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Cognitive Behavioral Therapy for Insomnia

Overview

Insomnia is a disorder of getting to sleep, staying asleep, and or returning to sleep that leads to daytime symptoms and or problems functioning. Cognitive behavioral therapy for insomnia (CBT-I) is a set of evidence-based therapeutic strategies, used singly or in combination, for changing sleep-related thinking and behavior patterns known to cause or worsen insomnia. It is beneficial for treating insomnia that occurs alone (primary) or in association with other medical or mental health conditions (comorbid/secondary) such as anxiety, depression, chronic pain, menopause, heart failure, Parkinson’s disease, and other health conditions. Cognitive behavioral therapy for insomnia is recommended by the American College of Physicians, American Academy of Sleep Medicine, Department of Veteran’s Affairs, and Department of Defense for the treatment of chronic insomnia in adults.

Chronic insomnia is the most common sleep disorder, occurring in approximately 10% of adults. An added 20% of also have a significant insomnia complaint that does not meet the diagnostic criteria. The American College of Physicians recognizes CBT-I as a first-line treatment for insomnia and, in many cases, is preferred over sleep medication.

Between 40% and 92% of all cases of insomnia occur in the context of mental health disorders. However, insomnia often persists despite targeted medication or psychotherapy treatment of mental health problems and requires independent targeted intervention. CBT-I is an effective treatment for insomnia that occurs with medical and mental health disorders. In addition, CBT-I is associated with enhanced depression and anxiety outcomes when delivered concurrent with medication or therapy for depression and anxiety.

Who benefits from CBT-I?

The American College of Physicians recommends CBT-I as the first-line treatment for individuals whose insomnia is considered primary, secondary, or comorbid when clear psychological, cognitive, or behavioral factors are causing or worsening to the sleep problem. CBT-I is designed to treat negative psychological conditioning, hyperarousal, problematic sleep schedules, lifestyle factors, stress, problematic coping responses, poor sleep hygiene, and problematic sleep-related thoughts and beliefs.

Many of these factors, especially negative psychological conditioning and problematic sleep-related behaviors, occurs in most cases of chronic insomnia. So, insomnia should be considered as occurring with, rather than caused by, other medical or mental health problems. Because of this, CBT-I is appropriate and is recommended in most cases of chronic insomnia, even when it occurs with other medical or mental health problems.

CBT-I is beneficial in both older and younger adults. It is also beneficial for people using prescription or over-the-counter sleep medication for short or extended periods of time. CBT-I supports maintenance of satisfactory sleep during systematic tapered discontinuation of sleep medications.

Is CBT-I sleep training right for me?

The questions below ask about common experiences of insomnia that can be addressed with CBT-I. If you check 2 or more, CBT-I may help you sleep better.

  • Do you have to take a pill to sleep?
  • Do you have trouble sleeping because of stress?
  • Do you have trouble sleeping because your mind is too active?
  • Do you feel sleepy at bedtime but then become more awake when you lie down and try to sleep?
  • Does frustration about not sleeping just make it harder to sleep?
  • Do you worry about your sleep or how you’ll feel or perform the next day?
  • Does worry about sleep make it even harder to sleep?
  • Do you sleep better when away from your own bed or away from home?
  • Do you “dread the bed” or avoid going to bed because you know you’ll have difficulty sleeping?

How does CBT-I Work?

Much more than “sleep hygiene” or “healthy sleep habits,” CBT-I techniques are based on 30 years of sleep science and focus on:

  • Adjusting sleep schedules to boost natural sleep chemicals and take advantage of your natural internal clock (circadian rhythm)
  • Building strong connections between sleep, the bed and bedroom
  • Identifying and challenging unhelpful thinking patterns about sleep
  • Relaxation and meditation training

When you take part in CBT-I you will be systematically changing sleep activity and thinking patterns to enhance sleep-related brain chemicals and sleep stages in a way that helps you:

  • Strengthen your natural sleep system
  • Fall asleep faster
  • Wake up less often
  • Return to sleep more easily
  • Sleep more deeply
  • Wake up feeling more rested
  • Reduce the need for sleep medication

What are the individual components of CBT-I?

Cognitive-Behavioral Therapy for Insomnia is composed of several individual therapeutic interventions. Depending on the treatment setting and method of delivery, these interventions may be delivered individually or in the form of a multicomponent treatment package.

