s content. The therapist thus avoids
being categorical/classifying so that the client or group members do not feel judged.
Here are two phrases that usually promote welcoming: “Very interesting.” and
“Thank you for sharing.”

Assessment of attempts to control and avoid Creative hopelessness
discomfort
Mindfulness Creative hopelessness
practice on creative hopelessness – Insomnia Observe the avoidance of discomfort
Tug-of-war with a monster metaphor Creative hopelessness
Acceptance
Mindfulness – Leaves on a stream Cognitive defusion
Homework assignment To develop extra-session therapeutic
activities
2. Assessment of attempts to control and avoid discomfort

Creative hopelessness refers to the observation of contingencies that involve
experiential avoidance behaviors, with relief as an immediate consequence and the
subsequent reappearance of aversive stimuli that again demand the avoidance
behavior (Saban, 2015).
To address creative hopelessness, the therapist proposes an activity aimed at
exploring the feelings and thoughts associated with insomnia and the avoidance and
control strategies used. A pen and paper are used for this activity.
The therapist asks the client or group members to recall the last time they had
difficulties sleeping. Based on this memory, the patient or group members are
invited to respond individually to the following questions given in the Table 15.4.
In the case of group intervention, the participants should share the answers in
pairs. After sharing with the partner, the participants discuss the issues in the group.
Each partner of the pair should describe what they observed in the other. This helps
to synthesize and to hear yourself through the other. In that case, those who listen to
the description about themselves can also complete.
When the intervention is conducted individually with the client, the therapist
reserves time for the patient to complete the answers and then opens it up for
discussion.
At this point, the client or group members may have difficulty identifying their
emotions during insomnia. To help the participant connect with the insomnia expe-
rience, the therapist conducts the following mindfulness practice:
Mindfulness practice on creative hopelessness – Insomnia

Find a comfortable position and when you are ready, close your eyes. Focus on your
breathing, feel the air come in and out through your nostrils.
Now, remember the last time you had difficulty sleeping. Where were you? As
much as possible, bring to mind what the experience was like. What thoughts are
appearing? Observe any emotions that arise. Name them silently. What do you feel
in your body? Observe the sensations.
With the memory of this experience, connect with the environment where you
are. Slowly move and, when you feel comfortable, you can open your eyes.
Source: The author.
Table 15.4 – Evaluation of control and avoidance

Describe your feelings and sensations in face of
1. How do I feel when I cannot sleep? the sleeping difficulty
2. What do I do right away? Describe the strategies used when you have
insomnia
3. Does it work as I would like? Right away Describe whether the strategies are effective in
and in the long term? the short and long terms
4. How have insomnia and the use of coping Describe how insomnia and strategies for coping
strategies transformed my life? with sleep have transformed your life
5. What will managing insomnia improve in Describe what managing insomnia may add to
my life? your life
Source: The author
After the mindfulness practice on creative hopelessness, the therapist asks whether
the client or group members want to share their experience. The question remains:
What if the attempt to control what we feel is in itself a problem and not the solution
to sleep better?
What the client or group member generally reports is that their actions to cope
with insomnia usually work at the time to get rid of the discomfort of not sleeping,
yet in the long term they create bad routines that often harm them. The attempt to
control sleep, thoughts, and emotions often make them even bigger and is not an
effective strategy. These strategies may be effective momentarily but not in the long
term, and often just distance the individual from what really matters.
3. Tug-of-war with a monster metaphor
To exemplify the cost of trying to control what you feel and think, the therapist
uses the following metaphor:
Tug-of-war with a monster metaphor

This situation is like playing tug-of-war with a monster. This monster is big and very
strong. It seems to be disgusting and very ugly. You can name this monster. Does it
have a name? What is its name? Then imagine that between you and the monster
there is a very deep well, it is so deep that it is difficult to see the end. If you lose this
tug-of-war, you are going to fall into this hole that has no end. So, you struggle to
pull the rope, pull, pull, but the hardest thing is that the monster pulls too, and the
monster is strong and it pulls hard, it feels like you are getting closer and closer to
the hole. Do you need to win this tug-of-war? The most difficult to notice here is that
your work is not to win the tug-of-war. Your work is to let go of the rope.
Source: Adapted from Hayes et al. (1999).
The client or group members may often ask, “How can I do this?” The therapist
responds openly, saying something like “Well, I don’t know. But the first step is to
realize that the tug-of-war cannot be won and that it does not have to be won.” The
goal is to allow the client or group members to reach their own conclusions.
4. Mindfulness – Leaves on a stream

The therapist ends the session with a mindfulness practice of observing thoughts
in order to address cognitive defusion.
Leaves on a stream
Look for a comfortable place where you can sit or lie down. Focus on your breath-
ing. Feel the air come in and out of your nostrils. And then imagine yourself in a
forest. In this forest there are trees and a stream. Walk through the trees towards the
stream. When you see the stream, sit down by the water and start watching the leaves
detach from the trees, fly, and fall into the stream.
At this point, write your thought on a sheet of paper and observe it. Watch this
thought next to the leaf detaching from the tree, flying, and falling into the serene
current of a stream. A new thought, a new leaf that detaches from the tree, flies, and
falls into the stream. Try to observe the thoughts that, little by little, appear in your
mind like a sequence of leaves that float on the serene current of a stream.
Carefully pay attention to the leaves passing through your field of attention. Note
that you are just watching your thoughts on the leaves from a distance.
When you notice that you have forgotten what you are doing, or that you have
suddenly started to think about something else, or that you have become attached to
a particular thought, gently return your attention to watching the leaves floating
down the stream.
Slowly say goodbye to the stream, go back to walking among the trees, say good-
bye to this experience, being certain that you can return to that forest to observe your
thoughts at any time.
Concentrate on your breathing, on the sounds of the environment where you are
and, when you feel comfortable, you can open your eyes.
Source: Adapted from Hayes et al. (2011), p. 255.
sleep diary template can be found in the Chap. 9 of this book.
2. Make/maintain changes in sleep hygiene
Check out the information about habits, activities, and environments that can
promote sleep. Sleep hygiene guidelines can be found in the Chap. 10 of
this book.
3. Write thoughts/feelings present at bedtime in a notebook. When your
thoughts/feelings overflow at bedtime, write them in a notebook. A notebook
template can be found in the Chap. 10 of this book.
4. Practice the mindfulness exercise daily – Leaves on a stream. Practicing
mindfulness daily as homework is key to developing and maintaining the
ability to meditate. The leaves on a stream practice is described in this chapter.
15.4 Fourth Session: Self as Context and Acceptance
The fourth session addresses self as context and acceptance. Self as context refers
to the individual’s conception of themselves. Acceptance is a process of opening to
feeling and perceiving sensations without trying to avoid possible discomforts that
may arise. Table 15.5 shows the interventions used in session 4 and their objectives.
about maintaining the changes made in sleep hygiene and about practicing the
leaves on a stream mindfulness exercise. The client or group members report the
week’s feedback. When reviewing the homework assignment, the therapist asks the
client if there have been any changes since the last session.
2. Pain versus suffering
Pain is the feeling arising when we experience situations that cannot be avoided,
such as the death of a close and loved person, unemployment, the diagnosis of a
serious illness, divorce, suffering humiliation, some frustrations, or natural condi-
tions of life. Suffering is what we do to avoid the feeling/thought/sensation or mem-
ory inherent to the situation, that is, the behaviors we develop in an attempt to avoid
pain. For example: “Not going to parties to avoid feeling humiliated or isolated,”
“Not leaving the house to avoid having an accident,” “Not enrolling in courses to
avoid failure.”
To avoid the pain of not sleeping and of spending a sleepless night, we often
engage in avoidance behaviors (suffering). Such behaviors to avoid pain (not sleep-
ing and/or staying up all night) include the use of medications, rituals, counting the
minutes, etc. It is through avoidance behaviors that we restrict our repertoire of
actions to deal with facts and difficulties. They are a defense. A situation is avoided
in order not to feel, for fear of suffering. People thus restrict life. This intervention
is an invitation to face the pain.

Pain versus suffering Creative hopelessness
Acceptance
Pudding metaphor Creative hopelessness
Suffering
Poem – The Guest House Acceptance
Poem – The Invitation Self as context
Front-back sheet activity Self as context and cost of discomfort
3. Pudding metaphor
The therapist presents the pudding metaphor to the patient or group members to
illustrate situations of suffering.
Pudding metaphor
I will tell you a story in the form of a metaphor that represents human suffering.
Imagine that Carla loves puddings. Every time she eats pudding, she smears herself
happily with it. She even likes to go eat pudding with her friends and appreciates the
diner where they eat pudding among friends. One day, Carla ate pudding number 1
and this pudding was spoiled, which caused a lot of abdominal pain. Carla vomited
and had diarrhea. It was a very uncomfortable situation. After this episode, Carla
stopped eating puddings. Although pudding number 2 or number 20 was not pud-
ding number 1, Carla did not want to taste any more pudding. Over time, in addition
to no longer eating pudding, Carla stopped eating sweets resembling pudding such
as blancmange and flan. Any sweet with resemblance to pudding, Carla did not try
it. Carla also started to avoid the diner where she ate pudding number 1. One day,
Carla’s grandmother offered her a cake that looked nothing like pudding. However,
the grandmother told her that the taste was very similar to that of pudding. Carla did
not eat it and became suspicious of cakes. Thus, the range of sweets became more
and more restricted as Carla avoided tasting them.
Source: Adapted from Saban (2015).
After presenting the metaphor, the discussion proceeds with the question: “How
many puddings do we have?”
4. Acceptance and present moment – The Guest House poem
Acceptance refers to the training of feeling, of observing sensations without
avoiding, noticing the emotional curve. To be in control of the world as it presents
itself is to be in the present moment (Saban, 2015).
Rumi’s poem “The Guest House” (Rumi, n.d.) is used to discuss how the process
of accepting the uncomfortable would be. The therapist reads the poem and asks the
client or group members how each of them welcomes their guests.
After discussion of the poem, the therapist proceeds with the next intervention.
5. Self as context – The Invitation poem
Self as context refers to the conception of oneself. Identifying the self as a con-
text is addressed by reading the poem The Invitation.
The Invitation
It doesn’t interest me what you do for a living. I want to know what you ache for, and if you
dare to dream of meeting your heart’s longing.
It doesn’t interest me how old you are. I want to know if you will risk looking like a fool
for love, for your dream, for the adventure of being alive.
It doesn’t interest me what planets are squaring your moon. I want to know if you have
touched the center of your own sorrow, if you have been opened by life’s betrayals or have
become shriveled and closed from fear of further pain. I want to know if you can sit with
pain, mine or your own, without moving to hide it or fade it or fix it.
I want to know if you can be with joy, mine or your own, if you can dance with wildness
and let the ecstasy fill you to the tips of your fingers and toes without cautioning us to be
careful, to be realistic, to remember the limitations of being human.
It doesn’t interest me if the story you are telling me is true. I want to know if you can
disappoint another to be true to yourself; if you can bear the accusation of betrayal and not
betray your own soul; if you can be faithless and therefore trustworthy.
I want to know if you can see Beauty, even when it’s not pretty, everyday, and if you can
source your own life from its presence.
I want to know if you can live with failure, yours and mine, and still stand on the edge
of the lake and shout to the silver of the full moon, "Yes!"
It doesn’t interest me to know where you live or how much money you have. I want to
know if you can get up, after the night of grief and despair, weary and bruised to the bone
and do what needs to be done to feed the children.
It doesn’t interest me who you know or how you came to be here. I want to know if you
will stand in the center of the fire with me and not shrink back.
It doesn’t interest me where or what or with whom you have studied. I want to know
what sustains you, from the inside, when all else falls away.
I want to know if you can be alone with yourself and if you truly like the company you
keep in the empty moments.
Source: Oriah © Mountain Dreaming (Oriah, 1999).

The therapist presents the poem and asks which part the client or group members
identified with and proceeds with the front-back sheet activity.
The therapist asks the client or group members to observe this sheet of paper,
its front and back. The therapist then asks them to write on one side of the
paper positive memories, feelings, and thoughts, and on the other side neg-
ative memories, thoughts, and feelings.
After this, the therapist asks the client or group members to read out loud what
they wrote and what they would like to do with the paper. On this occasion,
the therapist questions whether it would be possible to crumple or throw
away the paper and points out that, even if that were possible, they would
also deprive themselves of the feelings, thoughts, and memories that they
identified as pleasant and positive.
Next, the client or group members are asked whether any of the elements writ-
ten on the paper would represent them. At this point, the therapist high-
lights that the client or group members are not any of those thoughts,
feelings or memories, and much less are they represented by labels.
The therapist asks the client or group members to select an action that they
stop doing because of some thought, feeling or memory, and to try to per-
form that action. This is defined as the mission of the week.
Based on the requested activity, conditions are created for the group partici-
pants or the client to start expose themselves to contingencies, experienc-
ing feelings, sensations, thoughts, and memories without trying to
control them.
Table 15.6 Checklist – Situation avoided Situation faced

avoided and faced situations
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
6. Front-back sheet
A double-sided sheet of paper and a pen will be necessary for this activity.
Source: Activity adapted from Costa et al. (2017).
Obtain information about habits, activities, and environments that can promote
sleep. For this, check out the guidelines in the Chap. 10 of this book.
3. Write thoughts/feelings present at bedtime in a notebook. A notebook template
can be found in the Chap. 10 of this book.
4. Perform at least one informal mindfulness practice per day
Practicing mindfulness daily as homework is key to developing and maintaining
the ability to meditate.
5. Mission of the week: Do not avoid a certain situation identified in the activity
proposed in this session. Write down the situations you avoided and faced. A
checklist is proposed in Table 15.6.
15.5 Fifth Session: Values and Committed Actions
Values and committed actions will be the focus of the fifth session. Values refer to
the qualities of a behavior that we would like to cultivate, that is, that is important
to us. The questions “How do I want my life to be?” and “How do I ideally want to
behave?” help to identify these values. This stage of therapy aims to explore the
individual’s values, that is, to investigate how the individual wants to be and how he/
she ideally wants to behave.

Life compass Values clarification
Values-based committed action Values, objectives, barriers, and actions
Metta meditation – ACT variation Values
Mindfulness
After these definitions, action plans targeting these values are developed. The
interventions used in session 5, as well as their objectives, are presented in
Table 15.7.
about maintaining the changes made in sleep hygiene, about the informal mindful-
ness practice, and about trying not to avoid a certain situation identified in the previ-
ous session. The client or group members report the week’s feedback. When
reviewing the homework assignment, the therapist asks the client if there have been
any changes since the last session.
2. Values
At this stage of treatment, it is expected that the client or group members are less
involved in struggling with sleep-related thoughts and experience some improve-
ments in sleep quality.
Some sleep researchers believe that processes that occur during the day are just
as important as those that occur at night. Consistent with this assumption, engaging
in actions that target values can be important for improving psychological well-
being. At this point in the intervention, the therapist helps the client or group mem-
bers to assess their values.
Values clarification helps to guide individuals toward what they really want to be
and not toward what they avoid. Thus, the exercise will help the person to observe
what h/she wants and what behaviors he/she needs to perform to reach their goals.
At the same time, individuals will perceive how much they engage in behaviors
related to the avoidance of aversive situations. Individuals often dedicate most of
their time to avoidance behaviors rather than values-based behaviors. Within this
context, the “life compass” activity is proposed to address values.
Life compass
The therapist explains the “life compass” activity to the client or group members
and allows time so that the client or group members can complete the activity. The
activity is described below.
In the main part of each large box, write a few keywords about what is impor-
tant or meaningful to you in this life domain. To guide your responses,
keep the following questions in mind: “What kind of person do you want
to be?” “What type of personal strengths and qualities do you want to cul-
tivate?” “How do you ideally want to behave?”
If a box seems irrelevant to you, you can leave it blank. There is no given
order to fill out the boxes; thus, feel free to first fill out the boxes whose
domains are most clear to you. There is no problem if the same words are
repeated in different boxes; this repetition helps us to identify the core
values that run through many domains of our lives.
After you have filled out all boxes, rate how important each domain is to you
at this point in your life. For this, assign a score on a scale from 0 to 10 in
the small top square of each box, where 0 = unimportant and 10 = extremely
important.
In the small bottom square of each box, rate on a scale from 0 to 10 how much
you are investing in these values at this point in your life, where 0 = not
investing at all and 10 = fully investing.
Maternity/Paternity
Personal Growth
Leisure
Spirituality
Health
Work
Community and Environment

Family Relationships
Intimate Relationships
Social Relationships
____________________(any domain not mentioned)

