Cognitive Behavioral Therapy for Insomnia

Introduction

Almost everyone has struggled to fall asleep at some point. Experts in sle­ep studies estimate­ that between a third and a half of all adults occasionally experience symptoms of insomnia.¹ Insomnia is a sleep disorder, characterised by difficulty falling asleep or remaining asleep and feeling uneasy during daytime. 

Insomnia might show up suddenly, lasting just one­ night or a few weeks (acute). It can also last longer, appearing at le­ast three nights a wee­k for three months or more (chronic). Around 10% of people who experience insomnia symptoms also develop chronic insomnia.^1,2 People with chronic insomnia should see a physician, as insomnia can have negative health repercussions if left untreated.³

Some people can handle their occasional bouts of insomnia, while others find their chronic insomnia symptoms so severe that they turn to over-the-counter (OTC) medications for temporary solutions. Although they offer immediate relief, sleep medicines are generally not recommended for long-term usage because of the possibility of dependence and possible negative effects.⁴ 

However, a non-pharmacological alternative for insomnia, known as cognitive-be­havioural therapy for insomnia (CBT-I), presents a safer option. It achieves comparable results to sleep medicine but with the distinct advantage of longer-lasting results and is free from side effects.⁴

How does CBT-I work?

CBT-I is a comprehensive treatment that targets the underlying causes of insomnia using several evidence-based strategies. A CBT-I therapist usually organises these strategies into a planned program of six to eight sessions. This timeframe helps the provider track progress over several weeks. However, since insomnia can stem from multiple factors, the number of sessions in CBT-I may be customised to meet the needs and abilities of each patient.^3,5,6 

This approach draws from Dr Arthur Spielman's "3P" model, which categorises key factors associated with insomnia into:

• Predisposing factors: increasing the likelihood of insomnia (e.g., genetics)
• Precipitating factors: triggering the onset of insomnia (e.g., stress, mental health issues)
• Perpetuating factors: helping insomnia last longer. (e.g., daytime naps, alcohol)⁷

During CBT-I, the­ provider uses different techniques to help patients ide­ntify the exact reasons for their insomnia. This evidence-based approach not only targets cognitive and behavioural patterns associated with insomnia but also equips patients with practical strategies to manage these factors and adopt a more conducive lifestyle to achieve deeper sleep.⁸

Techniques used in CBT-I

CBTI consists of five key components:

1.) Sleep restriction: Sleep restriction works on reducing the long periods of lying awake in bed. This is done by going to bed later, so the body will be more ready to sleep.⁹ For example, if someone wants 8 hours of sleep but is currently only getting 5 hours, they are recommended to delay bedtime by three hours.

2.) Stimulus control: Stimulus control works on reinforcing the association of the bed with sleep and breaking its association with being awake. Key instructions include using the bed exclusively for sleeping and intimate activities, with other activities reserved for a different room. Additionally, patients are advised to set a regular alarm in the morning and avoid napping.⁹

3.) Cognitive restructuring: The primary goal of cognitive restructuring is to confront and transform harmful thoughts and beliefs stemming from past negative experiences.¹⁰ This process involves recognising and changing the thoughts and beliefs that contribute to insomnia, such as:

1. Anxiety surrounding previous episodes of insomnia
2. Unreasonable standards for what constitutes a good night's sleep
3. Concerns about feeling exhausted the following day 

To practice these skills between sessions, patients are given homework assignments. These assignments may include activities like keeping a sleep diary and changing any negative thoughts that surface into more positive ones.

4.) Sleep hygiene: Sleep hygiene focuses on educating people about the importance of creating a comfortable sleeping environment. This involves following some guidelines, such as:

1. Consistently waking up and sleeping at a set time
2. Being mindful of what you eat, and avoiding food and alcohol before bed
3. Minimising exposure to bright light 2 hours before bedtime⁸ 

5.) Relaxation techniques: During CBT-I sessions, patients learn several methods to ease physical and mental strain. These techniques include:

1. Mindfulness practices: breathing exercises, progressive muscle relaxation (PMR), and meditation to help soothe the body and calm the mind before sleep
2. Autogenic training: Redirecting attention to different body parts and focusing on sensations like heartbeats and warmth can make people feel relaxed and calm
3. Biofeedback: Tracking physiological processes such as heart rate, breathing, and body temperature helps patients become more aware of their surroundings and better manage how they react to stress⁸

How effective is CBT-I?