Stimulus Control

Stimulus control is a set of five behavioral instructions intended to establish a consistent sleep-wake schedule and associated bedtime and bed/bedroom conditions with rapid initiation of sleep. The five behavioral instructions are:

  1. Avoid napping.
  2. Go to bed only when sleeping.
  3. Get out of bed if unable to initiate sleep within 15 to 20 minutes.
  4. Use the bed and bedroom only for sleep.
  5. Get up at the same time every day.

Following these five stimulus control recommendations over a period of several weeks serves to strengthen sleep-promoting associations with bedtime, the bed, and the bedroom while extinguishing sleep-interfering associations that commonly arise in response to repeated difficulties initiating or maintaining sleep. Stimulus control procedures also eliminate many maladaptive coping behaviors often responsible for perpetuating insomnia. 

Although simple, stimulus control recommendations can be quite challenging to implement with sufficient integrity to produce clinically significant improvements in insomnia symptoms. As a result, multiple treatment visits are usually needed to help patients in achieving satisfactory adherence to this intervention. Stimulus control is the most researched single component of CBT-I and is recognized as a standard or accepted patient care strategy suggested for most patients.

Relaxation Training

Relaxation training includes one or more of a variety of procedures, including mindfulness meditation (focusing attention on present-moment experience without judgment), passive relaxation (imagining sensations of relaxation in the body), biofeedback (learning voluntary control of the relaxation through electronic monitoring and feedback), autogenic training (imagining heaviness and warmth in the body), and progressive muscle relaxation (systematically tensing and releasing muscles throughout the body). 

Relaxation training is intended to reduce muscle tension, autonomic arousal, and intrusive or anxiety- provoking pre-sleep cognitions. Specific relaxation training methods are commonly chosen to target specific complaints of physical versus cognitive arousal causing sleep interference. For example, progressive muscle relaxation might be chosen for an individual with muscle tension, while mindfulness meditation might be recommended for an individual with a complaint of racing or intrusive thoughts. Most relaxation training procedures require daily practice over a period of several weeks to achieve a clinically meaningful change in insomnia symptoms. 

Participants are typically most successful when supplied scripts or recordings for guided practice. Outcomes may be better with professional support. Based on current evidence, relaxation training is recognized as a standard or accepted patient care strategy suggested for most patients. There are no specific contraindications for the implementation of relaxation training. However, some individuals may experience a paradoxical response characterized by increased mental or physical agitation with relaxation training.

Sleep Restriction

Sleep restriction is a therapeutic strategy designed to increase the strength of the natural intrinsic drive for sleep and sleepiness. It also reverses the consequences of a common tendency toward increasing time in bed in response to insufficient or poor sleep. This is carried out by recommending a sleep schedule that reduces the amount of time spent in bed so that it more closely matches the reported total sleep time. For example, a sleep schedule of midnight to 6 a.m. (6 hours total time in bed per night) might be recommended for an individual who has been spending 8 hours a night in bed but who reports an average total sleep time of only 5 to 6 hours per night. 

As a rule, time in bed should not be reduced to fewer than 5 hours per night. Once improvements in sleep are achieved, the amount of time spent in bed is progressively increased over a period of days to weeks until adequate total sleep time is achieved. A sleep efficiency (percentage of time in bed that is spent sleeping) of 90% is desired prior to increasing time in bed. In clinical practice, sleep restriction is almost always paired with stimulus control.

This strategy may increase daytime sleepiness as a result of intentional mild sleep deprivation. Because sleep deprivation can increase the propensity for seizures and parasomnias, sleep restriction is not recommended for patients with these conditions. It should be used with caution for commercial drivers and others whose daily activities require maintenance of sustained best alertness. 

Some concern has been expressed that mild sleep deprivation resulting from this intervention may increase the risk for a manic episode in patients with bipolar disorder. However, at least one small clinical trial has failed to show any increased incidence of mania because of sleep restriction. Based on current evidence, sleep restriction is recognized as a standard or accepted patient care strategy suggested for most patients.

