The cognitive-behavioral model has also been applied to insomnia (Harvey, 2002a). It has been suggested that people with insomnia suffer from excessive negative thoughts both while trying to go to sleep and during the day and that as a consequence they change the way they behave. The negative thoughts and changed behavior lead to increased arousal, making sleep less likely, and so a vicious cycle is established. Cognitive and behavioral interventions have been found to be helpful in the management of insomnia (e.g., Espie et al, 2001; Harvey et al, 2002; Morin et al, 1999, 2000). Many studies have pointed to the benefits of a cognitive-behavioral approach in tinnitus management (Andersson and Lyttkens, 1999; Henry and Wilson, 1999; Jakes et al, 1986, 1992; Sweetow, 1989). Unfortunately, these studies have shown little benefit on the insomnia component of tinnitus complaint (see McKenna, 2000, for a review). The interventions used, however, rarely if ever focused specifically on insomnia. This has been the inspiration for the authors’ decision to facilitate group therapy focusing specifically on sleep difficulties in tinnitus patients.

Figure 7–1 A clinical cognitive-behavioral model of tinnitus-related insomnia.

Patient Selection Criteria and Definitions

The quantity of sleep a person gets is not an accurate guide to whether sleep will be regarded as problematic. Some of our patients complain of poor sleep while reporting that they get 8 or more hours of sleep a night; others manage well on little sleep. Subjective complaint about sleep is therefore a key factor in the clinical consideration of sleep problems. To obtain some measure of objectivity, we follow guidelines that are set out in the insomnia literature. We regard sleep as problematic if there is a delay in getting to sleep, or in getting back to sleep in the middle of the night, of at least 30 minutes, or if the total time awake in the middle of the night is 45 minutes, or if the person obtains a total of less than 61 hours sleep (Morin, 1993). These difficulties should occur at least 3 nights a week. In practice many of our patients complain of daytime problems due to insomnia, but we do not regard such complaints as necessary for inclusion in our sleep management program. Sticking to criteria that are rigidly based on time or frequency alone can be problematic. Considerable variability in sleep patterns is seen not only in the general population but also in people complaining of insomnia, and the unpredictability of sleep may be as much a feature of insomnia as a lack of sleep. The importance of complaints about insomnia is therefore often a matter of clinical judgment. Nonetheless, adherence to the time and frequency criteria results in greater homogeneity in the group and avoids the inclusion of people with problems that others regard as implausible.

Another important criterion in our selection process is the establishment that the insomnia is related to the person’s tinnitus. Insomnia, like tinnitus, is a symptom rather than a single disorder, and it can occur for a variety of reasons. Dement and Vaughan (1999) list disruption of the circadian rhythm and psychological disorder as among the main causes of persistent insomnia. Both of these problems are commonly reported by our sleep-disturbed tinnitus patients. Provided the psychological disorder is related to the patient’s struggle with tinnitus or the circadian rhythm disturbance is a result of, say, their inappropriate efforts to deal with their insomnia, rather than due to something like shift work, then such patients are included in our group. Restless legs syndrome, periodic limb movement disorder, gastroesophageal reflux, and fibrositis syndrome or other pain states are also possible reasons for persistent insomnia (Dement and Vaughan, 1999). Breathing disorders are also a common cause of insomnia (Williams, 1996), and it is possible for some medications to disturb sleep by producing arousal or by disturbing the phases of sleep (Idzikowski and Shapiro, 1993). Alcohol and illicit drug abuse also can lead to sleep disturbance. We suggest that therapists bear these things in mind when assessing people complaining of tinnitus-related insomnia and if necessary refer the person on appropriately.

Assessment

QUESTIONNAIRE MEASURES

Several questionnaire measures are used in the evaluation of our therapy. They are administered 1 month before the start of the therapy, at the start of the therapy, at the end of the therapy, and at a 4-month follow-up. The second edition of the Beck Depression Inventory (BDI-II; Beck et al, 1996) and the Beck Anxiety Inventory (BAI; Beck and Steer, 1990) are used as measures of emotional state, the Tinnitus Questionnaire (TQ; Hallam, 1996) as a measure of tinnitus complaint, and the Pittsburgh Sleep Quality Index (PSQI; Buysse et al, 1989) as one measure of sleep. The PSQI assesses sleep quality during the previous month in terms of seven components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime functioning. The seven component scores are then summed to yield a global PSQI score. A disadvantage is that it involves retrospective and somewhat global judgments about sleep that may be subject to reporting biases. An advantage of the PSQI is that it assesses sleep across a range of dimensions, has a high specificity, and is easily administered.

