Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach, Therapist Guide (2 edn)

Jack D. Edinger and Colleen E. Carney

https://doi.org/10.1093/med:psych/9780199339389.001.0001
Published: 2014 Online ISBN: 9780190261450 Print ISBN: 9780199339389

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
CHAPTER

6 Considerations in CBT Delivery: Challenging Patients and

Treatment Settings 
Jack D. Edinger, Colleen E. Carney

https://doi.org/10.1093/med:psych/9780199339389.003.0006 Pages 95–118

Published: October 2014

Abstract
The version of CBT presented in this book has been used successfully in a number of research trials
focused on insomnia patients with varied complex comorbidities. It is reasonable to the strategies
discussed in this book to address the insomnia complaints of such patients. Nonetheless, the presence
of comorbid problems can complicate treatment and may require exibility in applying these
techniques. As such, this chapter discusses the challenges that such patients present and outlines
methods for adapting these treatments to patients with a variety of comorbid conditions.

Keywords: comorbid insomnia, hypnotic dependence, chronic pain, sleep-disordered breathing,

depression, alcohol abuse, anxiety disorders, post-traumatic stress disorder, treatment dissemination
Subject: Psychosocial Interventions and Psychotherapy
Series: Treatments That Work

Overview of the Treatment Challenges

Thus far, the discussion in this manual has summarized strategies to employ during individual therapy
sessions with uncomplicated insomnia patients who are not reliant or dependent upon sleep medications. Of
course, many patients who present for treatment do so in the context of ongoing use of sleep medications.
Many other treatment-seeking patients have concurrent comorbid medical, psychiatric, or sleep disorders
that contribute signi cantly to their persistent sleep di culties. Furthermore, not all patients who seek
insomnia treatment present to psychologists or other providers who have training and skills in cognitive
behavior therapy (CBT) techniques. In fact, the majority of treatment-seeking insomnia patients present to
primary care or other types of medical venues where individualized one-on-one sessions with a CBT
therapist are either unavailable or not practical. The various types of patients with insomnia, as well as the
varied settings in which they present for treatment, present special challenges to those wishing to
implement the CBT procedures described herein. The discussion in this chapter thus considers how CBT
may be disseminated to the types of patients and settings mentioned.
 CBT with Hypnotic-Dependent Insomnia Patients

As noted in Chapter 1, various medications are commonly employed for insomnia management. Included
p. 96 among these are various types of benzodiazepine receptor agonists (BZRAs) that have been well tested
and are FDA approved for insomnia treatment. At times, other BZRAs that have FDA approval for treating
anxiety, but not insomnia, are prescribed alone or in addition to the approved medications to treat sleep
di culties. In addition, a variety of other medications, including antidepressants such as the sedating

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
tricyclics (e.g., doxepin) and trazodone, and the atypical antipsychotic quetiapine are often used to manage
patients’ sleep complaints. Of these latter medications, only doxepin has FDA approval for treating
insomnia. The others are used “o -label” for insomnia management. Finally, various over-the-counter
medications are available and are used frequently by insomnia patients in their e orts at self-management.
Of these, the antihistamine diphenhydramine, the hormone melatonin, and the herbal preparation valerian
root are perhaps most commonly used.

Over the years, concerns have been raised about protracted use of medications to address chronic insomnia.
Although there is considerable “clinical lore” supporting the prescription medications used “o -label” for
sleep, currently there are few data to support their safety and e cacy for long-term insomnia management.
Likewise, there are extremely limited data concerning the safety and e cacy of those sleep medications
available without prescription. With some of the rst generation FDA-approved BZRA hypnotics,
medication tolerance develops with continued use such that patients experience reduced e cacy while
being maintained on stable therapeutic doses for extended periods of time. Abrupt withdrawal of such
medications often results in a transient, albeit distressing, worsening of sleep that convinces many patients
to quickly resume their medication use. In contrast, some of the longer-acting BZRAs may result in
unwanted next-day e ects such as sluggishness or “hangover.”

Fortunately, the newer generation BZRAs (e.g., zolpidem, eszopiclone, zaleplon) have far less pronounced
unwanted properties such as these, and some such agents generally have proven safe and e ective over
extended periods of continued use. However, a small subset of patients, particularly those with histories of
sleepwaking, develop unusual behaviors during sleep such as sleepwalking, sleep eating, or actually driving
their motor vehicles while asleep when taking one of these agents. Patients who develop such sleep-related
p. 97 behaviors should discontinue the sleep medication immediately due to the dangers that such behaviors
may pose. In the absence of such nocturnal phenomena, long-term use of hypnotics can be problematic to
some patients for reasons other than those mentioned thus far. The following case example demonstrates
the di culties that long-term hypnotic use may pose.
 Case Example 6.1

Ms. R. was a middle-aged married woman who presented to our clinic with insomnia complaints. At
the time of her presentation, she reported a history of sleep di culties dating back about 10 years to a
time when she was having ongoing medical problems. She notes that at that time she had undergone
surgery on her left leg and the surgical wound did not heal properly. She noted pain, immobility, and