Cognitive Therapy

Cognitive therapy explicitly and implicitly reframes maladaptive sleep-related thoughts and beliefs through a combination of guided questioning, cognitive restructuring, and behavioral experiments. Cognitive therapy interventions are based on the understanding that appraisal of sleeplessness as a threat triggers anxiety-provoking cognition that is incompatible with sleep. The following are five primary targets of cognitive therapy:

  1. Unrealistic sleep expectations
  2. Faulty attributions about the cause of insomnia
  3. Catastrophizing the consequences of insomnia
  4. Inaccurate beliefs about sleep-promoting behavior
  5. Belief that sleep is outside one’s control

General recommendations for individuals taking part in cognitive therapy for insomnia include the following:

  • Maintain realistic expectations for nighttime sleep and daytime energy.
  • Daytime symptoms are the result of multiple factors, not just insomnia.
  • Do not try to sleep. Increased sleep effort worsens insomnia.
  • Do not overfocus on sleep or place too much importance on sleep.
  • Do not catastrophize the consequences of poor sleep.
  • Develop strategies for coping with and improving tolerance of the effects of insomnia.

Behavioral strategies including stimulus control and sleep restriction often result in alteration of sleep-related thoughts and beliefs. Behavioral experiments for targeting maladaptive sleep-related cognitions include opposite action and paradoxical intent. Experiments involving opposite action aim to reframe beliefs about the consequences of insomnia and beliefs about the most appropriate responses to insomnia. For example, an individual who believes that inactivity is the best way to conserve energy following a night of insomnia might be instructed to watch daytime energy and satisfaction on days when purposely active as compared with days spent resting. Paradoxical intent aims to reduce sleep-related performance anxiety with the instruction to lie in bed passively awake while giving up any effort to fall asleep. Although cognitive therapy is often included in multicomponent packages of CBT-I, research does not yet support the use of cognitive therapy as a single intervention.

Sleep Hygiene Education

Sleep hygiene education is a set of behavioral recommendations focused on removing obstacles to healthy sleep related to lifestyle and sleep environment choices. Different sets of sleep hygiene recommendations can be found online and on educational handouts provided by health care providers. The most common recommendations include:

  • Avoid stimulants such as caffeine and nicotine within several hours of bedtime.
  • Avoid alcohol within several hours of bedtime.
  • Exercise regularly but avoid moderate to high intensity exercise within several hours of bedtime.
  • Keep the bedroom comfortable, quiet, and dark.
  • Eat a light snack around bedtime but avoid meals within 2 to 3 hours of going to bed.
  • Follow an evening routine that allows 30 to 60 minutes to relax and unwind before going to bed.
  • Maintain a regular sleep schedule.

Sleep hygiene is often confused with and/or combined with behavioral treatment recommendations. This leads to significant confusion on the part of patients and health care providers about sleep hygiene versus evidence-based CBT-I. Although commonly included in multicomponent CBT-I packages, little evidence exists for the effectiveness of sleep hygiene education as an independent treatment for insomnia. Current clinical practice guidelines do not recommend sleep hygiene as a single intervention.

Multicomponent CBT-I

The American Academy of Sleep Medicine’s Clinical Practice Guidelines for the Psychological and Behavioral Treatment of Chronic Insomnia looks at standard (4-8 sessions) and brief (1-4 sessions). Standard multicomponent CBT-I combines one or more cognitive therapy strategies with education about sleep plus sleep restriction and stimulus control. It often also includes relaxation training and sleep hygiene education. Standard multicomponent CBT-I is strongly recommended as the treatment for almost all patients. Brief multicomponent CBT-I includes abbreviated versions of CBT-I emphasizing the behavioral components (sleep restriction and stimulus control). Based on current evidence, Brief Multicomponent CBT-I is a patient care strategy suggested for most patients.

Method of Delivery and Treatment Intensity

Traditionally, a licensed provider delivers CBT-I through individual therapy across four to eight 50-minute, face-to-face sessions. However, growing evidence supports the effectiveness of CBT-I delivered in a variety of formats with varying intensity and duration. Studies have shown that CBT-I delivered by video appointments is as effective as face-to-face sessions. Several programs deliver CBT-I via online self-help platforms. There is also evidence to support lower intensity interventions including self-help books, single-contact trainings, single- or two-contact consultations, and bibliotherapy (self-help books) with and without support. Regardless of intervention format and intensity, CBT-I appears to be an effective intervention. Although purely self-help interventions are effective, inclusion of professional support consistently results in improved results.