____________________(any domain not mentioned)
Source: Adapted from Hayes and Smith (2005).

After the activity, the client or group members share their experience.
3. Committed action
Once the values have been clarified, it is time to shift the focus to engaging in
behaviors targeting these values. Commitments help boost a person’s mood through-
out treatment. Now the commitment should be more focused on engaging in valued
activities rather than slipping back into the discomfort avoidance strategy.
Clients can experience deep emotions when they witness that they are not living
up to their values. What underlies this difficulty? What quality connects us to our
value? We often neglect ourselves by waiting outside and by not engaging based on
this quality.
At this stage, the therapist asks the client or group members to define, based on
their values, at least one goal and one action to achieve it. Short-term and long-term
goals should be considered. Short-term goals are those that can be accomplished
soon, while long-term goals are only achieved in the future. Having short-term
goals can help you achieve your long-term goals. Within this context, the following
exercise can contribute to identifying what the client or group members want and
how they need to act to achieve their goals.
The client or group members can reflect on the established goals and suggest
behaviors that facilitate achieving the expected results. Outlining concrete objec-
tives whose actions can be implemented immediately is encouraged. Use the chart
presented in Table 15.8 for this intervention.
By the end of this session, the client or group members will have identified some
core values, as well as their goals, barriers, and target behaviors. The purpose of this
exercise is to engage the client or group members in behaviors that will allow them
to achieve their goals.
4. Mindfulness focused on values and committed actions
Bearing in mind the identified values, the therapist proceeds with the following
mindfulness practice.
Table 15.8 Values-based committed actions

Value This value will be demonstrated by the
Describe a value that you want to cultivate following long-term goal:
To set goals, it is important that they are (1)
practical, (2) attainable, (3) are in line with the
current situation, and (4) take you toward your value
Long-term goal This goal will be achieved based on the
Describe the long-term goal following short-term goals:
Short-term goals 1.
Describe the short-term goals 2.
3.
Barriers to achieving my goals Barriers can be your own thoughts seen as
absolute truths. Describe when these
thoughts/barriers appear
Strategies What strategies can I use to tackle the
barriers?
Describe the strategies. They could be
those you learned in this intervention
Values
Goals
Barriers to achieving my goals
Behaviors that will allow me to achieve my goals
Source: Adapted from Hayes and Smith (2005)
Metta meditation – ACT variation

Close your eyes and focus on your breathing. Identify a core value, for exam-
ple, flexibility, compassion, love, freedom, or a value you would like to culti-
vate, and then imagine that value as a flash of light.
Imagine this light entering your body from the top of your head. Hence,
your value is slowly filling you with a brilliant light, permeating every cell in
your body.
Now visualize someone close to you with whom you have a positive rela-
tionship. Imagine that your value, represented by this light, is filling that per-
son. Now think of other people you know, acquaintances, friends, and family,
and visualize this light filling these people with your value. At this point, think
of someone you have a hard time dealing with and imagine your value filling
that person as well.
Imagine this light increasing and filling everyone now. Every living person
is filled with this light. All people are pulsing and vibrating in this light and in
this value.
Imagine yourself giving this gift to everyone and, at the same time, receiv-
ing this gift from everyone.
With the memory of this experience and connected to its value, say good-
bye to this moment. Slowly move parts of your body and, when you feel
comfortable, you can open your eyes.
Source: Adapted from Fletcher (2008)
3. Write thoughts/feelings present at bedtime in a notebook. Remember, if you
overflow with thoughts/feelings at bedtime, put them on paper. A notebook
4. Observe attempts of avoidances identified in session 4.
5. Perform a behavior that meets your values established in the activity proposed in
this session. Write in the checklist presented in Table 15.9 when you faced barri-
ers to achieving the goals and when you behaved toward achieving your goals.
6. Practice Metta meditation – ACT variation daily
Practicing the mindfulness exercise daily as homework is key to developing and
maintaining the ability to meditate. The Metta meditation is described in this
chapter.
15.6 Sixth Session: Values and Committed Action
In session 6, values and committed actions will be reinforced based on the interven-
tions described in Table 15.10.
Table 15.9 Barriers and Checklist Facing barriers Pro-goal behaviors

pro-goal behaviors Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Attending your own funeral – Epitaph Values clarification
The Unwelcomed Party Guest Acceptance when acting toward the values
Meditation focused on values and committed Acceptance and commitment with the values
actions – Tonglen meditation
about maintaining the changes made in sleep hygiene, about the Metta meditation
practice, about the attempt of not avoiding a certain situation identified in session 4,
and about behaviors that are in line with the values established in the proposed
activity of session 5. The client or group members report the week’s feedback.
When reviewing the homework assignment, the therapist asks the client if there
have been any changes since the last session.
Attending your own funeral – what message would you like to

leave behind?
Have you ever noticed that, when people die, they are remembered for their
virtues and their values? Try to identify someone who has died that you look
up to. Think of your heroines and heroes. What was the most important inheri-
tance of these people? My guess is that they were not material achievements
or fortunes but the values reflected in their lives.
Returning now to your life. You have a certain amount of time on earth and
you don’t know how much. The question is “Are you going to live knowing
that you are going to die?” This question is not different from the questions
“Will you love knowing you will be hurt?” or “Will you commit to living the
life you value knowing that, many times, it will not meet your expectations?”
Or “Will you aim for success knowing that sometimes you will fail?” The
potential to feel pain and the sense of vitality that arises from these experi-
ences cannot be separated.
Being aware that we are finite can help us to take advantage of the time we
have to invest in what we really believe and value. With that in mind, what
message would you like to leave behind when you die? We recognize that it
can be macabre to imagine the end of your life. It is not meant to be morbid
but realistic.
If you could live your life the way you envisioned it, what would your
values be? The question is not about what you have already done or what you
expect to do. The issue is for you to observe what you expect the people clos-
est to you to see about your life. The question is: What would be evident if you
could freely choose the values of your life? How would you like to be
remembered?
Source: Adapted from Hayes and Smith (2005)
2. Values
To reinforce the values addressed in the last session, the therapist proposes the fol-
lowing activity “Attending your own funeral – What message would you like to
leave behind?” The therapist reads the activity together with the client or group
members, explains the purpose, and allows time for the client or group members
to complete the activity.
REST HERE
Fig. 15.5 Epitaph
With that in mind, write your epitaph in Fig. 15.5.

The therapist invites the client or group members to share their sensations and
feelings during this activity.
3. Committed actions
To address acceptance during the action in pursuit of values, the therapist reads
the following text together with the client or group members:
The Unwelcomed Party Guest

Imagine you bought a new house and invited all neighbors to a housewarming
party. Everyone in the neighborhood was invited – you announced the party
on social media (Instagram, Facebook, Twitter) and placed an invitation
poster at the neighborhood mall. So, all neighbors showed up and the party
was great. Suddenly Joe the Bum arrived, an unexpected guest.
Joe the Bum is aggressive, inconvenient, rude, makes inappropriate jokes,
and is obnoxious. You think, “Oh no, why did he show up?” But you announced
on social media and on posters: “all are welcome.”
Do you think it is possible for you to welcome him? Truly welcome him,
although you do not like that he is at your party? You can welcome him even
if you do not think highly of him. You don’t have to like him. You don’t have
to like how he behaves, how he treats other people, how he views you and
people. You can be embarrassed by the way he stares at people, the way he
offends others, the fact that he makes unnecessary jokes and brags, the way he
disrespects women. Your opinion of Joe the Bum, your assessment of him, is
absolutely different from your willingness to have him as a guest in your house.
You might also decide that, although you said everyone was welcome, in
fact, Joe is not welcome. However, as soon as you do that, changes happen,
the party changes. Now you have to stay at the door of the house as the guard
so that he cannot go back to the party. Or if you say “Okay, you’re welcome”,
but you don’t really mean it, you just mean he is welcome as long as he stays
in the kitchen and does not mingle with the other guests, then you will con-
stantly have to keep an eye on him and your entire party will be about that. In
the meantime, life goes on, the party goes on, and you are on guard for the
unpleasant. This is not living. It is not quite like a party. It is a lot of work.
The metaphor is, of course, about the feelings, memories and thoughts that
arise and that you don’t like; they are just more Joes at the door. The issue is
the stance you take on your own contents. Are Joes welcome? You can choose
to welcome them even if you don’t like the fact that they showed up? If not,
how will the party turn out?
Source: Adapted from Hayes et al. (1999).
After reading the text, the therapist asks the client or group members about their
impressions. The therapist guides the discussion by demonstrating that the text
shows that, when we try to prevent Joe the Bum from joining the party, other unde-
sirable reactions will manifest. Would it not be better to become “a close friend of
Joe”? To understand him? To know how to deal with him? After all, he is already in
your house.
Committed actions involve unpleasant events that produce discomfort because
they refer to past situations with intense emotions and there is a fear of revisiting
them. The idea is to realize the importance of identifying and not rejecting feelings.
Individuals commonly deny feelings, resist them, and intertwine external and inter-
nal judgments. With this attitude, individuals avoid feeling what actually manifests
itself in them in terms of feeling and, therefore, they do not identify what they feel
and continue to avoid it.
After reflecting on the text, the therapist proceeds with the following mindful-
ness practice.
Meditation focused on values and committed actions – Tonglen

meditation
Find a comfortable position and settle in. Close your eyes and focus on your
breathing. Breathe…
Identify a value that you consider to be fundamental. Find a word that
describes this value. How do you keep this word in your mind? Observe the
sensations you are experiencing in your body.
Observe if there is lightness, warmth, and a sense of openness.
Think of an image that captures what you are experiencing.
Now identify a problem that you have been struggling with.
How do you keep this problem in your mind?
Observe your bodily sensations and how you are feeling as you think
about it.
Get in touch with this feeling of stress about a problem.
Think of an image that captures what you are experiencing, for example,
the last time this problem occurred.
Now try some slow, long, and deep breaths.
As you inhale, think about your struggle using the image you thought of or
a word to represent it. Observe any physical sensations that may arise. Breathe
into this pain wherever it is located in your body.
As you exhale, remember your value using the word or image that you
chose for this core value. Exhale in the sense of opening and relaxation.
Inhale again getting in touch with your pain and exhale getting in touch
with your value.
Continue to touch your pain upon inhaling and your value upon exhaling.
Observe whether the pain and value start to overlap? Is it difficult to sepa-
rate one from the other?
Observe this experience, this moment, and then say goodbye. Get in touch
again with your breathing, focus on the sounds of your environment. Slowly
move parts of your body and, when you feel comfortable, you can open
your eyes.
Source: Adapted from Fletcher (2008).
3. Write thoughts/feelings present at bedtime in a notebook. Remember, if you
overflow with thoughts/feelings at bedtime, put them on paper. A notebook
4. Observe attempts of avoidances identified in session 4.
5. Perform a behavior that is in line with your values established in the activity
proposed in the fifth session.
6. Perform Tonglen meditation with ACT variation daily.
7. Practicing the mindfulness exercise daily as homework is key to developing
and maintaining the ability to meditate. The Tonglen meditation practice is
described in this chapter.
5. Treatment closure and feedback
The therapist closes the treatment with the following questions:
“What did this experience change?”
The client or group members share their answers and say goodbye.
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Gouveia, & M. S. Oliveira (Eds.), Terapias Comportamentais de Terceira Geração: Guia para
profissionais (pp. 179–216). Sinopsys Editora.
Chapter 16
ACT Therapeutic Processes in the ACT-I
Protocol
This chapter describes the therapeutic processes of the Acceptance and Commitment
Therapy for insomnia (ACT-I) protocol in order to better understand the strategies
and execution of the exercises.
The therapeutic goal of ACT-based interventions is to promote a complex and
extremely useful behavioral repertoire that will enable the effective functioning of
individuals in their contexts and improve their quality of life, the so-called psycho-
logical flexibility. This repertoire consists of new approaches to deal with discom-
forts, symptoms, and suffering related, for example, to insomnia, which can include
thoughts, feelings, physical sensations, and uncomfortable or unpleasant memories.
The therapeutic process aims to create opportunities for the patient to learn to deal
with these uncomfortable events in order to achieve a more meaningful life.
ACT is based on the understanding of psychological suffering that seeks, with
precision, scope, and depth, to explain how inflexibility occurs and to propose inter-
ventions that will transform this suffering into its opposite – flexibility. From the
point of view of ACT and supported by relational frame theory (RFT), a behavioral
approach to human language and cognition (Hayes et al., 2001), typical processes
of human language can induce intense psychological suffering in a person and the
antidote to this suffering consists of new ways to relate to verbal and private events.
According to Luoma et al. (2007), “in essence, the problem is that literal language
leads to increases in pain and the tendency to overextend a problem-solving mode
of thinking as a way to solve that pain. As a result, we try to escape and avoid our
M. T. Saban-Bernauer (*)
School of Permanent Education, Clinics Hospital, Faculty of Medicine, University of São
Paulo, Sao Paulo, Brazil
R. Kovac
Paradigma Center of Behavioral Science and Technology, Sao Paulo, Brazil
feelings, we become entangled in our thinking, we lose contact with the present, and
we begin to believe and defend our own stories about ourselves” (p. 11).
Although fundamental and extremely advantageous for the human species – as
they are the same cognitive abilities that contribute to human advancement and
survival, this mode of functioning, enabled by symbolic behavior or by human lan-
guage and cognition, causes a type of suffering that is probably exclusive to humans.
From the perspective of RFT, a behavioral process is observed (arbitrary and derived
relational responding) that, at the same time, (1) facilitates and favors the relation-
ship of humans with their environment by responding to (arbitrary) relationships
between events (stimuli) and thus attributing meanings (functions) to them that, in
turn, affect the behavior itself. This process, which is typical of language, greatly
expands the number of events and functions of the environment since it includes, in
addition to present events, relationships between present and past or future events,
spatially absent events, or even never known or experienced events (concepts). (2)
The behavioral process forms the basis of psychological suffering. For example,
reports of situations imagined in the future and memories or thoughts of situations
suffered in the past themselves can produce pain in the present since both (report
and situation) are bidirectionally related (Wilson et al., 2001).
In the words of Wilson and collaborators, (…) “the paradox of our species is that
we have far less contact with direct sources of pain than any other species on the
planet; however, through language, we are capable of suffering with a degree of
intensity, constancy and pervasiveness that is literally unimaginable in the non-
human world. Because of the bidirectional transformation of functions, we can
judge ourselves and find ourselves ‘needy’; we can imagine ideals and find our pres-
ent situation unacceptable by comparison; we can reconstruct the past; we can
worry about imagined futures; we can suffer with the knowledge that we will die”
(Wilson et al., 2001, p. 215).
Therefore, cognitive and verbal skills, identified in their minimum unit – arbi-
trarily applicable relational responding, while providing an explanation of how
words and other symbols can affect behavior by participating in networks of rela-
tionships between events and thus acquiring many of the functions of these events,
also explain how to construct a way to relate with one’s own behavior – feeling,
thinking, remembering – which can amplify suffering. Favored and strengthened by
recurrent cultural practices that say things like “get rid of bad feelings” or “think
positive,” a rigid and inflexible way of reacting to one’s behavior is created – “bad”
parts must be eliminated. By doing this insistently, the person ends up remaining in
a vicious cycle in which, in an attempt to solve the problem, he or she engages in
responses, trying to change the form, frequency, or content of their feelings,
thoughts, sensations, and memories. Doing this over and over again, the individual
ends up limiting their life in the long run. This mode of functioning, called experi-
ential avoidance and psychological rigidity, represents the concept of suffering
defined by ACT. Thus, the interventions proposed in ACT address suffering by tar-
geting psychological flexibility – i.e., the abandonment of this rigid and limiting
pattern of dealing with parts of one’s own behavior.
16 ACT Therapeutic Processes in the ACT-I Protocol 195
The therapeutic processes described in ACT, which aim to promote psychologi-

cal flexibility, are creative hopelessness, acceptance, defusion, mindfulness, self as
context, values clarification, and committed action. Each of these processes will be
analyzed below to illustrate the ACT protocol applied to insomnia (ACT-I). It must
be noted that ACT uses experiential exercises, mindfulness practices, and meta-
phors to consistently and systematically address these processes in the office clini-
cal setting. Within this context, therapy should be an opportunity to create conditions
for learning this new flexible repertoire.
16.1 Creative Hopelessness
The different types of experiential avoidance commonly go unnoticed. They are not
very explicit ways of trying to avoid suffering and are usually so automatic that the
individual does not identify them in advance. This also occurs because noticing suf-
fering and what we do with it are aversive processes. We start therapy by observing
this pattern of experiential avoidance and its effect on:
• Avoiding short-term and long-term suffering
• How it transforms the life of the individual
This process is called creative hopelessness because the experiential avoidance
pattern tends to work in the short term in an attempt to eliminate suffering momen-
tarily; however, suffering returns in the medium and long term and the experiential
avoidance itself poses restrictions because it does not solve the problem of the expe-
rienced contingencies, thus amplifying the person’s suffering. Experiential avoid-
ance only reduces the felt or imagined suffering, while the situation remains the
same. For example, someone with family problems has insomnia as a consequence
and takes sleeping pills. The person sleeps instantly, but the insomnia returns
because the family problems are still present and their actions are focused on elimi-
nating the insomnia and not on addressing the relationships that generate the dis-
comfort. The process of creative hopelessness aims, in an experiential way
(observing your own experience), to unravel this ineffective way of dealing with
discomfort and observe its short-term (working temporarily) and medium- and
long-term effects (return of the discomfort and amplification of the problem, restrict-
ing life more and more).
The insomnia protocol contains interventions that focus on this process of
observing experiential avoidance and losing hope. For the exercise Evaluating
attempts to control and escape discomfort, the client fills out a table and discusses
the answers. The questions are stimuli that evoke observing responses of the expe-
riential avoidance pattern. In Table 16.1, you will find the questions of the exercise
and the description of the responses that the exercise intends to evoke.
The following exercise, Mindfulness practice on creative hopelessness – insom-
nia, dives deeper into the first question of the previous exercise about how individu-
als feel when they have insomnia, what they think and feel in their bodies. This
Table 16.1 Questions and responses of the evaluating attempts to control and escape discomfort
exercise
Does it work as I What will
How do I feel would like? Right How did this managing
when I cannot What do I do right away and in the transform my insomnia improve
sleep? away? long run? life? in my life?
Stimuli that Stimuli that evoke Experiential Stimuli that Based on a
evoke emotion- an observing avoidance evoke observing hypothetical
observing response of generally works responses of the situation, this
responses experiential right away to limitations that question
(covert avoidance. It is eliminate the experiential investigates the
response) at the important that the emotion that avoidance restrictions
time of answers here are accompanies generates, for generated by
insomnia. The those given at the insomnia or example, insomnia and the
emotions that time of insomnia, insomnia itself medication attempt to control
act as aversive not afterwards, but does not overuse and it and indicates
motivators of such as “I went to change the resulting possible positive
aversive emotion see a doctor,” “I situations that problems, reinforcement
avoidance talked to people generated the rumination, contingencies that
responses. Since about it.” The emotions and tiredness, and are deprived
the emotion is answer here refers insomnia in the fatigue in the because of the
aversive, to what the first place. For case of watching experiential
observing the individual did at this reason, TV. It should avoidance pattern.
emotion will the time of insomnia returns favor the This is the
also be aversive. insomnia, such as and the pattern of observation of beginning of a
The observing “I took some momentarily the amplification values-related
response is an medication,” “I working (if it of suffering in process.
alternative to the thought about works) and this mostly
avoidance several things (ask having no avoidance mode
response and is to specify),” “I medium- or of functioning.
the beginning of went to watch long-term effect
the acceptance TV.” is observed.
process.
mindfulness practice is both an exercise that supports creative hopelessness (condi-

