BBTI Deck Slide Handout

Brief Behavioral Treatment
of Insomnia (BBTI) in
Primary Care
2
3
3
• Sleep in the Military
• Overview of Normal
Agenda Human Sleep
• Insomnia Etiology &
Diagnosis
• Brief Behavioral Therapy
of Insomnia
• Putting BBTI into Practice
(Experiential Component)
45
SLEEP IN THE
MILITARY
Photo by David Chung, https://creativecommons.org/licenses/by/2.0
5 5
Disorders Common in the Military
Insomnia
https://www.flickr.com/photos/59632563@N04/6480297645/
Obstructive Sleep Apnea

https://www.flickr.com/photos/com_salud/7999032358
Circadian Rhythm Sleep-

Wake Disorders
Nightmares
Troxel et al. (2015) 6

Insomnia
Insomnia occurs when there are

adequate __________ for sleep but
the _____ to sleep is compromised.
7
Insomnia
Insomnia occurs when there are

adequate opportunities for sleep but
the ability to sleep is compromised.
8
Insomnia Prevalence
20-40% in
primary
25-30% of care
settings
9-15% of
Americans
SMs report
insomnia
post-
deployment
9
Ellis et al, 2012; Roth et al, 2011; pdhra.mil; Seelig et al, 2010
Insomnia in the Military
Caldwell, Knapik, & Lieberman, 2017 10

Insufficient Sleep
Sleep deprivation is characterized

by a restricted ___________ to
sleep (i.e., due to lifestyle choices or
work), despite adequate _______ to
sleep.
11
Insufficient Sleep
Sleep deprivation is characterized

by a restricted opportunity to
sleep (i.e., due to lifestyle choices or
work), despite adequate ability to
sleep.
12
Insufficient Sleep
60%
< 5 hours 6 hours 7 hours 8 Hours > 9 Hours
50%
40%
30%
20%
10%
0%
OIF Army Military Spouses Civilians
Luxton et al (2011) Holliday et al (2016) Krueger & Friedman (2009)
N=2,717 N=1805 N=10,441 civilians
Slide concept courtesy Dr. Anne Germain 13

Does the military culture contribute
to sleep issues?
“We do more before 9 a.m. than

most people do all day.”
14
When it’s Hard to Have Good Sleep Hygiene
Courtesy of Bill Brim, CDP
15
1616
1
7
Sleep and Insomnia:

The Basics
“I’ll sleep when I’m dead.”
-Warren Zevon
17
1
8
WHY DO WE SLEEP?
https://www.flickr.com/photos/malias/58672785 18
19
Why Do We Sleep?
Inactivity Theory (AKA Adaptive or Evolutionary Theory)
• Survival function developed through natural selection
• Animals that were able to stay out of harm’s way by being still and quiet during times of
vulnerability, usually at night, survived
Energy Conservation
• Related to inactivity theory
• Primary function of sleep is to reduce energy demand and expenditure
• Research findings: Significant reduction in energy metabolism during sleep
Restorative
• Repair and rejuvenation of the body
• Major restorative functions: Muscle growth, tissue repair, protein synthesis, and growth hormone
release occur mostly or exclusively during sleep
Brain Plasticity
• Sleep correlates to changes in the structure and organization of the brain
• Brain development in infants and children: 12-14 hours a day sleeping
• Also becoming clear: Link to sleep and adult brain plasticity
19
2
0
Sleep Regulation
Sleep Regulation
(Parris Island Style)
20
21
How is Sleep Regulated?
• Homeostatic sleep drive (Process S)
–During wakefulness, a drive for sleep builds up
that is discharged primarily during sleep
–As sleep drive increases, so do subjective feelings
of sleepiness
• Circadian rhythms (Process C)
–Varying strength alerting signal increases over the
course of the day and decreases across the night
until early morning
Borbely, 1982 22
How is Sleep Regulated?
Kilduff & Kushida, 1999 23