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
general distress over her condition. In that context, she experienced the onset of her sleep di culties.
Shortly after her sleep problem began, she obtained a prescription for lorazepam to treat her sleep
di culty and she had taken that medication almost nightly since that time. She subsequently had
received an additional prescription for zolpidem, 10 mg, to help her sleep. Hence, when she presented
for treatment, she was taking 10 mg of zolpidem along with .5–1 mg of lorazepam on a nightly basis as
sleep aids. Her stated goal for treatment was to learn how to sleep without sleep medications.
However, she noted that she became very anxious and unable to sleep without lorazepam, and she
admitted that she thought she would be unable to initiate and maintain sleep unless she took both of
her sleep medications. In support of this, she noted that her e orts to stop these medications had been
met with her experiencing elevated anxiety about sleep and pronounced wakefulness during the
subsequent night. With her medications, she indicated that she was able to function in the daytime
without severe daytime sleepiness (Epworth Sleepiness Scale = 9). However, she did indicate that her
sleep still was not ideal and she experienced a signi cant level of fatigue many days each week, despite
her nightly use of medicinal sleep aids. Her sleep diary (Figure 6.1) shows her sleep pattern at the time
of her initial clinic visit. Despite her nightly medication use, she still showed di culty initiating sleep
on two nights and relatively poor quality on several nights. This diary also showed the erratic sleep
scheduling common to insomnia patients in general.

Figure 6.1

Sleep Diary—Sleep Medication User.

p. 98

p. 99 Ms. R’s case highlights many of the characteristics commonly presented by those insomnia patients who
use sleep medications on a chronic basis. As her history demonstrates, her sleep medication use began for
good reason during a time when she was recovering from a painful medical condition that disrupted her
sleep. However, she was initially prescribed a BZRA medication for sleep that has FDA approval for anxiety
 management but not insomnia. While continued on this medication, she was given an FDA-approved
hypnotic as an additional sleep aid. Her history suggests that, over time, she developed a psychological
dependence on such medications as sleep aids. Indeed, her e orts to stop these medications were met with
increased sleep-focused anxiety and marked sleep disruption. When patients like Ms. R are interviewed
thoroughly, they often report a general lack of self-e cacy in regard to their ability to obtain adequate
sleep. In a sense, they have lost faith in themselves as sleepers. As a consequence, they come to rely on sleep
medication(s) to obtain the sleep they need.

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
Insomnia patients who use hypnotics chronically present with many of the cognitive and behavioral
treatment “targets” discussed in previous chapters. Speci cally, they have catastrophic beliefs about the
daytime e ects of their sleep di culties as well as a misunderstanding of how their sleep habits may
contribute to their insomnia. Accordingly they demonstrate many of the common sleep disruptive
compensatory practices (e.g., daytime napping, erratic sleep schedules, extended waking periods spent in
bed) seen in medication-free insomnia patients. However, they also present a unique set of cognitions and
behaviors that require treatment attention. Commonly such patients have strong beliefs that their insomnia
is “due to a chemical imbalance” so they conclude that they are unable to sleep without a medication. Many
appear rather con icted, on the one hand believing that long-term sleep medication use is harmful, while
on the other hand feeling helpless to sleep without some sort of sleep aid. Some patients who are concerned
about their medication use, cut their sleeping pills in half and surprisingly sleep well on sub-therapeutic
doses yet are unable to wean themselves completely from such medications without a marked worsening of
sleep. Others will intermittently try going to bed without their usual medication to “see how they do”
without it. Of course, this latter strategy usually tends to increase vigilance over one’s sleep performance,
p. 100 which, in turn, makes sleeping more di cult. Thus, chronic medication users present additional
cognitive and behavioral targets that merit the therapist’s attention.

Since many chronic hypnotic users present with the desire to discontinue their sleep medications, it is
important to implement a treatment plan that enables them to do so while maintaining or re-establishing a
satisfactory medication-free sleep pattern. Current evidence (Morin, Belanger, et al. 2005; Belleville, Guay,
et al. 2007; Soe ng, Lichstein, et al. 2007) suggests that a therapy that combines CBT techniques with a
structured medication-tapering program produces optimal results with medication-dependent patients.
Typically, it is helpful to initially have the patient continue on his or her usual medication, and to plan to
take this medication routinely, as prescribed, prior to going to bed each night. While the medication
regimen remains stable, treatment should commence by initiating the CBT strategies described in detail in
the preceding three chapters. While patients begin implementing the strategies they learn through CBT,
they should be dissuaded from making any changes in their sleep medication practices. Speci cally, they
should be discouraged from changing their medication dosages or experimenting with medication-free
nights. During the course of this treatment it may be helpful to identify some unhelpful beliefs about sleep
medications and to have patients complete thought records as “homework” to address such beliefs. It is
also important to have patients adhere strictly to the behavior strategies discussed in Chapter 3 to produce a
consolidated and consistent sleep pattern while they are still taking their medications. Encouraging
implementation and adherence to these strategies often results in improved sleep patterns and enhances
chances for success in the subsequent medication-tapering process.