tions for observing the motivating operation of experiential avoidance) and an
acceptance exercise that proposes the observation of covert responses (thoughts,
feelings, sensations, and memories) without reacting to them.
The protocol proceeds with the Tug-of-war with a monster metaphor. The meta-
phor represents a strategy to describe contingencies and their functions using con-
crete elements. Relationships that are often abstract playfully become characters,
which facilitates the observation of a specific type of functioning. According to this
metaphor, insomnia or the emotions associated with insomnia correspond to the
monster, the tug-of-war represents the struggle trying to control private events
(thoughts, feelings, sensations, and memories), and pulling the rope corresponds to
experiential avoidance and the feeling of responding in this way, i.e., struggle and
war. The tension of the tug-of-war and the imminence of falling into the hole trans-
late the fear of feeling and thinking, the fear of falling into an abyss of oneself.
Abandoning the control of private events corresponds to the therapist’s proposal to

let go of the rope and to relate to the monster in a new way.
Monitoring contingency elements and thus amplifying proximity, the contact
with their functions, is a widely used strategy in ACT, including in metaphors,
mindfulness practices, and exercises. It facilitates observation, especially when
some stimuli and responses are private, and the function of the current contingency.
It can also make explicit the therapeutic proposal. Metaphors in particular are a
much easier elucidation to be remembered in contexts outside of the therapeutic
setting, facilitating generalization. An image helps because it is easy to remember
and facilitates the observation of experiential avoidances in the contexts in which it
occurs in the client’s life. Thus, the issues of the exercise and mindfulness practices
are training and different learning opportunities, whose aim is to activate this reper-
toire of observing (1) one’s own behavior, (2) the way the person reacts to it, and (3)
the short-, medium-, and long-term effects inside and outside the therapy session.
In addition to the acceptance process, creative hopelessness or the opportunity to
learn to observe emotions in the experiential avoidance contingency is especially
important. The possibility of observing the emotion present during the experiential
avoidance response, without reacting directly to it, potentiates the alternative of
change. In contrast, engaging in typical avoidance responses – taking insomnia
medication – usually produces a feeling of failure or impotence. Thinking about
what could have been done or what can still be done increases worries or the feeling
of being trapped in a problem with no way out. Watching TV, turning on the TV, or
picking up the cell phone and viewing social media produces upset, guilt, sadness,
a feeling of wasted time. The consequence of experiential avoidance is immediate
relief, which is soon followed by even more uncomfortable emotions and dead-end
thoughts. When people observe emotions and experiential avoidance responses in
their daily lives, together with the observation of long-term losses and the resulting
paralysis of life, it arises what ACT calls hopelessness in trying to control the
uncontrollable, our inner world, the hopelessness regarding the strategy that has
been used for so long but which, after this observation process, can prove to be
clearly ineffective. A possible window is then created for a new way of relating to
this inner world, acceptance.
16.2 Acceptance
Acceptance has different meanings. In ACT, acceptance is a process composed of

willingness and an attitude of openness. Willingness is “the voluntary and values-
based choice to enable or sustain contact with private experiences or the events that
likely caused them” (Hayes et al., 1999/2012, p. 77).
Openness or psychological acceptance is “the adoption of an open, receptive,
flexible, and non-judgmental posture regarding moment-to-moment experience”
(Hayes et al., 1999/2012, p. 77). The posture of acceptance is also present in the
mindfulness process, differing only in terms of the emphasis of acceptance on the

private experience (thoughts, feelings, sensations, memories, and predispositions).
Regarding acceptance as an action (not as resignation or abandonment), being
willing to get in touch with our inner world is a very important factor for behavioral
change that is directly linked to values. Acting in accordance with individual values
means acting in the way and in the direction that is important to the person. However,
the reason why people do not do it or why they are how they are is important to them
because:
1. They acted like this in the past and were punished.
2. They were taught not to act like that because it would not be accepted. This
teaching can occur based on rules, differential reinforcement, vicarious learning,
or modeling.
3. They were trained to relate events in a way that such an action would not be posi-
tively reinforced, would have no consequence (extinction), or would be punished.
Therefore, when people do not act coherently with what matters to them or in the
direction toward what is important, it may indicate that the context in which they
find themselves contains stimuli that were paired or related to aversive stimuli in
their history of learning, eliciting sensations perceived as aversive and evoking
covert responses such as thoughts, feelings, and memories that are also aversive.
These responses possibly function as motivating operations to evoke avoidance
responses, called here experiential avoidance responses since they are escape or
avoidance responses to private events. Acceptance becomes a therapeutic goal when
the person is faced with antecedents consisting of aversive stimuli (public or pri-
vate) that do not permit escape or avoidance responses or that have even more aver-
sive medium- to long-term consequences. The desired outcome of acceptance
responses is not a change in the antecedent aversive stimulus (in terms of frequency
or intensity) but rather a change in the function of this aversive event, measured by
the reduction in or absence of avoidance responses and the occurrence of other
(new) responses – these in the direction toward what is important to the person in
the long term. To promote this action of acceptance, responses such as observation,
description, tentatively dealing with extant contingencies, and approximation (desir-
able consequences) are trained in acceptance exercises.
Considering this proposal, learning to deal with private experiences in an open,
receptive, flexible, and non-judgmental way is a key skill to be trained. Examples of
experiential exercises and metaphors used for this training can be found in the
Mindfulness practice on creative hopelessness – insomnia of the ACT-I protocol,
which encourages the client to perceive feelings, sensations, and thoughts during
insomnia, and in the poem The Guest House by Rumi (Sufi master of the nineteenth
century). Using the metaphor of private events as guests of the house (and “house”
here is a metaphor of the person themself, of the “I”), the poem invites to openly
welcome the guests.
The poem The Invitation by Dreamer (2000) continues to add elements of open-
ness to private experiences, combining committed actions, values, and self in a
poetic language (see Table 16.2).
Table 16.2 ACT elements in excerpts of the poem The Invitation

“It doesn’t interest me what you do for a living. I want to know what you Values
ache for and if you dare to dream of meeting your heart’s longing.
It doesn’t interest me how old you are. I want to know if you will risk Acceptance on
looking like a fool for love, for your dream, for the adventure of being behalf of values-
alive. based actions
It doesn’t interest me what planets are squaring your moon. I want to Values-based
know if you have touched the center of your own sorrow, if you have actions × experiential
been opened by life’s betrayals or have become shriveled and closed avoidance
from fear of further pain.
I want to know if you can sit with pain mine or your own, without Values-based actions
moving to hide it or fade it or fix it. I want to know if you can be with joy and positive
mine or your own, if you can dance with wildness and let the ecstasy fill reinforcers
you to the tips of your fingers and toes without cautioning us to be
careful, to be realistic, to remember the limitations of being human.
It doesn’t interest me if the story you are telling me is true. I want to Values-based actions
know if you can disappoint another to be true to yourself. If you can bear in aversive and
the accusation of betrayal and not betray your own soul. If you can be conflict situations
unfaithful and still be trustworthy.
I want to know if you can see beauty every day even when it is not pretty. Values-based actions
And if you can source your own life from its presence.
I want to know if you can live with failure, yours and mine, and still Acceptance and
stand at the edge of the lake and shout to the silver of the full moon: values-based actions
‘Yes!’
It doesn’t interest me to know where you live or how much money you Acceptance on
have. I want to know if you can get up after a night of grief and despair, behalf of values-
weary and bruised to the bone, and do what needs to be done to feed the based actions
children.
It doesn’t interest me who you know or how you came to be here. I want Acceptance on
to know if you will stand in the center of the fire with me and not shrink behalf of values-
back. based actions and
self as context
It doesn’t interest me where or what or with whom you have studied. I Values and
want to know what sustains you from the inside when all else falls away. acceptance
I want to know if you can be alone with yourself and if you truly like the Acceptance and
company you keep in the empty moments.” self-compassion
Poetry as a metaphor greatly facilitates communication of the processes pro-

posed by the therapy, without the need to teach clients theoretical terms that may not
have a function in their practical life.
The following exercise of the ACT-I protocol mixes processes of acceptance,
creative hopelessness, self, and committed actions with values. The technique is
designed to render feelings, thoughts and memories concrete by writing them on a
paper. On one side of the paper, the participants are asked to write good memories,
thoughts, and feelings, and on the other side, bad memories, thoughts and feeling.
In this activity, “I” is the paper and the written words are the private events. The
limitations in wanting to avoid this internal content are noted; it is observed that, by
doing so, one also avoids the positive reinforcing aspects (related to what is
important to the person – values). A concrete demonstration is the wish to crumple

the sheet of paper, which contains good and bad memories, thoughts, and feelings.
This is another way of illustrating how the process of creative hopelessness works.
When asking whether the client identifies him or herself with some written char-
acteristic, the therapist is metaphorically investigating responses to which an indi-
vidual relates by coordinating them with themselves, i.e., as an equal, as an
equivalent, and, within the terms of ACT, this individual is fusing with them and
considers them as inherent to themselves or to their personality. The therapeutic
proposal to expand this notion of the “I” is again exemplified metaphorically and
physically (concretely) by the sheet of paper, leading the person to understand that
the “I” is not a written characteristic but the place that contains all aspects. This
conception of the “I” is called self as context. It is produced by training multiple
exemplars of the perspective of an “I” that contains all aspects of the person –
thoughts, feelings, memories, sensations, actions, positive and negative, important
and insignificant – therefore, an “I” that can contain all of them without defining or
becoming any of these specific aspects.
At the end of the exercise, the therapist guides the client to identify with and
engage in a values-guided action that was suppressed by experiential avoidance
(stopped doing to avoid some thought or feeling). This action is also written on the
sheet since it is part of the content and not of the “I” (the self), promoting greater
flexibility, although it is a positive aspect that possibly results in positive reinforcers.
16.3 Defusion
Defusion is a term coined by the authors of ACT to describe a process using a meta-
phor – the opposite of fusion. Semantically, fusion designates a process in which
two elements mix and transform into a third. In the case of language, fusion refers
to how sound or written patterns relate to aspects of the world (so-called “referents”
in language theories) that are socially agreed upon as the “meaning” of those sound
or written patterns. The sound of the word “rice” fuses with a handful of white
grains in such a way that it becomes “rice” – both the sound and the grains can affect
us in very similar ways in certain situations. Language training is extremely exten-
sive and, as already mentioned, represents a great differential for our species.
Technically, we are trained to respond to a stimulus (sound or written word) as if it
were another (object), first by pairing, then the stimuli become functional classes
that interact with each other as we acquire the ability to relate events. The result of
this vast training in verbal behavior is a literal world, in which we relate to events
fundamentally through verbal relationships. When we eat rice without paying atten-
tion, we eat the “concept of rice”; our action of eating is conditioned to the “concept
of rice” and many times we do not even feel the taste of that “rice” as a specific and
unique object.
We interact with other spoken words or with sentences in the form of thoughts as
if they were literal truths. This occurs because it is consistent with our history that
the word “rice” is related to the actual rice. However, when we tell us things about
who we are, what we like, our assessments of others and about ourselves, we act as
if those words are as concrete as “rice.” In therapy, when clients talk about their suf-
fering, the word itself already generates discomfort as if it were the suffering itself.
When reporting, the client is in contact with the language, i.e., indirect/attributed
functions of a stimulus (experience of suffering) to another (report). The fusion
between words and thoughts, emotions and memories classified as negative, bad, or
uncomfortable then becomes a problem since it evokes a class of experiential avoid-
ance responses in an attempt to get rid of these private events.
Defusion interventions consist of the observation of language as a process, sepa-
rating direct (from experience) from indirect functions (attributed) and permitting
the observation of behavior (verbal – thought, emotion, memory) as it actually is – a
process and a product of the person’s ongoing interaction with their world.
We have an idea of how we think; in practice, this behavior is much more chaotic
than we imagine and is the result of learning. We believe that our thinking reflects
reality, as if we were analyzing or describing the world. In practice, what we observe
is what we have been trained to see in some specific way. What we do is establishing
relationships between events that we have been taught to do, and we evaluate and
judge those as if such comparisons were a confirmation of reality.
While acceptance is an approximation of private events, observing and feeling
these events as they are, defusion is the observation of the language process, notic-
ing it as it is and its impact on all behavior. When clients write their thoughts on a
sheet of paper or look at their thought and relate it to the monster of the metaphor,
the defusion process is present because they are invited to see this behavior as an
ongoing process, a flowing behavior. The mindfulness practice Leaves on a stream
is another example of a defusion exercise of the ACT-I protocol, in which the client
observes the flow of thoughts.
16.4 Mindfulness
In ACT, mindfulness practices represent an extensive training of focused or

expanded attention skills, either in the outer world or in the own inner world, in
lived or hypothetical situations. Like most of the ACT interventions, these exercises
are an alternative approach to learn to deal with the inner world, respecting it and
allowing it to be as it is. As mentioned before, the training of observing responses
underlies many of the practices and sometimes appears formally in the exercises.
Table 16.3 shows a list of the mindfulness exercises of the ACT-I protocol, with the
specification of focused and expanded attention training.
Technically, the therapist asks the client to sit down in a comfortable position in
which they can stay in for a few minutes and to close the eyes if the client feels
comfortable. The therapist proceeds by providing instructions and the spoken words
evoke and elicit the experience that the client is invited to observe.
Table 16.3 List of the mindfulness exercises of the ACT-I protocol

