Cognitive-behavioral therapy for insomnia
CBT-i is an effective nonpharmacologic multimodal combination of treatments for coping with sleep problems. It can either be effectively done by trained therapists face-to-face or as a telemedicine-based internet-delivered therapy.15 CBT-i aims to change thoughts that negatively interfere with sleep quality and improve sleep behaviors and unhealthy habits. CBT-i encompasses cognitive and behavioral interventions and relaxation training. For treatment success, good compliance of the patient is a prerequisite. Along with the motivation, patients also need to include the sleep diary as part of their daily routine.
Cognitive interventions as a form of psychotherapy aim to recognize and change the patient´s maladaptive beliefs about sleep. The first step is the identification of the stressors, which are subsequently replaced with an alternative interpretation. Quite common are unrealistic expectations about sleep duration. These thoughts create tension, impair the ability to sleep, and cause a vicious cycle. Education of patients about realistic expectations from sleep may reduce anxiety and hyperarousal associated with insomnia. The therapist can even advise the patient to make an active effort to stay awake, which may help relieve the anxiety linked to the pressure to fall asleep. The described technique is known as paradoxical intention .
Behavioral interventions emphasize the change in the patient´s maladaptive behavior. Therapy for insomnia should involve at least one intervention session. Individual or group format therapy aims at the development of new behavioral patterns. The intervention can easily be delivered in the office setting by a general practitioner, who advises the patient to maintain a sleep diary and is instructed on sleep hygiene, stimulus control, and sleep restriction therapy. Commonly used individual components comprise sleep hygiene, stimulus control, sleep restriction, paradoxical intention, and relaxation training.
Sleep hygiene was initially introduced in 1977 by Peter Hauri, who developed a concept of sleep-promoting recommendations.16 Sleep hygiene consists of a set of behavior and environmental factors modifications (e.g., avoiding naps during the day, avoiding physical exercise close to bedtime, limiting caffeine consumption, bedroom temperature) that may improve sleep quality.17 The International Classification of Sleep Disorders (ICSD) introduced a diagnostic category called ’Inadequate Sleep Hygiene’.18 The sleep habits that contribute to inadequate sleep hygiene, according to the ICSD, are presented in Table 1. In recent years, attention is paid to ’light hygiene’, a set of recommendations to alleviate the negative impact of blue light exposure on sleep quality. The wavelengths in the blue part of the spectrum (400–490 nm) suppress melatonin secretion, resulting in circadian dysregulation with delayed sleep onset.19 Patients may be advised to limit the use of blue light-emitting devices (e.g., TVs, laptops, tablets, smartphones) 90 minutes before bedtime.20 An alternative can be the use of blue-light filtering glasses.21
Stimulus control therapy aims to (re)associate the bedroom with sleep and set a regular sleep-wake cycle.22 Specific recommendations include a set of behavior modifications (e.g., only going to bed when feeling sleepy, using the bed and bedroom for sleep and sex only, keeping a fixed wake time in the morning). Together with sleep hygiene, stimulus control education is recommended as an initial intervention for all adults with insomnia.23
Sleep restriction may be beneficial for patients who spend a long time in bed, not sleeping. The initial goal is to achieve mild sleep deprivation by limiting the number of sleeping hours. The physician advises the patient to limit time in bed to the number of hours spent sleeping, while this time should not be less than five hours.24 Using the sleep diary, the patient is instructed to gradually increase sleep time as sleep quality improves.23 One important flaw of this approach is an increased risk of daytime drowsiness.
Evidence shows CBT’s consistent effectiveness in improving sleep problems across multiple outcomes25-27 and seems to be the optimal first-line treatment.12,14 Notably, no specific adverse effects were reported.28