What cognitive behavioral therapy for insomnia (CBT‑I) protocol can a nurse practitioner implement for a patient with insomnia, obsessive‑compulsive personality disorder (OCPD) traits, and generalized anxiety disorder (GAD)?

CBT-I Protocol for Nurse Practitioner Implementation

A nurse practitioner should implement a structured 4–8 session multicomponent CBT-I protocol that combines sleep restriction therapy, stimulus control, cognitive restructuring, and relaxation training, as this represents the American Academy of Sleep Medicine's strongly recommended first-line treatment for chronic insomnia disorder, including in patients with comorbid anxiety disorders. 1

Core Treatment Components to Implement

Sleep Restriction Therapy (Primary Behavioral Component)

• Calculate the patient's average total sleep time from a 1–2 week sleep diary, then prescribe time in bed equal to this duration (minimum 5 hours to prevent excessive daytime sleepiness) 1, 2
• Set a consistent wake time every morning regardless of sleep quality the previous night 3
• Adjust time in bed weekly based on sleep efficiency: if sleep efficiency exceeds 85%, increase time in bed by 15–30 minutes; if below 80%, decrease by 15–30 minutes 2, 4
• This method consolidates sleep by enhancing homeostatic sleep drive and reducing fragmented sleep patterns 1

Stimulus Control Instructions (Breaking Bed-Wakefulness Association)

• Instruct the patient to go to bed only when sleepy, not by clock time 1, 2
• Use the bed and bedroom only for sleep and sex—no reading, television, phone use, or worrying in bed 1, 3
• If unable to fall asleep within 20 minutes (perceived time, not clock-watching), leave the bedroom and return only when sleepy again 2, 4
• Eliminate all daytime napping to strengthen nocturnal sleep drive 1, 3
• Maintain the same wake time 7 days per week, including weekends 3

Cognitive Restructuring (Addressing Anxiety-Driven Sleep Beliefs)

• Identify and challenge catastrophic beliefs about sleep consequences using Socratic questioning and thought records 1, 2
• Target common dysfunctional cognitions in patients with OCPD traits and GAD, such as "I must get 8 hours or I'll fail at work" or "My anxiety will never let me sleep" 2
• Use behavioral experiments to test the validity of feared outcomes (e.g., functioning adequately after a poor night's sleep) 1
• Reframe perfectionist sleep expectations common in OCPD by normalizing night-to-night sleep variability 2

Relaxation Training (Reducing Somatic and Cognitive Arousal)

• Teach progressive muscle relaxation: systematically tensing and releasing muscle groups from feet to head for 15–20 minutes before bed 1, 2
• Implement diaphragmatic breathing exercises (4-7-8 technique: inhale 4 counts, hold 7, exhale 8) to activate parasympathetic response 1
• Consider guided imagery or meditation for patients with high cognitive arousal related to GAD 1, 3
• Practice these techniques daily, not just at bedtime, to develop skill proficiency 2

Sleep Hygiene Education (Adjunctive, Not Standalone)

• Provide education about caffeine avoidance after 2 PM, alcohol's sleep-fragmenting effects, and maintaining a cool, dark bedroom environment 2, 3
• Critical caveat: Sleep hygiene alone is insufficient and ineffective as monotherapy—it must be combined with the behavioral and cognitive components above 1, 3
• Allocate minimal session time to hygiene education; prioritize the evidence-based behavioral interventions 1

Session Structure and Timeline

Sessions 1–2: Assessment and Initiation

• Collect baseline sleep diary data for 1–2 weeks before starting treatment 2, 4
• Provide psychoeducation about the two-process model of sleep (homeostatic drive and circadian rhythm) 1
• Introduce stimulus control and calculate initial sleep restriction prescription 1, 2
• Begin relaxation training practice 2

Sessions 3–6: Adjustment and Cognitive Work

• Review weekly sleep diaries and adjust time in bed based on sleep efficiency thresholds 2, 4
• Implement cognitive restructuring exercises targeting anxiety-related sleep beliefs 1, 2
• Troubleshoot adherence barriers, particularly the initial discomfort of sleep restriction 1
• Address perfectionist tendencies in OCPD patients that may interfere with accepting imperfect sleep nights 2

Sessions 7–8: Consolidation and Relapse Prevention

• Finalize optimal sleep schedule based on achieved sleep efficiency and patient satisfaction 2
• Develop a written plan for managing future sleep disruptions without reverting to maladaptive behaviors 5
• Schedule follow-up reassessment at 6 months due to high relapse rates in chronic insomnia 2, 4

Evidence for Comorbid Anxiety and Personality Traits

• CBT-I produces large effect sizes (Cohen's d = 0.8–1.5) for insomnia severity in patients with comorbid anxiety disorders, with additional moderate effects (d = 0.8) on anxiety symptom reduction itself 6
• The treatment simultaneously addresses both insomnia and anxiety symptoms, making it particularly appropriate for this patient's GAD 3, 6
• CBT-I is effective in psychiatric populations and often improves the comorbid psychiatric condition alongside sleep 6, 7

Delivery Modality Options

• In-person individual therapy remains the gold standard and most extensively studied format 1
• Nurse-guided internet-delivered CBT-I (I-CBT-I) produces large effect sizes (d = 1.66 post-treatment, d = 1.02 at 6 months) and is a viable alternative when in-person access is limited 8
• Group therapy, telephone-based, or web-based modules show comparable effectiveness to individual therapy 2, 3
• Self-help books with minimal guidance can be considered if no other format is accessible 2

Critical Implementation Pitfalls to Avoid

• Do not rely on sleep hygiene education as the primary intervention—this is the most common error and produces minimal benefit 1, 3
• Warn patients that improvement is not immediate (unlike medication) and typically requires 2–4 weeks before noticeable benefit, which may challenge adherence 1
• Never allow time in bed to drop below 5 hours during sleep restriction, as this creates unsafe daytime sleepiness 2
• Discourage clock-watching—patients should leave bed based on perceived wakefulness, not actual time elapsed 2
• Address the patient's OCPD traits proactively: perfectionist adherence to rules may paradoxically increase performance anxiety about sleep; emphasize flexibility and self-compassion 2

When to Consider Adjunctive Medication

• Medication should supplement, not replace, CBT-I, as pharmacotherapy alone provides less durable improvement 3
• If CBT-I is insufficient after 2–4 weeks, consider adding short-term pharmacotherapy (eszopiclone 2–3 mg, zolpidem 10 mg, or low-dose doxepin 3–6 mg) while continuing CBT-I 3
• For this patient with GAD, avoid benzodiazepines due to dependence risk and cognitive impairment; if an antidepressant is indicated for GAD, consider mirtazapine 15–30 mg which addresses both anxiety and insomnia 3

Monitoring and Reassessment

• Collect sleep diary data throughout treatment to track sleep efficiency, total sleep time, sleep onset latency, and wake after sleep onset 2, 4
• Reassess clinically every 2–4 weeks during active treatment, then every 6 months after stabilization due to high relapse rates 2, 4
• Use standardized questionnaires (Insomnia Severity Index) to quantify progress and guide treatment adjustments 2, 8