Cognitive behavioral therapy for insomnia

Cognitive behavioral therapy for insomnia (CBT-I) is a method for treating insomnia without (or alongside) medications.

Components of CBT-I

Stimulus control

Stimulus control^[1] aims to associate the bed with sleeping and limit its association with stimulating behavior. People with insomnia are guided to do the following:

• go to bed only when they are tired
• limit activities in bed to sleep and sex
• get out of bed at the same time every morning
• get up and move to another room when sleep-onset does not occur within 10 minutes

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

Sleep restriction^[2] is probably the most controversial step of CBT-I, since (true to its name) it initially involves the restriction of sleep. Although it is counterintuitive, it is a crucial and very 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. 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 his or her TIB.

Sleep Efficiency = (Total Sleep Time / Time In Bed) x 100

• First, Time In Bed is restricted to the Total Sleep Time
• Increase or decrease TIB weekly by only 20-30 min
• Increase TIB if SE >90%
• Decrease TIB if SE <80%

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. 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.

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 ^{[1] [3] [4] [5]} 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 don't 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 necessarily true.

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.

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.^[6] 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 MDD and comorbid insomnia helped to alleviate symptoms for both disorders.^[7] The overlap between mood- and sleep disorders is just starting to be rigorously explored,^[8] but the efficacy of CBT-I for MDD and bipolar disorder looks promising.

Efficacy

• Patients who have undergone CBT-I spend more time in stages 3 and 4 sleep (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 6 months later, whereas zopiclone had no lasting results.^[3]

• 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. Surprisingly, CBT-I by itself was no less effective than CBT-I paired with Ambien.^[9]

• For a thorough review of CBT-I and its effectiveness, see the Morin, Bootzin, Buysse et al. article referenced below.^[1]

• For a meta-analysis of cognitive behavioral therapy for insomnia, see the Morin et al. article referenced below.^[10]

References

1. ^ ^{a b c} Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998–2004). Sleep. 2006;29:1398-1414.
2. ^ Spielman, A. J., Saskin, P., & Thorpy, M. J. (1987). Treatment of chronic insomnia by restriction of time in bed. Sleep, 10, 45–56.
3. ^ ^{a b} Sivertsen et al., Cognitive Behavioral Therapy vs Zopiclone for Treatment of Chronic Primary Insomnia in Older Adults, JAMA, June 28, 2006—Vol 295, No. 24
4. ^ 2007: An open trial of cognitive therapy for chronic insomnia. Behavioral Research and Therapy, 45, 2491-2501.
5. ^ 2002: A cognitive model of insomnia. Behavior Research and Therapy, 40, 869-93.
6. ^ Benca, Obermeyer, Thisted, & Gillin, Arch Gen Psychiatry. 1992;49(8):651-668.
7. ^ Manber et al., Cognitive Behavioral Therapy for Insomnia Enhances Depression Outcome in Patients with Comorbid Major Depressive Disorder and Insomnia, Sleep. 2008 April 1; 31(4): 489–495.
8. ^ Kennaway, David J. (2010) Review: Clock genes at the heart of depression. Journal of Psychopharmacology Vol. 24 No. 5
9. ^ Karl E. Miller, M.D. (July 2005). "Cognitive Behavior Therapy vs. Pharmacotherapy for Insomnia". American Family Physician.
10. ^ Morin et al., Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry 1994; 151:1172-1180