2
4
Sleep Architecture
24
Sleep Architecture
• ___________ (5%)
– 5 mins; transitional phase
– Low arousal threshold
• ___________(50-55%)
– 10-15 mins;
• ___________(20%)
– Lasts 20-40 mins; “delta”
“slow-wave sleep”
• ___________ (20%)
– Tonic (hypotonic muscles) and
Phasic (eye movement) stages
25
Sleep Architecture
• N1 or Stage 1 (5%)
– 5 mins; transitional phase
– Low arousal threshold
• N2 or Stage 2 (50-55%)
– 10-15 mins;
• N3 or Stage 3 & 4 (20%)
– Lasts 20-40 mins; “delta”
“slow-wave sleep”
• REM (20%)
– Tonic (hypotonic muscles) and
Phasic (eye movement) stages
26
Harvard University Sleep Lab
http://healthysleep.med.harvard.edu/
http://healthysleep.med.harvard.edu/interactive/sleep_lab
27
Terms & Abbreviations
• SOL = ________________________
• WASO = ________________________
• EMA = ________________________
• TWT = ________________________
• TST = ________________________
• TIB = ________________________
• FNA = ________________________
• SE = ________________________
28
Terms & Abbreviations
• SOL = Sleep Onset Latency
• WASO = Wake After Sleep Onset
• EMA = Early Morning Awakening
• TWT = Total Wake Time
• TST = Total Sleep Time
• TIB = Time in Bed
• FNA = Frequency of Nighttime Awakenings
• SE = Sleep Efficiency = TST / TIB
29
3
0
30
Sleep Quality
40
35
30
25
20
15
10
<30 yrs 31-40 yrs 41-50 yrs 51-60 yrs >60 yrs
N3% REM%
Mitterling et al, 2015 31

Sleep Timing
Thomas et al, 2014 32

How Medications Impact Sleep
• Indirect effects
– Side effects
– Dependence/tolerance
– Withdrawal
– Daytime sedation
• Direct effects
– Increases or decreases in total sleep time
– Alterations of sleep architecture
– Vivid dreams/nightmares
33 33
Medications for Insomnia:
FDA-Approved Nonbenzodiazepine Hypnotic Agents
Drug Half-Life Absorption Typical dose Active
(hours) (mg) metabolite
Sonata (zaleplon) 1-1.5 Fast 5-20 No
Ambien (zolpidem) 1.5-2.6 Fast 2.5-10 No
Ambien ER (zolpidem 2.8 Fast 6.25-12.5 No

CR)
Lunesta (eszopiclone) 6 Fast 1-3 Yes
Belsomra (suvorexant) 12 Slow 5, 10, 15, 20 No
Rozerem (ramelteon) 1-2.6 Fast 4-8 Yes
Silenor (doxepin) 4 Fast 3-6 Yes
34
Medications for Insomnia:
FDA-Approved Benzodiazepine Agents
Drug Half-Life Absorption Typical dose Active
(hours) (mg) metabolite
Halcion (triazolam) 2-5 Fast 0.125 -0.25 No
Restoril (temazepam) 8-12 Moderate 7.5-30 No
ProSom (estazolam) 12-20 Moderate 1-2 Minimal
Doral (quazepam) 50-200 Fast 7.5-15 Yes
Dalmane (flurazepam) 50-200 Fast 15-30 Yes
35
https://www.flickr.com/photos/122662432%40N04/13740073235/
Photo by Correogsk - Own work. Licensed under CC BY-SA 3.0 via Commons
Sleep-Wake Disorders
Photo by Shutterstock
36
Substance/ Insomnia
Medication- disorder Hyper-
induced somnolence
sleep disorder
disorder
Restless leg
Narcolepsy
syndrome
SLEEP WAKE
DISORDERS Breathing-
REM sleep
behavior
(DSM-5) related
sleep
disorder
disorders
Circadian
Nightmare rhythm
disorder Non-REM sleep-wake
sleep disorders
arousal
disorders
APA, 2013 37
Assessment of Sleep: Differential Dx’s
• Sleep-related breathing disorders
• Narcolepsy and other hypersomnolence disorders
• Circadian rhythm sleep-wake disorders
• Delayed sleep phase
• Shift work
• Parasomnias
• Sleep-related movement disorders
• Restless leg syndrome
• Periodic limb movements
38
Symptoms of Sleep Problems: OSA
– Snoring
– Pauses in your breathing at night
– Choking at night
– Gasping for air during the night
– Morning headaches, chest pain, or dry
mouth
– Partner report
– Excessive daytime sleepiness
39
Symptoms of Sleep Problems: Narcolepsy
– Excessive daytime sleepiness (daily x3 mos)

