Behavioral Strategies

Cognitive and Behavioral Therapies

A majority of people with insomnia respond to behavioral and nonpharmacologic methods. When compared with pharmacologic methods, they are at least as efficacious and have the advantage of continued benefit long after treatment sessions have ended.

Some major cognitive and behavioral modification interventions are outlined in Table 9-1. The goals of several of these interventions are summarized below (Table 9-2).

Patients with insomnia can benefit from a range of behavioral interventions. Many of these can, at least in part, be instituted in primary care, either by the physician, nurse practitioner, physician assistant, or even by properly trained medical assistants. However, in reality, despite its effectiveness, very few insomnia sufferers actually receive CBT due to a number of barriers inhibiting access to treatment. First, there exists a general lack of knowledge on the part of the public as well as health care professionals regarding CBT for insomnia. In fact, due to this and the belief that pharmacotherapy is the only option, patients with insomnia often do not consult their medical providers for their sleep problems. Second is the lack of trained professionals to administer CBT. Third, time constraints can dissuade patients from attending the therapy sessions. Finally, in the United States, lack of insurance coverage for CBT may present a financial barrier to many patients.

Cognitive and behavioral methods include:

• Sleep hygiene education: Individuals with insomnia may engage in poor sleep hygiene practices, such as smoking and drinking alcohol before bedtime. These tendencies may be key exacerbating or perpetuating factors for insomnia once it has already emerged due to other factors. Sleep hygiene education attempts to correct habits and behaviors that may be counterproductive to good sleep. Although evidence supporting sleep hygiene education as a stand-alone therapeutic modality is lacking, this modality is considered to be a necessary component of any behavioral strategy since poor sleep hygiene habits may impair the efficacy of other techniques. Many versions of sleep hygiene instructions have been described. A composite of the various recommendations appears in Table 9-2.
• Stimulus control therapy (SCT) is based on the premise that insomnia is caused by the conditioned arousal that occurs in response to the stimulus of repeated wakefulness and the bedroom environment. The assumption is that spending time awake in bed while doing daytime tasks strengthens the association between the bedroom cues and sleeplessness, perpetuating insomnia. The goal of SCT is to break the association between bedroom cues and conditioned arousal that occurs with repeated wakefulness, to imprint bed as sleep stimulus and to associate the bedroom environment with falling asleep.
• Sleep restriction therapy strives to improve sleep continuity by curtailing time spent in bed. This results in some sleep curtailment, which, in turn, results in greater sleep continuity (consolidation) as long as naps are avoided. It also leads to enhanced sleep efficiency, which, in turn, may result in the perception of improved sleep quality. The goal of treatment is to increase the homeostatic sleep drive, which leads to consolidation of sleep and an improvement in sleep depth.
• Cognitive therapy attempts to address the dysfunctional cognitions, catastrophic thinking and preoccupation with sleeplessness that accompany insomnia and ultimately contribute to poor sleep. During cognitive therapy, dysfunctional beliefs and attitudes toward sleep need to be challenged, unrealistic expectations about sleep need to be corrected, and perceptions of the consequences of insomnia need to be reappraised.
• Relaxation therapy was developed around the theory that hyperarousal leads to insomnia. The goal of relaxation therapy is not to induce sleep; the goal is to reduce arousal and induce a relaxed state (relaxation), thus allowing sleep to occur. Progressive muscle relaxation, autogenic training, guided imagery and biofeedback are among the many techniques that have been used to reduce arousal and induce relaxation. Before applying relaxation therapy at bedtime, the patients are trained and instructed to practice relaxation techniques during the day.
• Paradoxical intention may be useful for patients with sleep-onset insomnia. Patients are instructed to try to stay awake for as long as possible. Its effectiveness may be a result of redefining the task, thus removing the performance anxiety associated with the urgency of falling asleep. This parameter is limited to sleep initiation insomnia but may not necessarily apply to sleep maintenance or mixed insomnia.

The most commonly used techniques target common sleep habits and behaviors, which are presented in Figure 9-1. Initial approaches to treatment should include at least one behavioral intervention or a combination of behavioral interventions, collectively known as cognitive behavioral therapy for insomnia (CBT-I). Multicomponent therapy (without cognitive therapy) is also effective in the treatment of chronic insomnia. When an initial behavioral treatment has been ineffective, other behavioral therapies or combination CBT-I therapies may be considered. If these modalities are not instituted in the primary care setting, patients can be referred to the proper therapist where they can be delivered in individual treatment settings or in groups. They can also be administered by means of self-help programs using written materials or videos, or even via telemedicine.

Studies have investigated whether combining behavioral and pharmaceutical therapies are effective for treating chronic insomnia. In one study in which CBT, pharmacotherapy and a combination of the two was used in adults who had chronic sleep-onset insomnia, CBT-I alone was as effective as CBT-I in combination with pharmacotherapy (Figure 9-2). CBT-I has been shown to have superior effectiveness to benzodiazepine and nonbenzodiazepine drugs in the long term, although benzodiazepines were shown to be more effective in the short term. CBT-I might be important to improving psychological outcomes, as they may result in more durable long-term effects, well after therapy sessions have ended.

