The ABCs of CBT for Insomnia:

CBT-I for the Non-Psychologist

Michael Schmitz, PsyD, LP, CBSMClinical Director, Behavioral Sleep Medicine Services

Allina Health

612-832-7920

Michael.schmitz@allina.com

Explain model of development of insomnia that serves as basis for cognitive-behavioral therapy for insomnia (CBT-I)

Describe CBT-I modalities Describe major behavioral

elements of CBT-I Discuss clinical challenges of

each behavioral intervention

Goals of Presentation

40-70 million Americans affected by intermittent or chronic insomnia

Chronic Insomnia estimated to be between 9-12%

5-25% of persons with insomnia seek treatment 75% of insomnia is treated by primary physicians Increased health care utilization Increased work absenteeism Predictor of depression

Impact of Insomnia

Who’s at risk? Patients with medical/psychiatric

conditions

Shift Workers

Women

Older individuals

Impact of Insomnia

Three Factor Model of Insomnia

Increased arousal level Medical and mental

health factors Genetic predisposition

Predisposing factors

Life stress Trauma Medical stressor Medication side effect

Precipitating factors

Sleep hygiene issues Excessive time in bed Sleep-incompatible behavior in

bed Cognitive arousal, worry about

sleep, sleep effort Conditioned arousal – “classical

conditioning”

Perpetuating factors

Benefits of sleep medications inflated and offset by potential harm. (Buscemi, et al. (2005)

Meta-analysis of hypnotic use (Glass, J, et al. (2005) concludes that modest benefits outweighed by risk of harm in older adults

CBT-I compares favorably with sleep medication with behavioral treatments of equal or greater effectiveness and with sustained improvement at 12 and 18 months.

Sleeping pills present risk for falls and adverse health events in older adults.

Why CBT for Insomnia?

Drug dependent insomnia

Hauri, P, 1996

Meta-Analysis of CBT-I Results

Statistical Significance

SOL reduced 44 ► 24 min.

WASO reduced 79 ►40 min.

Awakenings reduced 2 ►1

TST increased from 316 to

358 min

SE increased from 57% to

83%

Okajima I, et al (2011) Sleep and Biological Rhythms, 9:24-34.

Clinical Significance

Subjective rating of

improved sleep quality.

50% improvement in target

symptoms

Depression scores reduced

Reduced hypnotic use

Evidence of sustained

improvement at 6 and 12

mo.

Lack of provider and patient awareness

Techniques time intensive compared to

prescribing meds

Lack of clinicians with skills/training to

implement treatment

Limited research on what combination of

strategies optimize effectiveness for

particular populations.

Why Aren’t Behavioral Interventions Used more

frequently?

Not all patients need office-based CBT-I Key is to match patient’s clinical

presentation with appropriate intervention

Acute insomnia due Chronic insomnia to poor sleep habits associated with

multiple medical, psychiatric and/or sleep disorder

comorbidities

Matching Intervention to Patient

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Increasing Complexity, Acuity, Failure to Respond Increasing Complexity, Acuity, Failure to Respond

CBT-I CBT-I provided by provided by Primary Care Primary Care Psychologists Psychologists

with CBT-I with CBT-I TrainingTraining

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Severity Index

Severity IndexWeb-Web-basedbasedCBT-ICBT-I

Least Least intensive intensive

interventiointerventions ns

Patient Patient instructioninstruction

, Self – , Self – help bookshelp books

Stimulus control therapy (SCT) Sleep restriction therapy (SRT) Cognitive therapy Relaxation training Sleep hygiene instruction Combined interventions are considered more

effective than single interventions.

Types of Cognitive-Behavioral Interventions for Insomnia

The sleep log as key tool for self-monitoring and treatment

Bedtime vs. SLWASO vs SLNapsRemind clients that all data is a

“guesstimate”Adherence – fit sleep log to

patient

Teaching clients how to keep track of their sleep

Assumption: Bed space associated with sleep incompatible behaviors/experience as individual tries to decrease physical and cognitive arousal associated with sleep effort.

Goal: Re-associate bedroom with sleep. May influence homeostatic and circadian sleep mechanisms.