– Sudden muscular weakness in situations of
high stress/emotion (cataplexy)
– Hypnogogic hallucinations
– Sleep paralysis
– Disrupted nocturnal sleep (SOL and WASO)
40
Symptoms of Sleep Problems: Parasomnias
• Awakening screaming and
confused
• Sleepwalking and/or physical
injuries, moved objects
• Awakening distressed with dream
recall
• Consider trauma history
• Sleep disruption
41
Symptoms of Sleep Problems: Movement
Disorders
RLS • Crawling or aching feeing in legs

• Inability to keep legs still
• Leg twitches or jerks during the night

• Waking up with cramps in legs
PLMD • Bed partner report
• Find covers all kicked off
• Grinding teeth at night/teeth worn down

Bruxism • Jaw pain or headaches during day
42
Circadian Rhythm Sleep-Wake Disorders
• Delayed sleep-wake phase disorder
• Advanced sleep-wake phase disorder
• Irregular sleep-wake rhythm disorder
• Non-24-hour sleep-wake rhythm
disorder
• Shift work disorder
• Jet lag disorder*
43
Insufficient Sleep Syndrome
• Inadequate sleep time resulting from
voluntarily restricted time in bed
– Results in excessive daytime sleepiness
– Restriction may occur at bedtime (i.e.,
staying up late for work, family, social, etc.
reasons) or at waketime (i.e., setting alarm)
– May be unintentional
– No underlying medical or psychiatric cause
– Differentiate from inability to sleep when in
bed
44
45
ICD-10 Diagnostic Codes

• G 47.0 Insomnia
• G 47.09 Other Specified Insomnia
Disorder
• G 47.00 Unspecified Insomnia
Disorder
• F 51.12 Insufficient Sleep Syndrome
• Z 72.82 Sleep Deprivation
• G 47.21 Delayed Sleep Phase
Disorder
45
Conditions & Symptoms
Requiring Further Consideration
Congestive Pulmonary
Diabetes
Heart Failure Disorders
Chronic Kidney Neurologic Psychiatric

Disease Diseases Conditions
Obesity –
Chronic
Hypoventilation Women’s Health
Rhinitis/GERD
Syndrome
46
4
7
Insomnia
U.S. Air Force photo by Tech. Sgt. Parker Gyokeres/released. https://creativecommons.org/licenses/by/2.0/
47
Common Effects of Insomnia
• Mood and motivational • Failure of routines/impaired
changes task performance
• Increased risk taking
• Decreased threat • Exaggerated feeling of
detection physical exertion
• Impaired • Lack of insight to
attention/concentration impairment
• Memory loss for recent
events • Failed verbal
• Variable and slowed communication
responses • Social discomfort
• Illusions/hallucinations • Increased health problems
Roth & Roehrs, 2003 48

The Nature of Insomnia
Three common types of Insomnia:
Sleep Onset
• Problems falling asleep at bedtime
Sleep Maintenance
• Waking during the night and having trouble falling back to sleep
Terminal
• Awakening too early in the morning
49
DSM-5 Insomnia Disorder 780.52
• A predominant complaint of dissatisfaction with
sleep quantity or quality, associated with one (or
more) of the following symptoms:
• difficulty initiating sleep
• difficulty maintaining sleep
• early morning awakening with inability to return to sleep
• Sleep complaint is accompanied by significant
distress or impairment in social, occupational or
other important area of function
• 3 nights per week
• Present for 3 months
• Occurs despite adequate opportunity for sleep
APA, 2013 50
DSM-5 Insomnia Disorder 780.52
• Insomnia is not better explained by
and does not occur exclusively
during the course of another sleep-
wake disorder
• Not attributable to substances
• Coexisting mental disorders and
medical conditions do not adequately
explain the insomnia
APA, 2013 51
DSM-5 Insomnia Disorder Specifiers
Episodic
• Symptoms last at least 1 month but
less than 3 months
Persistent
• Symptoms last 3 months or longer
AVAVA. Photo https://www.flickr.com/photos/74285857@N05/. Used with permission via
https://creativecomby mons.org/licenses/by/2.0/.
Recurrent
• Two or more episodes within the space
of 1 year
52
Quantitative Indicators of Insomnia
• Sleep-onset latency (SOL) > 30 mins

• Wake after sleep onset (WASO) >
30 mins
• Sleep efficiency (SE) < 85%
• Total sleep time (TST) < 6.5 hours
Schutte-Rodin et al, 2008 53

