Journal of Traumatic Stress, Vol. 18, No. 2, April 2005, pp.

155–159 (

C 2005)

Treatment of Residual Insomnia After CBT for PTSD:

Case Studies

Jason C. DeViva,1,4 Claudia Zayfert,1 Wilfred R. Pigeon,1,2 and Thomas A. Mellman1,3

Insomnia is one of the most common symptoms of posttraumatic stress disorder (PTSD). Evidence
suggests that insomnia may persist for many PTSD patients after other symptoms have responded to
cognitive-behavioral therapy (CBT). The present article reports the effects of administering a five-
session cognitive-behavioral insomnia treatment to 5 patients who responded to CBT for PTSD yet
continued to report insomnia. Insomnia treatment was associated with improvements on subjective
sleep measures (Pittsburgh Sleep Quality Index, Insomnia Severity Index, and Beliefs and Attitudes
about Sleep Scale) and self-monitored sleep efficiency and related measures in 4 of 5 cases. Results
highlight issues specific to treating insomnia in trauma populations and future directions for examining
treatment of insomnia associated with PTSD.

Difficulty initiating and maintaining sleep is the most
frequently reported symptom among various posttrau-
matic stress disorder (PTSD) populations, endorsed by
as many as 70% of individuals diagnosed with PTSD
(Ohayon & Shapiro, 2000). Because of its prominence
among posttraumatic sequelae, several studies have exam-
ined the effectiveness of treatments for insomnia in trau-
matized populations. Generally, theories to explain insom-
nia associated with PTSD have conceptualized insomnia
as one component of the syndrome of PTSD and focused
on associations between sleep and other PTSD symp-
toms, such as hypervigilance or nightmares (Krakow et al.,
2000). In an uncontrolled trial, Krakow, Johnston, et al.
(2001) found that cognitive behavioral therapy (CBT) for
insomnia combined with imagery rehearsal therapy for
nightmares was associated with significant improvements
1 Dartmouth Medical School, Lebanon, New Hampshire.
2 Now with the Department of Psychiatry, University of Rochester Med-
ical Center, Rochester, New York.
3 Now with the Department of Psychiatry, Howard University, Washing-
ton, DC.
4 To whom correspondence should be addressed at Veterans Affairs
Maryland Health Care System Baltimore, 10 North Greene Street,
Baltimore, Maryland 21201; e-mail: jason.deviva2@med.va.gov.
in sleep quality, nightmare frequency, and PTSD severity
in a sample of female crime victims with PTSD. Sub-
sequently, Krakow, Hollifield, et al. (2001) found the
treatment package superior to waitlist on measures of
nightmares, sleep quality, and posttraumatic symptoms
in a sample of female assault victims. Blake and Gomez
(1998) found that a five-session group sleep-hygiene treat-
ment was associated with improvements in self-reported
sleep-hygiene behaviors among 52 veterans in an inpa-
tient PTSD program, although they did not report effects
of the treatment on sleep.
Despite statistically significant treatment effects in
the studies by Krakow, Johnston, et al. (2001) and Krakow,
Hollifield, et al. (2001), posttreatment sleep, PTSD sever-
ity, and nightmare frequency scores remained in the clini-
cally significant range. These treatments have been shown
to be effective with nontrauma samples experiencing in-
somnia or nightmares, yet were limited in their effec-
tiveness with trauma samples. This suggests that PTSD
may complicate insomnia treatment. However, the only
two studies reporting effects of PTSD treatment on sleep
suggest that insomnia may not always remit with treat-
ment of PTSD. In their report of the effects of flooding
treatment in a sample of 7 combat veterans with PTSD,

155


C 2005 International Society for Traumatic Stress Studies • Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jts.20015
156 DeViva, Zayfert, Pigeon, and Mellman