Findings: Positive results for all sleep parameters. Considered by the American Academy of sleep medicine to be the first-line behavioral treatment for chronic insomnia

Stimulus Control Therapy (SCT)

Technique:1. Go to bed only when sleepy2. Use bedroom only for sleep and sex.3. Get out of bed if awake for more than 15-

200 minutes and go to another room..4. Return to bed when sleepy. Repeat

steps 3 and 4 as often as necessary.5. Maintain consistent wake time6. Avoid napping

Stimulus Control Therapy

Finding the best wake time. Method alone does not specifically

address the effect that maladaptive beliefs and cognitions may have on arousal, anxiety, and maintenance of wakefulness.

Individuals with mobility and pain issues may find instructions difficult to follow.

Prescribing a “sleep window” with SCT

Stimulus Control Treatment Challenges

Assumption: Individual spends excessive time in bed in an effort to cope with sleep loss and obtain more sleep. This may affect the homeostatic drive mechanism of sleep

Goal: Promote mild sleep deprivation, increase homeostatic pressure for sleep

Findings: Good results for most sleep parameters. Used in most multiple component CBT therapies

Sleep Restriction Therapy (SRT)

Technique:

1. Cut time in bed (TIB) to amount of time sleeping.

2. Increase TIB when sleep efficiency is >90% .

3. Decrease TIB when sleep efficiency is <85%

4. Keep hours same with sleep efficiency 85%--90%5. Adjust schedule weekly until optimum duration of sleep achieved.

Sleep Restriction Therapy

Sleep Restriction Therapy Challenges

Patients often equate extended time in bed with the opportunity to get more sleep and fear sleep restriction with be counterproductive to their effort to improve their sleep.

Preparing patients for the intervention Educating about improving sleep consolidation Managing sleep deprivation side effects

Assumption: High levels of somatic and cognitive arousal prevent sleep initiation and maintenance.

Goal: Reduce arousal with specific techniques

Findings: Most demonstrate significant improvements in reducing problems with sleep initiation. May be less effective than stimulus control

Relaxation Training

Techniques:PMR - tensing and relaxing muscle groups

Biofeedback - audio or visual feedback

Deep BreathingGuided Imagery

Relaxation Training

Assumption: Poor sleepers have worse sleep habits than good sleepers.

Goal: Improve environmental factors and health behaviors

Findings: Limited benefits used alone. Often used as placebo control in CBT-I RCTs. Used in conjunction with other behavioral therapies in most CBT protocols.

Sleep Hygiene Instruction

1. Avoid alcohol, nicotine, caffeine 4-6 hours before bed.2. Avoid a visible bedroom clock with a lighted dial3. Establish a relaxing bedtime routine4. Establish a regular sleep schedule5. Get regular exercise6. Make sure bedroom in comfortable,

cool, cark and quiet.

Sleep Hygiene Instructions

Assumption: Maladaptive thoughts produce stress and arousal affecting sleep

Goal: Alter faulty beliefs about sleep to reduce emotional distress. Identify beliefs about sleep that are

incorrect Challenge their truthfulness Substitute realistic thoughts

Cognitive therapy

Misconceptions about causes of insomnia “Insomnia is a normal part of aging.”

Unrealistic expectations re: sleep needs “I must have 8 hours of sleep each night.”

Faulty beliefs about insomnia consequences “Insomnia can make me sick or cause a mental breakdown.”

Misattributions of daytime impairments “I’ve had a bad day because of my insomnia.” “I can’t have a normal day after a sleepless night.”

Maladaptive beliefs about sleep

Techniques require psychological insight and homework

Thought-stopping does not workMay be resistance to cognitive

homeworkPatient education is not cognitive

therapy though accurate patient information is part of it.

Challenges in Cognitive Therapy

Multi-Component CBT for Insomnia

Assumption: Perpetuating factors and increase psychophysiological arousal affect intrinsic sleep promoting processes.

Goal: Identify primary factors contributing to maintenance of insomnia and apply appropriate cognitive-behavioral components to reduce arousal and promote behaviors that are sleep compatible

Findings: Most clinician -based CBT-I interventions are multi-component and in comparison trials with pharmacological intervention have demonstrated equal or greater efficacy.

Thank you!