SLEEP DIARY

SLEEP NARRATIVE

Patients are asked to give an account of their sleep and sleep-related behavior for a typical 24-hour period. They are asked to describe their preparations for bed. Patients’ bedtime and activity prior to lights out (e.g., reading in bed, watching television in bed) are noted. Patients are asked about their presleep experiences (e.g., checking tinnitus, worrying about the next day), the length of sleep, the timing and duration of any awakenings, what they do during awakenings, final waking times and rising times, and daytime activity, including any naps and any other activity that relates to sleep (e.g., exercise to tire the person out). The story is taken up to the time of preparing for bed the next night. This account highlights the areas in need of intervention; for example, intrusive ruminations and long delay in initial sleep onset and sleeping late in the day.

Group Structure

Our groups comprise 8 to 10 patients. This number of participants allows time to address individual problems within the group, to prevent the quieter members from feeling overwhelmed, and to help the group feel contained. The group runs for 2 hours every 2 weeks. There are eight sessions and one follow-up session at 4 months. The group sessions begin with individual members introducing themselves and giving a brief account of their experience of tinnitus and sleep problems. At this stage patients often state their individual treatment goals; however, goal setting is returned to following some basic sleep education. The introductions are followed by an educational component informing people about sleep, insomnia, and tinnitus. This is followed by the introduction of relaxation techniques and then by the introduction of the cognitive model. Sleep hygiene strategies are then introduced, and later on other techniques for the control of intrusive cognitions while in bed are described. The information provided is supported by handouts, and the participants are given pen and paper to make notes and thus build up a folder to use as a written summary for future use. Cognitive restructuring, relaxation, and sleep hygiene homework are reviewed in each session.

Treatment Protocol

TINNITUS AND SLEEP EDUCATION

Following the introductions, the program moves on to an educational component. This seeks to inform the group members about the nature of tinnitus and about the nature of sleep and insomnia. The intention is to demystify tinnitus and sleep and to provide a framework against which to normalize some of the patients’ experiences (e.g., frequent awakenings) and within which to set realistic goals.

Information about Sleep and Insomnia The sleep education element is derived from psychological writings within the insomnia literature (e.g., Espie, 1991; Morin, 1993) and in particular from a cognitive-behavioral model of insomnia (Harvey, 2002a). Therapists should acquire some basic knowledge about sleep and insomnia before offering a sleep management program to tinnitus patients. At this stage the information presented is restricted to several points about sleep stages, normal sleep times, and the effects of sleep deprivation.

Normal Sleep Times and Sleep Stages Most people get 7 to 8 hours sleep. There is, however, a considerable range in normal sleep times. We illustrate the point that some people manage well on little sleep by reference to a high-achieving person such as former British prime minister Margaret Thatcher, who famously got only 4 hours of sleep a night. It is a commonly held belief that older people do not need as much sleep as they did when younger. Although older people do tend to get less sleep at night, they also nap more in the daytime, so the total amount of sleep achieved remains relatively stable from middle age to later life (Morin, 1993; Reynolds et al, 1985). An attempt is made to normalize the experiences of the group members by reference to the literature.

Sleep stages—rapid eye movement (REM) sleep and non-REM stages 1 to 4—are described, and the cycle of REM and non-REM sleep throughout the night is outlined. Patients are informed that this cycle takes about 90 minutes to complete but can vary from 70 to 120 minutes; the cycle is repeated four or five times a night in normal young adults. A normal night’s sleep also includes several awakenings. These are usually brief, and many people are unaware of them. For most people the first awakening occurs after 2 or 3 hours of sleep. Awakenings become more common as the hours of sleep increase. The first awakening often represents a point at which the structure of sleep changes, with the periods of REM sleep becoming longer. Clinically, the experience is often described in terms of little really deep sleep after the first awakening. Age-related changes in sleep patterns are described. Older people experience less deep sleep; very deep sleep may be absent altogether in older people, and the number of awakenings increases with age. Young adults commonly experience two awakenings in a normal night’s sleep; older people may experience as many as nine awakenings a night. For many elderly people sleep is experienced as light and fragmented. This information is illustrated by using a histogram representation of sleep stages (McKenna, 2000) and by reference to the experiences of the group members. Many people find it difficult to clearly distinguish sleep from wakefulness. This difficulty may be accounted for by the observation that people may continue to think about things even during periods of light sleep; mental activity is mistaken for wakefulness.