Once the patient successfully implements the CBT strategies discussed in the previous chapters and shows a
stable sleep pattern for at least 2 consecutive weeks, a medication-tapering strategy can be introduced.
From a safety viewpoint, many prescription and over-the-counter medications taken for sleep can be
discontinued fairly rapidly without untoward medical concerns. However, patients who are dependent on
sleep medications usually are more successful discontinuing such medications if allowed to taper them
more slowly and deliberately. In this regard, strategies discussed elsewhere (Belleville, Guay, et al. 2007;
p. 101 Soe ng, Lichstein, et al. 2007) have proven e cacious for such patients. These approaches allow a slow,
 graded “step-down” approach to tapering that o ers the patient a gentle pace at fading the medication
while allowing some sense of gradually increasing self-e cacy regarding the discontinuation process. For
example, the approach described by Belleville et al. (2007) involves the following sequence of steps: (1)
setting a goal for medication use/reduction each week; (2) when more than one medication is being used,
reduction to a single medication at a stable dose is set as the rst goal; (3) the initial dosage of the
medication is reduced by 25% every 2 weeks until the lowest available (therapeutic) dosage is reached; (4)
drug-free nights are gradually introduced with drug-free nights being planned in advance; (5) the number

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
of drug-free nights per week are gradually increased until the patient is medication free. While instituting
this sort of withdrawal plan, it is important to have the patient continue monitoring his or her sleep with the
sleep diary and to continue with the cognitive tools (Thought Records, Constructive Worry worksheets) as
needed. It is also important to monitor CBT adherence using the techniques outlined in Chapter 5. Finally it
is wise to have the patient consult with his or her prescribing physician before beginning the tapering
process since that provider’s collaboration and medical advice are essential to a safe and successful
hypnotic withdrawal plan.

Whereas the combined CBT plus guided medication-tapering approach tends to produce the best results,
patients may vary in the success they achieve. Some show a good response and become able to sleep
medication free. Others experience setbacks along the way due to unexpected stressors or other factors.
Some patients may view such setbacks as indications of treatment failure, so it is helpful to assist such
patients in reframing such occurrences in a constructive manner. Again, use of Thought Records may help
with this problem. However, some patients may not succeed with medication discontinuation due to
ongoing stressors or other life circumstances that demand their attention. Like other problem areas that
merit a certain degree of readiness on the part of the patient to change, discontinuation of hypnotic
medication requires a level of readiness and commitment to the treatment processes discussed herein.
Hence, a thorough assessment to determine the patient’s readiness for the strategies described may be
useful prior to initiation of this approach.

p. 102
Treating Insomnia Patients with Comorbid Disorders

Whereas many insomnia patients encountered clinically su er only from insomnia, a far greater proportion
of all treatment-seeking insomnia patients present with complex comorbid conditions. A variety of medical
conditions, particularly those that result in chronic pain, breathing di culties, or immobility, can give rise
to insomnia problems. Likewise, a large proportion of psychiatric conditions have insomnia as a primary
presenting symptom. Furthermore, many medications prescribed for the treatment of medical and
psychiatric conditions may have insomnia as a common side e ect. Finally, excessive use of alcohol,
ca eine, and various illicit substances may cause or add to insomnia problems. In a sizable proportion of
patients, a mixture of medical, psychiatric, and substance-related causes of insomnia coexist and
complicate insomnia management.

In cases of comorbid insomnia, it is always helpful to optimize management of the comorbid

medical/psychiatric conditions to ensure the best insomnia treatment outcomes. In some cases, successful
treatment of the comorbid disorder(s) results in insomnia remission. However, frequently this is not the
case since factors in addition to or other than the comorbid condition may sustain insomnia over time.
Although the onset of insomnia may relate to endogenous physiological changes or acute stress reactions to
the onset of a comorbid illness, a host of cognitive and behavioral factors may perpetuate insomnia over
time. Even among individuals whose sleep disturbance initially emerged as a symptom of the comorbid
condition, the nightly experience of unsuccessful sleep attempts can result in conditioned arousal and
subsequent e orts to make up for lost sleep by spending excessive time in bed each night or napping during
the day. These practices can result in prolonged sleep di culties because they adversely a ect homeostatic
 and circadian mechanisms that control the normal sleep/wake rhythm. Since such sleep-disruptive
cognitions and habits may play important roles in perpetuating insomnia in comorbid patients, CBT
strategies may be useful as primary or adjunctive insomnia treatment for these individuals.

A growing number of randomized clinical trials have investigated the e cacy of CBT for treating insomnia
p. 103 patients with various types of comorbid conditions. Various studies have focused on medical disorders
and have suggested that CBT is e cacious for treating insomnia in chronic pain patients (Currie, Wilson, et
al. 2000), bromyalgia patients (Edinger, Wohlgemuth, et al. 2005), older medical patients with mixed

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
medical disorders (Rybarczyk, Lopez, et al. 2002), and cancer survivors (Savard, Simard, et al. 2005; Espie,
Fleming, et al. 2008). In addition, several case series and randomized clinical trials (Kuo, Manber, et al.
2001; Morawetz 2003; Taylor, Lichstein, et al. 2007; Manber, Edinger, et al. 2008) have suggested that CBT
is e ective for treatment of insomnia in patients with comorbid depression. Though additional randomized
trials are needed to test CBT with comorbid patients, it is useful to consider how CBT insomnia treatment
might be adapted for patients with various types of comorbidities.

