What is the recommended treatment approach based on the three factor model of insomnia?

Treatment Approach Based on the Three-Factor Model of Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia based on the three-factor model, targeting predisposing, precipitating, and perpetuating factors through a structured 6-8 session approach. 1

Understanding the Three-Factor Model

The three-factor model of insomnia explains the development and maintenance of chronic insomnia through:

1. Predisposing factors: Genetic predispositions, clock gene polymorphisms, and underlying medical/psychiatric conditions 2
2. Precipitating factors: Acute stressors or events that trigger sleep difficulties
3. Perpetuating factors: Maladaptive behaviors and cognitions that maintain insomnia, including:
   • Performance anxiety and negative expectations about sleep
   • Worry about consequences of not sleeping
   • Unhelpful beliefs and attitudes about sleep
   • Variable sleep-wake timing causing circadian dysregulation
   • Excessive time in bed diffusing sleep drive
   • Physiological hyperarousal 2

Recommended Treatment Components

CBT-I addresses perpetuating factors through multiple evidence-based components:

1. Sleep Restriction Therapy

• Limits time in bed to match actual sleep time
• Increases sleep efficiency and strengthens homeostatic sleep drive
• Gradually extends sleep opportunity as efficiency improves 1

2. Stimulus Control Therapy

• Breaks conditioned arousal to the bedroom environment
• Key instructions:
  • Only go to bed when sleepy
  • Use bed only for sleep and intimacy
  • Leave bed if unable to sleep within 15-20 minutes
  • Return only when sleepy
  • Maintain consistent wake time regardless of sleep quality 1, 3

3. Sleep Hygiene Education

• Create a restful bedroom environment
• Maintain consistent bed and wake times
• Avoid caffeine, nicotine, and alcohol
• Limit daytime napping
• Avoid late evening exercise and screen time before bed 4

4. Cognitive Therapy

• Addresses dysfunctional beliefs and attitudes about sleep
• Challenges catastrophic thinking about consequences of poor sleep
• Reduces sleep-related anxiety and worry 1

5. Relaxation Techniques

• Progressive muscle relaxation
• Deep breathing exercises
• Mindfulness meditation
• Reduces physiological and cognitive arousal 3

Implementation and Assessment

1. Establish diagnosis using standardized criteria (ICSD-3 or DSM-5)
2. Document sleep patterns using a 2-week sleep diary
3. Use assessment tools like the Insomnia Severity Index (ISI) or Pittsburgh Sleep Quality Index (PSQI) to track progress 4
4. Deliver CBT-I over 6-8 structured sessions
5. Follow up within 2-4 weeks to assess effectiveness and adjust treatment 4

Evidence for Effectiveness

CBT-I has substantial evidence supporting its efficacy:

• Reduces self-reported sleep complaints by 50-60%
• Effects are sustained for up to 2 years
• Recommended as first-line treatment by the American Academy of Sleep Medicine and American College of Physicians 2, 4, 1

Pharmacological Options (When Needed)

If CBT-I alone is insufficient, consider targeted medications based on specific insomnia type:

• Sleep onset issues:

  • Ramelteon 8mg
  • Zolpidem 5-10mg (short-term use)
  • Zaleplon 10mg 4

• Sleep maintenance issues:

  • Doxepin 3-6mg
  • Eszopiclone 2-3mg
  • Suvorexant 10-20mg 4

Common Pitfalls to Avoid

1. Overreliance on medications without addressing behavioral factors
2. Inadequate assessment of underlying medical or psychiatric conditions
3. Poor adherence to behavioral components, particularly sleep restriction
4. Failure to address all three factors in the model
5. Ignoring potential drug interactions when using pharmacological approaches 4, 3

While some research has explored tailored treatment approaches based on individual patient characteristics 5, the comprehensive CBT-I protocol addressing all components of the three-factor model remains the standard of care with the strongest evidence base 1.