Cognitive behavioral therapy for insomnia

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Cognitive behavioral therapy for insomnia
Specialty

Cognitive behavioral therapy for insomnia (CBT-I) is a technique for treating insomnia without (or alongside) medications. Insomnia is a common problem involving trouble falling asleep, staying asleep, or getting quality sleep. CBT-I aims to improve sleep habits and behaviors by identifying and changing the thoughts and the behaviors that affect the ability of a person to sleep or sleep well.

Contents

The first step in treating insomnia with CBT-I is to identify the underlying causes of insomnia. People with insomnia should evaluate or have their sleep patterns evaluated and take into account all possible factors that may be affecting the person's ability to sleep. This would involve keeping a sleep diary/journal for a couple of weeks. The journal will help to identify patterns of thoughts or behaviors, stressors, etc. that could be contributing to the person's insomnia. [1]

After identifying the possible underlying cause and the factors contributing to insomnia, the person can begin taking steps towards getting better sleep. In CBT-I these steps include stimulus control, sleep hygiene, sleep restriction, relaxation training, and cognitive therapy. Some sleep specialists recommend biofeedback as well. [2] Usually, several methods are combined into an overall treatment concept. [3] Currently no treatment method is recommended over another; [4] neither is it recommended to administer a single intervention over a combination of different interventions. [4]

CBT-I has been found to be an effective form of treatment of insomnia. It is also effective in treatment of insomnia related to or caused by mood disorders. Those with PTSD have also shown improvement.

Components

Behavioral practices to treat insomnia [5]
  • Practicing sleep hygiene by keeping a good sleeping environment
    • Removing distractions such as television, computers, and other engaging activities [5]
    • Keeping the sleeping space dark and quiet [5]
    • Having a good bed [5]
    • Committing to a consistent bedtime [5]
    • Committing to a consistent wake-up time [5]
    • Avoiding staying in bed while awake for a longer time period than ideal for going to sleep. A recommended practice is relaxing elsewhere, such as by sitting, then returning to bed when one is more likely to sleep. [5]
  • Stimulus control - limit stimulation before bed
    • Finishing meals three hours before bedtime, especially for those prone to indigestion or heartburn [5]
    • Avoiding alcoholic or caffeinated beverages before sleeping [5]
    • Because medications can delay or disrupt sleep, choosing to take them far in advance of sleeping times is preferred unless a physician directs otherwise [5]
    • Avoiding smoking for at least 3 hours before bed [5]
    • Engaging in regular physical exercise, but not within 4 hours of going to sleep [5]
    • Avoiding stressful situations before time for sleep [5]
    • Avoiding napping too soon before sleep [5]

Stimulus control

Stimulus control [6] aims to associate the bed with sleeping and limit its association with stimulating behavior. People with insomnia are guided to do the following:

Sleep hygiene

Sleep hygiene aims to control the environment and behaviors that precede sleep. This involves limiting substances that can interfere with proper sleep, particularly within 4–6 hours of going to bed. These substances include caffeine, nicotine and alcohol. Sometimes a light bedtime snack, such as milk or peanut butter, is recommended. The environment in which one sleeps, and the environment that directly precedes sleep, is also very important; patients should engage in relaxing activities prior to going to bed, such as reading, writing, listening to calming music or taking a bath. Importantly, they should limit stimulating activity such as watching television, using a computer or being around bright lights.

Sleep restriction therapy

Sleep restriction, [7] also known as sleep restriction therapy, is probably the most difficult step of CBT-I. This is because CBT-I initially involves the restriction of sleep. Insomniacs typically spend a long time in bed not sleeping, which CBT-I sees as creating a mental association between the bed and insomnia. The bed therefore becomes a site of nightly frustration where it is difficult to relax. Although it is counter-intuitive, sleep restriction is a significant and effective component of CBT-I. It involves controlling Time In Bed (TIB) based upon the person's sleep efficiency in order to restore the homeostatic drive to sleep and thereby re-enforce the "bed-sleep connection". [8] Sleep Efficiency (SE) is the measure of reported Total Sleep Time (TST), the actual amount of time the patient is usually able to sleep, compared with their TIB.

Sleep efficiency = Total sleep time/Time in bed

This process may take several weeks or months to complete, depending on the person's initial sleep efficiency and how effective the treatment is for them individually. (According to one expert, this should result in getting 7 to 8 hours of sleep within about six weeks. [8] ) Daytime sleepiness is a side-effect during the first week or two of treatment, so those who operate heavy machinery or otherwise cannot safely be sleep deprived should not undergo this process.