CBT-I Versus Sleep Medication

Sedating and hypnotic medications (sleep aids) are the most common treatment for chronic insomnia. However, at least one comparative meta-analysis has found that benefits of CBT-I are equal to those associated with common sleep aids for improving sleep, including time to fall asleep, time spent awake during the night, number of awakenings during the night, total sleep time, and sleep quality. Although sleep aids typically supply benefit on the first night of use, CBT-I typically needs 2 to 4 weeks to achieve clinically significant improvements in insomnia symptoms. However, CBT-I has an advantage over medication when considering long-term benefit. While sleep aids are beneficial only during active use, there is evidence for benefits of CBT-I lasting up to three years after treatment.

Whereas sleep aids are typically preferred for relief from short-term insomnia, CBT-I is often preferred in the treatment of chronic insomnia for several reasons. First, most sleep aids are associated with some degree of psychological and/or physical dependence. Second, some patients prefer nonpharmacological treatments. Third, sleep aids are often associated with adverse effects. Fourth, sleep aids commonly used for treatment of insomnia are often not recommended for patients with a history of substance use disorders.

Does CBT-I work?

Based on current evidence, clinical guidelines of the American College of PhysiciansAmerican Academy of Sleep MedicineDepartment of Veteran’s Affairs, and Department of Defense recommend Cognitive behavioral therapy for insomnia for the treatment of chronic insomnia in adults. There are more than 100 clinical trials evaluating the efficacy (therapeutic benefit seen in controlled scientific studies) or effectiveness (therapeutic benefit seen in the health care setting) of CBT-I for primary and secondary/comorbid insomnia. Several meta-analyses have been performed to summarize evidence on CBT-I for the treatment of primary insomnia. Current evidence shows that CBT-I produces reliable changes in a variety of basic sleep variables, including time to fall asleep, time spent awake during the night, number of awakenings, total sleep time, and sleep quality. It is estimated that 70% to 80% of patients benefit from CBT-I and that 40% to 50% experience full remission of insomnia.

Clinical trials of varying size and quality have proven efficacy of CBT-I for insomnia co- occurring with a variety of medical and mental health conditions including major depressive disorder, generalized anxiety disorder, alcohol use disorders, obstructive sleep apnea, various forms of cancer, and various forms of chronic pain. In cases in which insomnia is comorbid with anxiety or depression, insomnia symptoms often persist despite targeted intervention for anxiety or depression. Inclusion of cognitive behavioral therapy for insomnia in the treatment plan in these cases reliably leads to improved sleep as well as enhanced anxiety and depression outcomes. There is evidence for a similar role of CBT-I comorbid with a variety of chronic pain conditions.

References

  • Edinger et al. (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Seep Med, 17, 255-262.
  • Martin et al. (2020). The Veterans Administration and Department of Defense clinical practice guidelines for the diagnosis and management of sleep disorders: what does this mean for the practice of sleep medicine? J Clin Sleep Med. 2020;16(8):1377–1381.
  • Qaseem et al. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Ann Int Med, 165, 125-133.
  • Glidewell R. (2017). Cognitive Behavioral Therapy for Insomnia. In A. Wenzel (Ed.) SAGE Encyclopedia of Abnormal and Clinic Psychology (pp. 744-747). Thousand Oaks CA: SAGE Publications, Inc.
  • Edinger, J. D., Means, M. K., Carney, C. E., & Manber, R. (2011). Psychological and behavioral treatments for insomnia II: Implementation and specific populations. In M. H. Kryger, R. Roth, & W. C. Dement (Eds.), Principles and practices of sleep medicine (5th ed., pp. 884–904). St. Louis, MO: Elsevier Saunders.
  • Irwin, M. R., Cole, J. C., & Nicassio, P. M. (2006). Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychology, 25, 3–14.
  • Mitchell, M. D ., Gehrman, P., Perlis, M. L ., & Umscheid, C. A. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: A systematic review. BMC Family Practice, 13, 40.
  • Morin, C. M. (2011). Psychological and behavioral treatments for insomnia I: Approaches and efficacy. In M. H. Kryger, R. Roth, & W. C. Dement (Eds.), Principles and practices of sleep medicine (5th ed., pp. 866–883). St. Louis, MO: Elsevier Saunders.
  • Perlis, M. L., Aloia, M., & Kuhn, B. (2011). Behavioral treatments for sleep disorders: A comprehensive primer of behavioral sleep medicine interventions. New York, NY: Elsevier.
  • Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. (2008). Cognitive behavioral treatment of insomnia: A session-by-session guide. New York, NY: Springer.
  • Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., Giles, D. E., & Buysse, D. J. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159, 5–11.

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