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Cognitive Behavioral Therapy for Insomnia (CBT-I)

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Presentation on theme: "Cognitive Behavioral Therapy for Insomnia (CBT-I)"— Presentation transcript:

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 Difficulties
90 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?

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