1. Cognitive Behavioral Therapy for Insomnia (CBT-I)
Janet Constance, Ph.D.

2. Acknowledgement
Components of this presentation were developed by a group of national VA CBT-I training consultants led by Elissa McCarthy, PhD and sponsored by Mental Health Services, VA Central Office
Rachel Manber, PhD (Lead Developer of VA CBT-I Training Program)
Jason DeViva, PhD
Edward Haraburda, PhD
Christie Ulmer, PhD
Wendy Batdorf, PhD (VA CBT-I Program Coordinator)

3. What Is Insomnia Disorder?
Difficulty initiating sleep, difficulty maintaining sleep, or waking up too early
One or more is present at least 3 times a week, for at least 3 months
Poor sleep occurs despite adequate opportunity and circumstances for sleep
Poor sleep is associated with daytime impairment and distress
Insomnia is marked by difficulty initiating sleep, difficulty maintaining sleep, or waking up too early. Also, sleep may be non-restorative, as in the person doesn’t feel rested, or poor in quality, as in broken up and non-continuous.
The sleep difficulties must occur despite having adequate opportunity and circumstances for sleep. So a person waking up every two hours to feed a baby would not be diagnosed because there is not adequate opportunity to sleep.
Some providers think any episode of poor sleep is insomnia. For diagnosis of insomnia, the sleep problems must occur frequently and must persist for at least three months.
There misunderstanding that insomnia is a symptom, however, it is a disorder if it is has gone on for more than 3 months

4. The Evolution of Insomnia
Insomnia Threshold
Premorbid
Acute
Insomnia
Chronic
No Insomnia
Slide #22
Level 1
Insomnia can evolve. The right combination of predisposing factors and precipitating factors can push a person above the threshold for developing insomnia. An example of this would be a 45 year-old female with a previous history of insomnia. She experiences heightened stress at home, with subsequent anxiety and develops difficulty falling asleep.
Perpetuating factors are those factors which are the result of coping with the insomnia and therefore cause the insomnia to “perpetuate”. These may be viewed as the patient’s attempts to manage insomnia by trial and error. An example of this would be the same patient mentioned previously who after a week of difficulty falling asleep, becomes extremely anxious regarding her situation. Her insomnia may have theoretically run its course in a few weeks, but the heightened level of anxiety at bedtime causes a conditioned insomnia to develop (also known as psychophysiological insomnia). She is now “expecting” NOT to fall asleep…and is virtually unable to relax enough to fall asleep naturally.
Predisposing Factors
Precipitating Factors
Perpetuating Factors
Adapted from Spielman et al., 2000

5. Conditioned Insomnia
With repeated pairing of bed with wakefulness (high arousal)
Tossing
Turning
Sleeplessness
The bed becomes a cue for hyperarousal, rather than sleep
Conditioned Insomnia

6. Prevalence of Insomnia
Approximately 10% - 15% of adults suffer from chronic insomnia
An additional 1/3 have transient or occasional insomnia
Approximately 40% of veterans seen by VA primary care
Approximately 19% of primary care patients in the general community

7. Medical and Psychiatric Comorbidity
Insomnia is frequently comorbid with other medical and psychiatric disorders
Having another psychiatric disorder does not preclude diagnosis and treatment of insomnia disorder
Comorbid insomnia is often persistent
Unlike poor sleep, insomnia disorder does not spontaneously resolve even with successful treatment of a comorbid condition
Insomnia often co-occurs with other medical and mental health disorders.
Increased prevalence rate in:
Depression
PTSD
Substance use
Pain/medical disorders
Aging
Other sleep disorders
This is an important point, because poor sleep is often a symptom of many of psychological disorders. As a result, many providers may see a sleep problem as part of another condition, as opposed to a separate problem that itself requires treatment.
It is important to note that insomnia may not resolve even when the other symptoms remit. CBT-I can be provided while engaging in another therapy.

8. Personal and Societal Costs of Insomnia
Associated with a variety of physical, cognitive, and emotional difficulties
Disrupted sleep has been shown to reduce productivity, increase healthcare costs, and increase the risk of various medical and psychiatric disorders
Poor sleep is associated with several medical conditions (e.g., hypertension, obesity, metabolic syndrome, type 2 diabetes mellitus, all-cause mortality)
The effects of insomnia are wide reaching for the individual and society.
Poor sleep can impact outcomes related to a variety of health conditions such as hypertensions, obesity, metabolic syndrome, diabetes.
Hypertension: ≤5 hours = 2X risk of normal sleepers (Gangwisch et al, 2006).
Obesity (Mainous et al, 1993)
Metabolic Syndrome (Hall et al, 2008, Goodson et al, 2012)
Type 2 Diabetes Mellitus (Ayas et al, 2003)
All-Cause Mortality (Vgontzas, 2010)

