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