It has also been shown that different sequential combinations of medication and CBT-I all led to significant improvement of sleep efficiency and continuity but at different points in time. A sequence beginning with a combined treatment followed by CBT-I alone produced the best outcome. These patterns suggest that sleep improvement seems affected by the way treatments are combined.

Enlarge 

Enlarge 

Enlarge 

Enlarge 

Cognitive Behavioral Therapy for Insomnia

CBT-I is a combination of cognitive therapy, stimulus control therapy and sleep restriction therapy with or without relaxation therapy. It aims to target factors that may maintain insomnia over time, such as sleep drive dysregulation, sleep-related anxiety and sleep-interfering behaviors. This is accomplished by establishing a learned association between the bed and sleeping through stimulus control, restoring homeostatic regulation of sleep through sleep restriction and altering anxious sleep-related thoughts through cognitive restructuring. By changing sleep-related behaviors and thoughts, CBT-I may target those factors that cause insomnia to persist over time. CBT-I is abbreviated as a form of CBT specific for insomnia because its core therapies differ substantially from other forms of CBT.

CBT-I is delivered by a properly trained therapist over the course of four to eight sessions that occur weekly or every other week for 30 to 60 minutes each. CBT-I has been shown to have consistent short-term (average 5 weeks) efficacy, and durability of benefit of up to 6 months following the termination of treatment. CBT-I has been shown to improve not only nocturnal sleep problems but also daytime depressive mood, both at the and of treatment and on follow-up. A large body of evidence supports the efficacy of CBT-I for the treatment of insomnia. CBT-I interventions produce improvements in patients with insomnia equivalent to those achieved during acute treatment with hypnotic medications in terms of reducing nocturnal wakefulness, increasing sleep efficiency and improving subjective sleep quality. CBT-I therapy was found to be efficacious for improving sleep in a variety of patient populations, such as those with chronic pain or depression, and cancer survivors. Based on this collective body of evidence on its safety and efficacy, the current (2021) AASM guidelines strongly recommend multicomponent CBT-I for the treatment of chronic insomnia in adult patients, and the American College of Physicians (ACP) guidelines on insomnia recommend it as a first-line treatment of chronic insomnia in adults.

Advantages of treating with insomnia with CBT-I, as opposed to pharmaceutical methods, include fewer known side effects, and an explicit focus on treating the underlying perpetuating factors of chronic insomnia. However, improvements from CBT-I are typically not seen until 3 to 4 weeks into treatment. In fact, during the first few weeks of treatment, there is often an acute reduction in total sleep time that can lead to the side effect of increased daytime sleepiness, which may lead to decreased adherence in some individuals.

Despite its demonstrated benefits, CBT-I remains generally underutilized because of systemic barriers (availability of CBT-I providers, lack of referral from primary care providers) and patient barriers (lack of awareness, negative beliefs). To find therapists to administer CBT-I for their patients with insomnia, primary care physicians can research local sleep centers, psychologists and psychiatrists.

Variations in Methodology of CBT Delivery

Although behavioral therapy is quite effective and also highly acceptable to patients, it has several limitations. For example, implementation into a primary care or general practice setting requires resources and trained health care professionals to deliver the interventions. Sufficient time must be allotted for each patient, often multiple sessions taking place several times per week. Finally, patients must be motivated to attend the sessions and adhere to the regimen.

Several approaches to broaden the implementation of general practice–based CBT-I have been suggested and are being evaluated:

• Training of nurse practitioners and physician assistants
• Group therapy formats
• Shortening sessions
• Telephone or Internet-based treatment.

In a study directly comparing individual and group CBT-I treatments, both methods were effective in improving subjective and objective sleep parameters and subjective sleep evaluations, but individual CBT-I resulted in significantly better improvements in most areas. A meta-analysis of eight studies confirmed the efficacy of group CBT-I, finding significant improvements in sleep onset latency, sleep efficiency and WASO. One study of Brief Therapy for Insomnia (BTI) demonstrated the efficacy of individualized behavioral instructions delivered in two intervention sessions and two telephone calls over the course of 4 weeks; improvements were maintained over the course of 6 months. Another trial of BTI in older adults demonstrated improvements in sleep diary-reported SOL, WASO, SE and sleep quality. The short-term efficacy and long-term durability of benefit with internet CBT-I was demonstrated in a trial in 2009, and has since been confirmed in systematic reviews and meta-analyses. Thus, although the limited availability of trained therapists, inconvenience, time commitment and cost is a major limitation of CBT-I, attempts have been made to address some of these drawbacks through the provision of alternative treatment modalities.