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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
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
Allina Health BSM CBT-I ModelP
opu
latio
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erve
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Po
pula
tion
Ser
ved
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
Regional Regional BSM Certified BSM Certified PsychologistsPsychologists
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!