Cognitive Behavioral Therapy (CBT) for Insomnia
Learn more about the Insonmnia and Behavioral Sleep Medicine Program at Stanford
Cognitive behavioral therapy guides patients through a series of changes in sleep-related behaviors. The focus is on addressing the three factors that contribute to the persistence of insomnia:
- conditioned arousal,
- identifying and eliminating habits that were developed in an effort to improve sleep but have become ineffective, and
- reducing sleep-related worry and other sources of heightened arousal.
The therapist identifies the most relevant targets for behavior changes, and helps patients overcome obstacles to making the necessary and often difficult changes in sleep-related behaviors. This means that individual patients can concentrate their energy on changes that are most likely to produce improvements in their sleep. Sometimes the therapist helps patients re-evaluate beliefs about sleep that might be causing unnecessary anxiety.
The majority of patients respond to this treatment fairly quickly. Some experience significant changes after only two therapy sessions. Most improve after four to six sessions, but some might need more. Both group and individual treatments are effective.
Below is a list of some of the instructions and procedures used in this therapy:
Stimulus Control
This set of instructions addresses conditioned arousal. It was developed by Richard Bootzin. They are designed to strengthen the bed as a cue for sleep and weaken it as a cue for wakefulness. The key instructions are:
- Establish a regular morning rise time. This will help strengthen the circadian clock regulating sleep and wakefulness. Ideally, bedtime should also be regular, but for people with insomnia it is impossible to actually fall asleep around the same time nightly. When insomnia resolves, regular bedtime can further strengthen the circadian rhythm.
- Go to bed only when sleepy. This will increase the probability that you will fall asleep quickly. It is important to distinguish between fatigue and sleepiness. Fatigue is a state of low energy, physical or mental. Sleepiness is a state of having to struggle to stay awake. Dosing off while watching TV or as a passenger in a car involve sleepiness. People with insomnia often feel tired but “wired” (i.e. not sleepy) at bedtime.
- If unable to fall asleep, either at the beginning or in the middle of the night, get out of bed and return to bed only when sleepy again.
- Avoid excessive napping during the day. A brief nap (15 to 30 minutes), taken approximately 7 to 9 hours after rise time, can be refreshing and is not likely to disturb nocturnal sleep.
Sleep Restriction
This procedure, developed by Arthur Spielman, is designed to eliminate prolonged middle of the night awakenings. It doesn’t aim to restrict actual sleep time but rather to initially restrict the time spent in bed. Subsequent steps consist of gradually increasing the time spent in bed. The initial time in bed is usually the average nightly total sleep time over the last week. However, the time allowed in bed should not be less than 5.5 hours, even for people who sleep less than 5.5 hours per night.
For example, consider a person who goes to bed at 11:00 p.m. and gets out of bed at 8:00 a.m. but sleeps on average only 6 hours per night. During the first step of this procedure this person will be in bed only 6 hours (e.g., 12:00 am to 6:00 am). This sounds harsh but after a week or so there will be a marked decrease in time spent awake in the middle of the night.
Usually people experience marked improvement in the quality of sleep after a week of restricted time in bed, but they also realize that that they are not getting enough sleep. In this case, the next step is to gradually extend the time spent in bed by 15 to 30 minutes, as long as wakefulness in the middle of the night remains minimal.
Each new extension of the time in bed is followed for at least a week before progressing to the next extension. The decision as to when to extend the time in bed is based on the percent of the time slept relative to the time spent in bed. This is called sleep efficiency. If the average sleep efficiency is 85% or more, then the time in bed is extended. If it is below 80% then the time is bed is further restricted. Otherwise the time in bed remains unchanged. There are several variants of this procedure, and the therapist chooses the one that best fits an individual patient. In all variants, the procedure continues until one reaches a point after which no further extension is necessary because the amount of sleep obtained is sufficient for optimal daytime function.
Reducing Sleep-Interfering Arousal/Activation
This includes a variety of relaxation techniques, stress management skills, and reducing sleep-related worries. The behavioral sleep medicine specialist uses cognitive therapy to reduce arousal by helping patients shift from “trying hard to sleep” to “allowing sleep to happen.” In addition, the following can also facilitate sleep:
- Use the hour before bedtime to unwind from the day’s stresses. This down time will allow sleepiness to come to the surface and will therefore facilitate sleep onset. This is a time to engage in activities that are enjoyable yet calming.
- Avoid clock watching. Turn the clock around so you cannot see the time yet you can still use it as an alarm. A recent study showed that volunteers who were asked to monitor a digital clock at bedtime took longer to fall asleep than those monitoring a similarly looking device that displayed random digits.
- Avoid exercise within four hours before bedtime.
- Make sure that the sleep environment is safe, quiet and pleasant.
About Foods and Substances
- Alcohol: Alcohol speeds sleep onset but this positive effect is counteracted by increased wakefulness in the second half of the night.
- Stimulants: Caffeine has a rather long half-life (about 6 to 8 hours). People’s sensitivity to the effects of caffeine vary. Those with caffeine sensitivity should be particularly careful to avoid caffeine after lunch. (The amount of caffeine in different drinks and recommendations regarding caffeine consumption can be found on the National Sleep Foundation website.) Certain prescription and non-prescription drugs contain caffeine and when feasible should be avoided close to bedtime. Nicotine and nicotine withdrawal can also interfere with sleep.
- Eating at night: Digestion slows down during sleep and indigestion, caused by undigested food, can disrupt sleep. Eating in the middle of the night sends the body an alerting signal.
Taking the Biological Clock Into Account
Bed time and rise time should be congruent with one’s circadian clock. When the desired bed time and rise time are not aligned with the circadian clock the therapist can use procedures to shift the circadian clock, such as properly timed exposure to bright light.
Professional help should be sought by people who find it impossible to follow the above recommendations consistently. For example, some people say they never get sleepy. Others find it too hard to get out of bed at the same time every day.
Therapists with special training in sleep disorders and behavioral sleep medicine are best suited to help people with insomnia because they possess knowledge in the science of sleep and the science of behavior change. The American Academy of Sleep Medicine has established a certification in Behavioral Sleep Medicine and maintains a list of certified specialists and their geographic location on its web site.