Cognitive Behavioral Treatment for Insomnia
A diagnosis of Insomnia Disorder is utilized when one’s predominant complaint is difficulty initiating and/or maintaining sleep. Studies estimate that approximately 6-10% of adults meet criteria for Primary Insomnia, further characterized by:
- The sleep disturbance lasts at least one month with the main complaint of dissatisfaction with initiating and/or maintaining sleep or non-restorative sleep that is associated with significant distress and impairment of daytime functioning.
- Physical tension or agitation while attempting to sleep, commonly marked by increased muscle tension, rapid heart rate, sweating, and/or restlessness.
- A pattern of sleep interfering thoughts and reactions connected to the bedroom while attempting to sleep, such as feeling more awake upon entering the bedroom or having the thought “I won’t sleep at all tonight”.
While no specific criteria have been established as an adequate number of hours of sleep, Insomnia is a diagnosis based on one’s complaint and impaired daytime functioning. Frequent aspects of daytime impairment include fatigue, irritability, problems with attention/concentration, and distress regarding getting adequate sleep.
Often times, short-term insomnia occurs as a normal and possibly even adaptive response to a significant life stressor. Certain patterns of thought and behavior in reaction to this short-term sleep difficulty can exacerbate the problem, turning the insomnia into a more chronic condition. These reactions include the development of negative and worrisome thoughts about sleep, maladaptive sleep behaviors, compensatory behaviors such as allotting more time for sleep or using alcohol or drugs to induce sleep, as well as overall daily stress.
Negative Sleep Thoughts/Cognitions
People with chronic insomnia often experience negative and worrisome thoughts regarding sleep that can have a significant negative impact on sleep. Some examples of negative sleep thoughts include:
- “I’m going to toss and turn all night.”
- “I must get eight hours of sleep.”
- “I’ll never be able to work tomorrow.”
- “There’s something wrong with me.”
- “I hate bedtime.”
- “I didn’t sleep at all last night.”
- “I can’t sleep without a sleeping pill.”
Such negative thoughts regarding sleep can increase feelings of anxiety, frustration, and stress. These thoughts are often times automatic, maladaptive, and make it more difficult to fall asleep.
Maladaptive Sleep Behaviors
In an attempt to cope with short-term insomnia, people may develop sleep habits that ultimately serve to create chronic insomnia. Such habits include:
- Taking naps.
- Attempting to relax in bed by reading or watching television.
- Using alcohol or drugs to promote sleep or increased caffeine to combat daytime fatigue.
- Reducing physical activity and exercise due to fatigue.
- Extending sleep opportunity by going to bed earlier, sleeping later, or spending more overall time in bed.
Insomnia is maintained by these behavioral habits, as well as certain thoughts and associated physical reactions that we target for change in treatment.
Cognitive Behavioral Therapy (CBT) of Insomnia
Cognitive Behavioral Therapy of Insomnia (CBT-I) is an individualized, structured, and evidence-based form of psychotherapy that targets particular patterns of behavior and thought associated with insomnia. Under this framework, according to Dr. Greenberger “we typically begin treatment by having the patient record a sleep diary for one to two weeks.” The sleep diary will provide the baseline “data” that will assist us measuring and guiding the treatment, as well as evaluating the treatment progress. The sleep diary will also identify behaviors that maintain the insomnia. The most common cognitive-behavioral interventions for insomnia we utilize include:
- Stimulus Control: Considered to be the first line behavioral intervention, stimulus control instructions limit the amount of time one spends in the bedroom while awake and limiting the behaviors engaged in while in the bedroom. This intervention is designed to strengthen the association between the bedroom and bedtime with rapid sleep.
- Sleep Restriction: The clinician and patient work to increase sleep efficiency by going to bed later and waking up at a consistent time in the morning.
- Sleep Hygiene Education: Sleep hygiene instructions address a variety of behaviors and environmental conditions that can influence sleep quality.
- Relaxation Training: Cultivating one’s ability to relax can improve sleep by decreasing daily stress and producing physiological changes associated with sleep. This may include deep breathing, progressive muscle relaxation, and guided imagery.
- Thought Restructuring: Working collaboratively to recognize, evaluate, and change negative and worrisome thoughts and expectations can serve to decrease associated anxiety, depression, frustration, and arousal associated with insomnia.
- Mindfulness/Meditation Training: Developing the skill of being intentionally aware of and immersed in the present moment, with an attitude of compassion and non-judgment can decrease reactivity and distress by shifting one’s relationship to their thoughts and feelings.
Research studies have shown that Cognitive-Behavioral Therapy for Insomnia can be a highly effective treatment, with approximately 75% of individuals in treatment significantly improving sleep onset and maintenance compared to those without treatment. Studies have also shown that those who go through treatment consistently experience at least a 50% reduction in symptoms that is maintained or improved at follow up after discontinuing treatment. A full course of treatment in these research studies ranges from 6-12 sessions.
Bootzin, R.R. (1972). A stimulus control treatment for insomnia. Proceedings of the American Psychological Association 395-396.
Spielman, A.J., Saskin, P., & Thorpy, M.J. (1987). Treatment of chronic insomnia by restriction of time in bed. Journal of Sleep Research & Sleep Medicine, Vol 10(1), 45-56.
Jacobs, G.D., Pace-Schott, E.F., Stickgold, R., & Otta, M.W. (2004). Cognitive-behavior therapy and pharmacotherapy for insomnia. Arch Intern Medicine. 164(17):1888-1896.
Perlis, M.L., Jungquist, C., Smith, M.T., Posner, D. (2005). Cognitive behavioral treatment of Insomnia. New York: Springer.