Research has showed that sleep restriction therapy does create side effects such as "fatigue/exhaustion", "extreme sleepiness", "reduced motivation/energy", "headache/migraine", irritability, and changes in appetite. But the frequency and ratings of how much these side effects interfered were associated with improvement in sleep quality over the course of the treatment. [9] In another study, results of questionnaires measuring impairment through the psychomotor vigilance task (PVT) and the Epworth sleepiness scale (ESS) were stabilized at a normal level at 3-months follow-up. [10]

Restricting sleep has also been shown to be an effective but usually temporary measure for treating depression. [11]

Relaxation training

Relaxation training is a collection of practices that can help people to relax throughout the day and, particularly, close to bedtime. It is useful for insomnia patients with difficulty falling asleep. However it is unclear whether or not it is useful for those who tend to wake up in the middle of the night or very early in the morning. Techniques include hypnosis, guided imagery and meditation.

Cognitive therapy

Cognitive therapy [6] [12] [13] [14] within CBT-I is not synonymous with versions of cognitive behavioral therapy that are not targeted at insomnia. When dealing with insomnia, cognitive therapy is mostly about offering education about sleep in order to target dysfunctional beliefs/attitudes about sleep.

Cognitive therapists will directly question the logical basis of these dysfunctional beliefs in order to point out their flaws. If applicable, the therapist will arrange a situation for the individual to test these flawed beliefs. For instance, many insomniacs believe that if they do not get enough sleep they will be tired the entire following day. They will then try to conserve energy by not moving around or by taking a nap. These responses are understandable but can exacerbate the problem, since they do not generate energy. If instead a person actively tries to generate energy by taking a walk, talking to a friend and getting plenty of sunlight, he or she may find that the original belief was self-fulfilling and not actually true.

The crucial messages that the therapist tries to communicate to the patient are the following: [15]

Worry is a common factor of insomnia. Therapists will work to control worry and rumination with the use of a thought record, a log where a person writes down concerns. The therapist and the patient can then approach each of these concerns individually.

Paradoxical Intention

Paradoxical Intention is a treatment method which involves telling the patient to do the exact opposite of what they have been doing in bed: They should stay awake and avoid falling asleep. [3] The goal of this method is to decrease performance anxiety which may inhibit sleep onset. [3] [4] Paradoxical Intention has been shown to be an effective treatment for sleep initiation insomnia but might not be effective for sleep maintenance or mixed insomnia. [4]

Indication

CBT-I is indicated when the following criteria are met:

  1. The patient complains about difficulties initiating or maintaining sleep. [16] These difficulties cause a significant distress and/or impact daily functioning. [16] Complaints of non-restorative sleep without troubles of initiating or maintaining sleep are excluded. [16]
  2. These difficulties are not primarily caused by a circadian rhythm disorder. [16] In the case of a circadian rhythm disorder treatments such as phototherapy or chronobiologic interventions might be more suitable. [16] However many primary insomnia patients also show some degree of a chronobiologic dysregulation, so a combination of CBT-I and chronobiologic interventions might be the best approach for these patients. [16]
  3. The patient does not have an undiagnosed or unstable medical or psychiatric illness which could interfere with or be worsened by CBT-I. [16] For example, patients with severe major depression might not have the resources needed to accurately execute some CBT-I interventions and failure in doing so might further reduce their self-efficacy. [16] If it is likely that the insomnia will resolve with the resolution of the comorbid illness, specific treatment with CBT-I might not be necessary. [16]
  4. The patient shows some behavioral or psychological factors which play a part in the maintenance of the insomnia complaints. [16] This could be behaviors such as going to bed early or taking naps during the day. [16] Worries that interfere with sleep and somatized tension about insomnia may also be present. [16] As CBT-I mainly targets these factors, at least one of them should be present. [16]

CBT-I can be indicated for both primary and secondary insomnia. [16] It primarily focuses on how patients deal with acute insomnia symptoms and how these symptoms are maintained and become chronic. [16] These maintaining factors are often relevant in both primary and secondary insomnia. [16]

Contraindication

Some components of CBT-I can be contraindicated under certain circumstances.

