Cognitive behavioral therapy for insomnia

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Cognitive behavioral therapy for insomnia
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Cognitive behavioral therapy for insomnia (CBT-I) is a therapy technique for treating insomnia without (or alongside) medications. CBT-I aims to improve sleep habits and behaviors by identifying and changing thoughts and behaviors that prevent a person from sleeping well.

Contents

The first step in treating insomnia with CBT-I is to identify the underlying causes. 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 may involve keeping a sleep diary/journal for a couple of weeks, which can help identify patterns of thoughts or behaviors, stressors, etc. that could be contributing to the person's insomnia. [1]

After identifying the possible underlying causes and the factors contributing to insomnia, the person can begin taking steps toward 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 plan. [3] Currently no treatment method is recommended over another. [4]

CBT-I is an effective form of treatment for traditional insomnia, as well as insomnia related to or caused by mood disorders or post-traumatic stress disorder.

Components

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

Stimulus control

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

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 before going to bed, such as reading, writing, listening to calming music, or taking a bath. Importantly, they should limit stimulating activities such as watching television, using a computer or being around bright lights.[ citation needed ]

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 counterintuitive, 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 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 patients with insomnia who have 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 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 to target dysfunctional beliefs/attitudes about sleep.

Cognitive therapists will directly question the logical basis of these dysfunctional beliefs 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 true. [6] [12] [13] [14]

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

Worry is a common factor in 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 that 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 is an effective treatment for sleep initiation insomnia but might not be effective for sleep maintenance or mixed insomnia. [4]

Treatment recommendation

Indication

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

  1. The patient complains about difficulties initiating or maintaining sleep. These difficulties cause significant distress and/or impact daily functioning. Complaints of non-restorative sleep without trouble initiating or maintaining sleep are excluded.
  2. These difficulties are not primarily caused by a circadian rhythm disorder. In the case of a circadian rhythm disorder treatments such as phototherapy or chronobiologic interventions might be more suitable. 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.
  3. The patient does not have an undiagnosed or unstable medical or psychiatric illness that could interfere with or be worsened by CBT-I. 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. 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.
  4. The patient shows some behavioral or psychological factors which play a part in the maintenance of the insomnia complaints. This could be behaviors such as going to bed early or taking naps during the day. Worries that interfere with sleep and somatized tension about insomnia may also be present. As CBT-I mainly targets these factors, at least one of them should be present.

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

Contraindication

Due to preexisting conditions or undesirable side effects, CBT-I can sometimes be an undesirable method of treatment. Some examples of this are:

Efficacy

Patients who have undergone CBT-I spend more time in sleep stages three and four (also known as slow-wave sleep, delta sleep, or deep sleep) and less time awake than those treated with zopiclone (also known as Imovane or Zimovane). They also had lasting benefits according to a review six months later, whereas zopiclone had no lasting results. [12]

When the common hypnotic drug zolpidem (more commonly known as Ambien) was compared with CBT-I, the latter had a larger impact on sleep-onset insomnia. CBT-I by itself was no less effective than CBT-I paired with Ambien. [21]

Computer-based CBT-I was shown to be comparable in effectiveness to therapist-delivered CBT-I in a placebo-controlled clinical study. [22]

A meta-analysis showed that adherence and effectiveness are related in technology-mediated sleep treatment. [23]

Where sleep anxiety is a cause of insomnia, some evidence suggests that components of CBT-I, such as sleep restriction, may worsen the anxiety. A CBT-derived variant known as acceptance and commitment therapy (ACT) may be more effective in these cases. [24]

Application of CBT-I for specific conditions

Mood disorders

Psychiatric mood disorders, such as major depressive disorder (MDD) and bipolar disorder, are intertwined with sleep disorders. Most people with psychiatric diagnoses have significantly reduced sleep efficiency and total sleep time compared to controls; in these cases, CBT-I can be used as a treatment option. [25] 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. [26]

Post-traumatic stress disorders (PTSD)

Post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (C-PTSD) are anxiety disorders that may develop after a person experiences a traumatic event. Common symptoms of PTSD include nightmares, flashbacks and hyperarousal (fight-or-flight), all of which can induce insomnia and fatigue in various ways. [27]

Studies have shown that CBT-I can offer improvement for those with PTSD. The participants in studies displayed reduction of PTSD symptoms which lead to insomnia, such as nightmares and general fear of sleep after undergoing CBT-I. [28] [29] [30]