Cooper and Clum (1989) found that 4 participants im- quality among 5 pilot patients. We also examined quali-
proved their sleep by 1 hr or more nightly whereas the tative data that would inform further efforts to adapt stan-
sleep of the other 3 veterans remained poor. Zayfert and dard insomnia interventions for PTSD populations.
DeViva (2004) reported that 13 (48%) of 27 patients who
completed CBT for PTSD in a clinical setting contin-
Method
ued to report insomnia despite no longer meeting crite-
ria for PTSD. Together, these findings suggest that for
Treatment Cases
many patients, treatment of PTSD may be necessary but
not sufficient for improvement of sleep, and additional
Patients were 5 consecutive responders to CBT
insomnia-specific interventions may be warranted.
for PTSD who evidenced residual insomnia. All were
Krakow, Johnston, et al. (2001) proposed that insom-
Caucasian women (Table 1) with a principal diagnosis
nia associated with PTSD can develop into an independent
of PTSD at initial evaluation. Treatment of both PTSD
condition over time, maintained by maladaptive sleep-
and insomnia was delivered in the fee-for-service anxiety
related cognition and behavior and necessitating specific
clinic of a rural tertiary-care medical center. Clinic data
intervention. CBT for insomnia, which includes stimu-
were compiled with approval of the Institutional Review
lus control, sleep restriction, cognitive restructuring (CR),
Board for Protection of Human Subjects and patients’ con-
and sleep-hygiene components, has considerable empir-
sent. Patients 2 and 4 had been taking their current sleep
ical support with general insomnia populations (Morin
medication for over a year and were reluctant to taper
et al., 1999), and applications to PTSD thus far have been
(Table 1). Patient 5 expressed a preference to discontinue
promising (Blake & Gomez, 1998; Krakow, Hollifield,
all medications. Patients initially agreed to keep medica-
et al., 2001). We hypothesize that a sequential approach,
tion stable during treatment and taper upon completion.
in which CBT for insomnia follows CBT for PTSD, would
optimize the results of both interventions. In addition, we
considered that some maladaptive sleep behaviors might CBT for PTSD
be peculiar to trauma survivors (e.g., reflecting safety con-
cerns at night) and therefore would warrant a specific All patients had received CBT for PTSD consisting
approach. Therefore, we tailored CBT for insomnia to ad- of exposure therapy and CR based on the approach of
dress the specific needs of PTSD patients who have partic- Foa and Rothbaum (1998). Patients received an average
ipated in CBT for PTSD. This report presents preliminary of 21 individual sessions (range = 14–29), including 6
data on the effects of this intervention administered to imaginal exposure sessions (range = 4–7), 11 CR sessions
PTSD treatment responders who reported persistent in- (range = 4–19), and 4 other sessions (range = 1–7). Four
somnia following PTSD treatment. We hypothesized that patients also participated in group CBT.
insomnia treatment would result in improvements in sleep The mean pretreatment scores on the Clinician-
onset latency (SOL), wake time after sleep onset (WASO), Administered PTSD Scale (CAPS; Blake, 1994) was 69.0
sleep efficiency (SE), sleep-related cognition, and sleep (range = 34–95), and the mean posttreatment score was

Table 1. Patient Characteristics

Comorbid Diagnoses Medication

Patient Age Index Trauma Pre-PTSD Post-PTSD Sleep Medication Other Medication
1 34 CSA, APA None None None None
2 46 CSA MDD, GAD, SoP NA trazodone 137.5 mg None
3 49 CSA SoP, SP SoP (SP-NA) None None
4 56 CSA, brother’s suicide MDD, GAD None zolpidem 5 mg estradiol, progesterone,
venlafaxine 150 mg,
buproprion 75 mg,
synthroid 175 mcg
5 18 ASA GAD, MDD None trazodone 50 mg sertraline 150 mg, quetiapine
100 mg, clonazepam 5 mg

