Cognitive behavioral therapy is the mainstay in the management of insomnia disorder. However, lack of awareness and limited financial support restricts the users from its benefits.

Cognitive behavioral therapy for insomnia (CBT-I) is the long-recognized first-line approach to chronic insomnia, as indicated by the American Academy of Sleep Medicine (AASM) practice parameters. Although in-person CBT-I is not uniformly accessible, validated online options are increasingly available.

Cognitive Behavioral Therapy for Insomnia

Cognitive behavioral therapy is an excellent therapeutic option in the management of insomnia. Effective CBTi can show significant improvement in sleep onset latency, wakefulness after sleep onset and total sleep time.

Studies have shown CBTi is superior to pharmacotherapy in the management of insomnia. It is typically delivered in 6 sessions over 6 to 8 week period by either health care nurse, sleep therapist, physician assistant, or even a social worker.

The sessions include sleep education, relaxation techniques, sleep restriction therapy, stimulus control therapy, cognitive and behavioral therapy. The CBTi can be delivered even in group sessions in which people with similar complaints are grouped. It can also be provided through the telehealth (video conferencing) or internet-based versions that are beneficial for those who are hesitant to visit a therapist in person.

“SHUTi” is an online internet based CBTi program proven for insomnia. “Sleep Ninja” is a smartphone app, that delivers CBTi over the phone. However, the major limitation of these web-based versions is that a lot of self-encouragement is required to follow through the entire length of the programs regularly. Another limitation of the CBTi program is a shortage of efficient therapists to deliver the therapy effectively along with limited financial support which further restricts the patients from the benefits of the program.

Cognitive Behavioral Therapy for Insomnia, which is typically composed of multiple treatment elements: stimulus control therapy, sleep restriction therapy, relaxation training, cognitive therapy, and sleep hygiene education.

These treatment elements focus on:

  • increasing the association between the bed and being asleep
  • reestablishing a consistent sleep-wake schedule
  • restricting time in bed to increase sleep drive and, subsequently, sleep efficiency;
  • reducing somatic tension or intrusive thoughts that are antithetical to sleep
  • targeting maladaptive beliefs about sleep; and
  • maintaining good sleep practices.

Cognitive Therapy

Cognitive therapy seeks to alter faulty beliefs and attitudes about sleep.For example, insomniacs often display a great deal of apprehension about bedtime and performance anxiety in their attempt to control the process of sleep onset; some even entertain catastrophic thinking about the potential consequences of insomnia, all of which may heighten their effective response to poor sleep.

The objective of cognitive therapy is to cut short the vicious cycle of insomnia, emotional distress, dysfunctional cognition’s, and further sleep disturbances.

Examples of treatment targets for cognitive therapy include having unrealistic sleep expectations (e.g., “I must get 8 hours of sleep every night”), misconceptions about the causes of insomnia (e.g., “my insomnia is entirely due to chemical imbalances in my body”), amplifications of its consequences (e.g., “I am going to fail after a poor night’s sleep”), and performance anxiety resulting from excessive attempts at controlling the sleep process.

The advocates of cognitive therapy believe that “it consists of identifying patient-specific dysfunctional sleep cognitions, challenging their validity, and replacing them with more adaptive substitutes through the use of restructuring techniques such as reattribution training, decatastrophizing, hypothesis testing, reappraisal, and attention shifting.” The evidence for this mode of intervention is the strongest.

Paradoxical Intention

Paradoxical intention is a method that consists of persuading a patient to engage in his or her most feared behavior, i.e., staying awake. The basic premise is that performance anxiety inhibits sleep onset. Thus, if a patient stops trying to sleep and contrarily attempts to stay awake, performance anxiety will be reduced and sleep may come more easily. This procedure may be conceptualized as a form of cognitive restructuring technique to alleviate performance anxiety.

Behavioral Intervention

Having the patient keep a sleep diary for 2 weeks may be helpful. Depending on the findings in the sleep diary, a discussion of sleep hygiene may be beneficial to the patient. Adopting the practices of good sleep hygiene is often helpful regardless of whether the patient has primary insomnia or a sleep disturbance related to a medical condition.

Behavioral psychologists focus on encouraging the patient to eliminate behavior incompatible with sleep, such as lying in bed and worrying, by instructing the patient to leave the bedroom at these times. Patients can condition themselves to be insomniacs, and treatment focuses on de-conditioning the patient from associating the bedroom with a place of restlessness.

References

Chronic Insomnia @ https://www.ncbi.nlm.nih.gov/books/NBK526136/.
The Pathophysiology of Insomnia @ https://www.ncbi.nlm.nih.gov./pmc/articles/PMC4388122/.
Diagnosis and treatment of chronic insomnia @ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924526/.
Alternative remedies for insomnia: a proposed method for personalized therapeutic trials @ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5364017/.