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 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 plan. [3] Currently no treatment method is recommended over another. [4]

CBT-I has been found to be an effective form of treatment of traditional insomnia, as well as insomnia related to or caused by mood disorders or PTSD.

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 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.[ 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 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 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. [6] [12] [13] [14]

The 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]

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 a significant distress and/or impact daily functioning. Complaints of non-restorative sleep without troubles of 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 which 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]

Other conditions

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 mood, overall quality of life and lessen fatigue. [33]

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 has been shown to be effective in geriatric patients with insomnia as well. Medication might be problematic in such patients due to contradiction and they might prefer psychotherapy over medication, therefore it should be considered as a treatment option for them. [35]

Alternative treatment options

There are some therapies that 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 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 has been shown to be 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]

Related Research Articles

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

Cognitive behavioral therapy (CBT) is a form of psychotherapy that aims to reduce symptoms of various mental health conditions, primarily depression, PTSD and anxiety disorders. Cognitive behavioral therapy 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 and other 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">Sleep disorder</span> Medical disorder of a persons sleep patterns

A sleep disorder, or somnipathy, is a medical disorder of an individual's sleep patterns. Some sleep disorders are severe enough to interfere with normal physical, mental, social and emotional functioning. Sleep disorders are frequent and can have serious consequences on patients' health and quality of life. Polysomnography and actigraphy are tests commonly ordered for diagnosing sleep disorders.

<span class="mw-page-title-main">Insomnia</span> Disorder causing trouble with sleeping

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 distinct possibilities: insomnia disorder (ID) or insomnia symptoms, and many abstracts of randomized controlled trials and systematic reviews often underreport on which of these two possibilities the word refers to.

<span class="mw-page-title-main">Anxiety disorder</span> Cognitive disorder with an excessive, irrational dread of everyday situations

Anxiety disorders are a group of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause physical and cognitive symptoms, such as restlessness, irritability, easy fatigue, difficulty concentrating, increased heart rate, chest pain, abdominal pain, and a variety of other symptoms that may vary based on the individual.

Specific phobia is an anxiety disorder, characterized by an extreme, unreasonable, and irrational fear associated with a specific object, situation, or concept which poses little or no actual danger. Specific phobia can lead to avoidance of the object or situation, persistence of the fear, and significant distress or problems functioning associated with the fear. A phobia can be the fear of anything.

<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.

<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.

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.

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.

<span class="mw-page-title-main">Panic disorder</span> Anxiety disorder characterized by reoccurring unexpected panic attacks

Panic disorder is a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.

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.

Cognitive emotional behavioral therapy (CEBT) is an extended version of cognitive behavioral therapy (CBT) aimed at helping individuals to evaluate the basis of their emotional distress and thus reduce the need for associated dysfunctional coping behaviors. This psychotherapeutic intervention draws on a range of models and techniques including dialectical behavior therapy (DBT), mindfulness meditation, acceptance and commitment therapy (ACT), and experiential exercises.

Trauma focused cognitive behavioral therapy (TF-CBT) is an evidence-based therapeutic approach that aims at addressing the needs of individuals 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 the 1990's. The goal of TF-CBT is to provide psychoeducation to both the victim 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. While originally studied as a treatment for children and adolescents, its use has more recently expanded to include adult patients. Additionally, TF-CBT has been applied to and found effective in treating complex posttraumatic stress disorder (cPTSD).

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.

Pain psychology is the study of psychological and behavioral processes in chronic pain. Pain psychology involves the implementation of treatments for chronic pain. Pain psychology can also be regarded as a branch of medical psychology, as many conditions associated with chronic pain have significant medical outcomes. Untreated pain or ineffective treatment of pain can result in symptoms of anxiety and depression, thus it is vital that appropriate pain management occur in a timely fashion following symptom onset.

<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.

<span class="mw-page-title-main">Internet-based treatments for trauma survivors</span>

Internet-based treatments for trauma survivors is a growing class of online treatments that allow for an individual who has experienced trauma to seek and receive treatment without needing to attend psychotherapy in person. The progressive movement to online resources and the need for more accessible mental health services has given rise to the creation of online-based interventions aimed to help those who have experienced traumatic events. Cognitive behavioral therapy (CBT) has shown to be particularly effective in the treatment of trauma-related disorders and adapting CBT to an online format has been shown to be as effective as in-person CBT in the treatment of trauma. Due to its positive outcomes, CBT-based internet treatment options for trauma survivors has been an expanding field in both research and clinical settings.

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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