Tinnitus and Sleep Patients are asked to consider the fact that tinnitus does not lead inevitably to one or another negative consequence. The varying experiences of the group members are drawn upon to illustrate this. The point is then made with reference to tinnitus and insomnia. The group members are informed that only about half of people attending a tinnitus clinic complain of sleep problems. Emphasis is placed on the idea that tinnitus does not inevitably lead to insomnia. The factors that give rise to, and more importantly that maintain, insomnia are highly likely to be psychological in nature and susceptible to psychological treatment. It is our observation that our patients awaken in the night at about the times predicted from a typical sleep cycle, and it is our contention that tinnitus does not wake people up. Once awake, tinnitus may be the first thing that a person is aware of, and he or she may then remain awake for the reasons previously described. We stress the point that we do not view tinnitus as a specific sleep antagonist.

INDIVIDUAL GOAL SETTING

RELAXATION

Patients are given a rationale for relaxation therapy in terms of reducing autonomic nervous system arousal. The reduction of muscle tension provokes a similar reduction in other autonomic subsystems, such as heart rate, respiration, and blood pressure. Elevated levels of arousal decrease the likelihood of initiating sleep, and relaxation therapy increases the chances of sleep. Muscle relaxation also has been found to be effective in reducing intrusive thoughts (Nicassio et al, 1985; Sanavio, 1988). It has been suggested that the experience of tinnitus is related to heightened levels of autonomic arousal (Hallam et al, 1984) and that by reducing the level of autonomic arousal, the intrusiveness of tinnitus may also be reduced. Relaxation therapy has considerable face validity, and it may be that some of the benefit derived from it stems from the sense of control that people commonly report when practicing it. We believe that the provision of a clear rationale may enhance the face validity, thus promoting these nonspecific effects and encouraging compliance. By distinguishing relaxation therapy from other activities commonly thought to be “relaxing” (e.g., watching television, reading a novel), the rationale may also reduce these alternative, possibly arousing behaviors. Muscle relaxation exercises are taught in the group, and patients are given recorded relaxation instructions and asked to practice daily.

COGNITIVE THERAPY

VIDEO MODELING

There is evidence that seeing other people cope with a problem can be therapeutic for patients with some psychological problems. The present authors are not aware of any studies that have formally employed coping models in tinnitus management, but Davies and colleagues (1995) postulate that improvements in tinnitus patients undergoing group therapy may be due to the modeling seen in group environments. We therefore show recorded interviews with past patients who had a history of considerable tinnitus-related suffering, including insomnia, but who are now coping well following psychological treatment. In our experience tinnitus patients hear that others cope with tinnitus, but they rarely encounter such coping models. Our intention is to provide evidence that tinnitus and insomnia can be managed and to provide a model that the patients can emulate.

SLEEP HYGIENE

As the cognitive model suggests, thoughts and feelings influence people’s behavior. When people have difficulty sleeping, they do things that they believe will help them sleep. Such strategies include taking medication or drinking alcohol, avoiding going to bed, remaining in bed for long periods of time, and watching television in the bedroom. These strategies may offer short-term benefits, but in the long term they may perpetuate the insomnia (Spielman and Anderson, 1999). As long as the person continues to attribute sleep difficulties to the tinnitus rather than to these behaviors, he or she will unwittingly reduce the chances of sleep, and so a cycle is established. Helping the person with insomnia to gain insight into this cycle is the first intervention step. Once the group members have begun to question some of their behaviors, the next step is to discuss sleep hygiene and the behavioral changes they can begin to make to promote sleep. Sleep hygiene interventions must be considered for all people who have poor sleep because even if poor sleep hygiene is not the primary cause of sleep disturbance, it may be a secondary factor that is playing a role in maintaining sleep problems (Spielman and Anderson, 1999).

Alcohol Alcohol may help to induce sleep, but it can also cause sleep disruption throughout the night, especially the second half. The result is early morning wakening. Patients are encouraged to avoid using alcohol as a sleep or relaxation aid.

Nicotine People often have a cigarette before bed or when they wake up in the night. As with alcohol, they may be viewing cigarettes as a means of relaxation. People are advised about the physiological stimulating effect of nicotine and advised to reduce and carefully regulate their intake.

Food Hunger can result in difficulty initiating sleep, but so too can a heavy meal near bedtime. It is important to gain a balance between going to bed hungry or with a full stomach. People are advised not to eat while awake in the night.

