1. Application of Principles of CBT-I for Management of Insomnia in Primary Care
Presented by Kyle Davis, PhD

2. Disclosures
I have no relevant financial relationships to disclose

3. Learning Objectives Define the 4-Factor Model of Insomnia
Define the key fundamentals of CBT-I
Explain the application of principles of Sleep Efficiency Therapy and stimulus control in primary care

4. DSM-V Definition and Prevalence of Insomnia
“Dissatisfaction with sleep quality or quantity characterized by difficulty initiating sleep, maintaining sleep, or early morning awakenings that cause significant distress or impairment in daytime functioning and occur at least three nights per week for at least 3 months despite adequate opportunity for sleep.”
Prevalence of chronic insomnia is 15-30% of population

5. Pop Quiz Genetics Learned behavior An overactive mind
Insomnia is typically the result of …
Genetics
Learned behavior
An overactive mind
Chemical imbalance

6. Four Factor Model of Insomnia: Predisposing Factors
Hyperarousability trait
Female gender
Aging
Family history of insomnia
Personal history of insomnia
Presence of a psychiatric disorder
Other sleep disorders
”Night owls” with irregular wake schedules
What are YOUR Predisposing Factors?
Perlis modification of Spielman model

7. Four Factor Model of Insomnia: Precipitating Factors
Increased stress
Changes in work schedule
Traumatic events
Physical health problems
Mental health problems
What were YOUR precipitating factors?
Perlis modification of Spielman model

8. Risk Factors Acute Insomnia + Stress = In other words….
What do people do and/or think when they are having problems with acute insomnia?

9. Four Factor Model of Insomnia: Perpetuating Factors
Unrealistic sleep requirement expectations
Faulty appraisals of sleep difficulties
Misattributions of daytime impairments
Misconceptions about the causes of insomnia
Excessive amount of time spent in bed
Irregular sleep wake schedule
Napping
Engaging in sleep-interfering activities in the bedroom
Using substances for sleep and/or wake
Perlis modification of Spielman model

10. Four Factor Model of Insomnia: Conditioned Arousal
Learned expectation to be awake in bed
The more time you spend in bed awake, alert, frustrated, and/or anxious the stronger the association between being in bed and being awake becomes
This is often why your brain “turns on” when you get in bed at night
Perlis modification of Spielman model

11. How Does Chronic Insomnia Develop?
Perpetuating Factors
Conditioned Arousal
Acute Insomnia
Compensatory Behaviors & Beliefs About Sleep
Learned Association Between Being Awake and Being in Bed
Chronic Insomnia +

12. Targeting Perpetuating Factors in CBT-I
Chronic Insomnia
Circadian Disruption
Improper/irregular sleep scheduling
Arousal
Cognitive
Poor sleep habits
Conditioned arousal
Homeostatic Disruption
reduced sleep drive
Sleep Efficiency Therapy
Stimulus control
Cognitive Therapy/counter arousal
Sleep hygiene

13. Sleep Efficiency Therapy in CBT-I
Sleep less to sleep better?
Sleep Efficiency Therapy in CBT-I
Improving Sleep Efficiency on your own
Keep sleep diary
Restrict time in bed to the number of hours of sleep (≥5)
Set wake and bed times
Review strategies for staying awake
Sleep will probably be less before it is more
Goal is to consolidate sleep
Gradually extend sleep opportunity (15 min/week as sleep improves)
Only go to bed when you feel sleepy at night
Get up at the same time every day regardless of how well you sleep
Avoid napping/dozing to maximize your sleep debt
The greater your sleep debt, the more likely you will fall asleep faster, get back to sleep faster, and stay asleep longer

14. Sleep Debt
Normal Day-Night
Sleep
Deprivation
Process S
Daytime Nap

15. Do nothing in bed but sleep* AND sleep nowhere but the bed
Stimulus Control
Do nothing in bed but sleep* AND sleep nowhere but the bed
*and sex

16. Stimulus Control Go to bed only when you are sleepy
Do not use your bed or bedroom for anything other than sleep (or sex)
If you are unable to fall asleep after about minutes, leave the bed and bedroom
Hide the clock
Repeat as necessary
Wake up at a regular time regardless of how well or how long you slept
Avoid taking naps

17. Cognitive and Counterarousal Strategies in the Treatment of Insomnia
Cognitive Restructuring
Modify unhelpful beliefs about sleep and impact of sleep on daytime functioning
Designated worry time
Train your brain to worry at a specific time rather than when you are trying to sleep
Constructive worry
Categorize your worry and take action (or not)
To-do lists
Leave your worry at work
Paradoxical intention
Try to stay awake vs. falling asleep
Mindfulness exercises
Learn to recognize that you are separate from your thoughts and you can choose when to pay attention to them
Progressive muscle relaxation
Reduce physical tension and increase awareness of stress
Diaphragmatic breathing
Promote the relaxation response and learn to focus your mind
Yoga
Potentially induces relaxation, increases awareness of mind and body, redirects attention to present moment
Guided imagery
Evoke relaxation by using your imagination

18. Things to Promote Sleep
Sleep Hygiene
Things to Avoid
Things to Promote Sleep
Do not try to fall asleep
Avoid caffeine after noon
Avoid nicotine within 2 hours of bedtime (or completely!)
Avoid alcohol near bedtime
Do not go to bed hungry or too full
Avoid excessive liquids in the evening
Avoid naps
Do not watch the clock 
Use a bedtime ritual
Help your body get to the right temperature for sleep (60-67 °F)
Make sure your bedroom is a comfortable temperature
Make sure your bedroom is comfortable and free from light and noise

19. Wind Down Routine
Some people expect to be able to work or engage in other kinds of stimulating activity right up until the time they want to fall asleep
Your brain likely needs more time to relax and slow down before it will be able to sleep, otherwise it will just take the time to slow down while you’re in bed
Try giving yourself at least minutes of wind down time before trying to sleep
What can you do to relax during wind down time?

20. Recommendations PCP’s can give patients
Go to bed only when sleepy
Get out of bed when unable to sleep (after min or if you feel wide awake)
Get up at a consistent time every morning regardless of how well you sleep
Avoid napping/dozing during day
Use the bed and bedroom for sleep and sex only
Practice good sleep hygiene
Develop a consistent wind down routine that is relaxing
Give patients “PISLEEPTIPS” smartphrase handout

21. Thank you!
Please feel free to contact me at with any questions!

22. Generic Z drug taper schedule

23. Benzodiazepine taper schedule