Stimulus control requires the patients to leave their beds and move to another room if they are not asleep within 15–20 minutes. [16] This can be dangerous for patients with an elevated risk of falls. [16] For example, this might be the case for patients with restricted mobility or with orthostatic hypotension. [16]

Relaxation training can lead to paradoxical anxiety. [17] This might be the case for up to 15% of the patients. [17] However, it is unclear which patients are prone to such reactions. [16]

Sleep restriction may aggravate other preexisting conditions. [16] For example, sleep deprivation may act as a precipitant of epileptic seizures. [18] For patients with bipolar disorder, it can increase the risk of switching from depression into mania. [19] It might also increase daytime somnolence to a degree where driving a car or operating machinery is no longer safe. [16]

Applications to mood disorders

Psychiatric mood disorders, such as major depressive disorder (MDD) and bipolar disorder, are intertwined with sleep disorders. This is evident in the high rate of comorbidity with psychiatric disorders and insomnia and other sleep disorders. Most people with psychiatric diagnoses have significantly reduced sleep efficiency and total sleep time compared to controls. [20] Thus it is not surprising that treating insomnia with CBT-I can help to improve mood disorders. A study in 2008 showed that augmenting antidepressant medication with CBT-I in patients with major depressive disorder and comorbid insomnia helped to alleviate symptoms for both disorders. [21] The overlap between mood- and sleep disorders is just starting to be rigorously explored, but the efficacy of CBT-I for major depressive disorder and bipolar disorder looks promising. [22]

Application to post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is an anxiety disorder that may develop after a person experiences a traumatic event. Many people with PTSD relive or re-experience a traumatic event; memories of the event can appear at any time and the person feels the same fear/horror as when the event occurred. These can be either in the form of nightmares and/or flashbacks. Those with PTSD also experience hyperarousal (fight-or-flight) and can be too alert to go to sleep. [23] Due to this, many experience some form of insomnia.

Recent studies have shown that CBT-I offers some improvement for those with PTSD. For example, a study conducted in 2014 looked at whether CBT-I improved sleep in those with PTSD along with other PTSD related symptoms. The study showed improved sleep and improved psychosocial functioning. [24]

Other studies even suggest that CBT-I in combination with imagery rehearsal therapy helps improve sleep-related PTSD symptoms. Imagery rehearsal therapy (IRT) is a modified cognitive behavioral therapy technique used to treat recurring nightmares. This technique involves recalling the nightmare, writing it down, modifying parts of the dream to make it positive, and rehearsing the new dream to create a cognitive shift that counters the original dream. IRT can be used for anyone suffering from recurring nightmares. [25]

Application to other conditions

Individuals with cancer often experience insomnia due to psychological, behavioral or physical consequences of cancer diagnosis and treatment. [26] CBT-I has been shown to be an effective treatment in such individuals. [26] [27] Furthermore, it may also improve their mood, fatigue and overall quality of life. [26]

CBT-I can also be applied to patients with both chronic pain and insomnia. [28] Chronic pain can directly contribute to the difficulties in initiating and maintaining sleep via hyperarousal due to the experienced pain. [28] CBT-I has been shown to improve sleep continuity and reduce impairment in daily functioning due to pain in such individuals. [28]

CBT-I has been shown to be effective in geriatric patients with insomnia as well. [29] Medication might be problematic in such patients and they might prefer psychotherapy over medication. [29] Therefore, it should be considered as a treatment option for them. [29]

Efficacy

Alternative treatment options

There are some therapies that can be applied complementary to CBT-I or as an alternative. [35] Acupuncture, tai chi, hypnosis, and electrosleep therapy are just a few options. Exercise can also be a helpful addition to the patient's life. These approaches are not validated as extensively by empirical research, but may still provide a valuable contribution to the clinical practice. [35]

Acceptance and mindfulness techniques might be a good addition to conventional insomnia treatment. [36] Particularly, insomnia patients might benefit from concepts such as acceptance and cognitive defusion. [36] In case of insomnia this would mean nonjudgmental acceptance of fluctuations in the ability to fall asleep and sleep-interfering thoughts and feelings, as well as cognitive detachment from dysfunctional beliefs and automatic thoughts. [36] Research suggests that acceptance and commitment therapy might even be effective in patients not responding to CBT-I. [37]

Biofeedback has been shown to be an effective treatment for insomnia [38] and is listed in the American Academy of Sleep Medicine treatment guidelines. [4] This form of therapy includes visual or auditory feedback of e.g. EEG or EMG activity. [38] [4] This can help insomnia patients to control their physiological arousal. [4]

Researchers have also recently begun re-exploring the utility of the individual components of CBT-I, when delivered as monotherapies or multi-component therapies without cognitive therapy. A 2023 systematic review by McLaren et al. [39] demonstrated that Stimulus Control and Sleep Restriction are effective treatment options for insomnia in older adults. As well as indicating that when combined, they generate improvements with a magnitude similar to that of full CBT-I, in as little as two therapeutic sessions.