Evening Routine People are advised to have a prebedtime routine to help them and their body recognize that it is time to slow down, relax, and sleep. The routine can be very individual, and some of the sleep hygiene can be incorporated. It is helpful to discuss with people their plans for a new routine and to caution against potentially unhelpful behaviors. For example, people often think that a bath close to bedtime will help them to relax. Because of the changes in body temperature, however, it is more helpful to bathe about an hour before bedtime.

Exercise Regular exercise helps well-being and promotes sleep. During and for some time following exercise, however, the body is in an increased level of arousal. It is therefore advisable to engage in regular exercise but not just before going to bed.

The Bedroom and Use of Sound Activities in the bedroom other than sleep result in an association between these activities and the bedroom, thus lessening the association between the bedroom and sleep. People are advised to use the bedroom only for sleeping and sex. If they wish to watch television or read a book, for example, then it is best to do so in another room. Many patients use sound in the bedroom to alleviate their tinnitus. We discourage the use of radios or televisions for this purpose because of their potentially arousing properties, and instead suggest that people use other sources of sound such as commercially available noise generators. If, however, a radio is all that is available, we suggest that it is set to a nonstimulating program at a volume that prohibits hearing what is being said, or better still, to have it out of tune so a noise similar to white noise can be heard. We suggest that if sound is used it be maintained in the bedroom on a 24-hour basis so that it quickly becomes part of the bedroom environment, and any arousing effects are minimized. We discourage the use of sound to completely mask tinnitus because this is considered counterproductive for the habituation process.

Time in Bed There is a tendency for people who have sleep problems to spend long periods of time in bed in an attempt to compensate for the poor sleep. People are encouraged to spend no more time in bed than absolutely necessary to avoid associating bed with wakefulness and triggering a cycle of unhelpful cognitions and unpleasant emotions, thereby reducing the chances of sleep. It is suggested that people wait until they are feeling tired before going to bed. If they are unable to go to sleep or go back to sleep, it is suggested that after ∼20 minutes they get up, leave the bedroom, and do something restful, avoiding any physiological or psychological stimulation. Once they feel sleepy, they should return to bed; if they are not asleep after another 20 minutes, the routine should be repeated. It is also suggested that people anchor the wake-up time to a regular time (even on weekends). This can be difficult to do, especially when someone has obtained only a small amount of sleep by the wake-up time, but it is crucial to maintain a helpful sleep–wake cycle. Sleeping during the day is discouraged for the same reason but also because it can be a type of safety behavior that prevents the person’s anxieties about poor sleep being challenged and disproved. If a person feels sleepy in the day, he or she should do something that is not conducive to sleep, such as going for a walk.

Worry Time The role of unhelpful cognitions about sleep has been discussed. This can also be applied to other worries in the person’s life. As we are all aware, it tends to be the nighttime when our worries come into and remain in the forefront of our thoughts. Although this may not be helpful for everyone, a suggestion can be to allow a “worry time” in the early evening. During this time, people are encouraged to write down the thoughts that are causing them to feel anxious. They then write down possible solutions to these worries. Should they wake up in the night, they can then remind themselves that they have attended to these worries, have done all they possibly can, and tomorrow is the next time when they will consider them again.

OTHER METHODS OF CONTROLLING THOUGHTS

Conclusion

Complaints about sleep disturbance are ubiquitous in patients with medical problems and are a key feature in the presentation of tinnitus patients. It has been argued that improving sleep facilitates healing, well-being, and the ability to cope with illness (Shapiro et al, 1993). Improving the sleep of tinnitus patients may not “heal” tinnitus, but the other points in this argument seem as relevant to people with tinnitus as to those with other health problems. Overall, however, clinical effectiveness studies of psychological treatment for tinnitus have not produced encouraging results in the management of insomnia (Andersson and Lyttkens, 1999). Reviewing this area, McKenna (2000) noted that in many outcome studies no measures or only very crude measures of sleep disturbance were included. Even where some measure of sleep disturbance was included, treatments were rarely directed, specifically at insomnia management. As yet there is no published outcome study that targets tinnitus-related insomnia as the central variable, and that includes the sorts of measures that are commonly reported upon in the insomnia literature. This chapter describes the clinical approach employed by the authors in the management of tinnitus-related insomnia. The work is informed as much by the insomnia literature as by the tinnitus literature. Our central proposition is that tinnitus is not a sleep antagonist, but that both tinnitus distress and insomnia are provoked by a process akin to anxiety. As yet our assumptions have not been empirically tested, but our work is being systematically evaluated. It is possible at this stage to report only our most preliminary impressions. To date the vast majority of our patients report some benefit from the group therapy. Most achieve their treatment goals, although such goals vary considerably between individuals and are not restricted simply to increased sleep time.