Other studies[ which? ] suggest that CBT-I in combination with imagery rehearsal therapy further lessens 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. [31]

Cancer

Cancer patients often experience insomnia due to psychological, behavioral or physical consequences of cancer diagnosis and treatment. CBT-I has been shown to be an effective treatment in these cases [32] as it may improve sleep quality, mood, overall quality of life and lessen fatigue. [33]

Other conditions

In studies examining sufferers of chronic pain induced insomnia via hyperarousal, CBT-I has been shown to improve sleep continuity and reduce impairment in daily functioning. [34]

CBT-I is effective in geriatric patients with insomnia as well. Medication might be problematic in such patients due to contraindications, and they might prefer psychotherapy over medication, therefore, it should be considered as a treatment option for them. [35]

Alternative treatment options

Some therapies can be applied as complementary or as an alternative to CBT-I.

Acceptance and mindfulness techniques can be used in addition to CBT-I, as some insomnia patients can benefit from concepts such as acceptance and cognitive defusion. In the 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] A 2014 study suggests that acceptance and commitment therapy might even be effective in patients not responding to CBT-I. [37]

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

There has also been research into the utility of the individual components of CBT-I when delivered as monotherapies or multi-component therapies without cognitive therapy. A 2023 systematic review [39] demonstrated that just stimulus control and sleep restriction are effective treatment options for insomnia in older adults. It also indicated that when combined, they generate improvements with a magnitude similar to that of full CBT-I, in as little as two therapeutic sessions. [39]