Related Research Articles

<span class="mw-page-title-main">Cognitive behavioral therapy</span> Therapy to improve mental health

Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

Paradoxical intention (PI) is a psychotherapeutic technique used to treat recursive anxiety by repeatedly rehearsing the anxiety-inducing pattern of thought or behaviour, often with exaggeration and humor. Paradoxical intention has been shown to be effective in treating psychosomatic illnesses such as chronic insomnia, public speaking phobias, etc. by making patients do the opposite of their hyper-intended goal, hindering their ability to perform the activity.

<span class="mw-page-title-main">Insomnia</span> Inability to fall or stay asleep

Insomnia, also known as sleeplessness, is a sleep disorder where people have trouble sleeping. They may have difficulty falling asleep, or staying asleep for as long as desired. Insomnia is typically followed by daytime sleepiness, low energy, irritability, and a depressed mood. It may result in an increased risk of accidents of all kinds as well as problems focusing and learning. Insomnia can be short term, lasting for days or weeks, or long term, lasting more than a month. The concept of the word insomnia has two possibilities: insomnia disorder (ID) and insomnia symptoms, and many abstracts of randomized controlled trials and systematic reviews often underreport on which of these two possibilities the word insomnia refers to.

<span class="mw-page-title-main">Dialectical behavior therapy</span> Psychotherapy for emotional dysregulation

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.

<span class="mw-page-title-main">Nightmare disorder</span> Medical condition

Nightmare disorder is a sleep disorder characterized by repeated intense nightmares that most often center on threats to physical safety and security. The nightmares usually occur during the REM stage of sleep, and the person who experiences the nightmares typically remembers them well upon waking. More specifically, nightmare disorder is a type of parasomnia, a subset of sleep disorders categorized by abnormal movement or behavior or verbal actions during sleep or shortly before or after. Other parasomnias include sleepwalking, sleep terrors, bedwetting, and sleep paralysis.

Cognitive restructuring (CR) is a psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking, overgeneralization, magnification, and emotional reasoning, which are commonly associated with many mental health disorders. CR employs many strategies, such as Socratic questioning, thought recording, and guided imagery, and is used in many types of therapies, including cognitive behavioral therapy (CBT) and rational emotive behaviour therapy (REBT). A number of studies demonstrate considerable efficacy in using CR-based therapies.

Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy that is controversial within the psychological community. It was devised by Francine Shapiro in 1987 and originally designed to alleviate the distress associated with traumatic memories such as post-traumatic stress disorder (PTSD).

<span class="mw-page-title-main">Sleep hygiene</span> Set of practices around healthy sleeping

Sleep hygiene is a behavioral and environmental practice developed in the late 1970s as a method to help people with mild to moderate insomnia. Clinicians assess the sleep hygiene of people with insomnia and other conditions, such as depression, and offer recommendations based on the assessment. Sleep hygiene recommendations include: establishing a regular sleep schedule; using naps with care; not exercising physically or mentally too close to bedtime; limiting worry; limiting exposure to light in the hours before sleep; getting out of bed if sleep does not come; not using bed for anything but sleep and sex; avoiding alcohol as well as nicotine, caffeine, and other stimulants in the hours before bedtime; and having a peaceful, comfortable and dark sleep environment. However, as of 2021, the empirical evidence for the effectiveness of sleep hygiene is "limited and inconclusive" for the general population and for the treatment of insomnia, despite being the oldest treatment for insomnia. A systematic review by the AASM concluded that clinicians should not prescribe sleep hygiene for insomnia due to the evidence of absence of its efficacy and potential delaying of adequate treatment, recommending instead that effective therapies such as CBT-i should be preferred.

<span class="mw-page-title-main">Psychological intervention</span>

In applied psychology, interventions are actions performed to bring about change in people. A wide range of intervention strategies exist and they are directed towards various types of issues. Most generally, it means any activities used to modify behavior, emotional state, or feelings. Psychological interventions have many different applications and the most common use is for the treatment of mental disorders, most commonly using psychotherapy. The ultimate goal behind these interventions is not only to alleviate symptoms but also to target the root cause of mental disorders.

<span class="mw-page-title-main">Sleep medicine</span> Medical specialty devoted to the diagnosis and therapy of sleep disturbances and disorders

Sleep medicine is a medical specialty or subspecialty devoted to the diagnosis and therapy of sleep disturbances and disorders. From the middle of the 20th century, research has provided increasing knowledge of, and answered many questions about, sleep–wake functioning. The rapidly evolving field has become a recognized medical subspecialty in some countries. Dental sleep medicine also qualifies for board certification in some countries. Properly organized, minimum 12-month, postgraduate training programs are still being defined in the United States. In some countries, the sleep researchers and the physicians who treat patients may be the same people.