Chronic Pain
Chronic pain tends to fragment sleep and decrease the depth of sleep; acute pain, in contrast, tends to rouse
people out of sleep or prevent them from falling asleep. Thus, the primary target in those with chronic pain
tends to be increasing the drive for deep sleep (i.e., by restricting the time spent in bed in a 24-hour period
and increasing activity modestly). Asking people to spend less time inactive, or less time in bed or resting,
can be met with resistance. Part of this may be cognitively mediated, “I should rest,” or “My doctor told me
I need to be napping and resting.” It is important to encourage patients to use pain relief. Some patients
exhibit all-or-none thinking and refrain from any pain medications because the medication does not
eliminate 100% of the pain. Ask patients to consider whether 20% pain relief has a more positive impact on
sleep than 0% pain relief. Encourage patients to consult with their doctor to ensure that their doctor has
cleared them for less inactive time. Once the doctor has cleared them to make modest decreases in the time
they spend in bed or at rest, assess for beliefs such as, “It is better to stay and try to sleep than to leave the
bed,” or “If I get up it will aggravate my pain.” It is often more e ective to focus on whether such beliefs are
helpful in the goal of addressing the insomnia rather than whether such beliefs are true. Fragmented sleep is
p. 104 associated with increased pain so addressing the sleep quality of those with chronic pain can help with
pain as well as sleep. Ask patients to look at their sleep diaries and their current time in bed and ask them to
re ect on how they slept and felt during the day. Ask the patient to engage in a behavioral experiment over
the next 2 weeks that tests whether reducing the amount of time in bed has a more positive e ect on pain
and sleep. With patients concerned about not being able to rest, explore ways they can rest when needed
without the likelihood of falling asleep or remaining inactive for long periods of time. For example,
encourage the patient to refrain from resting in a supine position or in a location such as a recliner, where
they might doze o to sleep. Some patients may have concerns about injury or for other medical reasons
nd it too di cult to get out of bed during the night when they have di culty initiating or maintaining
sleep. For such patients it may be best to employ a counter-control strategy that requires them to sit up in
bed or preferably move to the other side of the bed, rather than leaving the bed or bedroom, until sleepy
again (Davies, Lacks, et al. 1986). Counter-control also may be a good solution for patients at risk for falls
during the night, such as those who are elderly or very medically ill.
 Sleep-Disordered Breathing
Many patients who have breathing-related sleep disorders, such as those with obstructive sleep apnea, will
su er from a comorbid insomnia disorder as well. When the apnea remains untreated, it may be di cult to
ascertain which of the patient’s sleep complaints are related to apnea and which represent a separate
insomnia disorder. This is the case because the repeated breathing disturbances resulting from the sleep
apnea fragment sleep and may lead to the sorts of sleep maintenance complaints presented by many

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
insomnia su erers. However, the evidence (Caetano Mota et al. 2012) suggests that over 50% of apnea
su erers continue to have insomnia symptoms after they receive e ective apnea treatment, whereas
slightly over 20% of all apnea patients may develop insomnia de novo once they begin the most commonly
prescribed apnea therapy, positive airway pressure (PAP). Since PAP therapy requires the patient to wear a
nasal or full face mask that forces pressurized air through the nose or mouth during sleep, it is not di cult
to understand that many patients have di culty tolerating this therapy and thus continue to have or
p. 105
develop a new insomnia after PAP therapy commences. Alternatively, some apnea patients are treated with a
dental appliance that repositions the lower jaw to open the airway, and intolerance to this treatment can at
times contribute to or exacerbate insomnia complaints.

To date there have been a limited number of studies that have tested CBT for the treatment of insomnia in
comorbid sleep apnea. Although one fairly large study (Lack, Hunter, et al. 2011) showed that sleep apnea
patients treated solely with CBT appreciate improvements in their sleep and waking function, other studies
(Krakow, Melendrez, et al. 2004; Guilleminault, Davis, and Huynh 2008) have indicated that the best
outcomes are achieved when CBT is combined with an e ective apnea therapy. However, it is important to
con rm that the concurrent apnea therapy is e ectively controlling the apnea at the time CBT is provided
for the comorbid insomnia disorder. It is also essential to determine that the patient is indeed su ciently
adherent to the apnea therapy to derive su cient bene ts from this. If either the apnea therapy is not fully
e ective or the patient is insu ciently treatment adherent, sleep disturbance will remain even if CBT for
insomnia e ectively eradicates the patient’s sleep-disruptive habits and cognitions.

