Cognitive Behaviour Therapy for Insomnia in Co-morbid
9.2 Practical Considerations for the Implementation of CBT for Insomnia
9.2.7 Is There a Role for CBT-I in Co-morbid Paradoxical Insomnia?
Paradoxical insomnia (previously termed ‘sleep state misperception’) is a complaint of severe insomnia, which is disproportionate to the presence of objective sleep disturbance or daytime impairment (AASM 2005). Hypervigilance occurs as the patient is trying to sleep, and subsequent physiological and/or perceptual deficits result in impaired sleep/wake discrimination, leading to an underestimation of the time spent asleep (Bonne and Arand 1997).
Despite being a prevalent (up to 43%) subtype of chronic insomnia, it is a notoriously difficult condition to assess (owing in part to a lack of standardized diagnostic criteria) and to treat (Dorsey and Bootzin 1997; Edinger and Sampson 2003). To our knowledge, there are no published data in regard to its co-occur- rence with other psychiatric disorders. There are also no standard treatments for paradoxical insomnia, and it typically responds poorly to usual CBT-I approaches.
Recent therapeutic efforts have focused on enhancing the patient’s ability to dis- criminate between sleep/wake periods (Geyer et al. 2008). In their case series study, Geyer et al. (2011) followed a course of CBT-I with a novel sleep education tech- nique, where they utilized a polysomnogram with video, to help patients explore the
discrepancy between their reported and observed sleep experiences. For two of the four patients, this resulted in a meaningful improvement in their ISI scores and in their self-reported sleep onset latency and total sleep times. Although this was a small case series study, it provides therapeutic hope for patients with paradoxical insomnia, as well as for the clinicians treating them. A randomized controlled trial comparing CBT-I, this novel sleep education technique and a combination of both therapies would shed much-needed light on how best to approach this challenging condition.
Conclusion
Insomnia and psychiatric disorders are commonly intertwined. CBT-I is a well- established treatment for insomnia and, increasingly, appears to also benefit co- morbid psychiatric conditions. The basic challenges for us as clinicians remain ones of recognizing co-morbid insomnia and providing access to therapy for our patients.
Other treatment modalities, such as Acceptance and Commitment Therapy and Mindfulness and Intensive Sleep Retraining, have yet to demonstrate their equivalence to CBT-I in resolving insomnia, including co-morbid psychiatric conditions.
Future research, via large-scale randomized controlled trials, is required to expand our knowledge of the clinical effectiveness of CBT-I in the treatment of co- morbid insomnia and psychiatric disorders.
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