Note. Pre-PTSD indicates prior to posttraumatic stress disorder treatment, Post-PTSD indicates following posttraumatic stress disorder
treatment; CSA = childhood sexual abuse; APA = adult physical assault; ASA = adult sexual assault; MDD = major depression; GAD
= generalized anxiety disorder; SoP = social phobia; SP = specific phobia; NA = not assessed; CAPS = Clinician-Administered PTSD
Scale.
Treatment of Residual Insomnia
22.6 (range = 14–40). None met criteria for PTSD on the
CAPS at posttreatment.
PTSD Insomnia Treatment (PIT)
PIT was based on Morin’s (1993) protocol for in-
somnia. Treatment began with stimulus control and sleep
restriction, focused on strengthening connections be-
tween sleep-related cues such as bed and sleep. CR tar-
geted beliefs that could interfere with sleep, emphasiz-
ing vigilance- and threat-related beliefs with this sample.
Sleep hygiene focused on education about behaviors that
affect sleep, such as caffeine use and exercise.
Due to overlap between CBT for insomnia and PTSD
treatment patients had already received, we reduced treat-
ment from 10 to 11 sessions to 5 (Table 2). All insom-
nia treatment was delivered by the first author (J.C.D.),
who has specific training and several years of experience
in CBT for PTSD, in consultation with the third author
(W.R.P.), who has extensive experience in CBT for in-
somnia.
Measures
Patients were assessed before and after sleep inter-
vention. Qualitative data were gathered during interviews
and treatment sessions; questionnaire and sleep-diary data
were completed at home.
Pittsburgh Sleep Quality Index (PSQI)
The PSQI is a psychometrically sound 19-item mea-
sure of overall sleep quality (Buysse, Reynolds, Monk,
Berman, & Kupfer, 1989). Cutoff for clinically signifi-
cant sleep disturbance is 6.
Insomnia Severity Index (ISI)
The ISI is an internally consistent seven-item self-
report measure of insomnia symptoms and related distress
Table 2. PTSD Insomnia Treatment
Session Contents
1 Insomnia evaluation
2 Sleep restriction and stimulus control
3 Review homework; begin cognitive restructuring
4 Review homework; sleep hygiene
5 Review/integrate components; relapse prevention
157
(Bastien, Vallières, & Morin, 2001). Cutoff for clinically
significant sleep disturbance is 8.
Beliefs and Attitudes about Sleep Scale (BASS)
The BASS is a 30-item self-report measure of sleep-
related cognition (Morin & Savard, 2002).
Sleep Diary
Patients used the sleep diary to record time in bed,
SOL, time asleep, WASO, and SE (time asleep divided by
total time in bed) each night from 1 week before through
1 week after insomnia treatment. Data reported are means
for the pre- and posttreatment weeks only.
Results
Treatment Adherence and Completion
Four of the 5 patients completed all five sessions of
insomnia treatment. Due to scheduling difficulties, Patient
4 did not attend Session 5 but completed posttreatment
assessment. All 5 patients complied with sleep-diary pro-
cedures and completed all assigned homework.
Assessment Results
Initial PSQI scores exceeded the accepted cutoff for
significant sleep disturbance (6) and the mean (M = 11.8,
SD = 2.3) exceeded the mean reported by Buysse et al.
(1989) for a sleep-disordered sample. Pretreatment ISI
and BASS scores also were comparable to scores of in-
somnia samples (Bastien et al., 2001; Morin & Savard,
2002). Generally, scores improved from pretreatment to
posttreatment, with effect sizes of 2.8 on the PSQI, 3.4 on
the ISI, and 2.5 on the BASS (all effect sizes Cohen’s d;
Fig. 1).
Sleep-diary data also indicated significant sleep im-
pairment prior to treatment, with the sample averaging
less than 6 hr of nightly sleep and sleep latency over 30
min. At posttreatment, most sleep-diary variables had im-
proved (Table 3).
Qualitative Results
During CBT for PTSD, Patient 3 could not recall
her perpetrator’s identity, and imaginal exposure had fo-
cused on indistinct assault-related images. After PTSD
158 DeViva, Zayfert, Pigeon, and Mellman

Fig. 1. Pre- and posttreatment scores on the Pittsburgh Sleep Quality Index (PSQI; Panel 1), the Insomnia Severity Index (ISI;
Panel 2), and the Beliefs and Attitudes about Sleep Scale (BASS; Panel 3).

treatment, Patient 3 no longer met PTSD criteria, yet
still had disturbing dreams she perceived as clues about
her perpetrator. During insomnia treatment, she reported
having identified her perpetrator while scanning old pho-
tographs, resulting in dreams that awakened her. She re-
ported that arousal caused by the dreams interfered with
return to sleep, accounting for her high posttreatment
WASO.
Patients 1, 2, 4, and 5 had been assaulted in bed.
During CR, Patients 2 and 4 reported anxiety-provoking
thoughts about loss of vigilance associated with sleep,
and Patients 2, 3, and 5 reported beliefs about nocturnal
danger, despite safe living situations. Because of danger-
related beliefs, Patients 2, 3, and 5 engaged in maladap-
tive sleep behaviors (e.g., too many blankets or win-
dows closed in summer). These beliefs were addressed
using CR, and patients subsequently reported decreased
safety behaviors and improved sleep. Midtreatment, Pa-
tient 2 began spontaneously decreasing her trazodone in
12.5-mg increments and reported using stimulus control
procedures to cope with the ensuing sleep disturbance.
No other patients reported medication changes during
PIT.
Discussion
The five-session insomnia treatment resulted in im-
provement on self-recorded total sleep time, SOL, WASO,
and SE. Scores on measures of sleep quality, impairment
resulting from sleep difficulty, and maladaptive sleep-
related cognition also improved, with changes compara-
ble to effect sizes reported in meta-analyses of cognitive
and behavioral insomnia treatments (Morin, Culbert, &
Schwartz, 1994; Murtagh & Greenwood, 1995). Despite
significant gains, scores on the IS and the PSQI generally
remained at or above cutoffs for clinical significance. Be-
cause PIT condensed the standard insomnia protocol into
five sessions, it may not have provided a sufficient dose of
the intervention. Alternatively, it is possible that treatment
was sufficient and that patients continued to improve after
the final assessment point.

