Cognitive behavioural therapy for insomnia (CBTi) aims to change sleep habits and scheduling factors, as well as correcting misconceptions about sleep and insomnia that perpetuate sleep difficulties.
CBTi includes various combinations of both cognitive as well as behavioural interventions.
The cognitive component is aimed at changing patients’ beliefs and attitudes about insomnia. The behavioural component includes combining treatments such as sleep hygiene, stimulus control therapy, muscle relaxation training and sleep restriction.
Sleep education is the most fundamental aspect of managing sleep difficulties. Education is necessary to encourage substantial and sustained behavioural change. The patient needs to understand the rationale for the changes required to improve their sleep quality in order to be motivated and also to accept personal responsibility for initiating change.
The right amount of sleep one needs in order to feel awake, refreshed and function throughout the day may vary with age, gender as well as mental, health and physiological status. Sleep education is the foundation for teaching patients how to improve their sleep and also helps reshape their expectation of normal sleep and therefore serves as the foundation for successful treatment of insomnia. This is because patients’ expectations and what they consider to be normal sleep may be inaccurate and based on misinformation from others. This presents the opportunity for practitioners to provide the patient with reliable and useful information on sleep.
Basic sleep knowledge includes:
Sleep is regulated by an ‘internal body clock’ that is sensitive to light, time of day and other relevant cues for sleeping and awakening. There are four stages of sleep and these stages are important for overall sleep quality.
Cognitive elements of sleep are activities associated with thinking that disrupts sleep and replacing them with more adequate ones. This consists primarily of sleep education, keeping patients expectations realistic and examination of internal and external causes as well as the consequences of sleep disturbances.
The patient tends to focus on their sleep difficulty which leads to a vicious cycle which increases arousal at bedtime and therefore increases the severity of sleep disturbance. They may complain that they are “unable to shut off my mind”. ‘Trying to sleep’ may actually increase anxiety and make the problem even worse. Cognitive elements of insomnia, if left untreated, could lead to persistence of the problem.
Cognitive treatment is aimed at addressing cognitive changes that accompany sleep disturbances and eventually contribute to the problem. These include irrational fears (I can’t function normally if I don’t get more sleep), unrealistic expectations (I need more than 8 hours of sleep to be able to function) and excessive worrying about sleep (I wonder if I will be able to sleep tonight which put additional pressure on the sufferer leading to stress, arousal and further sleep disturbance.
Cognitive therapy challenges these beliefs and fears and provides the sufferer with other approaches to viewing sleep. This can be accomplished by first identifying the cognitive problems then challenging (cognitive reconstruction) and replacing them with more rational interpretations of the situation.
Sleep hygiene methods play a significant role in the management of sleep disturbances and could be considered as ‘self care’. These include environmental and lifestyle modifications such as reducing the intake of caffeinated drinks and keeping the bedroom at a comfortable temperature. These habits may seem like common sense but surprisingly are often overlooked. Below is a list of lifestyle changes that one can recommend to patients presenting with insomnia.
Here are some useful patient information leaflets and sites covering various aspects of sleep treatment:
The Good Sleep Guide and Good Relaxation Guide (Prof. Colin Espie)
Insomnia (poor sleep) (patient.co.uk)
Sleeping Well (Royal College of Psychiatrists)
Living with insomnia (NHS Choices)
Sleeping tablets (patient.co.uk)
Stopping benzodiazepines and z-drugs (patient.co.uk)