References

  1. ↑ Cognitive Behavioral Therapy for Insomnia Part 1. (n.d.). Psychology Today: Health, Help, Happiness + Find a Therapist. Retrieved April 30, 2014, from http://www.psychologytoday.com/blog/sleepless-in-america/200905/cognitive-behavioral-therapy-insomnia-part-1
  2. ↑ Insomnia. (n.d.). treatment: Cognitive behavioral therapy instead of sleeping pills. Retrieved April 30, 2014, from http://www.mayoclinic.org/diseases-conditions/insomnia/in-depth/insomnia-treatment/art-20046677
  3. 1 2 3 Hermann, Ernst; Hermann, Rebecca (2018). "Schlaf-Wach-Störungen". Lehrbuch der Verhaltenstherapie, Band 2. pp. 185–225. doi:10.1007/978-3-662-54909-4_10. ISBN   978-3-662-54908-7.
  4. 1 2 3 4 Morgenthaler, Timothy (2006). "Practice Parameters for the Psychological and Behavioral Treatment of Insomnia: An Update. An American Academy of Sleep Medicine Report" (PDF). Sleep. 29 (11): 1415–1419. doi: 10.1093/sleep/29.11.1415 . PMID   17162987. Archived from the original (PDF) on 2019-06-17. Retrieved 2019-06-17.
  5. ↑ Consumer Reports; Drug Effectiveness Review Project (July 2008), "Evaluating Newer Sleeping Pills Used to Treat Insomnia: Comparing Effectiveness, Safety, and Price" (PDF), Best Buy Drugs, Consumer Reports, p. 4, retrieved 4 June 2013
  6. 1 2 Morin, CM; Bootzin, RR; Buysse, DJ; Edinger, JD; Espie, CA; Lichstein, KL (2006). "Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004)". Sleep. 29 (11): 1398–414. doi: 10.1093/sleep/29.11.1398 . PMID   17162986.
  7. ↑ Spielman, AJ; Saskin, P; Thorpy, MJ (1987). "Treatment of chronic insomnia by restriction of time in bed". Sleep. 10 (1): 45–56. PMID   3563247.
  8. 1 2 3 "Teach Insomniacs That Beds Are for Sleeping". Family Practice News. 2012-02-07. Retrieved 2016-12-28.
  9. ↑ Kyle, Simon D.; Morgan, Kevin; Spiegelhalder, Kai; Espie, Colin A. (September 2011). "No pain, no gain: An exploratory within-subjects mixed-methods evaluation of the patient experience of sleep restriction therapy (SRT) for insomnia". Sleep Medicine. 12 (8): 735–747. doi:10.1016/j.sleep.2011.03.016. PMID   21907616.
  10. ↑ Miller, Christopher B.; Espie, Colin A.; Epstein, Dana R.; Friedman, Leah; Morin, Charles M.; Pigeon, Wilfred R.; Spielman, Arthur J.; Kyle, Simon D. (October 2014). "The evidence base of sleep restriction therapy for treating insomnia disorder". Sleep Medicine Reviews. 18 (5): 415–424. doi:10.1016/j.smrv.2014.01.006. PMID   24629826.
  11. ↑ "Sleep Deprivation For Depression: A Potent, Short-Term Treatment". Mental Health Daily. 2015-08-07. Retrieved 10 August 2016.
  12. 1 2 Sivertsen, B.; Omvik, S; Pallesen, S; Bjorvatn, B; Havik, OE; Kvale, G; Nielsen, GH; Nordhus, IH (2006). "Cognitive Behavioral Therapy vs Zopiclone for Treatment of Chronic Primary Insomnia in Older Adults: A Randomized Controlled Trial". JAMA. 295 (24): 2851–8. doi: 10.1001/jama.295.24.2851 . PMID   16804151.
  13. ↑ Harvey, A; Sharpley, A; Ree, M; Stinson, K; Clark, D (2007). "An open trial of cognitive therapy for chronic insomnia". Behaviour Research and Therapy. 45 (10): 2491–501. doi:10.1016/j.brat.2007.04.007. PMID   17583673.
  14. ↑ Harvey, A.G (2002). "A cognitive model of insomnia". Behaviour Research and Therapy. 40 (8): 869–93. doi:10.1016/S0005-7967(01)00061-4. PMID   12186352.
  15. ↑ Morin, Charles M. (1993). Insomnia: psychological assessment and management. Guilford Press. ISBN   1572301201. OCLC   455860736.
  16. 1 2 3 4 Smith, Michael T.; Perlis, Michael L. (2006). "Who Is a Candidate for Cognitive–Behavioral Therapy for Insomnia?". Health Psychology. 25 (1): 15–19. doi:10.1037/0278-6133.25.1.15. PMID   16448293.
  17. ↑ Heide, F.J. (1983). "Relaxation-induced anxiety: Paradoxical anxiety enhancement due to relaxation training". Journal of Consulting and Clinical Psychology. 51 (2): 171–182. doi:10.1037/0022-006X.51.2.171. PMID   6341426.
  18. ↑ Kim, Hanjoo; Newman, Michelle G. (2019-12-01). "The paradox of relaxation training: Relaxation induced anxiety and mediation effects of negative contrast sensitivity in generalized anxiety disorder and major depressive disorder". Journal of Affective Disorders. 259: 271–278. doi:10.1016/j.jad.2019.08.045. ISSN   0165-0327. PMC   7288612 . PMID   31450137.
  19. ↑ Colombo, Cristina (1999). "Rate of switch from depression into mania after therapeutic sleep deprivation in bipolar depression". Psychiatry Research. 86 (3): 267–270. doi:10.1016/S0165-1781(99)00036-0. PMID   10482346. S2CID   13425006.
