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Cognitive-Behavior therapy for insomnia

Posted by gardenergirl on June 22, 2006, at 0:09:56 [reposted on June 23, 2006, at 9:53:15 | original URL]

In reply to Re: Have you tried behavior treatments? They work » FrequentFryer, posted by Racer on June 21, 2006, at 22:55:05

From a presentation I gave last year:

I. Insomnia
II. CBT for insomnia
III. Case (not included here)


Duration of at least one month of sleep disturbance of difficulty initiating sleep, maintaining sleep, or early awakening which impairs the person’s social, occupational, or personal functioning. The disturbance is not secondary to the presence of another sleep disorder type, a medical or physical condition, substance use or mental disorder.

· According to Drake, insomnia prevalence has been estimated at between 10 and 15% of the US population
· Insomnia is an under-recognized and under-treated problem.
· More common in women and older adults, people who are lower in SES, people who are divorced, widowed or separated

Signs (in order of increasing impairment)
Slowed speech
Flat affect
Impaired memory
Difficulty multitasking
Falls into “micro-sleeps” affecting attention
Falls asleep while doing activities
Hypnologic hallucinations, the beginning of REM sleep.


· According to the Department of Transportation (DOT), one to four percent of all highway crashes are due to sleepiness, especially in rural areas and four percent of these crashes are fatal.
· Negative impact on quality of life
· Associated with increased risk for major depression if untreated
· Insomnia with major depression has been associated with higher rates of suicidal behavior compared to depressed patients without insomnia.
· Estimated cost of $77 billion per year due days off work, accidents, and poor productivity.
· Correlation between teenage insomnia and later substance use and abuse.
· Interferes with learning due to falling asleep in class and failure to consolidate new material.

CBT for Insomnia (Adapted from Morin’s Model, 1993)
Cognitive-Behavioral Therapy (CBT)
· Action-oriented versus insight-oriented therapy
· Cognitive restructuring and behavior modification integrated into one approach
· “Faulty” thinking or distortions lead to maladaptive behavior and negative emotions
· Change the automatic thought patterns in order to change the behavior and/or emotional state. Think your way into a new way of acting.

· Meta-analytic studies show CBT has been effective as high as in 70% to 80% of patients resulting in improvement in objective and subjective reports of sleep and self-efficacy and decreases in emotional distress associated with sleep disturbances. One third return to normal sleep patterns and the majority of clients make satisfactory gains.
· Gains have been shown to last for six months to two years.
· May be just as effective in group or even telephone modalities, making it a potentially cost-effective treatment approach.

I. Screening
II. Assessment
III. Sleep Restriction
IV. Stimulus Control
V. Cognitive Restructuring
VI. Sleep Hygiene
VII. Relaxation
VIII. Maintenance and Relapse Prevention

I. Screening
Type of problem? Onset, maintenance, early awakening
Time awake at night?
Physical complaints?
What has been tried?

II. Assessment
A. Sleep history
1. Description of symptoms
2. Frequency and duration of symptoms
3. Psychological contributing factors
4. Sleep hygiene practices
5. Psychopathology
6. Organic pathology
7. Serious medical problems
8. Previous treatment for insomnia.
B. Rule outs
1. Mood or anxiety disorders causing secondary insomnia
2. Medical, organic, or physical condition causing secondary insomnia
3. Substances
4. Other sleep disorders
C. Daily Sleep Diaries (also used for homework to demonstrate compliance)

III. Sleep Restriction
1. Reduce time in bed to the greater of five hours or the client’s duration of sleep.
2. Keep stable wake time and gradually have client go to bed earlier and earlier.
3. Resets homeostatic sleep mechanism by forcing lost sleep.
4. Increases the chances of longer, deeper sleep.
5. Improves efficiency of time in bed and reduces associations between bed and being awake.
6. Useful for short term, acute problems to return to client’s baseline
7. Important to carefully and consistently follow the prescribed regimen. Client may need help problem solving when resistance or obstacles present.
8. Paradoxical intention: permission not to sleep decreases worry.