Prolonged exposure therapy (PE) is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder. It is characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal exposure is repeated 'on-purpose' retelling of the trauma memory. In vivo exposure is gradually confronting situations, places, and things that are reminders of the trauma or feel dangerous. Additional procedures include processing of the trauma memory and breathing retraining.

<span class="mw-page-title-main">Sleep deprivation</span> Condition of not having enough sleep

Sleep deprivation, also known as sleep insufficiency or sleeplessness, is the condition of not having adequate duration and/or quality of sleep to support decent alertness, performance, and health. It can be either chronic or acute and may vary widely in severity. All known animals sleep or exhibit some form of sleep behavior, and the importance of sleep is self-evident for humans, as nearly a third of a person's life is spent sleeping.

Interoceptive exposure is a cognitive behavioral therapy technique used in the treatment of panic disorder. It refers to carrying out exercises that bring about the physical sensations of a panic attack, such as hyperventilation and high muscle tension, and in the process removing the patient's conditioned response that the physical sensations will cause an attack to happen.

Cognitive processing therapy (CPT) is a manualized therapy used by clinicians to help people recover from posttraumatic stress disorder (PTSD) and related conditions. It includes elements of cognitive behavioral therapy (CBT) treatments, one of the most widely used evidence-based therapies. A typical 12-session run of CPT has proven effective in treating PTSD across a variety of populations, including combat veterans, sexual assault victims, and refugees. CPT can be provided in individual and group treatment formats and is considered one of the most effective treatments for PTSD.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

Colin Espie PhD, DSc, FRSM, FBPsS FAASM is a Scottish Professor of Sleep Medicine in the Nuffield Department of Clinical Neuroscience at the University of Oxford and Fellow of Somerville College. He is closely involved with the development of the Sir Jules Thorn Sleep & Circadian Neuroscience Institute (SCNi) where he is Founding Director of the Experimental & Clinical Sleep Medicine Research programme, and Clinical Director of the Oxford Online Programme in Sleep Medicine. His particular areas of research expertise are in the assessment and treatment of sleep disorders, most particularly the management of insomnia using Cognitive Behavioral Therapy, and in studies on the aetiology and pathophysiology of insomnia.

Trauma focused cognitive behavioral therapy (TF-CBT) is an evidence-based psychotherapy or counselling that aims at addressing the needs of children and adolescents with post traumatic stress disorder (PTSD) and other difficulties related to traumatic life events. This treatment was developed and proposed by Drs. Anthony Mannarino, Judith Cohen, and Esther Deblinger in 2006. The goal of TF-CBT is to provide psychoeducation to both the child and non-offending caregivers, then help them identify, cope, and re-regulate maladaptive emotions, thoughts, and behaviors. Research has shown TF-CBT to be effective in treating childhood PTSD and with children who have experienced or witnessed traumatic events, including but not limited to physical or sexual victimization, child maltreatment, domestic violence, community violence, accidents, natural disasters, and war. More recently, TF-CBT has been applied to and found effective in treating complex posttraumatic stress disorder.

Metacognitive therapy (MCT) is a psychotherapy focused on modifying metacognitive beliefs that perpetuate states of worry, rumination and attention fixation. It was created by Adrian Wells based on an information processing model by Wells and Gerald Matthews. It is supported by scientific evidence from a large number of studies.

<span class="mw-page-title-main">Behavioral sleep medicine</span>

Behavioral sleep medicine (BSM) is a field within sleep medicine that encompasses scientific inquiry and clinical treatment of sleep-related disorders, with a focus on the psychological, physiological, behavioral, cognitive, social, and cultural factors that affect sleep, as well as the impact of sleep on those factors. The clinical practice of BSM is an evidence-based behavioral health discipline that uses primarily non-pharmacological treatments. BSM interventions are typically problem-focused and oriented towards specific sleep complaints, but can be integrated with other medical or mental health treatments. The primary techniques used in BSM interventions involve education and systematic changes to the behaviors, thoughts, and environmental factors that initiate and maintain sleep-related difficulties.

Sexual trauma therapy is medical and psychological interventions provided to survivors of sexual violence aiming to treat their physical injuries and cope with mental trauma caused by the event. Examples of sexual violence include any acts of unwanted sexual actions like sexual harassment, groping, rape, and circulation of sexual content without consent.

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