Cognitive Behavioral Therapy
for Insomnia (CBT-I)


The Impacts of Poor Sleep Quality Are Significant


Cognitive Behavioral Treatment for Insomnia

Variants of CBT-I are considered a first-line treatment option for insomnia
AASM clinical guidelines for the evaluation and management of chronic insomnia consider behavioral treatment options, such as CBT-I, to be a recommended "first-line treatment option". Common pharmacological interventions such as benzodiazepine receptor agonist medications (i.e., 'sleeping pills') are increasingly revealed to be associated with adverse outcomes with long-term use. CBT-I is a combination of component behavioral therapy interventions, including therapeutic protocols derived from: (1) Stimulus Control Therapy; (2) Sleep Restriction Therapy; (3) Relaxation-Based Interventions; (4) Cognitive Strategies; and (5) Sleep Hygiene Education.

I. STIMULUS CONTROL THERAPY. Given the “Predisposing” factors for a number of individuals who are likely to develop insomnia, apprehension about sleep quality is concentrated onto reflexive bedroom cues and a generally bad association with that time of night. These reflexes are particularly likely before events that are deemed important the next day. On top of predispositions, however, many individuals engage sleep preparatory habits that exacerbate the problem. Many individuals stay in bed for long periods “attempting” to force sleep onset. Individuals that sleep poor may engage in napping patterns that are not conducive to better sleep at night.

Stimulus Control therapies are designed, in tandem with Sleep Restriction, to reset the association with sleep as a positive, restorative one. They include pre-sleep “rituals”. Like Sleep Hygiene, Stimulus Control instructions appear to be very simple, but taken out of context from a CBT-I protocol (or a general appreciation of the way that sleep works), the instructions may not be taken serious enough for long enough to be effective. Their efficacy increases when practiced over a consistent period during its introduction. Moreover, the initial counter-intuitive step of Sleep Restriction is actually the driving force for the capacity of sleep to be “reset” at the physiological level, since it is not amenable to cognitive (willful) onset.

Stimulus Control Therapy INSTRUCTIONS include: (1) Going to bed only when sleepy. Protocols emphasize the need for physiological sleepiness, as opposed to mere ‘fatigue’. (2) Get out of bed after 20 minutes. If sleepiness does not arrive in roughly 20 minutes or so, individuals should get out of bed and go to another room until sleepy. (3) Curtail sleep incompatible behaviors (before sleep attempts and in other room if necessary). No eating, no watching TV, no electronic devices, no planning or ruminating on tomorrow’s problems. That leaves only reading or other relaxation techniques. (4) Arise at consistent time every morning regardless of the amount of sleep achieved. This is part of the resetting of the physiological sleep drive (and circadian rhythm) that places Sleep Restriction as a necessary tandem technique with Stimulus Control Therapy. (5) Avoid napping. During the period that therapy is engaged, naps should be avoided. Power naps assist for rotating shift workers and night-shift workers that are generally sleep deprived. They can also assist performance in certain situations, but naps disrupt the CBT-I protocol during the treatment period.

II. SLEEP RESTRICTION: There is, of course, a reflexive tendency to stay in bed longer when sleep onset problems begin. However, Sleep Restriction Therapy temporarily curtails the amount of time in bed (and hence sleep itself) to the amount of time that problematic insomnia suffers receive during bouts of insomnia. If a person can only achieve 5 hours of quality sleep, then therapy requires only 5 hours in bed initially. This will drive physiological sleepiness to its existing non-problematic sleep onset level. Some protocols keep the restricted sleep time for a week before increasing the sleep opportunity time by only 20 minutes IF sleep efficiency reaches 85% of the time in bed, otherwise it stays until that threshold is reached. If sleep efficiency is less than 80%, time in bed is actually reduced by 20 minutes until the threshold reaches 85%. Adjustments are made weekly until the combination of the drive for sleepiness and the disruptive factors expand the sleep window.

The goal is to increase the homeostatic sleep drive or “sleep pressure” to overcome the anxiety constraints associated with normal sleep periods until mild sleep deprivation and the relaxation of constraints resets a pattern closer to recommended sleep time.