9. What is CBT-I? Targeted treatment with CBT-I is effective
Comprehensive approach targeting factors that maintain insomnia
Rooted in the science of sleep/wake regulation and principles of behavior change
Skills-based & brief (4-8 sessions)
Deliverable in individual or group format
Targeted treatment with CBT-I is effective

10. CBT-I Components Technique Aims Stimulus Control
Strengthen bed & bedroom as sleep cues
Sleep Restriction
Restrict time in bed to increase sleep drive and consolidate sleep
Relaxation, buffer, worry time
Arousal reduction
Sleep Hygiene
Address substance, exercise, eating, environment
Cognitive Restructuring
Address thoughts and beliefs that interfere with sleep and adherence
Circadian Rhythm Entrainment
Shift or strengthen the circadian sleep/wake rhythm
SC: A set of instructions designed to reinforce the association between the bed and bedroom with sleep and to re-establish a consistent sleep–wake schedule
SH: “General guidelines about health practices (e.g., diet, exercise, substance use) and environmental factors (e.g., light, noise, excessive temperature) that may promote or interfere with sleep. This may also include some basic information about normal sleep and changes in sleep patterns with aging.” Principles and Practice of SLEEP MEDICINE, 5th Edition, (2011). M.H. Kryger, T. Roth, & W.C. Dement. Elsevier Saunders: St. Louis. Table 79-1, Page 867.
Cognitive therapy: Based on the theory that our emotional experiences are impacted by our beliefs, thoughts, and interpretation of situations. Aims to change beliefs and thoughts that may interfere with sleep and/or adherence. “Psychological approach using Socratic questioning and behavioral experiments to reduce excessive worrying about sleep and to reframe faulty beliefs about insomnia and its daytime consequences. Usually requires a trained and skilled clinician. Additional cognitive strategies may involve paradoxical intention technique to alleviate performance anxiety associated with the attempt to fall asleep.” Principles and Practice of SLEEP MEDICINE, 5th Edition, (2011). M.H. Kryger, T. Roth, & W.C. Dement. Elsevier Saunders: St. Louis. Table 79-1, Page 867.
SRT: To restore normal homeostatic sleep drive. “A method designed by Spielman and colleagues (1983) to restrict time spent in bed (i.e., the sleep window) as close as possible to the actual sleep time, thereby strengthening the homeostatic sleep drive. This sleep window is then gradually increased over a period of a few days or weeks until optimal sleep duration is achieved.” Principles and Practice of SLEEP MEDICINE, 5th Edition, (2011). M.H. Kryger, T. Roth, & W.C. Dement. Elsevier Saunders: St. Louis. Table 79-1, Page 867.

11. CBT-I is Effective Is effective among veterans and general population
70% of patients experience full remission of insomnia or dramatic reduction in symptoms
Improves sleep initiation
Reduces time awake in the middle of the night
Recommended as a first-line of treatment of insomnia
Practice parameters published by the American Academy of Sleep Medicine
NIMH state of the science consensus statement
Based on this and more evidence CBTI is recommended as the first line of treatment for insomnia by ……
AASM guidelines:
Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008; 4(5):487–504.
NIMH statement:
NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults. NIH Consens Sci Statements Jun 13-15; 22(2) 1–30.

12. Comparative Efficacy: CBT-I for Sleep Onset Difficulties
Sleep latency is the amount of time it takes someone to fall asleep. Sleep efficiency is a calculation of the total time spent in bed with the amount of time one sleeps. The greater the sleep efficiency the better quality of sleep (e.g., less interrupted sleep). SE over 85% is considered good sleep.
This chart illustrates the benefit of CBT-I and CBT-I in combination with medication as demonstrating significant benefit beyond medication alone or placebo.
Cognitive Behavior Therapy and Pharmacotherapy for Insomnia A Randomized Controlled Trial and Direct Comparison
Gregg D. Jacobs, PhD; Edward F. Pace-Schott, MA; Robert Stickgold, PhD; Michael W. Otto, PhD
Background: Chronic sleep-onset insomnia is a prevalent health complaint in adults. Although behavioral and pharmacological therapies have been shown to be effective for insomnia, no placebo-controlled trials have evaluated their separate and combined effects for sleep-onset insomnia. The objective of this study was to evaluate the clinical efficacy of behavioral and pharmacological therapy, singly and in combination, for chronic sleep onset insomnia.
Methods: This was a randomized, placebo-controlled clinical trial that involved 63 young and middle-aged adults with chronic sleep-onset insomnia. Interventions
included cognitive behavior therapy (CBT), pharmacotherapy, or combination therapy compared with placebo. The main outcome measures were sleep-onset
latency as measured by sleep diaries; secondary measures included sleep diary measures of sleep efficiency and total sleep time, objective measures of sleep variables (Nightcap sleep monitor recorder), and measures of daytime functioning.
Results: In most measures, CBT was the most sleep effective intervention; it produced the greatest changes in sleep-onset latency and sleep efficiency, yielded the largest number of normal sleepers after treatment, and maintained therapeutic gains at long-term follow-up. The combined treatment provided no advantage over CBT alone, whereas pharmacotherapy produced only moderate improvements during drug administration and returned measures toward baseline after drug use discontinuation.
Conclusions: These findings suggest that young and middle-age patients with sleep-onset insomnia can derive significantly greater benefit from CBT than pharmacotherapy and that CBT should be considered a firstline intervention for chronic insomnia. Increased recognition of the efficacy of CBT and more widespread
recommendations for its use could improve the quality of life of a large numbers of patients with insomnia.
Arch Intern Med. 2004;164:
Jacobs et al., 2004

