What is an example of Cognitive Behavioral Therapy (CBT) for insomnia?

Cognitive Behavioral Therapy for Insomnia (CBT-I): An Example

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia disorder, with strong evidence supporting its effectiveness across multiple components including sleep restriction therapy, stimulus control, and cognitive restructuring. 1

Core Components of CBT-I

CBT-I is a multicomponent intervention typically delivered over 6-8 sessions that targets the perpetuating factors of chronic insomnia. The main components include:

1. Sleep Restriction Therapy:

   • Limits time in bed to match actual sleep time
   • Gradually increases time in bed as sleep efficiency improves
   • Example: A patient reporting 5 hours of actual sleep while spending 8 hours in bed would initially be prescribed a 5-hour sleep window (e.g., 12:00 AM to 5:00 AM), with weekly adjustments based on sleep efficiency

2. Stimulus Control:

   • Strengthens the association between the bedroom and sleep
   • Example: Patient is instructed to:
     • Only go to bed when sleepy
     • Use the bed only for sleep and sex
     • Leave the bedroom if unable to fall asleep within 15-20 minutes
     • Return to bed only when sleepy again
     • Maintain a consistent wake-up time regardless of sleep duration

3. Cognitive Therapy:

   • Addresses maladaptive thoughts and beliefs about sleep
   • Example: Patient identifies thought "If I don't get 8 hours of sleep, I won't function tomorrow" and works with therapist to challenge this belief by examining evidence for and against it, then develops more balanced thinking like "Even with less sleep, I've managed to function adequately in the past"

4. Sleep Hygiene Education:

   • Provides information about healthy sleep practices
   • Example: Patient receives guidance on limiting caffeine after noon, avoiding alcohol before bedtime, creating a comfortable sleep environment, and establishing a relaxing pre-sleep routine

Practical CBT-I Example

Here's a comprehensive example of how CBT-I might be implemented for a patient with chronic insomnia:

Patient Profile: 45-year-old woman reporting difficulty falling asleep (takes 60+ minutes) and staying asleep (wakes 2-3 times nightly for 30+ minutes each). Currently spends 9 hours in bed (10:00 PM to 7:00 AM) but only sleeps about 5.5 hours total.

Session 1: Assessment and Education

• Patient completes a 2-week sleep diary showing average sleep efficiency of 61%
• Therapist explains the three-factor model of insomnia (predisposing, precipitating, and perpetuating factors)
• Patient learns about normal sleep architecture and factors affecting sleep quality

Session 2: Sleep Restriction and Stimulus Control

• Based on sleep diary, therapist prescribes initial sleep window of 6 hours (12:00 AM to 6:00 AM)
• Patient instructed to:
  • Only go to bed at midnight, regardless of sleepiness
  • Get out of bed at 6:00 AM every day, including weekends
  • Leave bedroom if unable to sleep within 20 minutes
  • Avoid daytime napping

Session 3: Cognitive Restructuring

• Patient identifies problematic sleep-related thoughts:
  • "I must get 8 hours of sleep to function"
  • "One bad night will ruin my entire week"
• Therapist helps challenge these thoughts through evidence examination and developing alternative perspectives
• Patient practices thought records to identify and modify catastrophic thinking about sleep consequences

Session 4: Sleep Window Adjustment

• Sleep diary shows improved sleep efficiency (85%)
• Sleep window extended by 15 minutes (11:45 PM to 6:00 AM)
• Relaxation techniques introduced (progressive muscle relaxation)

Sessions 5-6: Refinement and Relapse Prevention

• Continued adjustments to sleep window based on efficiency
• Development of strategies to maintain gains during high-stress periods
• Creation of a personalized plan for managing occasional sleep difficulties

Evidence and Effectiveness

CBT-I is highly effective, with 70-80% of patients showing significant improvement 2. The American Academy of Sleep Medicine provides a strong recommendation for CBT-I as the treatment of choice for chronic insomnia 1. Recent evidence suggests that critical components include cognitive restructuring, sleep restriction, and stimulus control, while sleep hygiene education alone is insufficient 3.

Delivery Formats

While in-person one-on-one delivery by a trained CBT-I provider is considered the most effective approach 3, other formats include:

• Group therapy sessions
• Internet-based self-help programs
• Brief behavioral treatment for insomnia (BBT-I) focusing only on behavioral components
• Telehealth delivery platforms

Common Pitfalls to Avoid

• Implementing sleep hygiene education alone without other CBT-I components
• Setting unrealistic expectations for immediate improvement
• Failing to adjust sleep windows based on sleep efficiency data
• Inconsistent application of stimulus control principles
• Overlooking the importance of cognitive restructuring

By systematically addressing both the behavioral and cognitive aspects of insomnia through this structured approach, CBT-I helps patients break the cycle of chronic insomnia and develop sustainable sleep habits.