References

Andersson G, Lyttkens L. A meta-analytic review of psychological treatments for tinnitus. Br J Audiol 1999;33:201–210

Beck A. Cognitive Therapy and the Emotional Disorders. New York: Penguin; 1976

Beck A, Steer R. Manual of the Beck Anxiety Inventory. San Antonio, TX: The Psychology Corporation/Harcourt, Brace; 1990

Beck A, Steer R, Brown G. Manual of the Beck Depression Inventory. 2nd ed. San Antonio, TX: The Psychology Corporation/Harcourt, Brace; 1996

Borkovec T. Insomnia. J Consult Clin Psychol 1982;50:880–895

Buysse D, Reynolds C, Monk T, Berman S, Kupfer D. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193–213

Chambers M, Keller B. Alert insomniacs: are they really sleep deprived? Clin Psychol Rev 1993;13:649–665

Clark D. A cognitive approach to panic. Behav Res Ther 1986;24:461–470

Davies S, McKenna L, Hallam R. Relaxation and cognitive therapy: a controlled trial in chronic tinnitus. Psychol Health 1995;10:129–143

Dement WC, Seidel W, Carskadon MA. Daytime alertness, insomnia and benzodiazepines. Sleep 1982;5:S28–S45

Dement WC, Vaughan C. The Promise of Sleep. New York: Delacorte; 1999

Espie CA. The Psychological Treatment of Insomnia. Chichester, UK: Wiley; 1991

Espie CA, Inglis SJ, Tessier S, Harvey L. The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in general medical practice. Behav Res Ther 2001;39:45–60

Folmer R, Griest S. Tinnitus and insomnia. Am J Otolaryngol 2000;21(5):287–293

Fowler D, Garety P, Kuipers E. Cognitive Behaviour Therapy for Psychosis: Theory and Practice. Chichester, UK: Wiley; 1995

Gabriels P. Children with tinnitus. In: Vernon JA, Reich GE, eds. Proceedings of the Fifth International Tinnitus Seminar. Portland, OR: American Tinnitus Association; 1995:270–274

Greenberger D, Padesky CA. Mind Over Mood. New York: Guilford Press; 1995

Hallam RS. Correlates of sleep disturbance in chronic distressing tinnitus. Scand Audiol 1996;25: 263–266

Hallam RS, Rachman S, Hinchcliffe R. Psychological aspects of tinnitus. In: Rachman S, ed. Contributions to Medical Psychology. Vol 3. Oxford: Pergamon Press; 1984:31–53

Harvey AG. A cognitive model of insomnia. Behav Res Ther 2002a;40:869–893

Harvey AG. Trouble in bed: the role of pre-sleep worry and intrusions in the maintenance of insomnia. J Cog Psychother 2002b;16:161–177

Harvey AG, Payne S. The management of unwanted pre-sleep thoughts in insomnia: distraction with imagery versus general distraction. Behav Res Ther 2002;40:267–277

Harvey L, Inglis SJ, Espie CA. Insomniacs’ reported use of CBT components and relationship to long-term clinical outcome. Behav Res Ther 2002;40:75–83

Henry JL, Wilson PH. Cognitive behavioural therapy for tinnitus distress: an experimental evaluation of initial treatment and relapse prevention. In: Hazell J, ed. Proceedings of the Seventh International Tinnitus Seminar. Cambridge: Tinnitus and Hyperacusis Centre; 1999:118–124

Idzikowski C, Shapiro C. Non-psychotropic drugs and sleep. In: Shapiro C, ed. ABC of Sleep Disorders. London: BMJ Publishing; 1993

Jakes S, Hallam R, McKenna L, Hinchcliff R. Group cognitive therapy for medical patients: an application to tinnitus. Cognit Ther Res 1992;16(1):67–82

Jakes S, Hallam RS, Rachman S, Hinchcliff R. The effects of reassurance, relaxation training and distraction on chronic tinnitus sufferers. Behav Res Ther 1986;24:497–507

Kentish RC, Crocker SR, McKenna L. Children’s experience of tinnitus: a preliminary survey of children presenting to a psychology department. Br J Audiol 2000;34:335–340

