Introduction to Behavioral Sleep Medicine (CBT-I)TREATMENT OF INSOMNIA THROUGH COGNITIVE BEHAVIORAL THERAPY

NANCY J. LIN, PH.D.

GO TO SLEEP SAN DIEGO

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What is Sleep?

Definition of sleep (n) state of not being awake: a state of partial or

full unconsciousness in people and animals, during which voluntary functions are suspended and the body rests and restores itself, or a period spent in this state

associated with decreased mobility, closed eyes, a characteristic species-specific sleeping posture, reduced response to external stimulation, quiescence, increased reaction time, elevated arousal threshold, impaired cognitive function, and a reversible unconscious state.

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What is Insomnia?

Inability to obtain an adequate amount or quality of sleep.

Types of Insomnia: Early insomnia – increased sleep latency (trouble falling asleep)

Middle insomnia – disrupted sleep (trouble staying asleep)

Late insomnia – insufficient duration of sleep (waking up too early)

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Chronic Insomnia

Less than 4.5 of sleep per night for prolonged periods is associated with: Increased urge to fall asleep

Irritability

Slowed thinking

Increased reaction time

Symptoms similar to ADHD

Impaired growth hormone secretion

Increased risk of obesity and type 2 diabetes

Impaired immune function

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How does insomnia develop?

Predisposing factors Genetics

Environment

Social influences

Precipitating factors Stressful or life-changing events

Perpetuating factors Behavioral compensation for lost sleep

Conditioned arousal Entrenched conscious or unconscious sleep-sabotaging habits

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Behavioral Sleep Medicine (BSM)Overview

Evaluation

Is this Primary Insomnia?

Rule-out other conditions

Possible co-occurring conditions

Referrals

What is the nature of this person’s insomnia?

CBT-I

Primary Components

Stimulus Control Therapy (SCT)

Sleep Restriction (SRT)

Sleep Hygiene Education

Second-Line Interventions

Cognitive Therapy

Relaxation Training

Phototherapy

Sleep Compression

Imagery Rehearsal Therapy for Nightmares

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Stimulus Control Therapy (SCT)

Indication Recommended for sleep initiation and maintenance problems

Rationale Chronic insomnia is often characterized by a breakdown of the

healthy association of the bed/bedroom with rapid, well-consolidated sleep

SCT’s mode of action Limits the amount of a time a person may spend in bed

Limits the types of behaviors in which a person may engage in bed/ the bedroom

Efficacy Most effective component of CBT-I. Can be effective as a stand-

alone therapy for many insomnia sufferers.

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Sleep Restriction Therapy (SRT)

Indication Recommended for sleep initiation and maintenance problems

Rationale Chronic insomnia sufferers are unable to get the appropriate

amount of consolidated sleep at the appropriate time of day. They may benefit from a “hard reset” of their sleep schedule.

SRT’s mode of action Limits the amount of a time a person may spend in bed to

their average sleep time.

Sets a sleep schedule that is more adaptive to the person’s lifestyle.

Efficacy Very effective. Generally not used alone but considered a

critical component of CBT-I.

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Sleep Hygiene Education

Indication Recommended for sleep initiation and maintenance problems

Rationale Chronic insomnia sufferers often overcompensate for lost sleep by

engaging in behaviors that over time become sleep-sabotaging habits.

Sleep Hygiene Education’s mode of action Bring to awareness about habits that can contribute to chronic

insomnia

Empower the person to engage in actions that are healthy and sleep-promoting

Effectiveness Not considered an effective stand-along therapy for chronic insomnia

Increases the effectiveness of treatment when combined with SCT and SRT

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Cognitive Therapy

Indication Recommended for whose insomnia is worsened by excessive or

intrusive worry about the negative consequences of sleep problems or other stressors.

Rationale Chronic insomnia sufferers who have negative thoughts and beliefs

about their condition typically do worse than those who feel hopeful and believe they can get better.

Cognitive Therapy’s modes of action Cognitive Restructuring

Paradoxical Intent

Problem-solving

Efficacy Gold standard therapy for treatment of anxiety-related problems

Catch itCheck it

Change it

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Relaxation Training

Indication Recommended for insomnia sufferers who view their insomnia as an

“inability to relax”

Rationale Chronic insomnia can arise from an overactive sympathetic nervous

system.

Relaxation Training’s modes of action Progressive Muscle Relaxation (PMR)

Diaphragmatic Breathing

Guided Imagery

Efficacy Considered effective adjunctive therapy for anxiety-related problems

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Phototherapy

Indication Recommended for insomnia sufferers who experience a phase-delay

component (go to bed late, get up late)

Rationale Chronic insomnia sufferers can experience a disruption in their

circadian rhythm and have dysregulation in the timing of melatonin production

Phototherapy’s mode of action Lightbox therapy

Increased exposure to natural sunlight

Efficacy Considered effective adjunctive therapy for anxiety-related problems

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Sleep Compression

Indication Recommended for sleep initiation and maintenance problems

Alternative to SRT for those who cannot tolerate sudden reduction in total sleep time

Rationale Chronic insomnia sufferers are unable to get a healthy amount of consolidated

sleep at the appropriate time of day. They may benefit from a “slow reset” of their sleep schedule.

Sleep Compression’s mode of action Gradually limits the amount of a time a person may spend in bed to their average

sleep time.

Over time, sets a sleep schedule that is more adaptive to the person’s lifestyle.

Efficacy Generally works more slowly than SRT but is equally efficacious.

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Typical Course of BSM

Components Evaluation

90-minute individual session (more if referral is needed)

Format: Individual or group sessions

5 to 8 x 50-minute weekly individual sessions

8 x 90-minute weekly group sessions

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Benefits of BSM

Non-addictive, no drug interactions

May be effective in cases where insomnia is resistant to other interventions due to patient’s habits, attitude or other behavioral factors

Patient demands time and resources that are not well served in current treatment setting

Can be used as an adjunct to other treatments Not recommended for patients also on pharmacological therapy for

insomnia.

Can be a less-stigmatizing first step towards further psychological treatment for co-occurring mental health issues Referrals

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About the Clinician

Nancy J. Lin, Ph.D. is a California licensed clinical psychologist (PSY23741) and member of American Academy of Sleep Medicine Clinical Experience and Training

Staff Psychologist at a military hospital specializing in sleep problems in combat veterans with PTSD

Staff Psychologist at VA San Diego Healthcare System

Assistant Professor at UCSD Medical School Psychiatry Department

Postdoctoral training at VA San Diego Healthcare System

Trained in CBT-I by Sean Drummond, Ph.D., clinical psychologist and BSM Specialist

American Psychological Associated accredited internship training

Education Ph.D. and MA in Clinical Psychology from UMass Boston

BA in Psychology from UC Berkeley

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About the Practice

Availability Current openings in the evening

Now accepting new patients for BSM

Location Convenient Mission Valley location

7860 Mission Center Court, Suite 209, San Diego, CA 92108

Co-located* with Center for Stress and Anxiety Management (CSAM)

Contact info:

Telephone – (619) 618-2020

Email – Nancy.Lin@GotoSleepSD.com

* Separate entity

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References

Perlis, M., Aloia, M., & Kuhn, B. (2011). Behavioral Treatments for Sleep Disorders. Elsevier, Amsterdam.

Perlis, M. L., Jungquist, C., Smith, M.T., & Posner, D., (2005). Cognitive Behavioral Treatment of Insomnia. Springer Science + Business Media, LLC, New York.

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