Tips to Rule Out Insomnia
• Don’t focus too much on ___: Insomnia is
determined by severity, frequency, duration, and
daytime sequelae.
• Do __________: A brief TST combined with a
short TIB may simply reflect inadequate TIB, but a
TST that is short with a long TIB suggests
insomnia.
• Sleep logs are ____________: While both good
and poor sleepers tend to overestimate SOL and
WASO, insomniac sleep tends to be poorer on
both sleep diary and polysomnography.
• What about ___________?: Assess and address
sleep opportunity problems before making a
definitive insomnia diagnosis.
54
Tips to Rule Out Insomnia
• Don’t focus too much on TST : Insomnia is
determined by severity, frequency, duration, and
daytime sequelae.
• Do consider TIB : A brief TST combined with a
short TIB may simply reflect inadequate TIB, but a
TST that is short with a long TIB suggests
insomnia.
• Sleep logs are key for diagnosis: While both good
and poor sleepers tend to overestimate SOL and
WASO, insomniac sleep tends to be poorer on
both sleep diary and polysomnography.
• What about opportunity?: Assess and address
sleep opportunity problems before making a
definitive insomnia diagnosis.
55
Primary vs Secondary Insomnia
• Insomnia is no longer labeled “primary”
or “secondary”
• Now use the term “comorbid” insomnia
• Ex: depression – insomnia as a prodromal
symptom and risk factor for relapse
• DSM-5 Insomnia Disorder
• With non-sleep disorder mental
comorbidity
• With other medical comorbidity
• With other sleep disorder
56
5
7
The Etiology of Insomnia
A Cognitive-Behavioral Conceptualization
57
Behavioral Model of Insomnia
Predisposing Precipitating Perpetuating
Spielman, 1987 58
• Genetics
• Arousal level
• Weak sleep
generation system
• Worry or rumination
tendency
• Sleep schedule
• Environment
• Previous episodes
59
A Closer Look at Hyperarousal
• Physiological
Hyperarousal
• Emotional
Hyperarousal
• Cognitive By M. L. Haen (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via
Wikimedia Commons
Hyperarousal
60
• Genetics • Situational stressors
• Arousal level
• Weak sleep • Illness / injury
generation system
• Acute stress reaction
• Worry or rumination • Environmental

tendency changes
• Sleep schedule
• Environment
61
• Genetics • Situational stressors • Maladaptive habits
• Arousal level
• Weak sleep • Illness / injury • Dysfunctional/alarming
beliefs, attitudes and
generation system
• Acute stress reaction cognitions
• Worry or rumination • Environmental

tendency changes
• Sleep schedule
• Environment
62
A Closer Look at Maladaptive Habits
Conditioning
–For good sleepers, bedroom/bedtime stimuli are potent
cues associated with drowsiness and sleep onset.
–For poor sleepers, these stimuli are often associated with

frustration, arousal, and sleeplessness
Tossing
Bed and Turning Conditioned
Bedroom Arousal Arousal
Sleeplessness
63
Evolution from Sleep Disturbance to Insomnia
Spielman, 1987 64
Are there military-specific
predisposing, precipitating and
perpetuating factors?
65
Insomnia Factors: Combat-Exposed SMs

• Adverse childhood events • Deployment/TDY • Nightmares
• Pre-military/Deployment • Combat exposure • Energy drink consumption

sleep problems and
patterns • Shift work/Irregular • PTSD/Psychopathology
scheduling
• Military norms and attitudes
• Hypervigilance
• Expectation of falling asleep
without wind down
• Coping mechanisms:
alcohol/substance use
Bramoweth & Germain, 2013; Pruiksma et al, 2018 66

Sleep Effort = Poor Sleep Onset
“No matter
how hard I
try, I can’t fall
asleep!”
Photo by https://www.flickr.com/photos/barkbud/. Used with permission via https://creativecommons.org/licenses/by/2.0/
Photo by https://www.flickr.com/photos/mrehan00/. Used with permission via https://creativecommons.org/licenses/by-sa/2.0/
67
An Integrative Model of Insomnia
Dysfunctional
Cognitions
•Worry over sleep loss
•Rumination over consequences
•Unrealistic expectations
•Misattributions/amplifications
Maladaptive Habits
Arousal •Excessive time in bed
•Emotional •Irregular sleep schedule
•Cognitive •Daytime napping
•Physiologic •Sleep-incompatible
activities
Consequences
•Mood disturbances
•Fatigue
•Performance/impairments
•Social discomfort
68
69
Brief Behavioral Therapy of Insomnia