Levey AB, Aldaz JA, Watts F, Coyle K. Articulatory suppression and the treatment of insomnia. Behav Res Ther 1991;29(1):85–89

McKenna L. Tinnitus and insomnia. In: Tyler RS, ed. Tinnitus Handbook. San Diego: Singular; 2000

Mendleson WB. Insomnia: the patient and the pill. In: Bootzin RR, Kihlstrom JF, Schacter DL, eds. Sleep and Cognition. Washington, DC: American Psychological Association; 1990:139–147

Mendelson W, Garnett D, Linnoila M. Do insomniacs have impaired daytime functioning? Biol Psychiatry 1984;19:1261–1264

Morin C. Insomnia: Psychological Assessment and Management. New York: Guilford Press; 1993

Morin CM, Savard J, Bliss FC. Cognitive therapy. In: Lichstein KL, Morin CM, eds. Treatment of Late-Life Insomnia. Thousand Oaks, CA: Sage; 2000:207–230

Nicassio PM, Mendlowitz DR, Fussell JJ, Petras L. The phenomenology of the pre-sleep state: the development of the Pre-sleep Arousal Scale. Behav Res Ther 1985;23:263–271

Persons JB, Bertagnolli A. Cognitive-behavioural treatment of multiple problem patients: application to personality disorders. Clin Psychol Psychother 1994;1(5):279–285

Reynolds CF, Kupfer DJ, Hoch CC, Sewitch DE. Sleeping pills for the elderly: are they ever justified? J Clin Psychiatry 1985;46(2):9–12

Salkovskis PM. Cognitive behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behav Res Ther 1989;27:677–682

Sanavio E. Pre-sleep cognitive intrusions and treatment of onset-insomnia. Behav Res Ther 1988;26:451–459

Sateia M, Doghramji K, Haurl P, Morin C. Evaluation of chronic insomnia. Sleep 2000;23:243–308

Schneider-Helmert D. Twenty-four hour sleep-wake function and personality patterns in chronic insomniacs and healthy controls. Sleep 1987;10:452–462

Scott B, Lindberg P, Lennart M, Lyttkens L. Predictors of tinnitus discomfort, adaptation and subjective loudness. Br J Audiol 1990;24:51–62

Scott B, Lindberg P, Lyttkens L, Melin L. Psychological treatment of tinnitus: an experimental group study. Scand Audiol 1985;14:223–230

Seidel W, Ball S, Cohen S, Patterson N, Yost O, Dement W. Daytime alertness in relation to mood, performance and nocturnal sleep in chronic insomniacs and non-complaining sleepers. Sleep 1984;7:230–238

Shapiro C, Dement W. Impact and epidemiology of sleep disorders. In: Shapiro C, ed. The ABC of Sleep Disorders. London: BMJ Publishing; 1993:1604–1607

Shapiro C, Falnigan M. Function of sleep. In: Shapiro C, ed. The ABC of Sleep Disorders. London: BMJ Publishing; 1993:383–385

Shapiro C, Devins GM, Hussain MR. Sleep problem inpatients with chronic illness. In: Shapiro C, ed. The ABC of Sleep Disorders. London: BMJ Publishing; 1993:1532–1535

Spielman AJ, Anderson MW. The clinical interview and treatment planning as a guide to understanding the nature of insomnia: the CCNY Insomnia Interview. In: Chorkroverty S, ed. Sleep Disorders Medicine: Basic Science, Technical Considerations and Clinical Aspects. 2nd ed. Woburn, MA: Butterworth-Heinemann; 1999:385–426

Stepanski E, Zorick F, Roehrs T, Young D, Roth T. Daytime alertness in patients with chronic insomnia compared with asymptomatic control subjects. Sleep 1988;11:54–60

Sugarman J, Stern J, Walsh J. Daytime alertness in subjective and objective insomnia: some preliminary findings. Biol Psychiatry 1985;20:741–750

Sweetow RW. Adjunctive approaches to tinnitus patient management. Hearing J 1989;42:38–43

Wegner DM, Schneider DJ, Carter SR, White TL. Paradoxical effects of thought suppression. J Pers Soc Psychol 1987;53:5–13

White C. Cognitive Behaviour Therapy for Chronic Medical Problems. Chichester, UK: Wiley; 2000

Williams A. Insomnia: Doctor I Can’t Sleep. Rochester, Kent, UK: Amberwood; 1996

Williams C. Overcoming Depression: A Five Areas Approach. London: Arnold; 2001