  20. ↑ Malow, Beth, A. (2004). "Sleep Deprivation and Epilepsy". Epilepsy Currents. 4 (5): 193–195. doi:10.1111/j.1535-7597.2004.04509.x. PMC   1176369 . PMID   16059497.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  21. ↑ Jacobs, Gregg D.; Pace-Schott, EF; Stickgold, R; Otto, MW (2004). "Cognitive Behavior Therapy and Pharmacotherapy for Insomnia: A Randomized Controlled Trial and Direct Comparison". Archives of Internal Medicine. 164 (17): 1888–96. doi: 10.1001/archinte.164.17.1888 . PMID   15451764.
  22. ↑ Espie, Colin A.; Kyle, Simon D.; Williams, Chris; Ong, Jason C.; Douglas, Neil J.; Hames, Peter; Brown, June S.L. (2012). "A Randomized, Placebo-Controlled Trial of Online Cognitive Behavioral Therapy for Chronic Insomnia Disorder Delivered via an Automated Media-Rich Web Application". Sleep. 35 (6): 769–81. doi:10.5665/sleep.1872. PMC   3353040 . PMID   22654196.
  23. ↑ Horsch, C; Lancee, J; Beun, RJ; Neerincx, MA; Brinkman, WP (2015). "Adherence to Technology-Mediated Insomnia Treatment: A Meta-Analysis, Interviews, and Focus Groups". Journal of Medical Internet Research. 17 (9): e214. doi: 10.2196/jmir.4115 . PMC   4642391 . PMID   26341671.
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  26. ↑ Manber, R; Edinger, JD; Gress, JL; San Pedro-Salcedo, MG; Kuo, TF; Kalista, T (2008). "Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia". Sleep. 31 (4): 489–95. doi:10.1093/sleep/31.4.489. PMC   2279754 . PMID   18457236.
  27. ↑ PTSD: National Center for PTSD. (n.d.). Symptoms of PTSD -. Retrieved April 30, 2014, from http://www.ptsd.va.gov/public/PTSD-overview/basics/symptoms_of_ptsd.asp
  28. ↑ Weber, Franziska C.; Wetter, Thomas C. (2022). "The Many Faces of Sleep Disorders in Post-Traumatic Stress Disorder: An Update on Clinical Features and Treatment". Neuropsychobiology. 81 (2): 85–97. doi:10.1159/000517329. ISSN   0302-282X. PMC   9153357 . PMID   34474413.
  29. ↑ Talbot, LS; Maguen, S; Metzler, TJ; Schmitz, M; McCaslin, SE; Richards, A; Perlis, ML; Posner, DA; Weiss, B; Ruoff, L; Varbel, J; Neylan, TC (2014). "Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial". Sleep. 37 (2): 327–41. doi:10.5665/sleep.3408. PMC   3900619 . PMID   24497661.
  30. ↑ Qaseem, Amir; Kansagara, Devan; Forciea, Mary Ann; Cooke, Molly; Denberg, Thomas D.; for the Clinical Guidelines Committee of the American College of Physicians (2016-07-19). "Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians". Annals of Internal Medicine. 165 (2): 125–133. doi: 10.7326/M15-2175 . ISSN   0003-4819. PMID   27136449.
  31. ↑ "Best Practice for the Treatment of Nightmare Disorder in Adults". Journal of Clinical Sleep Medicine. 6: 395.
  32. ↑ Johnson, Jillian A. (2016). "A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors". Sleep Medicine Reviews. 27: 20–28. doi:10.1016/j.smrv.2015.07.001. PMID   26434673.
  33. ↑ Garland, Sheila (2014). "Sleeping well with cancer: a systematic review of cognitive behavioral therapy for insomnia in cancer patients". Neuropsychiatric Disease and Treatment. 10: 1113–1124. doi: 10.2147/NDT.S47790 . PMC   4069142 . PMID   24971014.
  34. ↑ Jungquist, Carla R. (2010). "The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain". Sleep Medicine. 11 (3): 302–209. doi:10.1016/j.sleep.2009.05.018. PMC   2830371 . PMID   20133188.
  35. ↑ Chand, S.P. (2013). "How to adapt cognitive-behavioral therapy for older adults". Current Psychiatry. 12 (3): 10–15.
  36. ↑ Lundh, Lars-Gunnar (2005). "The role of acceptance and mindfulness in the treatment of insomnia". Journal of Cognitive Psychotherapy. 19 (1): 29–39. doi:10.1891/jcop.19.1.29.66331. S2CID   219213746.
  37. ↑ Hertenstein, Elisabeth (2014). "Quality of life improvements after acceptance and commitment therapy in nonresponders to cognitive behavioral therapy for primary insomnia". Psychother Psychosom. 83 (6): 371–373. doi:10.1159/000365173. PMID   25323449. S2CID   42941701.
  38. ↑ Morin, Charles M. (1999). "Nonpharmacologic treatment of chronic insomnia". Sleep. 22 (8): 1134–1156. doi: 10.1093/sleep/22.8.1134 . PMID   10617176.
  39. 1 2 McLaren, Declan M.; Evans, Jonathan; Baylan, Satu; Smith, Sarah; Gardani, Maria (2023-02-19). "The effectiveness of the behavioural components of cognitive behavioural therapy for insomnia in older adults: A systematic review". Journal of Sleep Research. 32 (4): e13843. doi: 10.1111/jsr.13843 . hdl: 20.500.11820/2e13f3ce-604d-46c9-b157-343492c74fea . ISSN   0962-1105. PMC   10909422 . PMID   36802110. S2CID   257047712.
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