http://www.carson.army.mil/dhr/DHR/ACES/GettingStarted.html 69
Insomnia in Primary Care
• Insomnia is common in primary care
• 79% Vets w/ sleep problems prefer PC treatment
• 85% of soldiers expect PCP to recommend
and 59% prefer behavioral strategies
• Half of PCPs do not chart sleep problems
• 80% believe sleep hygiene is effective
• Only 10% refer for behavioral sleep treatment
Shepardson et al, 2014; Ee et al, 2016; Ulmer et al, 2017; Koffel, Bramoweth, & Ulmer, 2018 70
Brief Behavioral Treatment of
Insomnia: BBTI
– Initially designed for primary care setting
• Brief
• Decreased barriers to care
• Can be delivered by medical staff w/o specialty
mental health training - nurse or paraprofessional
• Rapidly effective
– Specific behavioral focus
• Stimulus control
• Adapted sleep restriction
Bramoweth et al, 2018 7171

Does BBTI Work?
ISI
Effect Sizes
PSQI
SOL Civilians
Combat Vets
WASO
SE
0 0.2 0.4 0.6 0.8 1
• ↑ levels of depressed mood, anxiety, and

↑ SOL linked to better treatment response
Germain et al, 2014; Buysse et al, 2011; Troxel et al 2013 72

72
73
BBTI Rationale
• Waking behaviors have a direct impact on
sleep
• Changing behaviors can worsen or
improve sleep
• By leveraging the homeostatic and
circadian processes, sleep can be
consolidated and sleep quality improved
73
BBTI Emphasis
STRONG SLEEP
DRIVE
CORRECT GOOD
CIRCADIAN
PLACEMENT SLEEP
LOW AROUSAL
7474
BBTI Protocol
Appt 1 • Mini-Assessment In Person
• Intro Sleep Log
Appt 2 • Score Sleep Log In Person

• Psychoeducation
• “Four Rules”
Appt 3 • Adherence Check In Person or
Phone
Appt 4 • “30/30 Rule” for Sleep Titration In Person
Appt 5 • Score Sleep Log In Person or

• Sleep Titration Phone
• Review Progress
• Relapse Prevention
75
76
Phone vs In-Person Appts

• Appointments 3 and
5 may be conducted
over the phone
• Consider MTF/clinic
policies
http://cliparts.co/clipart/2312448 76
77
BBTI Protocol
• Appointment length should not
exceed 30 minutes
• Appointments where sleep log is
not “scored” can be done in 20
minutes
http://www.clipartpanda.com/clipart_images/clip-art-analogue-clock-1636404 77
78
BBTI Protocol
Appointment Structure
I. Assessment
Includes screeners after initial
assessment
II. Intervention
III. PCM Feedback
78
79
BBTI Appointment-by-Appointment Guide

U.S. Army photo by SSG Jim Greenhill, released.
79
Appointment 1 (30 Min)
• Review medical chart
beforehand
I. Assessment
• Sleep-focused mini-assessment
• Sleep measures
• Psychoeducation:
II. Intervention Introduce BBTI
• Introduce sleep log
III. Feedback/
• PCM/AHLTA
Recommendations
80
81
Appointment 1: Assessment
1) Review medical chart in AHLTA
• Most recent PCP note
• Relevant sleep information, diagnosis,
intervention
• Most recent behavioral health and
sleep medicine notes
• Medication tab (sort by date)
81
2) Goal of the Sleep-Focused Mini-Assessment
Is this Insomnia Is BBTI

Disorder? appropriate?
Y/N Y/N
82
83
2) Sleep-Focused Mini-Assessment via TSWF
• Nature of sleep problem
• Behaviors affecting sleep
• Symptoms of other sleep or medical
conditions, or medications potentially
contributing to sleep problems
• Functional impact/consequences
• Current and past interventions
• Includes OTC, supplements, self-help, etc.
83
84
Sleep-Focused Mini-Assessment
Nature of Sleep Problem
Do you have problems falling asleep?
Do you have problems staying asleep?
Do you have problems waking too early?
Do you have nightmares?
How long have you had sleep problems?
What was going on when problems started?
How many nights per week do you have difficulty
sleeping?
Are sleep problems worse on work days?
What psychosocial factors are present?
What makes your sleep better or worse?
When do you get in bed to go to sleep?*
How long does it take you to fall asleep?*
How many times do you wake up?*
How long does it take to return to sleep after
awakenings?*
When do you wake up in the morning?*
When do you get out of bed in the morning?*
(consider weekday vs end)
84
85
Behaviors
Affecting
Sleep
Behaviors Affecting Sleep