As implied by the foregoing discussion, successful CBT intervention for patients with comorbid sleep apnea
requires not only monitoring of the patient’s follow-through on CBT interventions, but also consideration
of the patient’s response and adherence to the apnea therapy. Since a majority of apnea patients are treated
with some form of PAP, information about treatment e ectiveness and adherence is monitored objectively
and stored in most currently available PAP devices. Such information is periodically downloaded by sleep
center personnel who are following the patient for his or her sleep apnea and/or by the home healthcare
company that supplies the PAP device to the patient. Hence, it is useful to partner with one or the other such
colleagues who can obtain and interpret this information so that can be considered in the overall
management of the patient’s sleep complaints. When such data suggest good treatment adherence (i.e.,
used most or all of the night on at least 70% of all nights) and control of the patient’s apnea (i.e., the patient
is having fewer than 5 events of sleep-disordered breathing per hour of sleep), then it can generally be
p. 106 surmised that the remaining insomnia symptoms represent reasonable treatment targets for CBT,
particularly for patients who show the common sleep-disruptive habits and cognitions presumed to
perpetuate insomnia per se. However, when PAP adherence is poor or a greater than desired level of apnea
remains with PAP therapy, then intervention by the patient’s sleep disorder specialist will be necessary to
fully address the patient’s sleep/wake complaints.

In addition to such considerations, it may be necessary to alter the CBT behavioral treatment regimen
somewhat to accommodate the apnea patient. Some such patients remain very sleepy in the daytime, even
when adequate treatment for their sleep apnea is being provided. Such patients may have trouble adhering
to sleep restriction requirements and/or the admonition against daytime napping. In such cases, relaxing
time in bed restrictions somewhat or allowing limited (30–45 minutes) daytime napping in the morning or
early afternoon hours may be needed to optimize treatment adherence and therapeutic outcomes. Also,
 those patients using PAP therapy may nd it inconvenient or more sleep disruptive to get out of bed at night
when awake then they do to stay in bed. This is true since getting out of bed requires removal of the PAP
mask and then placing it back on the face when returning to bed to reinitiate sleep. This process can be
viewed as an excessive burden that adds to their sleep disruption instead of reducing it. Hence, in such
circumstances use of the counter-control procedure mentioned earlier may be the best solution. With this
procedure the patient can remain in bed without removing the PAP device and thus can be poised to return
to sleep more easily when sleepiness returns.

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
Depression
Major depressive disorder is a disorder that can pose special challenges related to depression symptoms
such as anhedonia, avoidance, and diurnal mood worsening. To escape from the chronic experience of low
mood, many people with depression retreat to their bed or bedroom, or engage in very little activity.
Bedrooms have little distraction, and when there is little distraction, patients are likely to continue to
p. 107 ruminate, which results in their continuing to feel terrible. When patients with depression become
trapped in a cycle of feeling poorly and ruminating about how poorly they feel, they typically engage in little
activity and spend excessive amounts of time in bed as an [ine ective] avoidance strategy. It is not unusual
for those with depression to come home from work, change into their nightclothes, and do very little for the
remainder of the evening. Inactivity reduces sleep drive, increases the likelihood of dozing, increases the
likelihood of rumination, and limits exposure to positive reinforcers in the environment. In working with
depressed patients it is therefore important to ask about evening activities. Such questioning can provide
some clues as to whether there may be dozing, avoidance, or rumination occurring. It is also useful to
calculate the time in bed in the 24-hour period (including naps) to determine if it seems unusually high. It is
common to nd depressed patients spending greater than 9 hours in bed in the 24-hour period. Spending
large amounts of time in the bedroom or bed without sleeping can create conditioned arousal. The bed
should have a strong stimulus value for sleep and increased periods of time in bed while not sleeping will
disrupt this association. Additionally, excessive time in bed can di use the homeostatic drive for deep sleep.
Whereas providing an explanation of this factor through psychoeducation may be enough for most patients
to stop this behavior, some patients will need alternative strategies to address the reasons they are engaging
in avoidance. Ask them to monitor their mood, sleep, and activity over the next week. Review the log with
them to encourage them to see the links between inactivity, low mood, and poor sleep. Assess whether they
are more likely to engage in rumination when experiencing low mood and/or fatigue. Provide a model of
rumination, low mood, inactivity, and poor sleep. The following interchange demonstrates the sort of
dialogue that can be helpful with such patients.

Therapist : When you are experiencing low mood, it is like a burning re. When you ruminate, it is
like continuously pouring gas on the re. What happens if you pour gas on the re?
Patient : It continues to burn? Probably even worse, too.
Therapist : What would happen if you were distracted from the re and walked away from the re
pit?
Patient : I guess you wouldn’t be thinking about the re?
Therapist : And what would happen to the re?
p. 108 Patient : Eventually it would go out, I guess.
Therapist : Would you be willing to try an experiment this week? We have seen what happens when
you spend all evening in your bedroom—there is little to distract you and you spend some time
dozing and then have di culty sleeping later at night. I wonder what you would nd if this week
you engaged in one activity in the evening meant to distract you and essentially keep you out of bed
until later in the evening. Are you willing to try it and see if there is any noticeable di erence from
staying in your room all evening?
 Asking patients to try an alternate activity can lead to some positive results. In cases wherein the target is
not rumination, ask the patient whether it would be more or less likely for them to doze o if they were out
with a friend versus lying on their couch? Ask the patient to test out scheduling activities to increase their
response to the sleep treatment.