IV. Stimulus Control (Pavlov’s dogs)
1. Replace maladaptive associations between bed and non-sleep related activities with an increasingly strong association between bed and sleep.
2. Go to bed only when sleepy.
3. Get out of bed and go into another room if unable to fall asleep or easily return to sleep.
4. Time in bed is limited to sleep and/or sexual activity only.
5. Get up at the same time every day regardless of time spent asleep. (No sleeping in.)
6. Avoid daytime napping (older adults may take one nap up to 30-45 minutes to avoid excessive daytime sleepiness.)
7. Useful for sleep onset and sleep maintenance problems.
8. Important to carefully and consistently follow the prescribed regimen. Client may need help problem solving when resistance or obstacles present.

V. Cognitive Restructuring
1. Identify maladaptive beliefs and replace with adaptive ones.
2. Goal is to increase sense of self-efficacy.
3. Identify what is within the client’s locus of control and what is not.
4. Question the evidence
5. Develop adaptive coping skills for consequences in order to stop viewing self as a victim.
6. Minimize worry and arousal associated with insomnia.

VI. Sleep Hygiene
1. Keep a regular sleep/wake schedule
2. Don’t drink or eat caffeine four to six hours before bed and minimize daytime use
3. Don’t smoke, especially near bedtime or if you awake in the night
4. Avoid alcohol and heavy meals before sleep
5. Get regular exercise
6. Minimize noise, light and excessive hot and cold temperatures where you sleep
7. Develop a regular bed time and go to bed at the same time each night
8. Try and wake up without an alarm clock
9. Attempt to go to bed earlier every night for certain period; this will ensure that you’re getting enough sleep

· Reduces muscle tension
· Reduces time spent in worry
· Associates bed and sleep with a relaxed state
· Can lower respiration and heart rate and blood pressure, improving overall health and decreasing the effects of health conditions on sleep.
· Multiple techniques available
· Meditation
· Progressive muscle relaxation
· Visualization
· Deep breathing
· Guided imagery
· Biofeedback

VII. Maintenance and Relapse Prevention
Predictors of relapse:
· Severity of residual symptoms at termination
· Psychological distress
· Discontinuation of BZD in long-term users prior to CBT
· Significant predictors of relapse included treatment condition, end of treatment
· Maladaptive beliefs about meaning of relapse
· New physical condition, surgery, or stressful event
· Environmental changes
Booster sessions
· Allow for problem-solving
· Reinforce new behaviors and adaptive thoughts
· Normalize the relapse event to avoid catastrophizing and all or nothing view.

American Psychological Association. Why sleep is important and what happens when you don't get enough. Downloaded from the World Wide Web on June 16, 2005.
Bastien, C. H., Morin, C. M, Ouellet, M., Blais, F. C. & Bouchard, S. Cognitive-Behavioral Therapy for insomnia: Comparison of individual therapy, group therapy, and telephone consultations. Journal of Consulting & Clinical Psychology, 72(4), 653-659.
DeViva, J.C., Zayfert, C., Pigeon, W. R, & Mellman, T. (2005). Treatment of residual insomnia after CBT for PTSD: Case Studies. A. Journal of Traumatic Stress,18(2), 155-159.
Drake, C.L., Roehrs, T. & Roth, T. (2003). Insomnia causes, consequences, and therapeutics: An overview. Depression & Anxiety, 18(4), 163-176.
Jannson, M. & Linton, S. J. (2005). Cognitive-Behavioral group therapy as an early intervention for insomnia: A randomized controlled trial. Journal of Occupational Rehabilitation, 15(2), 177-190.
Lacks, P. (1987). Behavior Treatment for Persistent Insomnia. New York: Pergamon Press.
Morin, C. M. (2004). Cognitive-Behavioral approaches to the treatment of insomnia. Journal of Clinical Psychiatry, 65(Suppl16), .33-40.
Morin, C. M., Belanger, L., Bastien, C. & Vallieres, A. (2005). Long-term outcome after discontinuation of benzodiazepines for insomnia: A survival analysis of relapse Behaviour Research & Therapy, 43(1). 1-14.
National Institutes of Health (1998). Insomnia: Management in primary care. Downloaded from the World Wide Web on June 16, 2005.

Useful Resources

National Sleep Foundation
American Academy of Sleep Medicine
American Insomnia Association
Sleep Research Society
NIH National Center for Sleep Disorders Research
The Sleep Center

And so if anyone here attended this and recognizes these slides, well...I'm outed. :)

Not in any way prescribing any of this...





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