A part of her nighttime regiment was getting into bed with her smartphone. While in bed, she spent several hours texting, talking on the phone, and visiting social media sites. Due to the stimulating social content as well as the potential effect of short wave blue light emitting from this device on her melatonin levels and circadian rhythms these activities prolonged her bedtime. Because communicating with her friends was exciting and physically arousing, she would not feel tired for several hours after the conversations were done. Therefore, she was advised to refrain from going to bed with her smartphone. Removing the arousing and emotionally and physiologically engaging stimulus from her bedtime routine was recommended to help her relax.

Because the negative thoughts associated with sleep caused her frustration at bedtime, cognitive restructuring was introduced. This patient’s negative beliefs were identified with open-ended questions about her thoughts and feelings about sleep. Clinicians may also utilize the Dysfunctional Beliefs and Attitudes about Sleep (DBAS-16 ) [1] questionnaire, which is a tool that is often used to assess dysfunctional beliefs about sleep. The patient was encouraged to begin to recognizing her negative thoughts associated with sleep and bedtime. Some of the thoughts that she reported included, “falling asleep is stressful and I’m not good at it,” “I will lie in bed for hours,” “I will not be able to study for my test tomorrow because I cannot sleep long enough.” Once the thoughts were identified, she was taught the connection between her thoughts and their impact on emotional and physiological arousal. Because her negative thoughts about sleep contribute to emotional arousal and produce anxiety at bedtime, she was encouraged to change her beliefs about sleep from thoughts that induced feelings of stress, such as “I am going to sleep right now,” to thoughts that would help her relax, such as “I am going to lie in my bed and rest.” She was also taught to change her negative thoughts about sleep: “falling asleep is stressful” to positive thoughts “falling asleep is relaxing and comforting.” In addition, her irrational beliefs associated with popular myths about most people needing 8 h of sleep to function during the day were challenged. The patient was explained that the recommended amount of sleep follows a normal distribution, with some people needing more than 8 h and other needing less than 8 h. To help her understand the amount of time that she needs to sleep, she was shown her sleep log . The sleep log from the first week exhibited that her average sleep time was 6 h. Therefore, she was explained that for her, 6 h is a sufficient sleep amount.

To help the patient relax at bedtime and begin to gain control over her fleeting thoughts, she was taught visual imagery (Table 10.1). The patient was advised to think of a story, in which she had to be the only character and needed to pay attention to every single detail. In addition, the story needed to have a beginning, middle, and an end. This technique was recommended to help her to gain control over her mind–body relationship. The patient was learning to recognize the effect of her worrisome thoughts about daily stressors on her physiological parameters. She noticed that as she was thinking about her test performance, her heart rate became more rapid. She began using the technique and reported that it provided a way to manage her never-ending thinking process and de-escalated her heart rate.

In the beginning of every session, the patient and I reviewed her sleep log from the previous week. In doing so, she could see the impact of napping on her sleep routine. With the support of her roommates, she was able to refrain from napping. Initially, the patient complained of difficulty functioning due to feeling more irritable and less focused during her studies. She was encouraged to continue adhering to her sleep restriction schedule and explained that these experiences are a normal part of treatment. The patient reported experiencing stress prior to bedtime associated with poor performance on a test she had recently taken. She also indicated that she began experiencing worrisome thoughts about her future and career. These thoughts kept her up until 5:00 am. On this night, she was too upset to use cognitive restructuring and visual imagery. In order to gain control over her stress, which may have exacerbated her physiological arousal, she was taught diaphragmatic breathing exercises (Table 10.1). She was also reminded that cognitive restructuring and visual imagery have worked for her in the past and that she should try to rely on these techniques even more during stressful time periods.

The patient reported that using cognitive restructuring (Table 10.2) aided her in gaining control over her stressful thoughts at bedtime. She was successful at sleep restriction during the school week, being able to sleep 6 h on most nights, with one or two short awakenings. It was more challenging for the patient to follow her sleep schedule during the weekends. She was engaged in social activities with her friends and did not go to bed until 4:00 am. She reported being unable to wake up at 6:00 am because she would not be able to study on this limited amount of sleep. She also expressed that she could not get out of bed when her alarm clock rang. She kept falling asleep and pressing the snooze bottom until 8:00 am. However, showing her the impact her weekend sleep schedule (e.g., bedtime of 4:00 am and morning awakening of 10:00 am) (see sleep log 3, week 5 (Fig. 10.3)) had on her daytime functioning on Monday, motivated her to adhere to her designed bedtime schedule. Despite her attempts, she has not been able to maintain her sleep restriction schedule on weekends. She realizes that waking up at 6:00 am on weekends is important to her treatment, but has not been able to do so.

The patient reported improvement in initiation, maintenance, and quality of sleep during the night. During treatment, she was successful in eliminating naps and caffeine consumption from her daily routine. She learned to identify the connection between her thoughts, emotional experiences, and physiological reactions. The patient may occasionally stay up to study later than 12:00 am, but she adheres to her morning awakening time of 6:00 am most of her time during the week. She indicated being able to concentrate better in classes and reported improvement in daytime functioning.