Session Mindfulness Training
2 Body scan Observation of the body
3 Mindfulness practice on Observation of a situation experienced in the past in
creative order to identify and describe context, action, thought,
hopelessness – insomnia feeling, and sensation
3 Leaves on a stream Observation of the flow of thoughts
5 Metta meditation (ACT Observation of thoughts, feelings, and sensations in the
variation) presence of a value
6 Meditation focused on values Observation of thoughts, feelings, and sensations in the
and committed actions – presence of a value and of the difficulty and the process
Tonglen meditation of approximation of suffering followed by
approximation of the value
16.5 Self as Context
Self as context is a term that designates the perception of oneself as the locus, as the
perspective from which experiences unfold. The aim of this concept is to system-
atize the notion of “I” as the result of a continuous process of experiences, the
expanded perspective of that we are “who” think and not our thoughts, we are not
our feelings but “who” feel, “who” remember and even “who” act. When fusion
occurs at a high frequency, we tend to describe ourselves negatively and believe that
our assessment is “the truth”; however, our inner and outer experiences are con-
stantly changing. Interventions that seek to strengthen the self as context are aimed
at the person’s perception of (1) what is constant and (2) what is flow, focusing the
observation on the perspective from which all behaviors depart. Technically, con-
ceptual analysis of the RFT is aimed at establishing a hierarchical relationship
between the observing “I” (deictic) and thoughts, feelings, sensations, memories,
and actions. In other words, they can be seen as parts of the “I.” The perspective
from where I can include the thoughts and feelings and observe them. Naturally or
typically, our tendency is to relate such events as equivalent to the “I.” Practically, it
is about creating opportunities for the person to perceive, feel, and describe them-
selves as the “I,” the place, the perspective, the origin of the action, and not the
action, feeling, sensation, or thought.
The poem The Guest House reflects the idea that private events come and go
(they are guests) and the house is the place where they transit. Likewise, the activity
of writing on a sheet of paper follows the same logic of conceiving the “I” as the
sheet that contains thoughts and feelings.
The process of perceiving the self/I as context promotes flexibility and greater
openness to get in touch with private events since the individual is not each one of
them but the one who notices them.
Values and Committed Action
When clients realize their experiential avoidances and the cost of them in their life
(creative hopelessness); when they reach out and open up to whatever feeling
(acceptance); when they observe their thoughts as flowing behaviors and not neces-
sarily connected with each part of the experience (defusion); when they perceive
themselves as the observing “I” and include all of these events in their experience
(self as context), and when they observe attentively and curiously everything that
presents itself (mindfulness posture), then the prerequisites for clarifying what is
important to the person (values) and acting toward them (committed action) are
complete.
At this stage, all trained skills are implemented for the main purpose of ACT –
bringing meaning to the person’s life.
The guiding questions for values clarification are:
• What is important to you?
• Who is important to you?
• How do you want to live your life?
These questions are addressed in the Life compass exercise, which asks the cli-
ents to describe what they consider to be important in different life domains. The
clients then evaluate the priority of each domain and how much they have been
dedicating themselves to them. It is interesting to note the similarities of values in
the different domains of life and how they represent a pool of adjectives that reveal
important characteristics of how a person is or wants to be.
In the following exercise, Values-based committed actions, the value is translated
into concrete goals and actions and the barriers to achieving these goals are made
explicit, as shown in Table 16.4.
Table 16.4 Values, goals, barriers, and behaviors in the values-based committed actions exercise
Concept Explanation Example
Values What is important and how the person Be true to the family
wants to be
Goals Concrete situation in which the value is Tell family members what bothers
achieved you (be explicit and specify what
you mean)
Barriers to Challenging feelings, thoughts, sensations, Anxiety, fear of the reactions of
achieving my and memories that arise in the context others (possible aggression from
goals (there might be external barriers such as others), thoughts of ruminating
reactions from third parties and limits; in about situations that the person
these cases, it refers to how the person will experienced
feel in face of the reaction of third parties
and alternatives regarding limits)
Behaviors Observable and measurable concrete Schedule a conversation with the
that allow to actions family on Tuesday, send a message
achieve my to family members, get together,
goals contextualize that you would like to
clarify some things and expose how
you feel, and tell the content of the
discomfort
Some care is necessary at this stage of the intervention:

• Make sure that the value is a genuine value of the client and is not a way to please
or feel socially accepted.
• Actions and goals need to be concrete and observable. Abstract collocations indi-
cate experiential avoidances. In general, because it is something new, it is diffi-
cult to imagine what a concrete action would be like. In this respect, it is a
creative process and a clear description facilitates the answer.
• The action must correspond to the client’s skills. In the example above, if the
person has never expressed themselves freely and truly, there should be time for
some training such as role play.
Session 5 ends with a mindfulness practice called Metta meditation (ACT varia-
tion), which is focused on observing the sensations when acting toward values.
Since the values-based actions generally addressed in therapy are often new, they
may not be positively reinforced in the short term. It is therefore important that the
client perceives that the reinforcement of the values-guided action lies in the action
itself – being that way (intrinsic reinforcement). In the example, being truthful can
and will probably generate criticism (that is why the person is not “truthful” in the
first place); however, acting according to what is important to the person, being hon-
est becomes reinforcing in the medium and long terms. Therefore, training the
observation of sensations that occur in these actions increases the perception and
competes with possible punishments that may result from the behavior in the natural
environment.
The last session covers exercises that enhance the intrinsic positive reinforce-
ment of the committed action and the openness to the often-inherent discomfort
when acting this way.
The exercise Attending your own funeral – What message would you like to leave
behind represents a context that strongly evokes values clarification. Remembering
the finitude of life makes the time we have precious. We are going to die and what
we have here, our life, the people we love, what we can do, all this will end. We do
not think about death because it is aversive, but it is our human condition – finitude.
How do we want to live this indeterminate time that we have? This is the answer that
ACT seeks to trigger and its main purpose.
We know that this is not an easy task because it involves aversive stories that
prevent individuals from acting naturally according to their values. For this reason,
we address openness to suffering and all acceptance and defusion training is com-
monly done a priori. In the metaphor The Unwelcome Party Guest, Joe represents
this discomfort and how experiential avoidance responses compete with values-
based actions, either we are surrounding Joe or we are enjoying the party. Again,
metaphorically, it is expected to produce new meanings and transform functions in
such a way that the person can focus on new possibilities regarding their own behav-
ior and new results, different from those that they have been achieving (and
debating).
The protocol ends with Meditation focused on values and committed actions –
Tonglen meditation. In this practice, breathing is used to connect with the suffering
and value. The perception of these alternating sensations is analogous to the experi-
ence that the individual will go through when performing a values-guided action.
The therapeutic goal of ACT – flexibility – can be divided into other more specific
processes of observation and contact with the inner world in an open and compas-
sionate way, perceiving the processes of thinking and feeling emotions. This train-
ing and the perception of self as context of these experiences enables changes in
behavior from a pattern of experiential avoidance to values-guided actions that can
evoke and elicit challenging experiences; the latter, however, induce, within the
action itself, what is important for individuals to be and to live their life.
These processes overlap in the mindfulness exercises, metaphors, and practices
that make up the ACT intervention methodology. The ACT-I protocol is an example
of a studied therapeutic management applied to the population that suffers from this
discomfort. The novice therapist who is venturing into ACT is advised to follow the
protocol in order to try unusual exercises. The professional should first go through
the protocol as a participant and then as a therapist. Since the exercises trigger emo-
tions, the therapist must understand the proposed experience for the client from
their own perspective in order to conduct the intervention properly and respectfully.
The protocol can also be conducted in groups; however, individual differences in the
therapeutic process cannot be fully addressed in this case.
Finally, when the therapist experiences the process and trains it, the protocol will
serve as an example and suggestion of activities. The clinical management is shaped
by the analysis of which observation skills and training the client requires at
each point.
References
Dreamer, O. M. (2000). O Convite. Trad de Maria Helena Rangel. Editora Sextante.

Hayes, S., Strosahl, K., & Wilson, K. (1999/2012). Acceptance and commitment therapy: An expe-
riential approach to behavior change. Guilford Press.
Hayes, S., Barnes-Holmes, D., & Roche, B. (2001). Relational frame theory: A post-Skinnerian
account of human language and cognition. Kluwer Academic/Plenum Publishers.
Wilson, K. G., Hayes, S. C., Gregg, J., & Zettle, R. D. (2001). Psychopathology and psycho-
therapy. In S. C. Hayes, D. Barnes-Holmes, & B. Roche (Eds.), Relational frame theory: A
post-Skinnerian account of human language and cognition (pp. 211–237). Kluwer Academic/
Plenum Publishers.
Part V
Application of ACT-I and ACT-BBI-I
Chapter 17
Case Example: Application of ACT-I
in a Group Intervention
The present chapter describes the application of the ACT-I protocol to a group of
five adults with insomnia complaints.1 ACT-I was applied as monotherapy, i.e.,
stimulus control or sleep restriction techniques were not used. The chapter focuses
on the description of the session-by-session protocol based on the main excerpts
from the exchanges of experiences that occurred between group members that
accessed some of the therapeutic elements.
The participants sought group therapy for complaints of insomnia. After being
interviewed by a sleep specialist, the participants were referred to the group therapy
sessions. Six sessions were held. Below is a brief description of the participants,
followed by the description of the main transcribed excerpts from the six sessions.
A brief description of the participants
Raíssa (fictitious name), 22 years, single, physiotherapy student. Her main com-
plaint was unrefreshing sleep and daytime sleepiness. She had irregular bedtime
and wake-up times and fragmented sleep. As a teenager, she was diagnosed with
depression and had a history of ineffective treatments. According to Raíssa, on
the occasion of the group therapy, depression was not prominent and insomnia
was her main complaint.
Cirley (fictitious name), 36 years, married, social worker. She had difficulty initiat-
ing sleep and reported poor bedtime control. She went through a difficult time
trying repeatedly to get pregnant without success. She believes that this fact may
have interfered with her ability to fall asleep.
1
The cases reported in this book signed the free informed consent form since they are part of a
research project on ACT for insomnia.
Fábio (fictitious name), 37 years, single, engineer. Extremely strict regarding sleep-
ing habits, with difficulty in initiating and maintaining sleep and hypnotic depen-
dence. He reported that he stopped doing several activities that he liked in order
to avoid compromising his sleep. He started to reduce meetings with friends and
everything that could disturb his routine and consequently compromise his hours
of sleep. With insomnia, his activities were increasingly limited.
Graziela (fictitious name), 49 years, divorced, housewife. She complained mainly
about initiating sleep, but also about sleep maintenance. She reported frustration
with her divorce 20 years ago, feeling left out by her children, and great difficulty
trusting people. She experiences a lot of tension at night and often drinks alcohol
in an attempt to relax and sleep.
Ludmila (fictitious name), 59 years, married, retired. Complaint of initiating and
maintaining sleep. She reported the habit of going to bed much earlier than rec-
ommended in an attempt to sleep more. She would like to be more independent,
but she sees herself very closed to new activities and new friendships and very
dependent on others for doing trips. As a child, she was bullied and she believes
that this fact made her afraid of getting hurt when making new friends.
17.1 Session 1
1. Presentation: Therapist and group members introduced themselves. Each partici-

pant introduced themselves and reported the complaint, the reason for seeking
the group therapy, and what they like to do. Table 17.1 shows the presentation of
each participant.
1. Group rules: The therapist explained the rules regarding absences, schedules, and
confidentiality.
1. Wound metaphor and group dynamics: After the description of the wound meta-
phor, some comic drawings of insomnia manifestations were presented. The
dynamics regarding the different manifestations of insomnia present in the comic
drawings brought the group members closer together. Most participants identi-
fied themselves with all the drawings and laughed a lot.
1. Psychoeducation about sleep: Psychoeducation was applied as Power Point
slides. The group cleared questions and curiosities about sleep.
1. Task: At the end of the session, the therapist highlighted the importance of record-
ing sleep patterns in the sleep diary.
Brief considerations on session 1: The group dynamics appeared to have broken
the ice and promoted the integration between group members. Based on psychoedu-
cation, the group members cleared doubts about sleep patterns, increasing their
knowledge about sleep and the insomnia complaint.
17 Case Example: Application of ACT-I in a Group Intervention 211
Table 17.1 Presentation of the group members

Participant Who am I? What brought me here? What do I like to do?
Raíssa I’m Raíssa, I’m 22 years old, I’m a physiotherapy student, and I’m single.
I looked for the group because I experience unrefreshing sleep, daytime sleepiness,
and frequent night awakenings.
I like going out with friends to dance.
Cirley I’m Cirley, I’m 36 years old, I’m a social worker, and I’m married.
My main complaint is the difficulty initiating sleep.
I like to be among family and friends and in the company of children and elderly
people. I love getting friends and family together to chat. I like to cook for the
people in my house.
Fábio I’m Fábio, I’m 37 years old, I’m an engineer, and I’m single.
I have difficulties initiating and maintaining sleep and I am insecure about trying to
sleep without medication.
I love going to the cinema, theater, museum, and cultural events
Graziela I’m Graziela, I’m 49 years old, I’m divorced, and I have two children.
I have difficulties falling and staying asleep.
I like to travel, discover new places and nature.
Ludmila I’m Ludmila, I’m 59 years old, I’m retired and married, and I have two children.
I have difficulty initiating and maintaining sleep.
I like to watch movies and series on Netflix and to discover different places, travel.
17.2 Session 2
1. Task revision: For the second session, the group only completed the information
in the sleep diary.
1. Sleep hygiene: The therapist provided explanations and guidance on sleep hygiene
in Power Point. The group members asked questions during the presentation. At
the end, each participant identified together with the therapist the necessary
changes in sleep hygiene. Table 17.2 shows the necessary changes identified by
each participant.
After the participants had identified what they needed to change in their sleep
hygiene, Graziela proposed to help each other with reminders that could be sent via
WhatsApp. The group was committed to making the changes during the week
1. Mindfulness: The therapist explained mindfulness principles for sleep and then
guided the participants in a mindfulness practice, the body scan. After this prac-
tice, the members of the group explained their experience. Table 17.3 shows how
each participant experienced the body scan practice.
After each participant had shared their experience, Cirley reported feeling more
comfortable knowing that she was not the only one who got distracted and had dif-
ficulty concentrating and proposed to the group to charge themselves in the daily
body scan task.
1. Task: The task established was practicing body scan daily and the changes in
sleep hygiene.
Table 17.2 Changes in sleep hygiene identified by each participant

Participant Instructions for change
Raíssa Do not sleep with the TV on void using your cell phone before going to bed
Regular bedtime and wake-up times
Do not nap during the day
Cirley Perform physical activity
Do not go to bed hungry
Avoid drinking too much water before going to bed
Fábio Avoid smoking at night
Do not use your cell phone before going to bed
Graziela Avoid drinking alcohol at night
Install blackout curtains on the bedroom window
Ludmila Avoid drinking coffee during the afternoon–night period
Avoid napping during the day
Perform physical activity
Table 17.3 Feedback of the participants on body scan

Participant Body scan
Raíssa I felt so relaxed, I even wanted to sleep.
Cirley It was very difficult for me, other thoughts invaded my mind. It was hard to
concentrate.
Fábio In the first minutes, I was able to be aware of how my body was but at the end I got
distracted.
Graziela It was a very interesting practice, I was able to surrender and concentrate on my
body.
Ludmila At first, my mind was invaded by other thoughts; however, after I persisted, I was
able to concentrate and at the end I was very relaxed.
Therapist The experience is individual and can have a different effect on each of you. The
experience that each one had was interesting. Thank you for sharing.
Brief considerations on session 2: Using psychoeducation on sleep hygiene, the

participants identified habits that could be modified to improve their quality of
sleep. The exchange of experiences on the body scan practice facilitated identifica-
tion by group members and support in performing the practice as a task assignment.
17.3 Session 3
1. Task revision: The third session started with exchanging experiences on the tasks
established in the last session. Each participant reported the changes made dur-
ing the week in sleep hygiene and body scan practice. Table 17.4 presents the
report of the participants.
2. Creative hopelessness: After the mindfulness practice of creative hopelessness,

the therapist asked some questions in order to assess attempts to control and
Table 17.4 Report on the tasks established in session 2

Participant Tasks established in session 2
Raíssa It was very easy for me to do the body scan practice. I really felt that it helped me
relax. I even felt that I slept a little better this week.
Regarding the sleep hygiene changes, I was unable to do all. For example, I did not
use my cell phone at night or sleep with the TV on all week. However, keeping
regular bedtime and wake-up times and not napping, I did not.
Cirley Throughout the week I reduced my fluid intake before going to bed, I also started to
eat a light snack an hour before going to bed. It felt really good to go to bed not
hungry. Physical activity I’m starting little by little, I went for a walk three times
this week. But I confess that the body scan practice is not easy for me. I think I get
even more anxious. I only did it for 2 days and one of those days I stopped the
practice in the middle.
Fábio I did everything that was agreed upon. I did not smoke at night and stopped using
my cell phone an hour before going to bed. I did the body scan practice, and when I
do it, I feel very good. But it is still difficult to sleep. I wonder when my insomnia
will get better?
Graziela Well, let’s go … this week I only drank twice. It is already a step forward, right?
Laughter. I’ve also had a blackout curtain made for my bedroom. I believe that in
2 days I will already sleep with new curtains.
I chose to do the body scan practice in the morning and I felt less anxious during
the day.
Ludmila Am I the only one who was lazy not doing physical activity this week? Laughter. I
still have not been able to put physical activity into practice. However, I managed
not to nap during the day and reduced coffee. Since the last session, I have only
been drinking coffee in the morning.
The body scan relaxes me a lot, this one I managed to do every day. Of course, I
was not able to be mindful during the entire meditation but I was able to observe
myself at least during most part of the practice.
Therapist It is very good to see that we are making progress and that everyone, within their
limits, is committed to the tasks.
avoid discomfort. Once everyone had answered the five questions, the therapist
asked the group members to share their answers. These responses are presented
in Table 17.5.
3. Tug-of-war metaphor: After the metaphor, the group members identified what
“pulling the rope” means for each of them. Figure 17.1 shows their answers.
After group reflection, the proposal was to find ways to let go of the rope.
After the participants had identified and expressed what “pulling the rope” means
for each of them, some participants shared how the group exchange experience was.
It was interesting for me to hear Fábio speak, it seems that seeing the situation in the other
person made me see my own avoidance. (Graziela)
I understood the metaphor but it was difficult for me to see how the attempt of control was
occurring in my sleep. While listening to Ludmila, it seems that I was able to identify my
attempt at controlling as well. (Raíssa)
Table 17.5 Creative hopelessness