13. Comparative Efficacy: CBT-I for Sleep Maintenance Difficulties90 80 70 60
CBTI (18)
Minutes awake after sleep onset 50
Temazepam (20) 40
Combined (20) 30
Placebo (20) 20
This graph illustrated how CBT either alone or in combination with temazepam resulted in better initial gains and better sleep two years after the termination of treatment. The effects of CBT extend beyond the termination of the treatment.
There is better long-term efficacy for CBT-I than sleep medications and similar short-term efficacy. Those treated with CBT-I slept better immediately after treatment and those gains were maintained during the 2 years post-treatment
Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA 1999, 17:281(11):
This hallmark study by Morin and colleagues addressed the relative short and long term efficacy of pharmacological and nonpharmacological interventions for insomnia. The study examined the comparative efficacy of four types of treatment in a sample of 78 older adults (cut off age 55 mean age 65) with sleep maintenance insomnia.1 Participants were randomized to receive one of the following four treatments for 8 weeks:
Weekly sessions of CBT provided in groups of four to six patients.
Temazepam 7.5 to 30 mg one hour before bedtime, as needed but at least two to three times per night. Patients met weekly with study physician for 20 minutes.
Combination of the two (Combined)
Pill placebo administered with the same instructions and physician visits as temazepam in a double blind fashion.
The study included a no treatment follow-up phase that lasted 24 months post treatment. The study demonstrates that the three active treatments were similarly effective immediately after the last treatment dose, and that participants receiving CBT either alone or in combination with temazepam maintained their gains better and had better sleep two years after the termination of treatment. 10
Baseline
Post-
3 Months
12 Months
24 months
Treatment
Follow-up
Follow-up
Follow-up
Adapted from Morin et al., JAMA 1999 13

14. How does Sleep Hygiene differ from CBT-I? Sleep Hygiene Education
Avoid stimulants for several hours before bedtime.
Avoid alcohol around bedtime.
Exercise regularly.
Allow at least a 1-hour period to unwind before bedtime.
Keep the bedroom environment quiet, dark and comfortable.
Maintain a regular sleep schedule.
Sleep Restriction
Stimulus Control
Relaxation Training
Cognitive Therapy
Sleep Hygiene Education (except for regular bedtime)
Standard Guidelines
Individualized Multi-Component Intervention
Helps Normal Sleepers Maintain Sleep Health
Treatment for Insomnia Disorder
Preventive
Curative
The Dental Hygienist
The Dentist
Minimal Impact on Insomnia Disorder
Very Effective Insomnia Disorder Treatment
Inactive Condition in Insomnia Research
Active Condition in Insomnia Research
Sleep Hygiene ≠ CBT-I
Dental hygienist: go to for annual cleaning similar
Dentist: go to when you need a root canal (problem is well beyond cleaning). You would not go to your hygienist for the root canal, you would go to a specialist for the focused work.

15. Reasons to Refer for CBT-I
No risk of drug interactions
Minimizes risk for confused arousal upon awakening
Benefits continue (and often increase) even after treatment is discontinued
Brevity and effectiveness of approach
Involves behavioral changes that improve quality of life in general such as winding down before bed
Patients feel empowered by not relying on medication to sleep (increased self-efficacy)
VA CBT for Insomnia Training Program

16. CBT-I and Comorbidities
Experienced CBT-I providers can tailor CBT-I for patients with complex presentations such as:
A history of alcohol and drug abuse (but are not currently abusing)
Comorbid psychiatric or medical conditions, even those known to impact sleep
For example, bipolar disorder, pain conditions, and seizure disorder
Comorbid sleep disorders such as sleep apnea

17. Contraindications CBT-I is NOT indicated when patient:
Does not meets criteria for insomnia disorder (e.g., inadequate time allowed for sleep, shift work disorder)
Is engaged in exposure therapy for PTSD
Is working night or rotating shifts

18. CBT-I Referral Sources
American Board of Sleep Medicine
Society of Behavioral Sleep Medicine
American Academy of Sleep Medicine
National Sleep Foundation
Last year there were only 185 certified behavior sleep medicine specialists nationwide
Ratio of 1 specialist provider for every 470,000 adults reporting insufficient sleep

19. VA CBT-I Resources CBT-I Sharepoint (only accessible by VA providers)
default.aspx
VA CBT-I provider list
CBT-I patient brochures
CBT-I Clinician Factsheet

20. Questions?