According to the Royal Australian College of General Practitioners and the American College of Physicians, CBT-i should be considered the primary treatment for insomnia.¹¹ This is due to the compelling evidence supporting the effectiveness of CBT-I's techniques and comprehensive approach in treating insomnia.

A large scientific literature has shown that CBT-I interventions are as effective as medication and, unlike medications, produce long-term results that last after treatment is completed. In these studies, most of the patients have recovered their normal sleep with some even successfully discontinuing sleep medications. Not only this, but researchers have also found that CBT-I treatment can also improve and treat depression, PTSD, and other health conditions.^4,8,9,11-14

Is CBT-I safe?

While CBT-I is generally considered safe for chronic insomnia, the initial stages of sleep restriction therapy may result in temporary sleep deprivation. People who are sensitive to sleep loss and have conditions like bipolar disorders or epilepsy, need to be aware that they may be more prone to relapses.¹⁵ So, before starting CBT-I, it is important to openly discuss any concerns or pre-existing health conditions with your healthcare team.

How to access CBT-I

Your primary care doctor can guide you to a CBT-I provider, but this could be a challenge with the limited number of trained therapists. However, the American Psychological Association (APA) offers online access to CBT-I trained therapists. 

CBT-I programs can be:

• In-person CBT-I: Widely available through local practitioners, found via your doctor or online directories
• Telemedicine-based CBT-I: Offers one-on-one treatment through phone or video communication for remote options
• Self-guided online programs: Platforms like SHUTi and Sleep Ninja provide flexible CBT-I tools accessible via smartphones or computers
• Digital CBT-I (dCBT-I) applications: Apps like CBT-I Coach, offer comprehensive and cost-effective digital solutions

Tips for insomnia management

According to insomnia specialist Dr Hugh Selsick, these few tips can improve sleep quality:

• Ignore the universal eight-hour sleep myth and instead, find a sleep pattern that keeps you most alert
• Understand that there is a strong connection between insomnia and anxiety and seek support for mental health concerns
• Embrace daily exercise to improve sleep and health

FAQ's

How soon can I expect results from CBT-I?

Patients undergoing CBT-I should keep in mind that results might take a few weeks, especially with strategies like stimulus control and sleep restriction, which could initially disrupt sleep. Patience during this period is crucial for the success of the treatment.

Is it possible for my insomnia to go on its own?

Existing research indicates that chronic insomnia, lasting for more than three months, is unlikely to resolve without treatment.^1,2,8

Is there a specific age limit for CBT-I?

No. CBT-I is inclusive and can benefit individuals across different age groups, including children and teenagers. It is based on understanding the impact of thoughts and emotions on behaviour. You also don't necessarily need a diagnosed mental health condition to gain positive outcomes from CBT-I.

Is discontinuing sleeping pills a requirement?

Treatment plans differ, and your provider will work with you to create a customised plan. Depending on the situation, the plan may involve discontinuing medication before treatment or gradually reducing it during the course. The main goal, however, is to achieve restful sleep without relying on sleep medications.

Summary

Insomnia is a common sleep disorder, that can harm one's health and quality of life. Many take medications for a quick fix, however, these only provide temporary relief and come with side effects. Cognitive behavioural therapy for insomnia (CBT-I) is an effective non-pharmacological alternative, offering lasting results without the side effects associated with medications. CBT-I identifies the root causes of insomnia using evidence-based techniques.

CBT-I is considered the recommended treatment for insomnia, backed by substantial research evidence demonstrating its effectiveness. CBT-I stands out as a drug-free, safe, and effective way to overcome insomnia and improve overall well-being.