Participant Exchange – creative hopelessness
Cirley Can I talk first? I get very frustrated with not being able to fall asleep. I feel
incapable! So, what do I do then? I put it into my head that I need to sleep. I keep
my eyes closed, speaking in a mantra “sleep, sleep, sleep.” Look, it is not working
neither in the short nor in the long term.
Insomnia has compromised my quality of life and controlling it would make me
chase more satisfying situations for myself.
Fábio I identify myself with you Cirley because I also feel incapable and, before the fear
of not sleeping takes over, I already take my medication. It works at first but then it
becomes a snowball, and here I am looking for help. Today the medication is a
crutch for me. Getting off the medication and sleeping naturally would bring me my
life back.
Ludmila My feelings vary, I feel angry, angry about not being able to sleep. After all, my
main strategy is to go to bed earlier in an attempt to sleep more. But it has never
worked. I don’t know why I keep trying. If I slept better I would have a lot more
energy, I have no doubt.
Graziela Look, bedtime is not the worst, I need to relax and I use alcohol to help me. At the
time I relax, it works. But not in the long term. After the psychoeducation we had in
the previous session, I started to notice that, when I drink before going to bed, I
wake up many times during the night. So, it is not working. I don’t know how to
answer what better sleep would add to my life, I’m already used to the way it is.
But of course, I would like to sleep naturally, I think I would feel more independent.
Raíssa My problem is more with sleepiness during the day. I keep thinking that I have less
energy than other people. To help myself, I stay in bed longer. But I end up
compromising myself by losing most of the day. If I solved this problem, I would
have more time to do other things.
Therapist Thank you for sharing. Have you ever asked yourselves if trying to control the
discomfort caused by the sleep complaint is the problem rather than the solution?
Fábio In fact, it is very tiring to have control of everything…
It’s so hard to see this so rigid side of me, the metaphor allowed me to see it without avoid-
ing my own judgment. And apparently I am not the only controller, laughter. I confess that
it makes me feel more normal. Maybe a sense of belonging, it’s not just me who suffers with
my sleep. (Fábio)
After group reflection, the proposal was to find ways to let go of the rope.
4. Mindfulness: After the guided practice of leaves on a stream, the participants
shared their experiences. Some statements are cited below:
Watching my thoughts drift away with the leaves gave me the feeling that they were indeed
just thoughts. (Ludmila)
Unlike the body scan practice that flowed, in the leaves on a stream practice I had more
difficulty concentrating and imagining my thoughts. But I still felt relaxed because I imag-
ined myself in a forest. (Raíssa)
This practice I managed to do and I really liked it. I felt relieved and emptying my mind as
I got the thoughts out of my head and onto the leaves. (Cirley)
Ludmila
Pulling the rope – control – forcing to
sleep by going to bed much earlier
Raíssa
Pulling the rope – managing the
consequences of insomnia – staying in bed
when waking up and napping during the day
Fábio
Pulling the rope - taking medication to Therapeutic target
avoid the possibility of not sleeping Let go of the rope
Cirley
Pulling the rope - forcing sleep,
forcing to sleep. Keeping the eyes
closed thinking “I need to sleep,
commands – Sleep”
Graziela
Alcohol before going to bed to relax
and to start sleeping without tension
Fig. 17.1 Report of the participants on the exercise of creative hopelessness
I was stuck in a single thought for a long time. It was difficult to let it flow down the creek
but after it did, my mind went blank and I could observe my surroundings. The sound of the
forest, of the birds. (Graziela)
For me the thoughts came like a cascade, one after the other, as if it were a waterfall of
thoughts. (Fábio)
4. Tasks: In addition to maintaining the other tasks proposed in the previous ses-
sions, the daily use of the “leaves on a stream” practice was recommended.
Brief considerations on session 3: The use of metaphors facilitated access to
control strategies. In addition, observing the behavior of others served as a model
for identifying one’s own behavior. The group members also showed a sense of
belonging by identifying themselves with similar situations.
17.4 Session 4
1. Task revision: The participants shared their experiences on performing the pro-
posed tasks.
1. Pain versus suffering and pudding metaphor: The therapist explained the differ-
ence between pain and suffering and then presented the pudding metaphor (suf-
fering pain after eating a spoiled pudding). Based on this metaphor, the therapist
and members of the group discussed several examples to illustrate the difference
between pain and suffering and each participant described their number 1 pud-
dings. The following statements demonstrate how each participant identified
pain (pudding number 1) and subsequent sufferings based on the pudding
metaphor.
My number 1 pudding, my primary pain, was a bad night’s sleep that I spent awake, without
sleeping, after going to the movies with friends in the middle of the week instead of staying
at home and sleeping early… After that, I never again went to the movies, I decline invita-
tions from friends to events in the middle of the week, afraid of having another bad night’s
sleep. (Fábio)
In childhood they bullied me when I changed schools. It was very painful. This bullying
situation is my number 1 pudding. And my suffering since then is that I back off from new
friendships, social relations for fear of being “humiliated” again. (Ludmila)
It is really hard to admit, but my number 1 pudding is my frustration of not being able to get
pregnant. And to avoid getting in touch with this pain, I avoid meeting friends who are
mothers or going to events full of children. (Cirley)
The divorce 20 years ago was very painful for me, it was frustrating. It hurt so much that
today I close myself to new relationships for fear of further frustration. Once I almost
opened up but I self-sabotaged myself, I think it was a way to avoid the possibility of pain.
(Graziela)
Oh, I don’t know if I am as sure as you are about my number 1 pudding, but a few years ago
I had psychiatric treatment for depression and it did not work. I was so frustrated that today
I don’t trust new psychiatric or psychological treatments. Maybe that is my pudding. But I
am here…so I am opening myself up to the pain or not?. (Raíssa)
Listening to our reports gives the feeling that we have much more suffering than pain. For
example, I am a pain controller. In order not to have a sleepless night, I avoid many things
that could leave me more relaxed and happier. (Fábio)
1. Reading of poems: The session continued with the reading and discussion of two
poems that indirectly covered the processes of acceptance and self as context.
1. Sheet activity: The last activity of session 4 was to write positive memories, feel-
ings, and thoughts on one side of the paper and negative ones on the other side.
At the end of the activity, the therapist asked what each participant would like to
do with the paper, as can be seen in the following statements:
I will save it to look at the positive and negative points of life. It would be great if I could
throw away just the negative ones. (Ludmila)
I would crumple and throw away the negative points. (Cirley)
Table 17.6 Positive and negative points of the participant Ludmila

Positive Negative
Childhood friendships Dependence
Good family relationship Lack of freedom
Large family Death of loved ones
Experiences – travel, etc. Childhood bullying
Decision to marry just to please others (society,
family)
I would burn this paper. (Raíssa)

Can I just keep the positive part?. (Graziela)
I would also keep only the positive part. (Fábio)
But not, if you crumple or burn the paper, the positive side is gone too. And if you keep it,
the negative side will also be kept. (Therapist)
For life to be complete, we need the whole sheet, don’t we?. (Cirley)
And that means opening yourself up to the pain. (Graziela)
Would anyone like to share their paper?. (Therapist)
I would. (Ludmila)
Table 17.6 lists the positive and negative points of Ludmila.

1. Tasks: After exchange, the tasks of the week were determined. In addition to the
tasks already maintained in the other weeks, the task of the week would be to
identify a situation that has been avoided and to face it. The participants said
goodbye and the session ended.
Brief considerations on session 4: The use of the metaphor raised awareness of
behaviors to avoid discomfort. The sheet activity enabled to accept what is consid-
ered “negative” and uncomfortable as part of life. The group discussion promoted
openness to report the experience and learning by observing the behavior of
the others.
17.5 Session 5
1. Task revision: The therapist asked about the tasks and the group reported their
progress of the week. Cirley shared the task established in the last session, as can
be seen in the following statement.
I completed the mission of the week. I called a very dear friend that I had been avoid-
ing…her friendship does me a lot of good, but since she has recently become a mother, I am
frustrated that I’m not. But even considering this discomfort, I went to visit her and I had
very pleasant moments, I felt welcomed and I was happy that I faced it. (Cirley)
I was very happy to hear that, you know, I have been thinking very fondly of each one of
you in the group before the sessions. I keep asking myself “How is Cirley doing this week,
how has the group been committed to the tasks, do we help each other?”…. (Ludmila)
1. Values clarification: “Life compass” proposal. After the participants completed

the life compass activity, the therapist started a dialogue with the group, expressed
in the following statements:
Well, I see that everyone has completed the activity. Would anyone like to share how they
felt doing this exercise?
This activity made me rethink a lot what I am neglecting and in what I am investing. I
have noticed that I am neglecting important aspects of my social relations and personal
growth. The values I would like to develop and cultivate in these areas are “openness” and
“autonomy”.
I want to open myself up to new relationships, I have been closing myself for years for
fear of being rejected and humiliated. I want to have an open attitude to meet new people,
new places, experience different things. This is also in line with my search for indepen-
dence and, somehow, freedom. I depend a lot on my kids and husband for outings. I would
like not to depend on a family member to go out and have fun, I really want to be indepen-
dent. I dream of taking a trip alone and experiencing what it is like to be without family
around. Knowing myself better, being only with myself. (Ludmila)
Thank you for sharing, Ludmila. What do you think prevents you from seeking autonomy,
freedom and openness?. (Therapist)
I believe that on the one hand it is convenience. I am accommodated. I settled for my hus-
band to choose all the trips and I just follow. These days I have asked myself if I like the
trips he plans. I would like to plan and do whatever I choose, at least once in my life. But
deep down, I am afraid I won’t be able to. (Ludmila)
Ludmila, it was very good to listening to you because I feel something different. In my case,
I think I am too bossy and it hurts my relationships. Because I want things my way. During
the activity, I reflected on what values I would like to cultivate in my family relationships,
especially with my children. I noticed that I neglect my family relationships due to a lack of
tolerance. There is a value that I want to cultivate, tolerance. I find it difficult to hear the
wish of the other when this wish does not include me. I feel disadvantaged and rejected. For
example, on Easter my son let me know that he would have lunch with his wife’s family. I
was very aggressive since I expected him to have lunch with me. I realize that, by doing this,
I put an even greater distance between him and me. I want to be more tolerant in my rela-
tionships. (Graziela)
Listening to Graziela’s speech, I identified myself with some aspects, maybe we human
beings perceive the desire of the other as rejection when it does not include us and we attack
out of fear? But the children grow up and have other interests and activities…This activity
made me reflect a lot; however, unlike Graziela who attacks when she feels rejected, I agree
with the others, afraid of being rejected, often not revealing what I think, what I want. A
need to please. It even seems silly but when I go to a restaurant with a group of friends or
family and they ask what I want to eat, I always eat the same thing as the other person orders
and I end up sharing the dish, I never choose what I actually want to eat. (Cirley)
I thought a lot about my health. I think I need to develop self-care. Could this be considered
a value? Self-care? I thought I need to take care of my body, my food, my mental health. I
haven’t been doing this. (Raíssa)
Do you have any clue as to why you are not developing self-care?. (Therapist)
Physical activity often causes discomfort, pain, and I end up not persisting. Lack of persis-
tence, determination, laziness. There are so many reasons but I think mainly because it is
not comfortable to feel the initial discomforts when you start the gym. (Raíssa)
Raíssa, I understand you but I will tell you one thing, the discomfort is temporary, with time
physical activity starts to give results, it improves your mood, improves your health, and
then you will like it. You just have to endure the initial discomfort a little. (Fábio)
I give up many things because of this initial discomfort. (Raíssa)
I see that you are noticing the barriers to cultivating your values and are identifying what
you are trying to avoid, this is a very important step. (Therapist)
In my case, do I see that I am too controlling? Is this my barrier to achieving what I want,
the kind of person I want to be?. (Fábio)
And what do you want? What kind of person do you want to be?. (Therapist)
I want to be more flexible because I stop living by trying to control everything. I love art, I
love going to the movies, going to events, and I am so rigid in my routine that I don’t allow
myself. That’s it, I want to cultivate flexibility. This value, flexibility, was recurrent during
the life compass activity. At my own work I compromise myself by being too rigid and
methodical. (Fábio)
Fábio, I am going to use the same line of reasoning as you for me, regarding self-care. At
the beginning it will be difficult to be flexible, trying to control less, but after the initial
discomfort you will have advantages in cultivating flexibility. (Raíssa)
After exchanging their thoughts about values clarification, the therapist explored
with the participants committed actions based on values.
1. Committed actions: To address committed actions, the therapist asked the partici-
pants to organize their goals in a chart, the barriers that make it difficult to
achieve these goals, and which actions could be adopted to achieve the goals. At
the end, the participants exchanged the following charts with the group
(Table 17.7).
4. After exchange of the reasons identified by the participants that prevent them
from behaving in accordance with their values, a mindfulness practice on values
and committed actions was performed.
4. Committed actions were also the focus of the task of this session.
Brief considerations on session 5: After the life compass activity and further
reflection on barriers to achieving values-based goals, the participants had clarity
about avoidance-based versus values-based behaviors. The members of the group
supported and encouraged each other to take committed actions.
17.6 Session 6
1. Task revision: The participants shared their experiences by performing the pro-
posed tasks.
Table 17.7 Committed actions of the participants

Committed actions – Ludmila
Value Autonomy
Goal Traveling alone
Barriers Convenience, fear of not being able to fend for myself, facing
trouble
Behaviors to achieve my Step 1: Going out alone (going to the movies, going out for
goals lunch)
Step 2: Taking a day trip to a nearby town
Step 3: Traveling to a nearby town and stay in a hotel alone.
Committed actions – Graziela
Value Tolerance
Goal Accepting the children’s decisions without yelling or blackmailing
Barriers Fear of loneliness; feeling of being at a disadvantage
Behaviors to achieve my Listening to the son’s speech without attacking him
goals Not manipulating the situation
Enduring the discomfort of occasionally not being included in the
children’s plans
Committed actions – Fábio
Value Flexibility
Goal Having a less rigid routine, allowing exceptions
Barriers Fear of not sleeping well
Fear of breaking routine and compromising sleep
Behaviors to achieve my goals Going to the movies on Tuesday with a friend
Committed actions – Raíssa
Value Self-care
Goal Performing physical activity
Barriers Muscle soreness from adaptation to the gym
Behaviors to achieve my goals 1. Start walking 3×/week
2. Enrolling in the gym
Committed actions – Cirley
Value Honesty
Goal Exposing my wishes and thoughts
Barriers Possibility of conflict
Behaviors to achieve my 1. When in a group, choosing what I really want to eat at the
goals restaurant
2. Defending my opinion in conversation with friends
1. Attending your own funeral – epitaph: The proposal of reflecting on what mes-
sage the participants would like to leave when they die elicited emotion in some
of them and reinforced their values. The cited statements denote the impact of
the activity on each member of the group.
I never stopped thinking about death. Before thinking what message I would like to leave, I
thought about the message I do not want to leave. I realize that many of my actions are
focused on the opinion of others – what they think about me. I do not want my epitaph to
contain the message “The one who lived thinking about the opinion of others”. I want to be
honest about my own desires and that people like me for who I am and not what I look like.
Reflecting about this honesty that I want to cultivate, my epitaph would be “The one who
could be trusted and who was honest with others and especially with herself”. (Cirley)
I would like to be remembered as “the one who helped others, who gave herself”. But not
the one who was passed over or who was the dupe. Can you tell the difference? I am afraid
of being the dupe and that is why I am so distrustful and aggressive that I end up not expe-
riencing what I value so much, which is giving, openness to others, the possibility of help-
ing, of loving. I need to learn to balance these contradictions. (Graziela)
My epitaph would be “the one who learned to fly”. That’s it, I am going to learn to be inde-
pendent, autonomous. I am confident I will. Even late we can learn, even after 50, right?.
(Ludmila)
I always wanted to be very perfect. Make great contributions to the world. That is why I
have always been very disciplined at work, in health, in everything. I built myself in cement,
so inflexible and so gray that I can hardly bathe in the sun. My epitaph today would be “he
who fought to be an Apollo but became a statue”. But I want to change that, I want to be
weightless, malleable, break this statue and become a free, weightless and untied
human…laughter. (Fábio)
At my memorial people would say “The one who always made me laugh”, and that’s right.
People think I am funny. I love making people laugh. I like my mood. I am going to start
committing myself and go further, for my epitaph to be “The one who makes others smile,
but mostly makes herself smile”. I want to make myself smile. That’s why I will take care
of myself. (Raíssa)
After sharing their thoughts, there was a period of silence and reflection on the
content of the work.
1. Joe the Bum: Reading of the “Joe the Bum” parable was aimed at addressing the
acceptance of feelings, thoughts and memories, as well as the action in pursuit of
values. The participants identified with the character and contributed content
from their experiences, as illustrated by the following statements:
I would definitely go after Joe. That is what I do with my sleep, I watch myself to see if I
am going to sleep or not. In fact, this isn’t quite like a party, it is a lot of work. (Cirley)
I also see myself as a gatekeeper, a watchwoman of the consequences of a bad night. I pay
attention to everything that goes on in my body. I go after the Joes. (Raíssa)
I used to be like that a lot, today I let it go. If there is any discomfort, I will let it fend for
itself at the party. I am not going to worry, no. But it took me a while to stop watching the
Joes. (Ludmila)
I am the type who suffers before the party. I would be desperate before Joe arrived.
Sometimes he does not even show up and I suffer in anticipation. I am already suffering
from imagining him being inappropriate with person X or person Y. But mindfulness helps
me let Joe show up and learn to live with it. What to do…. (Fabio)
In fact, that is exactly what we do, we get so worried about the Joes in our lives that time
passes, life passes and what really matters? Are we following what matters? or Are we
distracting ourselves with Joes?. (Graziela)
1. Mindfulness: After the parable, the last mindfulness practice of the protocol was
performed, which focused on values and committed actions. After the practice
and a moment of silence, the therapist asked the group “What change did this
experience bring about?”
I realized that I try to control everything in order to avoid feeling discomfort. And a bad
night’s sleep is another one of those discomforts. My relationship with sleep has been
changing with therapy. (Fábio)
The therapy made me realize that I am very much of an immediatist and I have difficulties
in persisting to pursue what I really want because it is far away. I need to make a commit-
ment to reap medium- and long-term benefits. I am in the planting phase. Regarding sleep,
I noticed that I have been worrying less about the consequences of insomnia. I am less
neurotic. (Raíssa)
My sleep satisfaction has improved a lot. I do not even keep counting how many hours it
takes me to sleep and wake up, or how many hours I slept. Of course, I estimate it to answer
the diary. But I am less worried about that. I want to live, regardless of whether I have a
sleep problem or not. But that does not mean my sleep hasn’t improved, I am sleeping bet-
ter. Laughter. (Cirley)
I had never done group therapy, but it was interesting that seeing the situation of the other
made me perceive my own avoidances. Being able to share with the group and having this
welcoming space was very good. (Ludmila)
The metaphors are gentler in perceiving pains than objective speech. I had the impression
that discussing the metaphors in a group and seeing the others expose themselves also
encouraged me to expose myself, even in the case of things that even I did not notice about
myself. After the session, I continued reflecting, the pain of the other seemed so great and I
was afraid to face mine. It gave me the strength to face it too, after all it is not just me who
has this complaint. I am not alone. I felt supported to share my pains and discomforts with
those who could understand them, after all we had common pains. (Graziela)
At the end, all participants thanked the therapist and each member for all the
moments and shared experiences and the group ended.
Brief considerations on session 6: The activities proposed in session 6, such as
“Attending your own funeral” and the “Joe-the-Bum parable,” made the group
observe finitude and to what extent each one is or is not engaged in what really mat-
ters and what they really value. The mindfulness practice reinforced values-based
committed actions. The final statements demonstrated how the relationship of the
participants with their own sleep was addressed.
Figures 17.2, 17.3, 17.4, 17.5, 17.6, 17.7, 17.8, 17.9, 17.10, 17.11, 17.12, 17.13,
17.14, 17.15, 17.16, 17.17, 17.18, 17.19, 17.20, and 17.21 show the average sleep
parameters of each participant over the course of the sessions.
SLEEP ONSET LATENCY

