Please Note! This section provides a schematic overview of select sleep disorders that must be confirmed by a physician or sleep specialist. This information has been presented for educational purposes only.

Insomnia and
Cognitive Behavioral Therapy


The Impacts of Poor Sleep Quality Are Significant


The Characterization of Insomnia

Sleep Specialists Characterize & Treat Sleep Disorders
Insomnia is largely defined as persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs in the context of adequate opportunity for sleep, and results in some form of daytime impairment. The three components of insomnia— (1) persistent sleep difficulty, (2) adequate sleep opportunity, and (3) daytime dysfunction associated with sleep difficulty—are all implied with formal references to the term insomnia.

The subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep and results in some form of daytime impairment is required for a formal diagnosis of insomnia. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and The International Classification of Sleep Disorders, Third Edition (ICSD-3) have similar criteria. Criteria specify that symptoms must cause clinically significant functional distress or impairment, be present for at least 3 nights/week for at least 3 months, and not be linked to other sleep, medical, or mental disorders.

Insomnia classification underwent a significant change in the transition from ICSD-2 to ICSD-3.  The change reflects the emphasis that sleep disorders should be regarded as primary disorders treated independently, as opposed to secondary effects that are resolved only with the resolution of other primary disorders.

Various studies have shown the prevalence of insomnia to be 10%–30% of the population, but some even estimate a prevalence as high as 50%–60%. The discrepancy often has to do with the fact that the public largely utilizes the term for any sleep-related problem, which can often be far more prevalent than the strict medical criteria suggest. The differentiating factors for clinicians (apart from the absence of another primary disorder) are the frequency and the fact that functional impairment is involved.

Insomnia is common in older adults, females, and people with medical and mental illness. The consequences of insomnia include depression, impaired work performance/quality of life, and increased risk for motor vehicle accidents. Apart from increased safety risks and cognitive/emotional impacts, the data also increasingly link short sleep varieties to cardiovascular, metabolic and immune dysfunctions.

Insomnia is thought to emerge from a combination of factors that may make it more likely in some individuals. These factors have been summarized in the sleep literature as the “3 P’sof insomnia, including: Predisposing factors such as a general hyperarousal tendency that lowers one’s threshold for waking. Sleep clinicians consider predisposing tendencies to be difficult to modify relative to other factors because they often include a genetic predisposition, including mood/affective disorders that amplify anxiety and the tendency toward hyperarousal and other psychiatric disorders, including depression, bi-polar disorder and others. In addition to hyperarousal states, hyper-rumination or "excess worry" may be a tendency for a subset of this general class of predisposing dispositions. Precipitating factors of insomnia are events and episodes that have become triggers for the onset or worsening of sleep difficulties. They are often related to stressful life changes and intense emotional experiences (both positive and negative) that, in turn, precipitate sleep difficulties. Cognitive and behavioral interventions can diminish the intensity of these reflexive triggers. Perpetuating factors of insomnia are repeating behaviors or conditions that contribute to insomnia. Examples of perpetuating factors include inadequate sleep hygiene, negative forethought about the effects of insomnia, and environmental factors such as stimuli that impact the circadian rhythm entrainment system at the wrong time. Perpetuating factors are the most responsive to interventions, but perpetuating interventions do not treat insomnia on their own.

The AASM Fact Sheet (above) provides "What To Do" Insomnia guidance for providers. 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.

Are Sleeping Pills The Answer?

We suggest immediately below that cognitive behavioral therapy for insomnia (CBT-I) and related techniques are useful not just for insomnia, but also for comorbid psychiatric conditions such as depression, bipolar disorder, PTSD, and schizophrenia. The momentum toward CBT-I is not simply because of its apparent effectiveness to assist sleep quality, however. It is also because studies have disclosed sleep aids and sleeping pills to be problematic over the long-term relative to the capacity to re-engage our natural patterns.

One of the basic premises of CBT-I is that psychological patterns of thought become reflexive and thereby perpetuate and exacerbate sleep onset and sleep maintenance issues. Those issues, however, may not always begin as primary insomnia subtypes. In the circadian rhythm learning section we discover how easy it is to have our circadian rhythm 'drift' later and later, thereby causing sleep onset difficulties that may be exacerbated and "locked in" through our cognitive associations.
Sleep disordered breathing (SDB) subtypes such as obstructive sleep apnea (OSA), primary snoring, partial airway restriction, and now increasingly: central sleep apnea (CSA) due to opioid use, all contribute to the 'triggers' that turn our attempts to sleep into a wary battle.

To make matters worse, our culture has turned to both over-the-counter (OTC) sleep aids and prescribed sleeping pills with a voracious appetite. These substances, in many cases, have added to our cognitive dependence and lack of confidence in our natural capacity to slide into restorative sleep. Moreover, although there is a place for the disciplined use of some aids to temporarily assist, for example, circadian rhythm shifts for rotating shift workers, the long-term use of both OTC and prescribed pills is increasingly being disclosed by large meta studies to be robustly associated with adverse outcomes. These associations may or may not be mechanistic and causal, nonetheless the pattern is real.

Cognitive Behavioral Therapy for Insomnia (CBT-I)

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."
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/Mindfullness Techniques; and (5) Sleep Hygiene Education. To learn more about these effective strategies, select: CBT-I.

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.


Learn more about CBT-I

Circadian Rhythm Shifts & Insomnia

The actual diagnoses of a circadian rhythm shift disorder may not be very common in comparison to the diagnosis of other sleep disorders, but even subclinical circadian shifts impair the sleep onset timing of a significant number of individuals— enough even to apparently drive the frequent misdiagnoses of insomnia by primary care physicians who do not consider circadian rhythm shifts when prescribing sleeping pills. One of the differentiating features of a circadian rhythm delay relative to insomnia is that sleep onset difficulties do not arise during typical weekends or days off, but they are persistent during the week for individuals with delayed rhythms. More generally, apart from the potential impacts from sleep-related breathing disorders (below) and other medical disorders, circadian rhythm shifts may impact sleep quality more than nearly any other factor. Subtle shifts, drifting rhythms, and misaligned circadian rhythms are a great concern for much of risk management, and on the other side of the coin, when optimized, circadian rhythms create an organizing framework for increased athletic performance. More commonly, however, a shifted rhythm may create an environment that elicits problematic cognitive cycles that are conducive to the development of chronic insomnia. Circadian rhythm optimization is therefore a crucial component of good sleep hygiene practices that prepare the body for consistently timed sleep onset patterns. By virtue of this critical role for the timing of sleep onset and all of the intervening sleep stage functions within sleep, we present an entire learning section on circadian rhythm. We believe that it is important to take the time to understand the circadian rhythm section.

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.