III. RELAXATION-BASED INTERVENTION: Because the predisposition for insomnia includes heightened states of anxiety or an overall hyper-arousal tendency, interventions that assist in the reduction of physiological stress are another core feature of CBT-I protocols. Traditional relaxation techniques included progressive muscle relaxation, slow, deep rhythmic breathing and other methods to reduce somatic arousal in combination with techniques to reduce cognitive arousal and hyper-rumination, (excess intrusions of thought), focusing and imagery methodologies are also sometimes employed. Insomnia subtypes vary according to predisposing subtypes so the combination of somatic versus cognitive relaxation techniques should reflect the subtype. In fact, some persons will develop a reflexive “trigger” due to a hyper-vigilant mind when cognitive methods are employed, so CBT-I providers are advised to tailor their protocols to the individual.

The goal of the relaxation intervention component of CBT-I is to reduce arousal, not to induce sleep. Once viable techniques are discovered, practice should ensue for 2 to 4 weeks.

IV. COGNITIVE THERAPY seeks to diminish sleep-disruptive cognitive reflexes associated with sleep, including expectations. Excess self-monitoring occurs in some hyper-vigilant individuals. Reduction of self-monitoring is not always possible, but unrealistic expectations about sleep or the role of sleep for the individual’s performance, productivity or presentation may be diminished enough to eventually relax the self-monitoring intrusive intensity. Worry about the consequences of sleep loss or diminished sleep quality can be attenuated by pointing out that those consequences did not actually pan out relative to forethought of their impact. Clock watching and self-monitoring of the state of sleep needs to be curbed with cognitive therapy and practice. False expectations also include misguided notions about the sleep issue in general. For example, individuals may convince themselves that they have a psychiatric, sleep or other disorder when in fact their problematic patterns are not driven by a pre-existing disorder, but rather a vicious cycle.

Cognitive Therapy should teach individuals to: (1) Retain realistic expectations about necessary sleep or temporary sleep issues, (2) Do not use insomnia as a crutch to “explain” excess worrying patterns that can be addressed, (3) Reduce the striving ‘effort’ at falling asleep, and give in to a period of temporary sleepiness if need be, (4) Do not place too much importance on sleep if cognitive worry or hyper-vigilance are the issue; understand that there are ways to curb the problem, (5) Develop some intolerance and adaptation to temporary bouts of insomnia.

MINDFULNESS-BASED INTERVENTIONS: Additional components to Cognitive Therapy include mindfulness meditation based on awareness of the moment, without judgement. Mindfulness exercises can help dampen somatic arousal, but it is also the “without judgement” part that assists some CBT-I interventions. In this context, unwelcome judgements often include the notion that the effects of poor sleep will be catastrophic for the next day, when in fact the next day can be shown to seldom be as impacted as the negative cycles of thought project during the previous night. It may seem paradoxical that a hyper-vigilant, hyper ‘self-monitoring’ (and hence hyper “aware”) person can benefit from mindfulness exercises, but it is the case that mindfulness-based stress reduction (MBSR) methods may complement conventional cognitive behavioral therapies through the cultivation of a “non-striving” attitude. Non-striving can be practical and ambitious, without exaggerated self-monitoring.

V. SLEEP HYGIENE EDUCATION: Sleep hygiene education appears to be everywhere these days in the form of isolated lists that are often presented as "the" condensed formula for better sleep. In contrast to presenting only concise "tips-and-tricks", this learning platform has been created precisely because sleep bullet-points do not have the power to effect positive change unless they have been boiled down from a larger context that is specific to the individual. Context matters. Lists are effective the way that cheat sheets are effective: a condensed cheat sheet works best if it prods important features at the same time that it activates a broader association with where, why and how those select features are important. If isolated from context, their importance is never transferred.

Within CBT-I protocols, sleep hygiene education complements the other therapies and intervention methods. Sleep hygiene includes general sleep-facilities recommendations, including:

(1) Avoiding stimulants such as caffeine and nicotine for several hours prior to bedtime. See also the caffeine link to contextualize the 5 hour half-life of caffeine.

(2) Avoid alchohol around bedtime because it fragments sleep. See also the Sleep Architecture section to understand why the REM-suppressing qualities of alcohol are so disruptive.

(3) Exercise regularly. Exercise timing is also important to ensure that circadian rhythm delays do not interfere with desired sleep onset time. Morning and late afternoon exercise may be beneficial, provided that core body temperature is allowed to be reduced. Late evening exercise is not recommended. See the circadian rhythm section to learn more about exercise timing and influence.