140
120
100
80
60
40
20
0
T
E
EN
N
LI
TM
SE
EA
BA
R
-T
ST
PO
Fig. 17.2 Cirley: Sleep onset latency
WAKE AFTER SLEEP ONSET

30
25
20
15
10
5
0
T
1
6
E
EN
N
LI
TM
SE
EA
BA
R
-T
ST
PO
Fig. 17.3 Cirley: Wake after sleep onset

TOTAL SLEEP TIME

8
7
6
5
4
3
2
1
0
E
T
1
4
N
EN
LI
TM
SE
BA
EA
R
-T
ST
PO
Fig. 17.4 Cirley: Total sleep time
SLEEP EFFICIENCY
100
80
60
40
20
0
1
3
2
6
5
Fig. 17.5 Cirley: Sleep efficiency

SLEEP ONSET LATENCY

30
25
20
15
10
T
E
EN
5
1
6
3
4
2
N
LI
TM
SE
EA
BA
R
-T
ST
PO
Fig. 17.6 Raíssa: Sleep onset latency

100
90
80
70
60
50
40
30
20
10
0
E
T
1
6
5
2
3
N
EN
LI
TM
SE
BA
EA
R
-T
ST
PO
Fig. 17.7 Raíssa: Wake after sleep onset

TOTAL SLEEP TIME

8
7
6
5
4
3
2
1
0
E
T
1
4
N
EN
LI
TM
SE
BA
EA
R
-T
ST
PO
Fig. 17.8 Raíssa: Total sleep time
SLEEP EFFICIENCY
100
80
60
40
20
0
2
3
1
6
5
Fig. 17.9 Raíssa: Sleep efficiency

SLEEP ONSET LATENCY

45
40
35
30
25
20
15
10
5
0
T
E
EN
2
6
5
4
3
1
N
LI
TM
SE
EA
BA
R
-T
ST
PO
Fig. 17.10 Ludmila: Sleep onset latency

50
45
40
35
30
25
20
15
10
5
0
T
6
2
5
E
4
1
EN
N
LI
TM
SE
EA
BA
R
-T
ST
PO
Fig. 17.11 Ludmila: Wake after sleep onset

TOTAL SLEEP TIME

7
6
5
4
3
2
1
0
T
3
E
2
1
EN
4
N
LI
TM
SE
EA
BA
R
-T
ST
PO
Fig. 17.12 Ludmila: Total sleep time
SLEEP EFFICIENCY
100
90
80
70
60
50
40
30
20
10
0
3
1
4
2
Fig. 17.13 Ludmila: Sleep efficiency

SLEEP ONSET LATENCY

45
40
35
30
25
20
15
10
5
0
1
6
Fig. 17.14 Graziela: Sleep onset latency

45
40
35
30
25
20
15
10
5
0
3
1
4
2
Fig. 17.15 Graziela: Wake after sleep onset

TOTAL SLEEP TIME

9
8
7
6
5
4
3
2
1
0
3
1
4
2
6
Fig. 17.16 Graziela: Total sleep time
SLEEP EFFICIENCY
100
80
60
40
20
0
2
5
1
Fig. 17.17 Graziela: Sleep efficiency

SLEEP ONSET LATENCY

30
25
20
15
10
5
0
3
1
4
2
6
Fig. 17.18 Fabio: Sleep onset latency

100
90
80
70
60
50
40
30
20
10
0
3
1
4
2
Fig. 17.19 Fabio: Wake after sleep onset

TOTAL SLEEP TIME

9
8
7
6
5
4
3
2
1
1
6
Fig. 17.20 Fabio: Total sleep time
SLEEP EFFICIENCY
100
80
60
40
20
0
3
5
2
6
1
Fig. 17.21 Fabio: Sleep efficiency

17.7 Conclusion
ACT-I was found to have benefits for the sleep quality of the participants and mainly
changed their relationship with their own sleep. Metaphors facilitated access to
avoidance-based versus values-based behaviors. The group therapy format may
have contributed to the sense of belonging and welcoming and also as a model of
behavior. The present report demonstrated how group ACT-I can provide learning
conditions and consequent behavior changes based on both the individual’s active
participation in the proposed intervention and observation of the behavior of the
other group members in response to therapy.
Chapter 18
Case Example: Application of ACT-I
in an Individual Intervention
Ila Marques Porto Linares
Psychotherapy for clients with insomnia complaints can be conducted in different

formats, i.e., remote, face-to-face, groups, or individually. This chapter aims to
describe a session-by-session outline of an ACT-based intervention for a client com-
plaining of insomnia. The data below refer to the main points addressed in each
session.1
18.1 First Session
Goals: Conducting anamnesis, application of scales and questionnaires, and

instructions of how to fill out the sleep diary. The aim of the first session was also to
start building therapeutic rapport.
Anamnesis
A. Patient identification: Miguel (fictious name), 52 years, a widower and accoun-
tant who lives in the city of São Paulo, Brazil.
B. Complaint: Difficulty in initiating and maintaining sleep.
Client: “When I realized that I was sleeping poorly, I looked online for ways to
improve my sleep. It was then that I became even more concerned about the damage
of sleep deprivation. I count my hours of sleep when I wake up to see if I’m sleep
1
I. M. P. Linares (*)
236 I. M. P. Linares
deprived and I follow all the sleep hygiene instructions I have read online, and I still
do not get better.”
C. Daytime symptoms: The client reported some symptoms that are related mainly
to tiredness and concern about sleep.
Client: “I feel very tired during the day, sluggish, unproductive.”
“I realize that my mood is not very good either and I spend the day thinking about
how my night’s sleep will be, there are days when I get very anxious.”
D. History of complaint: When asked about his sleep history, Miguel reported that
he has slept poorly since he was a child but he thought that this was normal. The
client explained that he always took a long time to sleep, spending a lot of time
in another activity while “sleep did not come.” Fears and anxiety always seemed
to be present in Miguel’s life and contributed to this difficulty. He also reported
that he always had at least two nocturnal awakenings. When these nocturnal
awakenings occurred, Miguel usually stayed in bed waiting for sleep to return.
E. Although he always had difficulty initiating and maintaining sleep, the client
reported that these symptoms intensified after his wife passed away 2 years ago.
F. Sleep routine: Miguel’s sleep routine is very strict. Everything takes place at the
same time and in the same sequence: he takes a shower at 19.00 h, he has dinner
at 19.30 h, he watches the news at 20.00 h, he reads a book at 21.00 h, and he
goes to bed at 22.00 h. The client usually sleeps around midnight or 01.00 in the
morning. During this period, he stays in the bedroom waiting for sleep to
“come.” In the morning, he wakes up at 06.30 h and immediately starts his day.
Client: “It is better to stay in bed because at least I am resting my body.”
G. Personal information: Miguel grew up in a family with many rules and coercive
parenting practices. He was always pressured to perform perfectly and had few
opportunities to do what he wanted to do throughout his childhood and
adolescence.
At the age of 18, Miguel married his first girlfriend (Marina). The couple chose
not to have children. Marriage has always been an important pillar of his life since
it ensures security. His wife died unexpectedly after an acute myocardial infarction.
At the time of her death, the client was very unsettled, with lowered mood, had dif-
ficulty socializing, and exhibited a hypochondriac behavior. Miguel has also slept
worse every night since then, i.e., increased sleep onset latency and time to fall back
to sleep after nocturnal awakenings.
The client has always been reserved and had few friends. Thus, the loss of his
wife affected him even socially, given the lack of relationships in his life. Miguel
prefers not to get in touch with relatives and friends from the past, as it is very
unpleasant to talk about himself and he feels pressured to be the person he thinks
others expect him to be. Only with Marina could he be who he really is, she under-
stood Miguel.
18 Case Example: Application of ACT-I in an Individual Intervention 237
Table 18.1 Objective data Instrument Score

obtained by applying the
ISI 15
instruments at the start of the
intervention PSQI 14
AAQ 26
Throughout his life, avoidance has been Miguel’s main tool to deal with feelings.
It therefore always seemed that everything was under his control and that nothing
could unsettle him.
Client: “To avoid thinking about my worries, I spend the whole day performing
some activity, even while taking a shower I read.”
“Talking about how I feel makes me feel bad, so I just get on with life and do not
talk about it.”
“The only problem I think about is the sleep problem, the others I don’t even
think about.”
Also from an emotional point of view, Miguel was always very rigid and had
difficulty being flexible to deal with the adversities and setbacks of everyday life.
Client: “Everything has the right way of solving itself, there is no point in doing it
any other way.”
“I don’t understand why people do not follow the rules. Everything that has rules
works better.”
With the death of his wife, Miguel found himself without goals in life. The cou-
ple did not have many ambitions but they have been traveling once a year to the
same destination since they had gotten married. Now, the client saw no point in
traveling to this destination.
Interventions: The following instruments were applied during the first session:
Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and
Acceptance and Action Questionnaire (AAQ). In addition, the client was instructed
on how to fill out the sleep diary and the therapist explained the reason for engaging
in keeping this diary. The diary was filled out daily throughout the psychological
intervention.
Validation of the client’s complaint, welcoming, and listening are also essential
in this first session in order to start building rapport. Table 18.1 shows the scores
obtained with the instruments applied.
18.2 Second Session
Goals: Continuation of the process of building rapport, psychoeducation, analysis

of the sleep diary, mindfulness exercise, and case formulation.
All sessions that occurred after the anamnesis session started with the therapist
asking about how the client is doing, how he is perceiving himself, and what are his
greatest difficulties during the process, as well as the implementation of home

activities.
Client: “…it is okay but I look forward to knowing how to solve this sleep
problem.”
Interventions
A. Psychoeducation about sleep and its functions, as well as about the effects of
sleep deprivation and the main diagnostic aspects of insomnia, was applied.
Client: “I thought all adults need eight hours per night to get enough rest. How do
I know how many hours I need?”
Therapist: “This is a good question, we will need to understand this through-
out the process; to obtain a reliable perception, it will be necessary to strip ourselves
of the rules that we have in our head, that is, we will have to be sensitive to what we
are experiencing.”
B. Analysis of the sleep diary was based on understanding the following recorded
sleep parameters: sleep onset latency, frequency of nighttime awakenings, time
awake after sleep onset, total sleep time, total time in bed, and sleep efficiency.
Table 18.2 summarizes the main parameters derived from Miguel’s sleep diary.
C. Mindfulness exercise: To promote relaxation and attention to the present

moment, a mindfulness exercise was carried out with the client. The exercise
was short and was guided. In addition to in-session training, the client was
instructed to perform this type of exercise not only at bedtime but throughout the
subsequent days. For this purpose, the therapist made an audio recording of the
exercise performed in the session.
Client: “I have a lot of difficulty with this type of exercise, I don’t know if I will
succeed. I will do it since it will be great if this solves the problem.”
D. Case formulation: Case formulation is a continuous process2 that requires the
therapist to frequently revisit the approach they use to understand the case. The
first time a case formulation can be performed is at the beginning of therapy.
Table 18.2 Description of Parameter Time/frequency

the sleep parameters Sleep onset latency 120 min
evaluated by the sleep diary
after the first session Frequency of nighttime awakenings 2
Time awake after sleep onset 60 min
Total sleep time 5 h 30 min
Total time in bed 8 h 30 min
Sleep efficiency 64.7%
2
Case formulation based on the model of Kovak and Perez.
From the perspective of ACT, the process of case formulation includes the anal-
ysis of the client’s psychological flexibility and, based on that, the detailed
analysis of the six processes that make up this construct. Thus, assessing how
the client relates to acceptance, defusion, mindfulness, self as context, commit-
ted actions, and values is the first step necessary for structuring the intervention.
Table 18.3 describes each of these processes from the perspective of
Miguel’s case.
Examples of experiential avoidance responses identified during the ses-

sion: Miguel avoids telling details about his own sleep, only doing so when asked
directly. The client reiterates that he is looking for a quick and practical solution for
the sleeping difficulty. In addition, he avoids talking about any emotional issues.
Verbal responses related to the self (narrative about oneself; rules and self-
rules): Miguel hardly notices the context in which the sleeping difficulty occurs,
charging and judging himself most of the time (self as content). In other words, the
client fuses with the rules and self-rules, which increases the difficulty in perspec-
tive taking, with consequent poor contextual self-perception.
Client: “…I will never be able to sleep satisfactorily.”
“…I don’t even have the capacity to sleep a whole night.”
“…I don’t understand, these things only happen to me. I don’t sleep.”
“…I slept 5 h, that means I am not in good health.”
Values: The client has little clarity about his own values and seems to be quite lost.
Client: “…I don’t know what is of value to me today.”
“…I don’t know if at some point in my life I knew what my values were.”
Table 18.3 Main experiential avoidance responses

What brings What have Does this way of
you to you been dealing with it
therapy? trying to deal What happens help you
(the with this when you try to overcome the
problem problem deal with it that problem Overall
Related according to (experiential way (short-term (long-term cost for
antecedents the client) avoidance)? consequences)? consequences)? life
History of Difficulty Sleep hygiene Sleep hygiene No, he has Life
psychological sleeping and measures measures help in catastrophic “revolves
inflexibility falling back Spending the not worsening thoughts about around”
and difficulty to sleep day thinking the situation sleep deprivation sleep
sleeping after about how the Increased Spending a lot of issues
satisfactorily nighttime night will be anxiety time awake in He avoids
awakenings Staying in bed throughout the bed exacerbates contact
until sleep day the association with other
comes Bedtime between bedtime areas of
aversiveness and rapid sleep life
onset
“…my wife was very important to me, after she left, I lost the sense of things.”
“…my life is meaningless, I lost my wife and I can’t even rest.”
Value-based actions: Since Miguel has little clarity about his values, it is difficult
to identify values-based actions. The identification of values is therefore a prerequi-
site for outlining values-based actions.
In summary, analysis of each of the processes described reveals an important
pattern of psychological inflexibility, which is maintained by the short-term conse-
quences produced by the avoidance behaviors. Miguel seems quite fused with the
fear of what might happen if he does not sleep, as well as with the sleep parameters
such as how long he slept (cognitive fusion). In addition, he connects little to other
issues of his life (inflexible attention to the now) and even has difficulty knowing
what his values are.
Goals: Given the above, the therapeutic goals of the present case were (1) increas-
ing psychological flexibility; (2) associating the bedroom with sleep; and (3)
decreasing the state of physiological “alertness.”
Weekly activity: Performing mindfulness exercises.
18.3 Third Session
Goals: Instructions on stimulus control, mindfulness exercise, and strategies to

identify experiential avoidance and cognitive fusion.
Therapist: “Hello Miguel, how is everything?”

