Cognitive Behavioral Therapy for Insomnia (CBT-I)

Cognitive Behavioral Therapy for Insomnia is widely recognized as the effective treatment for a wide range of insomnias. The treatment is typically made up of a number of components including assessment, behavioral and cognitive interventions, motivational techniques and relapse prevention skills.  An overwhelming amount of evidence suggests that CBT-I is as effective as hypnotics and the newer non-benzodiazapine sleep aides in the acute treatment and is more effective than medications in the long term treatment of insomnia. 

Cognitive Behavioral Therapy for Insomnia can be delivered as individual or group therapy with manuals existing for both formats.  Additionally, CBTI has been effectively delivered in as few as 2-3 sessions, virtually and online.  It has been shown to be effective for Service members and Veterans of all eras and in austere, deployed settings and in other remote locations. 

Many clinicians are experienced with some of the components of CBTI but very few have been found to routinely use the full, evidence based complement of assessments, interventions and outcome measures in a systematic manner.  There are now a number of manualized versions of CBT assessment and treatment programs for insomnia, all of which share the same basic components.  These components include a thorough sleep disorders assessment, stimulus control therapy, sleep restriction therapy, cognitive therapy, relaxation, motivation enhancement and sleep hygiene education. 

Insomnia is a distinct condition not only from other medical and psychological conditions, of which it used to be considered a symptom or a secondary condition, but is also distinct from and often co-occurring with other sleep disorders such as Obstructive Sleep Apnea and Restless Leg Syndrome.  The cornerstone of effective treatment lies in effective assessment and referral of conditions that require further evaluation by overnight sleep study, called a polysomnogram, or for medical interventions.  CBTI is most effective with patients that have insomnia.

The guiding perspective that governs CBT for Insomnia was first put forward over 30 years ago by Dr Arthur Spielman as the Behavioral Model of Insomnia.  This model is the most articulated and most widely cited theory regarding the etiology of insomnia and continues to gain support despite amazing new developments in the ability to effectively assess sleep and the brain.  The model is a three factor diathesis stress model that suggests that acute insomnia is the result of biopsychosocial predisposing factors coupled with a precipitating stressor.  Chronic insomnia occurs because of maladaptive habits (behaviors such as napping, spending more time in bed awake etc) and unhelpful, alarming cognitions (“I have to get to sleep”) and their resulting emotions that exacerbate and maintain the insomnia.  By systematically countering these perpetuating factors, CBTI is able to effective break the cycle of insomnia and on average yield an average treatment effect of 50% improvement with large effect sizes of around 1.0 with sustained treatment effects and even improvement over time. 

Insomnia is one of the main residual complaints of people successfully treated for a range of psychological conditions including PTSD, Depression and Anxiety.  Complaints regarding sleep quantity and quality are the number one non wound or injury related complaint of Service members post deployment and there have been increases in the number of OIF/OEF veterans with other sleep disorders including Obstructive Sleep Apnea, Nightmare Disorder and REM Sleep Behavior Disorder.