Cognitive Behavioral Therapy for Insomniaby Michael Rack, M.D. Health Professional
Cognitive Behavioral Therapy for Insomnia (CBT-I) is an effective treatment for most cases of primary insomnia, and for selected cases of secondary insomnia. There are a variety of behavioral and psychological treatments that comprise CBT-I, including stimulus control therapy, relaxation training, biofeedback, paradoxical intention, sleep restriction therapy, sleep hygiene education, and cognitive therapy. Usually several of these treatments are combined.
Common sleep hygiene tips include avoiding alcohol, caffeine, and large meals close to bedtime. Sleep hygiene lists are found in most publications about insomnia. Good sleep hygiene does improve sleep quality. However, many of these tips have already been tried by patients by the time they seek medical attention, so sleep hygiene education by itself is not considered to be adequate medical treatment of insomnia. Sleep hygiene education is a component of most treatment courses of CBT-I.
Besides sleep hygiene education, the most common behavioral treatments of insomnia are stimulus control therapy and sleep restriction therapy. Stimulus control therapy was designed to counteract the negative psychological conditioning that occurs in insomnia. Sleepless nights cause the insomniac to mentally associate the bed with not sleeping. To counteract this negative association, the patient is instructed to get out of bed if he is unable to fall asleep in 10-20 minutes (either initially or after an awakening).
To help reestablish the psychological association between bed and sleep, the insomniac is instructed to avoid other activities such as television watching in bed. For practical reasons sex in bed is allowed, though theoretically sexual activities in bed weaken the association between bed and sleep.
In sleep restriction therapy, the time in bed is reduced. Many insomniacs spend excessive time in bed in attempt to catch up on lost sleep. They also try to nap during the day. These habits can lead to fragmented sleep at night. Reducing time spent in bed usually leads to more consolidated nocturnal sleep.
A set wake up time is crucial to all behavioral treatments of insomnia.
CBT-I concepts can be difficult to understand in the abstract, so let me relate this example: Mrs. M is a 45 year old woman with insomnia for several years. A thorough medical evaluation found no secondary cause of insomnia. She occasionally drinks 1 or 2 glasses of wine an hour before bedtime. She gets into bed at 8 or 9 pm and gets up at 6 am on weekdays for work. Mrs. M estimates that she only gets 5 hours of sleep and spends many hours in bed awake. She states she gets her best sleep from 4-6 am.
On weekends she is able to sleep in and often doesn't wake up until 8 or 9 am. Her physician instructed Mrs. M to get out of bed at 6 am every day and avoid naps. She was instructed to get into bed at midnight. This change in sleep schedule restricted the opportunity for sleep and resulted in mild sleep deprivation, which over a period of a week led to fewer awakenings.
As her sleep improved, her bedtime was gradually moved to an earlier time but the wake up time was kept at 6 am. In addition to sleep restriction therapy, she was also educated about good sleep hygiene and advised to avoid alcohol within several hours of bedtime.