*Please note that the below information is intended to provide generalized information to help increase awareness and education about CBT-I. It should not be used as a substitute for thorough, individualized assessment, diagnosis, or treatment by a licensed physician or other professional. Your provider may recommend an approach that differs from the below based on your individualized assessed needs.

Key points

• Cognitive behavioral therapy for insomnia (CBT-I) is a safe and effective means of managing chronic insomnia and its effects.
• It is considered a first-line treatment for insomnia, and has been shown to be equally, or more effective, for treatment of insomnia compared to sleep medications.
• It is aimed at altering sleep habits and scheduling factors, as well as misconceptions about sleep and insomnia, that perpetuate sleep difficulties.
• Therapy involves assessment of sleep difficulty and contributing factors, completion of a sleep diary, and assistance in changing the way patients sleep.
• Unlike sleeping medication, CBT-I treats the underlying problem disrupting sleep.
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What is insomnia?

• Insomnia is a common sleep disorder that can make it hard to fall asleep (initial or sleep onset insomnia), to stay asleep, or to wake up too early and be unable to fall back asleep (intermittent or sleep maintenance insomnia).
• Insomnia can impact energy level, mood, physical and mental health, work performance and quality of life.
• Amount of sleep required varies from person to person; most adults need 7-8 hours per night.
• Many adults experience short-term (acute) insomnia, which lasts for days or weeks. This usually stems from acute stressors or a traumatic event.
• Long-term (chronic) insomnia lasts for a month or more. Insomnia may be the primary problem, or it may be associated with other medical conditions or medications.

Symptoms of insomnia

• Difficulty falling asleep at night
• Waking up during the night
• Waking up too early
• Not feeling well-rested after a night's sleep
• Daytime tiredness or sleepiness
• Irritability, depression or anxiety
• Difficulty paying attention, focusing on tasks, or remembering things
• Increased errors or accidents
• Ongoing worries about sleep

Diagnosis

1. Physical Exam

This may be done to look for signs of medical problems that may be related to insomnia and to determine the cause. A blood test may be done to check for thyroid problems, or other conditions that may be associated with poor sleep.

2. Sleep Habits Review

In addition to asking sleep-related questions, patients may complete a questionnaire to determine sleep-wake patterns and level of daytime sleepiness. Patients might be asked to keep a sleep diary for a couple of weeks.

3. Sleep Study

This may be done if the cause of insomnia is unclear, or if there are signs of another sleep disorder such as sleep apnea or restless legs syndrome. Tests are done to monitor and record a variety of body activities during sleep including brain waves, breathing, heartbeat, eye movements and body movements.

Daily Sleep diary

Patients may be asked to complete a daily sleep diary, which provides a tracking of your sleep schedule which can be used to improve your sleep. Easy to use apps are also available for convenience in tracking as well as education and other resources.

Sample assessment questions your provider may ask:

About insomnia:

1.     How often do you have trouble sleeping, and when did the insomnia begin?

2.     How long does it take you to fall asleep?

3.     Do you snore or wake up choking for breath?

4.     How often do you awaken at night, and how long does it take you to fall back to sleep?

5.     What is your response when you can't sleep?

6.     What have you tried to improve your sleep?

About the patient’s day:

1.     Do you feel refreshed when you wake up, or are you tired during the day?

2.     Do you doze off or have trouble staying awake while sitting quietly or driving?

3.     Do you nap during the day?

4.     What do you typically eat and drink in the evening?

5.     More assessment questions

About bedtime routine:

1.     What is your bedtime routine?

2.     Do you currently take any medications or sleeping pills before bed?

3.     What time do you go to bed and wake up? Is this different on weekends?

4.     How many hours a night do you sleep?

About other issues that may affect sleep:

1.     Have you experienced any recent stressful events?

2.     Do you use tobacco or drink alcohol?

3.     Do you have any family members with sleep problems?

4.     What medications do you take regularly?

Insomnia:

• Insomnia is linked to a number of physical and mental health disorders.
• Ongoing lack of sleep increases risk of health conditions such as high blood pressure, heart disease, diabetes and chronic pain.
• Some medications, including over-the-counter medications, can contribute to insomnia (e.g., those containing pseudoephedrine).
• Insomnia is unlikely to remit without treatment.      

Treatment for insomnia

• Sleep medications can be an effective short-term treatment —they may provide immediate relief during a period of high stress or grief. Some newer sleeping medications have been approved for longer use. But they may not be the best long-term treatment for insomnia.
• CBT-I may be a good treatment choice for patients with long-term sleep problems, for those with greater concern or risk about becoming dependent on sleep medications, and for patients for whom medications do not work, or who do not tolerate medications.
• Unlike pills, CBT-I addresses the underlying causes of insomnia rather than just relieving symptoms. It takes time and effort, however, to be effective.
• In some cases, a combination of sleep medication and CBT-I may be the best approach.

CBT-I benefits

• CBT-I can help people with primary insomnia as well as those with physical problems such as chronic pain, or mental health disorders such as depression and anxiety.
• There is no evidence that CBT-I has adverse side effects.
• Effects of treatment seem to last.

