Rationale and Indications

The main targets of CBT include factors (psychological, behavioral, cognitive) that perpetuate or exacerbate sleep disturbances. Such features may include sleep scheduling factors, poor sleep habits, conditioning, hyperarousal, faulty beliefs and excessive worrying about sleep, and inadequate sleep hygiene practices (see Chapters 77 and 78).^2,4,8–10 Although numerous factors (e.g., life events, medical illness) can precipitate insomnia, when it becomes a persistent problem, psychological and behavioral factors are almost always involved in perpetuating it over time, hence the need to target those factors directly in treatment. CBT does not seek, however, to alter personality traits that might predispose to insomnia. Insight-oriented psychotherapy focusing on such predisposing variables may be useful in some patients, but there has been no controlled evaluation of its efficacy specifically for insomnia.

The main indication for CBT is persistent insomnia, both for primary insomnia and insomnia occurring in the context of another medical or psychiatric disorder. It is also indicated for insomnia in older and in younger adults, and for patients with prolonged use of hypnotics, although chronic use of hypnotics can interfere with CBT’s objectives. There is no absolute contraindication to using CBT.

Sleep restriction is contraindicated in patients with a history of seizures, some parasomnias (e.g., sleepwalking), or bipolar illness because sleep restriction can lower the threshold for a seizure or sleepwalking episode and might exacerbate a manic episode. Sleep restriction should also be used cautiously with patients who need to drive or operate heavy equipment and with those who might otherwise be at increased risk for falling asleep during the day.

Some stimulus control procedures (e.g., getting out of bed when unable to sleep) should be used with caution with the frail elderly, who may be at risk for falls when getting out of bed.¹¹

Sleep Restriction

There is a natural tendency among persons with insomnia to increase the amount of time they spend in bed simply to rest or provide more opportunity for sleep. Although this strategy may be effective in the short term, in the long run it is more likely to result in fragmented and poor-quality sleep.

Sleep restriction therapy consists of curtailing the amount of time spent in bed as close as possible to the actual amount of time asleep.¹² Time in bed is subsequently adjusted on the basis of sleep efficiency (ratio of total sleep time per time in bed × 100%) for a given period, usually the preceding week. For example, if a person reports sleeping an average of 6 hours per night out of 8 hours spent in bed, the initial prescribed sleep window (i.e., from initial bedtime to final arising time) would be 6 hours. The subsequent allowable time in bed is increased by about 15 to 20 minutes for a given week when sleep efficiency exceeds 85%, it is decreased by the same amount of time when sleep efficiency is lower than 80%, and it is kept stable when sleep efficiency falls between 80% and 85%. Adjustments are made periodically (weekly) until optimal sleep duration is achieved. Changes to the prescribed sleep window can be made at the beginning of the night (i.e., postponing bedtime), at the end of the sleep period (i.e., advancing arising time), or at both ends. Some variations in implementation might involve changing the time in bed on the basis of a moving average of the sleep efficiency (e.g., the past 3 to 5 days) or changing it on a weekly basis regardless of changes in sleep efficiency.¹³

Sleep restriction improves sleep continuity through two complementary mechanisms: It strengthens the homeostatic sleep drive through a mild sleep deprivation, and it alleviates some of the sleep anticipatory anxiety by changing the patient’s focus of attention (i.e., asking to stay up later rather than going to bed early). To prevent excessive daytime sleepiness, time in bed should not be reduced to less than 5 hours per night, regardless of the number of hours of sleep reported by the patient. This caution is particularly indicated for those whose jobs require operating motor vehicles or who have duties in which drowsiness may be a danger to the patient or others.

Stimulus Control Therapy

Stimulus control therapy¹⁴ involves five instructions designed to reassociate temporal (bedtime) and environmental (bed and bedroom) stimuli with rapid sleep onset and to establish a regular circadian sleep–wake rhythm. These are:

Persons with insomnia often develop apprehension around bedtime and the bedroom and come to associate this particular time of the day and environment with the frustration of being unable to sleep. Over time, the presleep rituals usually associated with relaxation and sleep become cues or stimuli for worrying and wakefulness. This conditioning process can take place over several weeks or months. In addition, many insomniac patients display poor sleep habits that initially emerge as a means of coping with sleep disturbances. For example, poor sleep at night can lead to daytime napping or sleeping late on weekends in an effort to catch up on lost sleep. Such persons might lie in bed for prolonged periods trying to force sleep, only to find themselves becoming more awake. Stimulus-control procedures are designed to recreate a positive association between the presleep rituals and the bedroom environment.

Stimulus control instructions appear quite simple on paper; however, the challenge for clinicians is to foster strict compliance with these instructions. Several consultation visits held on a weekly or biweekly basis are often necessary to assist patients in implementing these behavioral changes. When combined with sleep restriction, some of the stimulus-control procedures may be less relevant or even in conflict (e.g., going to bed only when sleepy, when the prescribed sleep window is fixed). Such situations might occur early on in treatment when time in bed is significantly reduced; as the sleep window is increased, all these procedures become more relevant. Also, daytime napping is usually discouraged in the treatment of insomnia, but a short nap in midday may be permissible in the early phase of sleep restriction, particularly in older adults, if it helps improve compliance with the adjusted sleep window at night. This option is usually phased out by midtreatment.

Relaxation-Based Interventions

Because stress, tension, and anxiety are often contributing factors to sleep disturbances, relaxation is probably the most commonly used intervention for insomnia. The goal of this treatment is to reduce arousal at bedtime or on nighttime awakening. Among the different relaxation interventions, some methods (e.g., progressive muscle relaxation, autogenic training) focus primarily on reducing somatic arousal, whereas attention-focusing procedures (e.g., imagery training, meditation, thought stopping) target mental arousal in the form of worries, intrusive thoughts, or a racing mind.^15,16 Mindfulness therapy is another form of relaxation that has been evaluated in the management of insomnia.¹⁷ Biofeedback is designed to train patients to control some physiologic parameters (e.g., tension, using electromyography) through visual or auditory feedback; despite its popularity in the 1980s, this method is not commonly used today.