Sometimes, spending increased time in bed or in the bedroom can occur in the morning as well. A key
component of behavioral insomnia treatment is xing a standard rise time. It provides a cue for the body
clock, and begins the accumulation of wake time needed for adequate sleep drive. It is important to

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
encourage patients to refrain from the temptation of trying to compensate for sleep loss by sleeping in or to
use lingering in bed as a strategy to avoid starting their day. However, responding to feelings of fatigue or
low mood by staying in bed is common and a di cult barrier to overcome. Often explaining the negative
e ects of staying in bed in the morning via psychoeducation can be enough to overcome the barrier;
however, sometimes more is necessary. Identifying the barrier is the rst step. In cases where mood is
lowest in the morning, it may be di cult to feel motivated to follow the rise time “plan.” Share with the
patient that it is important to nd a way to address barriers to getting up in the morning. Ensure that the
patient understands the rationale behind the recommendation. Using an activity log that simultaneously
monitors mood can help patients see the link between their lowest mood and inactivity. It is often helpful to
suggest an experiment in which the patient could get out of bed at a set time to determine if there were any
e ects on mood or fatigue. Ask if there are any strategies that could be tried over the next week to attempt
to help him or her make this important change, for example, scheduling something pleasurable in the
p. 109 morning, particularly with another person, or enlisting the help of another person to help him or her get
out of bed. Activities that involve light, preferably sunlight, and movement can be particularly helpful in
setting the clock, reducing fatigue, and lifting mood.

Alcohol Abuse
Alcohol is a central nervous system depressant that has relaxing and sopori c e ects that can ease the onset
of sleep. However, alcohol is very rapidly metabolized by most individuals, so alcohol withdrawal symptoms
emerge a few hours after alcohol is consumed. The latter become problematic when alcohol is consumed too
close to bedtime. In such cases, the alcohol withdrawal process actually will contribute to sleep
fragmentation and wake-ups during the course of the sleep period. It is not uncommon for insomnia
su erers to resort to alcohol as a sleep aid given its fairly immediate relaxing e ects. However, in doing so,
they can actually make their sleep problems worse, particularly if they routinely have sleep maintenance
di culties.

It is not uncommon to encounter insomnia occurring comorbid to chronic alcohol dependence or abuse. In
fact, chronic insomnia is one common reason given by patients for their chronic patterns of alcohol use.
Moreover, residual insomnia in patients who become abstinent from alcohol is the most common reason for
relapse into patterns of alcohol dependence/abuse. Although very limited, there is some evidence (Arnedt,
Conroy, et al. 2011) that CBT is an e ective intervention for patients who have insomnia comorbid to chronic
alcohol abuse patterns. However, with such patients special challenges related to their alcohol use often
emerge. Such patients often experience a rebound insomnia or worsening of their sleep at the time they
withdraw from alcohol. If this withdrawal process is ongoing at the time CBT is initiated, it certainly will
slow the therapy process and blunt the initial treatment response. Conversely, many patients with long-
term alcohol dependence/abuse patterns nd they have continued objective sleep disruption long after they
achieve abstinence, likely as a consequence of the deleterious e ects of long-term alcohol use on the central
nervous system.

p. 110 In implementing CBT with this patient group, it is important to consider the patient’s current status vis-à-
vis alcohol use. If the patient is routinely using alcohol as a sleep aid, it may be best to have the patient hold
 their current use pattern constant while you commence with CBT for insomnia, just as you would when
intervening with hypnotic-dependent patients. Once the patient has stabilized his or her sleep with this
therapy, you can then negotiate a gradual alcohol-fading plan. If the patient has evidence of more severe
alcohol dependence/abuse, it is usually wise to encourage enrollment in a formal substance abuse treatment
program. When working with a patient who has become abstinent after long-term use of alcohol, it is often
helpful to provide some education about the residual sleep disturbance that may persist after achieving
abstinence. This education helps the patient develop realistic expectations for treatment outcomes. Whereas

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
the CBT intervention may markedly improve sleep in such patients, there still may remain a less than
optimal sleep pattern. For healthy patients, the addition of routine aerobic exercise may compliment CBT’s
e ects and may help improve sleep quality. In other patients, treatment with CBT and hypnotic medications
may lead to optimal outcomes. If the latter is the case, it is best to partner with the patient’s prescribing
physician to achieve optimal results.