Client: “I am very tired, but I don’t stop working because that is the right
thing to do.”
“I am afraid this treatment will not solve the insomnia.”
Interventions
A. In an attempt to help Miguel to better associate the bedroom with sleep, he was
advised to only go to bed when he was feeling sleepy and not just tired. This
advice is based on stimulus control therapy, which is aimed at helping to pair
stimuli, i.e., associate the bed/bedroom with falling asleep.
B. Another mindfulness exercise was conducted that Miguel should practice
throughout the week.
C. In an attempt to help the client observe his experiential avoidance behaviors,
activities based on metaphors were conducted so that Miguel could identify his
usual attempts to control and escape the discomfort of not sleeping (experiential
avoidance/acceptance).
Client: “…I understand, every time I try to control my sleep, I feel frustrated
because there is no way to control it… the hard thing is to accept that I have no
control.”
“Every time I get into a tug-of-war with insomnia I stop doing other things in
my life.”
“…how am I going to accept that we can’t control what we feel?”
D. In a guided experiential exercise, the therapist invited Miguel to observe his
thoughts, without judgments, working on cognitive defusion.
Client: “I really get stuck in these thoughts about my sleep… as if the total number
of hours I have slept is going to determine my following day.”
“Thinking about insomnia all the time makes me not notice other things in my life.”
Weekly activity: Performing mindfulness exercises and taking note of thoughts in
the thoughts notebook before going to the bedroom.
18.4 Fourth Session
Goals: Mindfulness exercise and strategies to address self as context and

acceptance.
Therapist: “Hello Miguel, how are you?”

Client: “My sleep has still not improved, but I’m doing everything you asked.”
“This week I went to the park, I had not been there for a long time… it was good, I
even forgot that I slept badly.”
Interventions
A. Another mindfulness exercise was conducted that Miguel should practice
B. Using metaphors, the difference between what is real discomfort versus what
we avoid in order not to take the risk of experiencing discomfort (experiential
avoidance) was explained.
Client: “The real discomfort is staying awake, but what I do to avoid taking that
risk is lying in bed with my eyes closed, that does not help, right? Now I understand
that it only gets worse because my head does not stop while I am lying down, forc-
ing sleep to come.”
“I avoid talking to people so I don’t feel judged or charged, my interactions are only
with my customers, but I do everything right so I don’t have any problems.”
“I don’t even try to meet new women since I don’t want to risk losing some-
one again.”
C. An experiential exercise was conducted so that Miguel could perceive the sensa-
tion at the same moment, training to feel something without avoiding
(acceptance).
Client: “It is very difficult to accept feeling the discomfort. I have to be perfect in
what I do, there can be no mistakes, that is what I have learned my whole life…”
“It is as if I needed to change my way of dealing with life. I always pretended that I
did not feel anything so I would not suffer anymore, now I understand that this only
makes the situation worse.”
D. Finally, in an exercise in which Miguel should report positive and negative expe-
riences of his life, an attempt was made to address the process that involves the
self as context, i.e., how he perceives himself throughout all that he has lived.
Client: “hum… I understand… you cannot live only the good things, there are bad
things too… I wish I could control the bad part…”
“I have many good experiences with my wife, even though I lost her. It was better
to have known her, even if she is gone.”
“Looking back on my life, many things have happened, it seems like there is no way
I can pigeonhole myself into a single characteristic or event.”
Weekly activity: Performing mindfulness exercises, trying not to avoid a certain
situation identified in the activity on experiential avoidance.
18.5 Fifth Session
Goals: Mindfulness exercise and strategies to address values.
Therapist: “Hello Miguel, how is everything?”

Client: “Wow, it was hard, but I did it… I called some friends from the past, we
talked a little… it was uncomfortable but it was good.”
Interventions
B. The issue of how we escape different situations in our lives in order to avoid
discomfort and, at the same time, fail to do/be in situations that could be impor-
tant was resumed.
C. Next, Miguel’s values were addressed by investigating how he wants to be and
how he ideally wants to behave; thus, the aim was to guide him toward what he
really wants to be and not to what he avoids. For this purpose, an exercise was
conducted in which the client needed to identify areas of life that are important
and describe who he wants to be in each of these areas.
Client: “…wow, I had never done this kind of reflection… how hard it is to look at
all of this.”
“…it seems that I am discovering myself, understanding what is of value to me. I
feel that I am very far from what I understand is of value to me.”
“Affective relationships, health, religiosity, work, friends, leisure… all these areas
are important to me. I want to be a better person in each of them… there is a lot I
need to do to be closer to the direction that makes sense to me.”
D. After the definition of values, the therapist explains that plans for moving toward
value-based actions will be developed in the next session.
Weekly activity: Performing mindfulness exercises.
18.6 Sixth Session
Goals: Mindfulness exercise and strategies to develop values-based actions.

Client: “This week I went out with some friends, it was good…”
“I did not sleep well for a few nights, but I started thinking about the possibility of
taking a trip with these friends, I think it might be good, right?”
Interventions
B. Based on a story, the therapist discussed that values-based actions can involve
unpleasant events, which generate discomfort. This point is clarified so that the
client is aware that acting toward his own values will involve being willing to
eventually feel some discomfort.
Client: “It seems like the opposite of what I have done for a long time… I avoided
feeling the discomfort even if it brought my life to a standstill, but that did not mat-
ter, I had my wife, right?”
C. “Action plans” were drawn up for each of the values identified by the client in
the previous session, describing (1) the values, (2) the goals that this value
entails, (3) the barriers to achieving these goals, and (4) which behaviors are
needed to achieve these goals despite the barriers.
Client: “Wow, I never imagined that my actions were aimless because my values
were not clear to me.”
“I think the main barrier to my goals is my head, I put up barriers to things so I do
not risk getting hurt.”
Weekly activity: Performing mindfulness exercises. The second activity is to

define, based on his values, at least one goal and one short-term action to achieve it.
18.7 Seventh Session
Goals: Mindfulness exercise, resuming values and values-based actions, and ter-
mination of therapy.

Client: “I am going to travel with those friends, we are going at the end of the year.”
“I am thinking about taking acting classes, I think that I need to loosen up… I real-
ize that I have been very rigid my whole life.”
Interventions
A. Reinforcing the values addressed in the last sessions through an experiential
exercise regarding the legacy the client would like to leave behind when he dies.
Client: “I would like people to remember that I was a good, easygoing, cheerful
person… but I think that if I died today, people would still see me differently… I am
sure I want to change, get closer to my values.”
B. In one more exercise, the therapist returns to the idea that we need to learn to
identify feelings and not to reject them. The therapist tells a story and invites
Miguel to make some reflections.
Therapist: “Would it not be better to become ‘friend of our discomforts’?

Understand them? Know how to deal with them?”
Client: “Now I understand that yes… now I understand that my rigidity is a way
of protecting myself, but that is what I am able to do, maybe it will take time to get
better.”
C. A final mindfulness exercise focused on values and committed actions was con-
ducted to terminate the session.
D. The therapist ended the session with the following question:
Therapist: “What did this experience change?”

Client: “I have been able to sleep better, I go to bed when I am sleepy… I think my
life seems more fulfilled, that must have helped with sleep, right?”
“I feel that a lot of things in my head changed with this therapy, I understood how I
was functioning and how this brought my life to a standstill.”
Table 18.4 Objective data Instrument Score

obtained by applying the
ISI 5
instruments at the end of the
intervention PSQI 8
AAQ 12
Table 18.5 Description of Parameter Time/frequency

the sleep parameters
Sleep onset latency 15 min
evaluated by the sleep diary
after the therapy sessions Frequency of nighttime awakenings 2
Time awake after sleep onset 16 min
Total sleep time 6 h 20 min
Total time in bed 6 h 48 min
Sleep efficiency 95%
Table 18.4 shows the scores of the instruments applied in the last session. The
data of the sleep diary for the week preceding the last session are presented in
Table 18.5.
Weekly activity: Continuation of homework activities that were suggested along
the therapy sessions.
18.8 Conclusion
As described in this chapter, Miguel exhibited a pattern of psychological inflexibil-

ity that not only contributed to the persistence of difficulties in initiating and main-
taining sleep but also to the way he related to the psychological discomfort, i.e.,
fusing with rules and self-rules, perceiving himself in a poorly contextual way, and
looking to the past or the future, without perspective of values.
Based on the case formulation, some exercises of the protocol for the treatment
of insomnia described in this book were selected. The ACT-based intervention for
insomnia helped Miguel relate differently to the sleeping difficulties, which resulted
in lower physiological activation, greater acceptance of his difficulties, less fusion
with rules and self-rules, and better understanding of his values and, therefore, of
values-based actions. Despite the observed gains, the client will certainly benefit
from continuation of the sessions; he was therefore referred to individualized ACT-
based therapy.
Chapter 19
Case Example: Application of ACT-BBI-I
in an Individual Intervention
Renatha El Rafihi-Ferreira and Ila Marques Porto Linares
Here we describe a case1 to which the ACT protocol for insomnia was applied in
combination with behavioral techniques of stimulus control and sleep restriction.
This type of intervention is called Acceptance and Commitment Therapy-based
Behavioral Intervention for Insomnia (ACT-BBI-I). Despite the need for further
studies, ACT-BBI-I seems to meet the established criteria for an effective treatment
and has been recognized as a promising therapy (Chapoutot et al., 2021; El Rafihi-
Ferreira et al., 2020).
The client sought psychological treatment for complaints of insomnia and hyp-
notic dependence. The therapeutic process comprised an initial meeting for com-
plaint assessment and case formulation and nine sessions of ACT-BBI-I.
19.1 First Session
The first session consisted of a thorough assessment of the main complaint, its his-
tory, daytime symptoms, and data on behaviors that interfere with sleep, including
sleep routine and sleep habits. Information about the client’s life history was also
collected. Next, the client answered questionnaires used to assess sleep and
1
I. M. P. Linares
248 R. El Rafihi-Ferreira and I. M. P. Linares
psychological variables. At the end of the session, the therapist provided instruc-
tions about the use of the sleep diary. The diary was used for 14 days as baseline and
throughout therapy.
Client: Marta (fictious name), female, 31 years old, single, a lawyer who studied
for the exam for a career as a judge. She lived alone in an apartment in the city of
São Paulo, Brazil.
Main Complaint: Difficulty falling asleep, night awakenings, hypnotic

dependence.
I am having problems falling asleep since my relationship ended 2 years ago. During this
period, I started taking sleep medication (Z-drug) and since then I have not been able to
sleep without the medication. The doses of the drug increased gradually, and even with the
medication I wake up at night. My concern is that insomnia may affect my preparation for
the exam for a career as a judge.
Daytime Symptoms: Marta reported that she feels fatigued when she wakes up
and has difficulty concentrating. She was worried that fatigue will disrupt her daily
study routine and afraid of failing the exam because of sleep and fatigue.
History of the Complaint

Past history: Marta did not have sleep problems in childhood. As a teenager, she had
an episode of insomnia, in which she stayed up all night and performed poorly in
school tests that occurred the next day.
Current history: The complaint of difficulty falling asleep started 2 years ago after
the end of a relationship. Nicolas, her ex-boyfriend, ended the relationship.
Marta then started complaining about difficulty falling asleep every night of the
week for 3 months. She thus sought a general practitioner who prescribed zolpi-
dem (5 mg). Marta continued to use this dosage for a while, which was then
increased to 20 mg. In the first year of medication use, the only complaint was
initial insomnia. After 1 year, she started to have frequent nocturnal awakenings
even with the medication. Marta dreamt of becoming a judge and had been main-
taining a daily study routine of 8 hours. However, due to fatigue, Marta started to
increase her coffee consumption during the day in order to be able to study. She
reported drinking eight cups of coffee a day. At night, she felt agitated and drank
wine to relax and help her fall asleep.
Data on Behaviors That Interfere with Sleep
Sleep Environment
Marta lived in a one-bedroom apartment with a bathroom, living room, and
kitchen. The bedroom comprised a bed, a study table, and a chair. The bed and pil-
low were comfortable and well maintained. The window had blackout curtains that
kept the room dark at night. The street where Marta lived was quite noisy; even with
the windows closed the environment was noisy, especially in the morning.
19 Case Example: Application of ACT-BBI-I in an Individual Intervention 249
Eating Habits and Substance Use

Morning: When she woke up before 12.00 h, her breakfast included coffee, fruits,
and eggs.
Afternoon: The lunch generally included rice, beans, and a protein source (beef,
chicken, or fish). In the afternoon, Marta consumed chocolate, candies, and coffee.
Night: She generally ordered food by app. At least once a week, she had Japanese
food (sushi and sashimi), pizza, hamburger, and hot dog for dinner.
Daytime Routine
Marta proposed to study for 8 hours every day; however, there were no fixed times
for this activity. She usually started studying in her bed. When she studied at the
table, she felt tired, took the books, and went to bed to study. It was not uncommon
for her to have an afternoon nap while she studied in bed. There were also no fixed
times to go to bed and to wake up. She performed physical activity twice a week, at
variable times, usually in the early evening.
Sleep Routine
Most days, Marta studied until 22.00 h. However, there were days that she studied
until 02.00 in the morning. After studying, she ordered food and had dinner watch-
ing TV. After dinner, she showered and opened a bottle of wine. She went to bed and
drank two to three glasses of wine in order to relax while engaging in social net-
works using her cell phone and chatting via WhatsApp. When waking up in the
morning, she usually felt sleepy and therefore extended her time in bed for at least
an hour.
Worries
Marta reported frequent fear of not passing the exam for a career as a judge and that
she was afraid the insomnia would affect her academic performance. She blamed
herself for not studying more due to the fatigue she felt because of her insomnia.
Data on Personal Life
Marta reported having a good family relationship. She always felt cared for and
wanted by the family. However, she felt that the family is very demanding regarding
the performance of the children. Marta’s family worked in the legal area. Her par-
ents were judges and her younger brother recently passed the exam for a career as a
judge. Marta described her mother as vain and controlling.
Marta always did well in school and had no problems with her grades, except for
one situation in adolescence when she could not sleep and performed poorly on her
tests. On that occasion, a friend offered her a stimulant and she subsequently per-
formed well on the tests. She used stimulants for a few weeks as a teenager.
Marta reported having poor pain tolerance. Whenever she felt any discomfort in
her body, such as headache or menstrual cramps, she immediately took dipyrone,
even when the pain was mild.
From 23 to 29 years of age, Marta has dated Nicolas. She identified her dating as
a positive relationship, despite criticizing her ex-boyfriend’s lack of ambition. She
never imagined that Nicolas would end the relationship. With the end of the rela-
tionship, Marta started to have difficulties maintaining her study routine; even so,
Table 19.1 Results of the instruments applied in the first session

Assessment instrument Score range Patient score
Insomnia Severity Index 0–28 22
Epworth Sleepiness Scale 0–24 5
Dysfunctional Beliefs and Attitudes About Sleep Scale 0–160 100
Sleep Problem Acceptance Questionnaire 0–60 30
Hospital Anxiety Scale 0–21 7
Hospital Depression Scale 0–21 5
Acceptance and Action Questionnaire-II 0–49 26
Daily satisfaction score 0–10 3
Sleep diary Insomnia patterns Patient’s patterns
Sleep onset latency 30 minutes or more 35
Wake after sleep onset 30 minutes or more 40
Total sleep time 6.5 6
Sleep efficiency Less than 85% 70
Time in bed after waking up 60–120 minutes
Total bedtime 8.15
Time going to bed 00.00
02.00
Time getting out of bed 09.00
11.15
12.15
she enrolled in two exams in the legal area and failed in both. After the end of her
relationship and the failed exams, her self-charge to study intensified, as did her
thoughts of worthlessness and failure. Marta reported thoughts like “I’m not good
enough,” “I’m a failure,” “I can’t rest if I don’t study hard enough,” “If I don’t sleep,
I won’t pass the test.” Marta mentioned that, despite the negative thoughts, she
dreams of meeting a new person to build a nice relationship and of having an inter-
esting work environment. She also wants to be able to contribute to a fairer world
for women. Such thoughts were prominent before sleep.
Table 19.1 summarizes the results of the instruments applied in the first session.
19.2 Case Formulation
The process of case formulation consists of the following main steps that are inter-
connected and complement each other:
• Step 1: Identification of behaviors that affect the client’s sleep.
• Step 2: Identification of the processes of psychological inflexibility that are con-
tributing to the maintenance of the sleep complaint.
• Step 3: Development of intervention strategies addressing (a) behaviors focused
on sleep and (b) behaviors that go beyond the sleep complaint and are aimed at
psychological flexibility.
Step 1: Identification of behaviors that affect sleep (see Table 19.2).