Most relaxation procedures are equally effective for treating insomnia. Selection of a particular method (e.g., progressive muscle relaxation versus meditation) should be based on the subtype of arousal (autonomic versus cognitive) interfering with sleep, although these often overlap, as well as on the patient’s preference and skills in learning the technique. There is no formal contraindication to using relaxation, but some patients—those who tend to be perfectionists—might have a paradoxical response and actually become more anxious when trying to relax. The most critical issue is to ensure diligent and daily practice of the selected method for at least 2 to 4 weeks and to keep the focus on reducing arousal rather than on inducing sleep. Professional guidance is often necessary during initial training. Sometimes, it is necessary to implement a more comprehensive stress-management program involving relaxation and other therapeutic components, such as time management and problem-solving training.

Cognitive Therapy

Cognitive therapy for insomnia seeks to alter sleep-disruptive cognitions (e.g., beliefs, expectations) and maladaptive cognitive processes (e.g., excessive self-monitoring, worrying) through socratic questioning and behavioral experiments.^10,18 The basic premise of this approach is that appraisal of a given situation (sleeplessness) can trigger negative thoughts and emotions (fear, anxiety) that are incompatible with sleep. For example, when a person is unable to sleep at night and worries about the possible consequences of sleep loss on the next day’s performance, a spiral reaction is set off that feeds into a vicious cycle of emotional distress, increased arousal, and more sleep disturbance. Likewise, upon night waking, a person may engage in self-monitoring (e.g., clock watching to check how many hours are left in the night) and safety activities (e.g., trying to stop thinking), which can prolong the nocturnal awakenings.⁸

Cognitive therapy is designed to short-circuit the self-fulfilling nature of this vicious cycle through verbal interventions and behavioral homework. Some therapeutic targets for cognitive restructuring include unrealistic expectations (“I must get my 8 hours of sleep every night”), faulty causal attributions (“My insomnia is entirely caused by a biochemical imbalance”), and amplification of the consequences of insomnia (“After a poor night’s sleep, I am unable to function the next day”). There are several key messages to communicate to patients in the context of cognitive therapy:

In addition to these verbal interventions, behavioral experiments can be helpful to change a person’s beliefs about sleep and insomnia. For example, if a patient is convinced that bed rest is a good strategy to conserve energy, a behavioral experiment is designed to test the validity of this belief: The patient is instructed to engage specifically in this strategy (bed rest) on a day following insomnia and, on another day, to engage in the opposite behavior, such as performing a series of activities designed to generate energy after a poor night’s sleep (e.g., exercising, meeting with friends, doing errands). Such homework assignments can be quite effective to change a person’s belief about ways to preserve or generate energy in the context of insomnia.¹⁹

Additional cognitive strategies may be useful in treating insomnia. For instance, paradoxical intention is a procedure designed to eliminate performance anxiety. In the context of insomnia, any attempt to control or induce sleep voluntarily is likely to generate performance anxiety and to delay sleep onset. With paradoxical intention, the patient is instructed to remain passively awake and to give up any effort (intention) to fall asleep, the rationale being that good sleepers do not make any effort to fall asleep. To minimize worrying and mental activity interfering with sleep, it is also helpful to instruct patients to set aside a time and a place (other than bedtime and the bedroom) to write down thoughts or worries of the day and plans for the next day. Imagery techniques can also be useful to block out such unwanted presleep thoughts.²⁰

Sleep Hygiene Education

Sleep hygiene education is intended to provide information about lifestyle (diet, exercise, substance use) and environmental factors (light, noise, temperature) that might either interfere with or promote better sleep.¹⁶ It could also include general sleep-facilitating recommendations, such as allowing enough time to relax before bedtime, avoiding clock watching, and maintaining a regular sleep schedule. Some of these instructions overlap with other behavioral procedures. Sleep hygiene guidelines include:

Although inadequate sleep hygiene is rarely the primary cause of insomnia, it can potentiate sleep difficulties caused by other factors or can interfere with treatment progress. Even when patients are well informed about the detrimental impact of poor sleep hygiene, they might not maintain good sleep hygiene practices. Thus, it is important to directly address these factors in therapy. On the other hand, although sleep-hygiene education may be helpful for mild insomnia, it is rarely sufficient for more severe insomnia, which requires more directive and potent behavioral interventions.^21,22

A didactic approach can also be used to provide basic information about normal sleep, individual differences in sleep needs, and changes in sleep physiology with aging. This information is useful to help some patients distinguish clinical insomnia from normal (age-related) sleep disturbances. Such knowledge can prevent excessive worry and concern, which can themselves lead to clinical insomnia.

Multifaceted Cognitive Behavior Therapy

Single interventions described to this point are not incompatible with each other and can be combined effectively. Multicomponent therapy is becoming the preferred approach to treating insomnia. In a systematic review of the literature, 26 of 37 clinical studies conducted between 1999 and 2004 had evaluated a multicomponent approach for persistent insomnia.²² This approach typically included a behavioral (stimulus control, sleep restriction, and, sometimes, relaxation), a cognitive (cognitive restructuring therapy), and an educational component (sleep hygiene), hence the term cognitive behavior therapy (CBT). This multimodal approach is appealing because it addresses different insomnia features with different therapeutic recommendations, which is consistent with a multidimensional etiologic model of insomnia (see Chapter 78).^2–48