Anxiety Disorders
Insomnia is frequently accompanied by subsyndromal anxiety, so treating insomnia in the presence of a
comorbid anxiety disorder is often di erent in the degree of the anxiety symptoms only. There are,
however, some notable exceptions, including panic disorder and post-traumatic stress disorder. When
treating those with panic attacks, it should be noted that sleep deprivation is linked to a reduced panic
attack threshold. Sleep restriction will ideally result in some increased sleepiness if the treatment is
working, but this also renders the patient more susceptible to panic attacks. It should be noted that those
with previous hypomanic or manic episodes, as well as those with a history of seizures, are vulnerable to
possible mania/hypomania or seizures, respectively, as a result of the increased sleep deprivation. One
solution is to emphasize stimulus control or to restrict time in bed to a lesser degree. Sleep compression is a
p. 111 technique whereby patients gradually reduce the time spent in bed by weekly 30-minute decreases,
rather than starting at the desired time-in-bed target (Riedel, Lichstein, and Dwyer 1995). By proceeding
gradually, there may be less chance of inducing panic attacks, or other issues such as mania/hypomania or
seizures.

Post-Traumatic Stress Disorder

In contrast to depression, where there can be excessive time in the bedroom and in bed, people with post-
traumatic stress disorder (PTSD) often have avoidance of the bed and bedroom. Sleep can be a vulnerable
time for someone who believes they must be vigilant for signs of danger throughout the 24-hour period.
The night may also be a time in which nightmares are common; thus an ambivalence can develop regarding
the sleep opportunity.

The following case example shows the potential usefulness of CBT strategies with a patient with chronic
p. 112 insomnia and a comorbid anxiety disorder.
Case Example 6.2: Insomnia and Comorbid Anxiety Disorder

The patient was a 56-year-old married man who participated in a CBT insomnia treatment study at a
VA hospital. The patient has been seen for treatment at the hospital for a number of years in relation to
the combat-related post-traumatic stress disorder he developed as a result of his service experience
during the Vietnam War. At the time the patient presented for the study, he reported a 15-year history

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
of chronic insomnia problems. Speci cally, he reported that he would typically sleep soundly for only
about 2.5 hours per night and then he would toss and turn the remainder of the night. He reported that
he was receiving ongoing pharmacotherapy (Citalopram) for his PTSD, and his symptoms other than
his sleep di culty were relatively well controlled.

As part of his initial evaluation for the treatment study, he underwent diagnostic sleep monitoring
(polysomnography) in order to rule out sleep disorders not detectable from interview (e.g., sleep
apnea). Results showed no evidence of sleep apnea or other medically based primary sleep disorders.
However, the recording showed very poor sleep with a sleep onset latency of 63 minutes, 90 minutes
of wakefulness during the middle of the night, and a total sleep time of only 4 hours. A sleep diary
maintained by the patient for several weeks prior to treatment corroborated the ndings from his
sleep recording. Speci cally, this sleep diary showed an average sleep onset latency of 82 minutes, an
average wake time during the night of 165 minutes, and an average sleep time of only 4 hours and 25
minutes per night. The patient’s sleep diary for the rst week of this monitoring period, which
captures this general pattern of sleep di culty, is shown in Figure 6.2. This diary shows the patient’s
variable sleep schedule as well as his penchant to allot excessive times each night for sleep.

To treat this condition the patient received four biweekly 30–60 minutes sessions that included the
psychoeducational information and sleep improvement recommendations presented in Chapter 3.
During this time period, no changes were made in his pharmacological treatment for his PTSD
condition. Over the course of the CBT treatment, the patient’s sleep improved markedly. Sleep diaries
maintained by the patient immediately following treatment showed an average sleep onset latency of
15 minutes per night, an average wake time during the night of slightly under 31 minutes, and an
average total sleep time of 5 hours and 45 minutes. Figure 6.3 shows the rst week of these sleep diary
data collected by the patient following treatment. This diary shows the marked improvements in the
patient’s sleep pattern as well as greater stability in his chosen sleep schedule. When a follow-up of
this patient was conducted 6 months after he completed treatment, his sleep pattern continued to
show the improvement displayed immediately after treatment, with virtually no change in his sleep or
wake-time measures.
 Figure 6.2

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
Sleep Diary—Baseline.

Figure 6.3

Sleep Diary—Post-CBT.

A particular challenge to treating PTSD patients arises from their hypervigilance, which is prominent during
the sleep period. Those individuals who develop PTSD as a result of childhood sexual abuse may have a
proneness to remain vigilant during the nighttime when their sexual abuse historically took place.
Alternatively, it is not uncommon for military veterans with combat-related PTSD to remain on alert during
the nighttime and thus have di culty initiating and/or maintaining sleep. Moreover, such patients often
p. 113 will show patterns of

p. 114

p. 115
“checking the perimeter,” wherein they repeatedly check all the door locks and windows in their homes in a
compulsive fashion to assure the safety of their families and themselves. With these sorts of problems it is
often helpful to probe underlying cognitions that perpetuate the need for remaining vigilant at nighttime.
Use of Thought Records may be indicated to help patients challenge beliefs of nighttime danger in their
 current home situations relative to the original situations that precipitated their PTSD. When repeated
checking behaviors are observed, it may be useful to place limits on the amount of checking that the patient
can do each night. For some patients it is helpful to develop a paper checklist they can complete each night
to document that they actually have checked all doors and windows for their security. Once they complete
this checklist, they can then place it on their nightstand or other location near their bed to remind them that
they have done all of the checking they need for the night in question and they can feel more at ease about
going to sleep.

