Cognitive
Behavioral Therapy
for Insomnia (CBT-I)
JANET CONSTANCE, PH.D.
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)
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
The Evolution of Insomnia
Insomnia
Insomnia Threshold
No Insomnia
Premorbid
Acute
Insomnia
Chronic
Insomnia
Predisposing Factors
Precipitating Factors
Perpetuating Factors
Adapted from Spielman et al., 2000
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
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
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
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)
What is CBT-I?

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
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
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
Comparative Efficacy:
CBT-I for Sleep Onset Difficulties
Sleep Onset Latency
90
80
83.5
Sleep Efficiency
80.4
POST-TREATMENT
70
71.3
67.2
60
63.9
58.7
50
40
30
38.7
34.1
20
10
0
CBT
Jacobs et al., 2004
Zolpidem
Combination
Placebo
Minutes awake after sleep onset
Comparative Efficacy: CBT-I for
Sleep Maintenance Difficulties
90
80
70
60
CBTI (18)
50
Temazepam (20)
40
Combined (20)
30
Placebo (20)
20
10
0
Baseline
Post3 Months
12 Months
Treatment Follow-up Follow-up
Adapted from Morin et al., JAMA 1999
24 months
Follow-up
How does Sleep Hygiene differ from CBT-I?
Sleep Hygiene
Education
Sleep
Hygiene
≠ CBT-I
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.
•
•
•
•
CBT-I
Sleep Restriction
Stimulus Control
Relaxation Training
Cognitive Therapy
Sleep Hygiene Education (except for regular
bedtime)
• Cognitive Therapy
•
•
•
•
•
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
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
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

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
CBT-I Referral Sources

American Board of Sleep Medicine


Society of Behavioral Sleep Medicine


http://www.behavioralsleep.org/FindSpecialist.aspx
American Academy of Sleep Medicine


http://www.absm.org/BSMSpecialists.aspx
http://www.aasmnet.org/
National Sleep Foundation

http://sleepfoundation.org/find-sleep-professional
VA CBT-I Resources

CBT-I Sharepoint (only accessible by VA
providers)

https://vaww.portal.va.gov/sites/omhs/cbt_insomnia/
default.aspx
 VA
CBT-I provider list
 CBT-I
patient brochures
 CBT-I
Clinician Factsheet
Questions?