Table 3. Pre- and Posttreatment Sleep Diary Measures

SOL WASO EMA TST Efficiency

Patient Pre Post Pre Post Pre Post Pre Post Pre Post
1 40 24 55 14 24 46 311 401 .72 .83
2 24 12 19 16 55 49 356 362 .78 .82
3 39 20 93 62 13 0 321 384 .70 .82
4 26 17 11 16 25 17 418 413 .86 .86
5 143 45 19 3 9 1 474 430 .74 .90
Cohen’s d .84 .56 .12 .40 1.7

Note. All statistics are per-night averages. SOL = sleep onset latency (min);
#WASO = number of wakenings after sleep onset; WASO = wake time after sleep
onset (min); EMA = early morning awakenings (min); TST = total sleep time (min);
efficiency = TST/time in bed.
Treatment of Residual Insomnia
The qualitative data are pertinent to interpretation
of the results. Patient 2’s self-initiated trazodone taper-
ing suggests that her posttreatment assessment data may
overestimate insomnia severity and underestimate the ef-
fects of insomnia treatment on her functioning and her
perception of her control over sleep. Patient 3 reported
that trauma-related dreams were associated with extended
WASO. Persistent PTSD symptoms may have decreased
the effectiveness of PIT for this individual, a possibil-
ity consistent with our hypothesis that treatment for in-
somnia in the context of PTSD will be most effective
if initiated after PTSD has been addressed. Even after
resolution of PTSD, the patients in this sample reported
many trauma-related safety behaviors specifically in the
bedroom, which interfered with sleep in various ways.
These observations suggest the benefit of tailoring the gen-
eral insomnia intervention to the specific needs of PTSD
patients.
Overall, patients responded to CBT for PTSD and
generally reported no further reexperiencing of symp-
toms; however, it is possible that the sleep disturbance was
driven by persistent conditioned hyperarousal that had not
been addressed by in vivo exposure during standard CBT
for PTSD. There are good reasons to believe, however, that
this was not the case. First, patients were not avoiding the
bedroom despite anxiety in bed. If sleep disturbance were
due solely to conditioned arousal, their repeated expo-
sure to conditioned cues should have extinguished their
anxiety. Insomnia treatment, which prescribes leaving the
bed when not sleeping, was more effective than exposure.
Second, the insomnia literature is replete with examples
of insomnia “secondary” to another problem persisting
beyond the duration of the precipitating factor. In the case
of PTSD, sleep-specific maintaining factors (e.g., anxi-
ety about not sleeping), well documented in the insomnia
literature, may interact with residual trauma-related night-
time vigilance.
There were several limitations to the present data.
The sample was small and homogenous, with no control
or follow-up. The presence of other sleep disorders, such
as apnea, was not assessed. In addition, because all 5 pa-
tients had completed CBT for PTSD, the results cannot
be generalized to individuals with active (i.e., untreated)
PTSD and insomnia. The effectiveness of insomnia treat-
ment may be limited in that circumstance, as suggested by
Patient 3. Further study of PIT should determine whether
this sequence treatment (i.e., PTSD, then insomnia) is
indeed most effective or whether insomnia also can ef-
fectively be treated prior to or concurrent with PTSD. In
addition, research should investigate factors that predict
159
whether insomnia will remit after PTSD treatment to de-
termine which patients need this intervention.
Acknowledgments
The authors are grateful to the five patients for allow-
ing their data to be presented in this report. Please note
that the first author’s affiliation has changed.
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