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
Summing It Up

Whereas CBT strategies are well suited for treating those with comorbid insomnia, the foregoing discussion
shows that adaptations of CBT need to be considered with distinctive comorbid groups. Admittedly, there is
much to be learned about optimizing outcomes with these individuals. Indeed, there are many questions yet
to be answered. Among the more pertinent are (1) How can we best combine CBT with pharmacotherapy and
other medical management of the existing comorbid disorder? (2) Do the speci c sleep-focused CBT
techniques need to be altered or augmented in any way to maximize outcomes with comorbid insomnia? (3)
Should CBT for insomnia be incorporated into more global cognitive behavior protocols that exist for
various comorbid conditions (e.g., depression, anxiety disorders, etc.)? (4) Does CBT for insomnia in
comorbid patients require more extended therapy and follow-up than commonly required for insomnia
without an accompanying other disorder? These, among many other questions, will merit attention before
this treatment can be most e ectively adapted to insomnia su erers with various types of sleep-disruptive
p. 116 comorbidities. For a more thorough discussion of this topic, the reader is referred to the recent excellent
review article by Smith et al. (2005). Nonetheless, the research conducted to date and the results with cases
such as the ones presented here encourage further applications of this modality for addressing comorbid
insomnia problems.

Dissemination of CBT Across Settings

Whereas CBT have proven e cacy for insomnia management, it is currently challenging to make this
therapy available to all who may bene t from it. Whereas 10% to 22% of the population have chronic
insomnia, there are currently a paucity of trained providers who o er the treatment described in this
manual. Furthermore, those who are trained and skilled in these techniques tend to be found in larger
medical centers or specialty sleep centers and not in the general medical practice settings where most
treatment-seeking insomnia patients present for their care. Thus, expanding the provider pool and
exporting this treatment to the venues where most insomnia patients receive their initial treatment remain
as challenges to this therapeutic modality.

In e orts to facilitate dissemination of CBT for insomnia, some investigators have tested treatment models
suitable for medical practice settings or the public at large. Given that insomnia su erers typically present
rst in primary care settings, it seems reasonable to consider providing CBT training to those healthcare
professionals (e.g., nurses, general practitioners) commonly found in such settings. Two studies designed to
test the e cacy of such an approach have demonstrated that both family physicians (Baillargeon, Demers,
and Ladouceur 1998) and o ce-practice nurses (Espie, Inglis, et al. 2001; Espie, MacMahon, et al. 2007) can
e ectively administer CBT components in general medical practice settings. In contrast, Oosterhuis and
Klip (1997) reported delivery of behavioral insomnia therapy via a series of eight 15-minute educational
programs broadcast on radio and television in the Netherlands. Over 23,000 people ordered the
accompanying course material, and data from a random subset of these showed that sleep improvements
 and reductions in hypnotic use, medical visits, and physical complaints were achieved by this educational
p. 117 program. Thus, it appears that behavioral insomnia treatments can be e ective delivered by various
providers, and delivery of such treatment even through mass media outlets may provide bene ts to some
insomnia su erers. Of course, the relative e cacy of these alternative treatment modes of treatment
delivery vis-à-vis more traditional treatment with experienced CBT therapists is yet to be determined.

Other e orts aimed at treatment dissemination have tested treatment protocols that can be self-
administered outside the clinic setting. Mimeault and Morin (1999), for example, tested a self-help CBT

Downloaded from https://academic.oup.com/book/1154/chapter/138231353 by Mt Sinai School of Medicine, Levy Library user on 01 December 2022
book-based treatment (i.e., bibliotherapy) with and without supportive phone consultations against a wait-
list control. Compared to the control condition, those treated with the bibliotherapy showed substantially
greater sleep improvements, and these improvements were maintained at a 3-month follow-up. The
addition of phone consultations with a therapist provided some advantage over bibliotherapy alone, at least
in the short term. Over the past decade there have been considerable e orts to provide automated CBT
delivery through the development of interactive Internet-based self-help CBT interventions. To date, a total
of seven studies have tested these sorts of interventions with generally positive results. These Internet
approaches vary in nature; some provide video-based material delivered by expert therapists (Ritterband,
Bailey, et al. 2012), whereas others use animated characters to deliver treatment recommendations (Espie,
Kyle, et al. 2012). To date, such interventions have some promise and perhaps ll an important gap in CBT’s
availability. However, a number of questions about these sorts of interventions remain, such as what types
of patients bene t most from such self-help interventions and which sorts of patients require more
intensive therapist-directed treatment? Also, does a less than optimal response to these self-help
treatments reduce a patient’s acceptance or response to therapist directed therapy? And nally, can these
self-help treatments be combined with therapist-directed CBT to enhance treatment adherence and
outcomes? Nonetheless, these studies provide some initial ideas for wider dissemination of CBT strategies.
Such e orts may be useful to ll the void until a su cient number of traditional providers are trained in
these strategies and the more challenging insomnia patients will be able to access the comprehensive CBT
p. 118 they ultimately may need.

© Oxford University Press