Step 2: Identification of the processes of psychological inflexibility that are contrib-
uting to the maintenance of the sleep complaint (see Table 19.3).
At this point, it is important that the professional first determines the events
reported by the client in order to subsequently identify the relationships and pro-
cesses of psychological inflexibility and flexibility. Figure 19.1 illustrates how
inflexibility processes may contribute to the maintenance of the insomnia complaint.
Figure 19.1 shows the processes that maintain the insomnia complaint and the
use of hypnotics. The single-headed arrows indicate a single direction between
events, while the double-sided arrows indicate a reciprocal relationship between
events. Marta seems to be significantly fused with the fear of what might happen if
she does not sleep (cognitive fusion) and is very attentive to these fears instead of
paying attention to other issues (inflexible attention to the now). In an attempt to get
rid of insomnia, her actions seem to perpetuate the condition. This cycle of psycho-
logical inflexibility appears to be maintained by the short-term consequences pro-
duced by Marta’s avoidance behaviors.
Step 3: Development of intervention strategies
In view of the considerations in Step 2, the goals of the sleep-focused interven-
tion were (a) regularization of schedules; (b) self-care; (c) building a routine during
Table 19.2 Systematization of behaviors that affect sleep

Routine Stimulus control Cognition
Irregular sleeping and Spending excessive time in bed and in the Thoughts of
waking times bedroom worthlessness and failure
Lack of regular study Different activities in bed (studying, drinking
routines wine, using the cell phone, sleeping)
Little exercise
Screen exposure
before bed
Table 19.3 Identification and examples of processes of psychological inflexibility

Psychological inflexibility
process Events identified
Inflexible attention to the Worry and rumination about past failures and fears of the future
now (not passing the exam)
Conceptualized self “I’m not good enough”
“I’m a failure”
Experiential avoidance Taking medication for discomfort such as not sleeping, feeling
pain, failing tests, etc.
Cognitive fusion “I can’t rest if I don’t study hard enough”
“If I don’t sleep, I won’t pass the test”
Lack of values Poorly clarified values
Inaction Poorly established routine
Fig. 19.1 Processes that maintain the insomnia complaint and use of hypnotics. (Source: Image
from the archive of the authors)
the day; (d) using the bedroom only for sleeping and sexual activity; and (e) reduc-
tion of wake after sleep onset (WASO). The goals focusing on the development of
psychological flexibility involved (1) decreasing the experiential avoidance pattern
in response to the sleeping difficulties; (2) increasing contact with the present
moment; and (3) taking perspective in response to events that occur and pre-sleep
actions compatible with falling asleep.
The sleep-focused interventions planned for Marta are described in Table 19.4.
Figure 19.2 shows how the processes can be addressed in an attempt to develop
psychological flexibility. The processes of accepting sensations and feelings of dis-
comfort together with values-based behaviors can contribute to adhering to the
behavioral components of sleep hygiene, stimulus control, and sleep restriction
since some instructions of these techniques can cause discomfort. In addition,
encouraging Marta to focus on the present moment could help her pay attention to
what was actually happening and thus defuse her thoughts. Finally, helping the cli-
ent to understand the context in which she experiences insomnia will promote an
idea of self that is less content correlated and more contextual.
Table 19.4 Description of the interventions performed during each week of therapy
Weeks 1 and 2
Regularization of Set the alarm clock at a fixed time to wake up: for example, 07.00 h
schedules
Self-care Increase physical activity to at least four times a week, preferably in
the morning
Routine Morning:
30 minutes sunbathing
Breakfast
Physical activity
Bath
Start studying (2 hours)
Afternoon:
Lunch
Studying (5 hours) with intervals
Night:
Recreational activity
Dinner
Relaxing activity
Preparation to sleep
Stimulus control Guidelines for using the bedroom and bed only for sleep and sex
Weeks 3–9
Sleep restriction – 01.00–07.00
week 3
week 4
week 5
week 6
week 7
week 8
week 9
19.3 Intervention Sessions
The ACT-I protocol described in this book was applied, dividing it into nine ses-
sions. Regarding specific sleep components, psychoeducation, sleep hygiene, and
stimulus control were applied in the first two sessions. Sleep restriction was started
in the third week. All aspects related to psychological flexibility were addressed
from sessions 3 to 9.
Fig. 19.2 How the psychological flexibility processes can be addressed. (Source: Image from the
archive of the authors)
19.4 Assessment of Changes
Assessing the changes that occur during therapy is essential for understanding the
course and outcomes of treatment. By week 7, Marta reported being satisfied and
refreshed, sleeping a total of 7.20 hours. Thus, the sleep window was maintained
until the end of the intervention. After application of the protocol, the question-
naires were applied again and the results are summarized in Table 19.5.
The graphs in Fig. 19.3 show Marta’s sleep patterns over the course of the
intervention.
After the final assessment, Marta reported being satisfied with the resolution of
her sleep complaint and with the entire intervention process experienced. The case
was thus closed.
Table 19.5 Results of the instruments applied after the last session
Assessment instrument Score range Patient score
Insomnia Severity Index 0–28 12
Epworth Sleepiness Scale 0–24 01
Dysfunctional Beliefs and Attitudes About Sleep Scale 0–160 16
Sleep Problem Acceptance Questionnaire 0–60 24
Hospital Anxiety Scale 0–21 6
Hospital Depression Scale 0–21 4
Acceptance and Action Questionnaire-II 0–49 12
Daily satisfaction score 0–10 8
Sleep diary Insomnia patterns Patient’s patterns
Sleep onset latency 30 minutes or more 20
Wake after sleep onset 30 minutes or more 5
Total sleep time 6.5 7.20
Sleep efficiency Less than 85% 90
Time in bed after waking up 5
Total bedtime 7.30
Time going to bed 23.40
00.40
Time getting out of bed 07.00
08.00
19.5 Conclusion
Behavioral aspects were addressed in the BBI-I interventions, while other aspects,
particularly those related to psychological inflexibility, were treated using the ACT
tools. Thus, ACT-BBI-I proved effective in treating the client’s insomnia, reducing
the so-called experiential avoidance behaviors, and promoting greater engagement
in focusing on one’s own values. Finally, it is worth mentioning that the establish-
ment of a good therapeutic bond, as well as Marta’s openness and engagement in the
interventions, was preponderant for a good outcome.
Fig. 19.3 Sleep patterns of the client before, during, and at the end of the intervention (sleep onset
latency, wake after sleep onset, sleep efficiency, total sleep time, and satisfaction). (Source: Images
from the archive of the authors)
Fig. 19.3 (continued)
References
Chapoutot, M., Peter-Derex, L., Schoendorff, B., Faivre, T., Bastuji, H., & Putois, B. (2021).
Research, 30(1), 6–10. https://doi.org/10.1111/jsr.13199
El Rafihi-Ferreira, R., Morin, C. M., Toscanini, A. C., Lotufo Neto, F., Brasil, I. S., Gallinaro, J. G.,
Psychiatry, 43, 504–509. https://doi.org/10.1590/1516-4446-2020-0947
Index
A Comorbidity, 1, 32, 33, 36, 43–45, 59, 61–63,

Acceptance, 2, 72, 87, 142, 148, 161, 195, 81, 148, 154
216, 237, 247 Control, 2–4, 12, 14, 16, 24, 26, 56, 77, 78, 87,
Acceptance and commitment therapy (ACT), 113, 114, 116, 120, 122–123, 127,
1–4, 61, 62, 71–74, 77, 78, 88, 121, 140–143, 147, 148, 166, 168–170, 173,
134, 139–144, 147–154, 161, 162, 195–197, 209, 212–215, 219, 222,
176, 184, 185, 190, 193–205, 239, 237, 240–242
247, 255 Creative hopelessness, 143, 168–172,
Actigraphy, 24, 38, 43, 72, 93–104, 123, 195–200, 202, 212, 214, 215
124, 131–133
Adult, 19, 20, 24, 25, 33, 46, 53, 63, 72,
83–85, 87, 88, 94, 101, 116, 149, 150, D
209, 238 Daytime sleepiness, 20–22, 24, 35, 46–48, 75,
Assessment, 32, 45, 71–73, 76–78, 81–85, 87, 83, 86, 124, 133, 148, 209, 211
90, 91, 95, 104, 117, 161, 168, 169, Dependence, 51–64, 116, 210, 217, 247, 248
201, 202, 247, 250, 254, 255 Differential diagnosis, 58, 93
C E
Behavioral therapy, vii, 2, 61, 78 Eating habits, 76, 108–109, 165
Environment, 35, 38, 59, 71–74, 76, 93,
107–108, 115–117, 144, 165, 166, 168,
C 171, 175, 180, 185, 190, 194, 204,
Case formulation, 71–74, 77, 78, 153, 161, 248, 250
237–239, 245, 247, 250 Evidence, 3, 12, 14, 15, 23–25, 48, 53, 56,
Cognitive, 1, 2, 11, 20–22, 32, 36–38, 49, 52, 59–62, 64, 82, 85, 147–154
53, 58, 64, 72, 73, 109, 119, 121, 132,
133, 140–143, 148, 161, 168–171, 194,
240, 241, 251 G
Cognitive behavioral therapy (CBT), 1, 14, 15, Group, 4, 20, 22, 33, 38, 45, 46, 53, 57, 62, 63,
61, 62, 64, 119, 147, 152 73, 147, 148, 152, 154, 161–166,
Commitment, 3, 10, 74, 122–123, 162, 168–170, 172–174, 176, 183, 186–188,
183, 185 190, 205, 209–220, 222, 233, 235
© The Editor(s) (if applicable) and The Author(s), under exclusive license to 259
Springer Nature Switzerland AG 2024
https://doi.org/10.1007/978-3-031-50710-6
260 Index
H Sleep deprivation (SD), 19–26, 46, 47, 83, 84,

Hypnotics, 48, 51–64, 76, 115, 116, 149, 210, 97, 119–123, 127–129, 132–135, 162,
247, 248, 251, 252 164, 235, 238, 239
Sleep functions, 11–14, 16
Sleep importance, 16
I Sleep loss, 11, 21, 24, 120, 121, 123
Individual, 1, 3, 4, 9, 19–22, 24, 33, 37–39, Sleep psychoeducation, 134, 161
45, 46, 48, 49, 52, 56, 57, 72, 73, 77, Sleep quality, 1, 19, 75, 82, 83, 86, 87, 95, 97,
78, 86–90, 93, 107, 112, 116, 124, 140, 109, 124, 130, 134, 148–151, 154, 176,
141, 144, 152–154, 161, 164, 165, 170, 233, 237
172, 175, 176, 189, 193–196, 198, 200, Sleep restriction, 1, 3, 4, 77, 119–135, 148,
202, 204, 205, 212, 233 151, 161, 209, 247, 252, 253
Insomnia, 1, 22, 31, 43, 51, 72, 81, 93, 114, Sleep Restriction Therapy (SRT), 119, 121,
119, 141, 148, 161, 193, 209, 235, 247 123–126, 130
Insomnia disorder, 1, 31–37, 39, 45, 48, 61, Spielman model, 32
121–123, 134 Stimulus control, 1, 3, 4, 61, 77, 113–117,
Insufficient sleep, 20, 21, 25, 123 128, 148, 151, 161, 209, 240,
Insufficient sleep syndrome (ISS), 20–26 247, 251–253
Interview, 43, 71–75, 77, 78 Substance use disorder, 44, 45, 55, 58, 59, 64
M T
Measurement scales, 82 Therapeutic, 1, 2, 4, 32, 44, 58, 61, 71–78,
152, 161, 162, 164, 165, 169, 172,
176, 185, 193–205, 209, 235, 240,
P 247, 255
Phenotypes, 37–40, 45, 134 Therapeutic processes of change and clinical
Psychological flexibility, 2, 4, 72, 73, 77, 78, intervention, 90, 143, 144
84, 90, 140, 142–144, 147, 148, Therapy, 61, 73, 74, 153, 162, 175, 195, 197,
151–153, 161, 193–195, 239, 240, 199, 201, 204, 209, 210, 222, 233,
250, 252–254 238–240, 244, 245, 247, 248,
Psychology, 73 253, 254
Psychotherapy, 235 Treatment, 1–4, 23, 32, 36, 38, 40, 43–45, 51,
53, 58–64, 71–74, 76, 78, 81, 87, 93,
98, 100, 104, 114, 119, 124, 126, 128,
R 129, 131–133, 139, 140, 143, 144,
Routine, 22, 76, 82, 87, 109–111, 113, 123, 151–154, 162, 164, 168, 171, 175, 176,
126, 127, 131, 132, 165, 170, 210, 219, 183, 185, 190, 209, 216, 240, 245,
220, 236, 247–249, 251, 253 247, 254
S W
Sleep, 1, 9, 19, 31, 44, 52, 72, 81, 93, 107, Worries, 83, 87, 90, 100, 103, 111–112,
113, 119, 142, 148, 161, 195, 209, 114, 165, 168, 194, 197, 221, 237,
235, 247 249, 251

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Renatha El Rafihi-Ferreira Editor

Acceptance and Commitment

ISBN 978-3-031-50709-0 ISBN 978-3-031-50710-6 (eBook)

Paper in this product is recyclable.

Acceptance and Commitment Therapy for Insomnia: A Session-by-Session

Professor of Psychology and Canada Research Charles M. Morin

discusses comorbidities of insomnia, differential diagnoses, and hypnotic depen-

São Paulo, Brazil Renatha El Rafihi-Ferreira

Part I Sleep and Insomnia

Part II Assessment of Insomnia

Part III Behavioral Treatment for Insomnia

Part IV ACT for Insomnia

Part V Application of ACT-I and ACT-BBI-I

Renatha El Rafihi-Ferreira Professor at the Department of Clinical Psychology at the

Michaele Terena Saban-Bernauer Master in Experimental Psychology and specialist in

1.1 Why to Use Acceptance and Commitment Therapy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 1

1.2 Acceptance and Commitment Therapy for Insomnia

ACT is a behavioral therapy based on functional contextualism, a philosophy that

Andrea Cecilia Toscanini and Rosa Hasan

The classic definition of sleep is generally based on physiological characteristics

Sleep is the intermediate state between wakefulness and death;

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 9

Table 2.1 Physiological characteristics of wakefulness, NREM and REM

by around 40% during adolescence compared to previous years and continue to

2.1.1 Central and Autonomic Regulation of Cardiovascular

2.1.1.1 Immune System Regulation and Maintenance

Over the last 15 years, research following a system approach of neuroimmunology

The nocturnal sleep period in humans is characterized by a profound downregu-

supports the long-term maintenance of the antigenic memory, a function hallmark-

2.2 Thermoregulation and Energy Conservation

ratings of sleepiness and the level of activity in the electroencephalogram (EEG)

Kräuchi, K. (2007). The thermophysiological cascade leading to sleep initiation in relation to

Andrea Cecilia Toscanini and Rosa Hasan

Sleep is a vital biological function, so its existence is conditioned to a series of

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 19

3.1 Consequences of Insufficient Sleep Syndrome (ISS)

In general, the most prevalent consequences of insufficient sleep (low performance,

Table 3.1 Summary of the major adverse effects of insufficient sleep

distractibility, reduced motivation, anergia, dysphoria, fatigue, restlessness, lack of

3.1.1 Mental Health Impairment: Cognition and Mood

Table 3.2 Sleep deprivation and neurological disorders associated

anxiety disorder, and post-traumatic stress disorder (PTSD). Polisomnography stud-

A range of sleep and circadian disturbances are prominent features of bipolar

Metabolism is defined as the whole range of biochemical processes that occur

might contribute to the metabolic dysregulation. The third possible mechanism is

3.1.3 Immune Function and Inflammatory Response

immunological memory and the proinflammatory, and activating functions that

Sateia, M. J. (2014). International classification of sleep disorders-third edition: Highlights and

Israel Soares Pompeu de Sousa Brasil and Renatha El Rafihi-Ferreira

4.1 Insomnia: A Multiple Condition

I. S. P. de Sousa Brasil (*)

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 31

Previous versions of the International Classification of Sleep Disorders (ICSD)

Defining a clinical entity based on diagnostic criteria must consider fundamental

Box 4.1: Criteria of the DSM-V

Box 4.2: Criteria of the ICSD-3

The latest version of the International Classification of Diseases (ICD-11), which

4.4 Etiological Factors of Insomnia

São Paulo, Brazil Renatha El Rafihi-Ferreira

Part I Sleep and Insomnia

Part II Assessment of Insomnia

Part III Behavioral Treatment for Insomnia

Part IV ACT for Insomnia

Part V Application of ACT-I and ACT-BBI-I

1.1 Why to Use Acceptance and Commitment Therapy

1.2 Acceptance and Commitment Therapy for Insomnia

2.1.1 Central and Autonomic Regulation of Cardiovascular

2.1.1.1 Immune System Regulation and Maintenance

2.2 Thermoregulation and Energy Conservation

3.1 Consequences of Insufficient Sleep Syndrome (ISS)

3.1.1 Mental Health Impairment: Cognition and Mood

3.1.3 Immune Function and Inflammatory Response

4.1 Insomnia: A Multiple Condition

4.4 Etiological Factors of Insomnia

5.3.4 Circadian Rhythm Sleep–Wake Disorder

a cceptable social schedule. Sleep deprivation on workdays and rebounds on days

5.3.5 Restless Legs Syndrome

6.1 Hypnotics: A Story About Dependence

6.2.1 Hypnotic Drugs and the GABA Receptor Complex

6.2.2 Mechanisms of Tolerance and Dependence

promising (Lappalainen et al., 2019; Paulos-Guarnieri et al., 2022; El Rafihi-

7.1 Format and Environment for Conducting the Interview

7.2 Qualified and Appropriate Professional to Apply

7.3 First Contact with the Client

7.5 Determination if the Client Is a Candidate

7.7 Determination of Other Treatment Options, If Necessary

8.1 Assessment Strategies for Insomnia

8.1.1 A Note on Validity1

8.2.1 Sleep Assessment Instruments

8.2.2 Sleepiness and Fatigue Instruments

8.2.3 Sleep Cognitions and Sleep-Related

8.2.4 Complementary Instruments for Psychological