(4) Allow at least a 1-hour period to unwind and prepare for sleep. This preparation aligns with a natural inflection point in our circadian rhythm that should occur to assist a sleep onset preparation period.

(5) Keep the bedroom environment quiet, dark and at a comfortable temperature. Our natural dim light melatonin onset (DLMO) is interrupted with bright light, as is the inflection of a previous late afternoon rise in our circadian rhythm that abruptly turns downward in preparation for sleep to reduce our core body temperature. The bedroom should be between 62 and 68 degrees Fahrenheit to maintain this reduction.

(6) Maintain a regular sleep schedule to keep your circadian rhythm from drifting.

(7) Remove electronic devices from the bedroom. Electronic devices emit enough light to interrupt normal melatonin release. In addition, increased cortical arousal delays sleep onset.

Sleep Hygiene is rarely adequate to treat sleep onset difficulties on its own in the absence of a multi-component therapy similar to those available in the form of CBT-I.

Stimulus Control

The goal is to turn your negative reflexives about the challenges you have with sleep onset into positive, confident associations with your bedroom and your sleep environment.


Sleep Restriction

It is completely counter-intuitive at first but one of the best ways to "reset" your association with sleep is to make you physiologically sleepy enough to overcome your intruding concerns.


Relaxation & Feedback

You will learn in the circadian rhythm education section that sleep onset follows a natural dip that prepares the way for sleep. Relaxation techniques can assist this natural process.


Cognitive Control & Therapy

Therapy, guided imagery and mindfulness can help control intrusive thoughts. After all, one of sleep's basic functions is to "finish" processing your emotions if you are ready to let it.

If patients or practitioners need to find a sleep specialist associated with a sleep center in their area, the American Academy of Sleep Medicine (AASM) has also developed a sleep center: locator.

CBT-I for Other Disorders

A very telling fact about the efficacy of CBT-I is to note its effectiveness for the treatment of insomnia in the context of other disorders. CBT-I is effective for the treatment of insomnia related to: depression, anxiety, PTSD, and substance-abuse issues. It is well-established that insomnia is closely associated with mental illnesses, both as a symptom and as a trigger. Its co-occurrance with major depression is 80%. In some studies, CBT-I is considered more effective than cognitive therapies addressed specifically to those psychiatric disorders. In addition to psychiatric disorders, CBT-I has also been shown to be effective for insomnia due to medical disorders, including chronic pain, fibromyalgia, cancer and various medical conditions in the elderly population. Insomnia in older individuals is more likely to be comorbid with other medical conditions, medications, or substances. If insomnia is comorbid with OSA or any other condition, CBT-I and insomnia treatment in general are no longer considered secondary treatment priorities but can be applied in tandem with other treatment modalities because contraindications do not arise with CBT-I, except for some advanced illnesses.

Self-paced commercial online CBT-I programs such as SHUTI and SLEEPIO have been validated clinically to be, in some cases, as effective as face-to-face therapy sessions guided by a sleep specialist or mental health clinician trained in CBT-I. Nonetheless, some individuals respond better to more intensely focused one-on-one training and motivation techniques. To assist in locating a sleep specialist in your area, use the American Academy of Sleep Medicine sleep center locator above.

Sleep Is Not Rest

Although Nourish Sleep is a non-clinical entity, we do not operate outside of a responsible care pathway. Nourish Sleep screening does not constitute confirmation of a sleep disorder or lack thereof. Only a face-to-face clinical evaluation with a clinician or board certified sleep physician can affirm the necessity for further diagnostics or treatment. Our role is to educate you and provide you a rigorous, but highly tailored and comprehensive understanding of your specific sleep quality. Although we work collaboratively with a diverse array of clinical and educational resources to fulfill that mission, Tri-Nourish Inc and Nourish Sleep constitute non-clinical entities offering non-clinical services. Our goal is to assist your sleep quality in a pre-pathological (preventative) approach that takes into consideration domains that impact health and wellbeing before they transition into common sleep, mental or physiological disorders. Poor sleep quality radically impacts productivity, performance, health, emotional resilience, and safety— well before the sleep disorder threshold has been breached.