Cognitive Behaviour Therapy for Insomnia in Co-morbid
9.2 Practical Considerations for the Implementation of CBT for Insomnia
9.2.2 Anatomy of CBT-I
CBT-I is typically delivered in the context of five to six once-weekly therapy ses- sions (see Fig. 9.3 and Table 9.2; for more in-depth guides, see Perlis et al. 2008;
Last caffeine intake
12midnight
6pm 6am
12 noon
Buffer Zone 2am Sleep Thresholdi.e.
earliest time our individual can go to bed, provided they are also feeling sleepy.
Out of the bed & bedroom:
• Complete sleep diary
• Review ‘to do list’
7am Anchor Time In bed:
• PMR
• Guided imagery
• Thought algorithm
• Thought stopping
• 15-minute rule
Afternoon exercise Buffer Zone:
• Begin with a warm bath
• Pre-bed routine
• Relaxing activities
• Scheduled worry i.e.
‘Put the day to bed’
diary & ‘to do list’
Stimulus Control i.e. remaining out of the bedroom between the Anchor Time and Sleep Threshold.
Bedroom is used for sleep, sex and getting dressed only.
Fig. 9.3 Diagram illustrating how the various components of CBT-I fit into a 24-h period for an individual with a sleep threshold time of 2 a.m. and an anchor time of 7 a.m. CBT-I cognitive behavioural therapy, PMR progressive muscular relaxation
Table 9.2 Components of a typical group CBT-I treatment package Session 1: Sleep and CBT-I education
Education about the nature and science of sleep, and explanation of the CBT-I model, including:
• Why we treat insomnia with CBT-I
• How insomnia originates and is maintained (explanation of the ‘3P’ model) • An explanation of the normal age-related sleep changes
• The stages of sleep and REM sleep (i.e. explanation of the normal hypnogram) • The daytime consequences of inadequate sleep
• How insomnia differs from sleep deprivation—this can be strikingly potent in alleviating anxieties about the long-term effects of insomnia on one’s physical health
• How to assess how much sleep is enough
• Exploration of popular sleep myths (e.g. ‘everyone needs 8 h per night’; ‘insomnia damages your brain’)
• How common sleep problems are
• Introduction to maintaining a sleep diary (see Appendix C)
Session 2: Sleep hygiene education, stimulus control, anchoring the day and the 15-min rulea Exploring habits/behaviours associated with sleep interference and ways of reducing/
eliminating them. These include dietary factors (e.g. caffeine and alcohol intake), other lifestyle factors (e.g. nicotine use before bed, lack of a bedtime routine) and bedroom factors (e.g. noise, temperature, clock watching)
Stimulus control helps people to reduce the association of the bedroom as being a place of wakeful, purposeful activity. It limits bed and bedroom activities to sleep, sex and getting dressed only. It further emphasizes the importance of only going to bed when sleepy
‘Anchoring the day’ teaches the importance of rising at (or before) a set time each morning, 7 days a week, regardless of how well an individual has slept the previous night
The 15-min rule encourages individuals to leave the bedroom and to engage in a relaxing activity if they have not fallen asleep after 15 min (a time period they guess, rather than calculate via an alarm or via clock watching, etc.). Individuals return to bed when they feel sleepy again. This rule is maintained throughout the night
Session 3: Sleep rescheduling and progressive muscular relaxation
In sleep rescheduling, the initial requirement is to limit the time in bed to the average estimated time spent asleep each night (calculated from each individual’s sleep diary; a minimum lower limit is set to 5 h). This generally increases the individual’s sleep threshold, i.e. the earliest time they can go to bed provided they are also feeling sleepy. The aim here is to bring the total sleep time as close as possible to the time spent in bed. As the sleep efficiency improves, the time spent in bed can be increased
Progressive muscular relaxation is introduced and supported by a CD guide which is given to individuals
Session 4: Sleep cognitions
Encouraging individuals to include a ‘buffer zone’ (usually lasting 1.5–2 h) before their sleep threshold. During this buffer zone, they implement a pre-bed routine (e.g. commencing with a warm bath) and ‘put the day to bed’ by dealing constructively with worries or anxieties arising from the day, e.g. via use of a reflective diary of what has gone well and not so well during the day. This ‘buffer zone’ is used solely for relaxation, and as a ‘wind-down’ period, during which all work-related and stimulating activities are stopped
We also teach individuals how to cope with unwanted thoughts or worries that arise during the night, e.g. via use of a thought algorithm and via thought-stopping techniques, e.g. the
‘The’ technique
Espie 2010). Thereafter, the number of follow-up visits depends on the insomnia severity, co-morbidity and patient motivation. Whilst acute uncomplicated insomnia might require less time and can typically be managed in a non-specialist setting (Espie et al. 2007, 2008), more complex cases probably require the input of behav- ioural sleep medicine specialists.
Since individual face-to-face therapy with a sleep specialist is not always feasi- ble, research has focused on the viability of alternative treatment delivery models.
There is now evidence to support self-help approaches, using printed materials (Belleville et al. 2007; Mimeault and Morin 1999), videos (Savard et al. 2011) or Internet-based programmes (Ritterband et al. 2009). These are helpful either on their own or when supplemented by professional administered therapy. Other effica- cious and cost-effective treatment modalities include telephone conversations (Bastien et al. 2004) and group therapy (Currie et al. 2004). Finally, there is also a growing evidence to support the use of a brief two-session CBT-I intervention (Edinger and Sampson 2003) as well as a single day-long intensive CBT-I workshop (Swift et al. 2012).
Each treatment modality has its own specific characteristics and unique advan- tages (e.g. increased social support in group therapy). These need to be considered during the initial assessment of the patient’s needs so that a successful therapeutic outcome can be achieved. Some patients might require little guidance, whereas oth- ers might need a more intensive and structured approach. Regardless of the therapy entry level, there should be scope to move between modalities as required, i.e. the provision of a stepped-care approach (Espie 2009).
Table 9.2 (continued)
Session 5: Further relaxation techniques, bringing it all together and forward planning Further relaxation techniques are taught, e.g. guided imagery
We review all of the techniques discussed by drawing a map of a typical day, indicating where each technique and strategy can be used (see Fig. 9.3)
We remind patients how to use their sleep efficiencies to alter their sleep threshold timesb, provide time for individual queries, give guidance on realistic expectations over the coming weeks and give encouragement
Some patients may be anxious that therapy is ending at this point and that they will be on their own until their 3-month follow-up review. Advising bibliotherapy (e.g. Colin Espie’s
‘Overcoming insomnia and sleep problems; a self-help guide using Cognitive Behavioral Techniques’) can be useful to address these anxieties
CBT-I cognitive behavioural therapy for insomnia, REM rapid eye movement
aSleep efficiency (SE, time asleep/time in bed × 100) is usually ≥90% in individuals without insomnia. For individuals undergoing CBT-I with an SE of ≥90%, we advise a reduction of their sleep threshold time by 15 min. When the SE is between 85% and 89.9%, we advise main- taining the same sleep threshold time. Finally, when the SE is ≤84.9%, we advise bringing the sleep threshold time forward by 15 min. Eventually, adjusting the sleep threshold time by 15 min in either direction will not affect the SE; maintenance of a weekly sleep diary can be stopped at this point
bFor patients taking hypnotic medication, Sessions 1 and 2 may be completed over three sessions to allow for discussion and support of how and when to withdraw hypnotics
Ultimately, the success of CBT-I depends on the patient’s ability to adhere to treatment recommendations. To optimize outcomes, follow-up consultations are often necessary to monitor progress, to address concordance difficulties and to pro- vide guidance and support.