Components of Cbt-I

1.     Sleep Restriction Therapy

2.     Stimulus Control Instructions  

3.     Sleep Hygiene Education

4.     Sleep Environment Using Senses

5.     Cognitive Therapy

6.     Relaxation Training

7.     Paradoxical Intention

8.     Relapse Prevention

Sleep Restriction Therapy

• Patients are coached to stay out of bed when awake.
• Eliminate daytime napping.
• Bedtime is altered so they do not go to bed too early.
• Patients may experience some sleep deprivation early in treatment.
• Once sleep has improved, time in bed is gradually increased.
• Caution must be exercised with patients with conditions such as bipolar disorder/history of mania.

Stimulus Control Instructions 

• Patient’s sleep habits are altered by pinpointing different behaviors that may be prohibiting initiation and maintenance of sleep.
• Patients are coached to set a consistent bedtime and wake time, even on weekends.
• Patients are taught to reserve time in bed for sleep and sex only.
• Patients are coached to leave the bedroom if they cannot fall asleep within 20 minutes and to return to bed only when they feel sleepy.

Sleep Hygiene Education

• Patients are taught do’s and don’ts to promote sleep.
• Sleep environment is targeted.
• Lifestyle & behavioral changes such as avoiding caffeine, alcohol and tobacco before bedtime; eliminating clock watching; getting regular daytime exercise; and avoiding exercise or work near bedtime are taught.
• This education is most helpful when it is individually tailored to an analysis of the patient's sleep/wake behaviors.
• Review medications that may be interfering with sleep.

Sleep environment

• Your bedroom is your sanctuary from the stressors of the day.
• It should look and feel like a sanctuary!
• Use your senses to create the best environment for sleep.

Sight

• Create a dark bedroom. Eliminate artificial lights from inside and outside sources, which can send wake-up messages to the brain, suppressing the production of the sleep-inducing hormone melatonin and making it harder to fall and stay asleep.
• If you go to the bathroom during the night, do so by nightlight, instead of turning on stronger overhead lights.
• Keep electronics (tv, computers, cell phones) out of the bedroom and turn them off for at least an hour before bed. Create an evening wind-down time by reading a book.
• Eliminate clutter in the bedroom. Create a clean, pleasing and restful space. Select wall colors, art and bedding that elicit warmth and calm.
• Light therapy may be used to push back a patient’s internal clock for those who struggle with falling asleep too early and then awakening too early.

Hearing

• Eliminate noise, or use white noise (a constant soothing sound from a white noise machine, fan, or air purifier) to mask sound or activity from inside and outside your bedroom.
• Create a soothing wind-down routine at least 30 minutes before bed. Use soft music or even lullabies. Turn off the television.

Taste

• Bedtime snacks containing the amino acid tryptophan—a building block of the sleep-related chemical serotonin—may potentially promote sleep.
• Eat foods such as turkey, eggs, chicken, fish, nuts, a few whole wheat crackers with a small amount of peanut butter, or cereal with milk to help promote sleep. Do not overeat.
• Avoid foods that tax or upset your stomach such as fatty, fried, or spicy foods.
• While alcohol may lead to drowsiness and help falling asleep, it can lessen the quality of sleep and lead to early morning awakening.
• Avoid caffeine after the mid-afternoon.

Touch

• Research suggests that regulation of air temperature impacts sleep; 65 degrees is recommended.
• The feel of your mattress, pillows, sheets, and pajamas affect the quality of sleep. Your mattress should be comfortable and supportive so that you wake up feeling rested. Replace pillows and bedding as needed.
• Keep water near your bed for nighttime thirst/cooling. 

Smell

• Lavender has been shown to decrease heart rate and blood pressure, which may promote relaxation and sleep readiness.
• Keep your room clean and free of unwanted or alerting smells.
• Address allergens with bedding if present.
• Use laundry detergents and other scented products with a pleasing smell, or no smell at all if preferred.

Cognitive therapy

• Teaches patients to recognize and alter beliefs that interfere with ability to sleep.
• This helps patients to control or eliminate negative thoughts and worries that interfere with sleep.

Relaxation training

• This method helps patients learn to calm their mind and body.
• Approaches include meditation, imagery, biofeedback, autogenic training, and progressive muscle relaxation.
• A warm bath, or a massage before bedtime may promote sleep.
• Creating a relaxing bedtime ritual, such as taking a hot bath, reading, soft music, breathing exercises, yoga or prayer may also be helpful.

Paradoxical intention

• Remaining passively awake.
• This involves avoiding efforts to fall asleep.
• Paradoxically, worrying that you can't sleep can actually keep you awake.
• Letting go of this worry can promote relaxation and sleep initiation.
• Help patients adopt an attitude of, “If not tonight, tomorrow night.”

Relapse prevention

• Patients learn how to maintain progress and to prepare for the possibility of a future flare up.
• Patients learn to recognize triggers for insomnia and effective means of coping.
• Patients learn to protect themselves from a relapse by not compensating for sleep loss, starting stimulus control procedures immediately upon encountering resumed difficulty, and re-engaging in sleep restriction if insomnia persists beyond a few days.

Summing it up

• CBT-I is a safe, effective and typically long-lasting treatment for chronic insomnia.
• It may be used in lieu of, or in combination with sleep medications.
• It involves assessment of sleep barriers; altering environmental factors, behavioral habits and cognitions that interfere with sleep; and use of relaxation skills and other strategies to promote sleep.

References

Mayoclinic.org

Sleepfoundation.org

Perlis, M. L.; Jungquist, C.; Smith, M.T.; & Posner, D. (2008). Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide. New York, NY: Springer Science + Business Media.

Looks awesome!rachel cady