Do you stay in bed when you have difficulty sleeping?
Do you worry in bed?
Do you read, watch TV, or engage in other activities in bed?
Is the bedroom environment conducive to sleep (quiet, dark, cool, comfortable, etc)?
Do you nap?
Do you use caffeine within six hours of going to bed?
Do you use tobacco within two hours of going to bed?
Do you engage in physical activity within two hours of going to bed?
Do you use alcohol to fall asleep? Any OTC aids to fall asleep?
85
86
Symptoms of
Potential
Other Sleep
Disorders
Symptoms of Potential Other Sleep Disorders

Do you snore?
Do you ever wake with a headache?
Has someone else told you that you gasp for breath at night?
Do you feel tired despite feeling you slept at night?
Unusual sleep behaviors (sleep paralysis, hallucinations, sleepwalking)?

Presence of shift work?
Preference for a different schedule than work or school requires?
Discomfort in legs when attempting to sleep? Relieved with movement?
86
87
Functional Impact/Consequences
Functional Impact/
Consequences
Work
Home
Family
Social/recreational
Physical activity/exercise
87
88
Current/Past Treatment
88
“Red Flags”: Differential/Comorbidities
• Insufficient sleep*
• Circadian Rhythm Sleep-Wake Disorders*
• Delayed Sleep Phase
• Shift Work
• Sleep-Related Breathing Disorders
• Narcolepsy / Hypersomnolence Disorders
• Parasomnias
• Sleep-Related Movement Disorders
• Restless Leg Syndrome
• Periodic Limb Movements
8989
“Red Flags”: Contraindications
− Untreated disorders of
excessive sleepiness
− Bipolar - Mania
− Epilepsy
− Parasomnias
− High risk for falls
Perlis, et al, 2005; Troxel et al, 2012; Wu, et al, 2015; Geiger-Brown et al, 2014 90
90
1. Determine whether specialty Suspect
BH indicated something
needs further
2. Determine suspicion of OSA evaluation?
• If yes, can assess while
starting/continuing BHC
interventions
• EMR note to facilitate sleep
medicine referral
3. Recommend further PCM
evaluation while
starting/continuing BHC
interventions
91
92
3) Sleep Measures
• Insomnia Severity Index
• Via TSWF
• Behavioral Health Measure-20
• Via TSWF
92
Insomnia Severity Index
• 7 items: 0-4 scale, score range 0-28

– 8+ indicates at least subthreshold insomnia
• Assesses over the past two weeks:
– type of sleep difficulty (falling asleep, staying
asleep, early awakening)
– Consequences/impact on daytime
function
Morin, 1993; Bastien, Vallieres, & Morin, 2001 93
Insomnia Severity Index
• Screener; not diagnostic
• Suggested plans:
• Clinical insomnia (ISI ≥ 15) 
proceed with BBTI
• Subclinical insomnia (ISI 11-14 or
short sx duration) + clinician
judgment / patient context 
proceed with BBTI
94
Appointment 1: Intervention
Psychoeducation
• Psychoeducation: Briefly provide feedback
to patient on Insomnia Disorder diagnosis
and helpfulness of BBTI.
“After reviewing your medical record and completing the

assessment of your sleep today, it sounds like you have
insomnia. The first line treatment for insomnia is a behavioral
treatment, such as ‘Brief Behavioral Treatment for Insomnia’ or
BBTI. BBTI involves seeing me every 1-2 weeks for about four
more appointments to make some changes to your sleep (and
we can do some of these appointments by phone). We’ll start by
getting some specific data about your current sleep…”
95
Introduce Sleep Log
9696
Sleep Log
• Sleep log is a central part of BBTI
– Data will be used throughout treatment
• Emphasize the importance of daily
recording close to getting out of bed
– Location, location, location
– Reminders
– Habit development principles
• You will spend part of every
appointment reviewing the sleep log
97
97
Sleep Diary Exercise
Please fill in the last three nights’

sleep information.
Did you have trouble recalling all of

the data?
98
Appt 1+: BBTI Interventions
99
BBTI & Medication
• Consult with patient’s PCP
• If not discontinuing prior to BBTI:
• Encourage predictable, proactive
medication use
• Take medication as prescribed (i.e.,
at bedtime, not hours before)
• Provide general info on
discontinuation if/when patient is
ready
100
Troxel et al, 2012 100
BBTI & Medication
• Can collaborate with PCP on 4-week D/C plan
• Week 1: No Change
• Week 2: ½ Regular Dose (either by amount or days)
• Week 3: ¼ Regular Dose
• Week 4: Discontinue
• Patient benefits if discontinue during BBTI:

– Learn negative effects of withdrawal are short-lived
– Learn minimal differences between regular use and
no use
– D/C before therapy prevents future setbacks
Perlis et al, 2005

101
101
Appointment 2 (30 Min.)
• BHM-20
I. Assessment • ISI
• Score baseline sleep log
• Psychoeducation: Two-Process Model,

3Ps
II. Intervention • Introduce “4 Rules”
• Prescribe new sleep schedule and
behaviors
• PCM/AHLTA
III. Feedback/
Recommendations
102
2) BHM, ISI entered in TSWF
103
103
3) Score baseline sleep log
• With patient, use sleep log to calculate
average sleep parameters and
document this assessment in AHLTA
• Patient will retain sleep logs
104
104
Sleep Log Scoring
o Step 1
• Calculate time
in bed
• Count hours
between dark
bars
• For example,
bars here are
at 10:30 pm
and 6 am, for
7.5 hours in
bed
105
105
Sleep Log Scoring
o Step 1 cont’d
• Sum total
hours across
week and
average
• For example,
here 7.5 +7.5
+9 +8.5 +9.75
+7.75 +6.5
=56.5 /7 =8.1
hours in bed
on average
106
106
Sleep Log Scoring
o Step 2
• Calculate total
sleep time
• Count up
hours in the
shaded boxes
• For example,
boxes here are
1.5 +2 +1.5, or
5 hours of
sleep
107
107
Sleep Log Scoring
o Step 2 cont’d
• Sum total
hours across
week and
average
• For example,
here 5 +4 +5
+6 +6 +4 +5
=35 /7 =5
hours average
total sleep
time
108
108
Sleep Log Scoring
o Step 3
• Calculate
average SOL by
adding up gap
between the
first dark bar
and the start
of shading
• For example,
here 60 +90 +0
+30 +0 +90
+30 =5 /7
=42.9 minutes
average SOL
109
`109
Sleep Log Scoring
o Step 4
• Calculate
average WASO
by adding up all
other gaps
• For example,
here 1.5 +2 +4
+2 +3.75 +2.5
+1 =16.75 /7
=2.4 hours
average WASO
• Can use
minutes or
hours
110
110
Sleep Log Scoring
o Summary:
• Average TIB:
8.1 hours
• Average TST:
5 hours
• Average SOL:
42.9 minutes
• Average
WASO: 2.4
hours
• Enter in AHLTA
111
111
Sleep Log Scoring
112
112
1) Psychoeducation:
Two-Process
Model, 3 Ps
• Use script to
introduce Two-
Process Model and
3 Ps
113
113
Psychoeducation Script
“There are two basic processes that control
sleep. The first process is our ‘sleep drive.’ You
can think of the sleep drive as similar to hunger
– the longer it’s been since you’ve eaten, the
more hungry you get. By the end of a day
without food, you’d be starving and have plenty
of room to eat. The same is true for sleep; the
longer you go without sleep, the more sleep
‘hunger’ you build up, and the more sleepy you
are. This can help you fall asleep more quickly
at the chance you have to sleep. Does this
make sense?”
114
From Troxel et al, 2012 114
“When we’re hungry and we snack, we
reduce our hunger drive just a little. If
you snack a little bit before dinner, you
might not be as hungry and might not
eat your full meal. The same thing can
happen with sleep. What do you think
happens to your sleep drive when you to
go to bed too early or nap?”
[Patient response]
115
“Exactly. Instead of having a really high
drive or need for sleep, you might not
really be sleepy, leading to difficulty
falling asleep and/or poor sleep quality.
On the other hand, like when you
haven’t eaten in a long time, what do
you think staying awake longer would
do to your sleep drive?”
[Patient response]
116
“Right. The longer you’re awake, the more
likely you are to fall asleep quickly and
deeply. Now, if the sleep drive were the
only process regulating sleep, then if you
stayed awake long enough, you should fall
asleep equally well at 1100 as at 2300.
Have you ever tried this, for instance, after
pulling an all-nighter or flying to a different
time zone?”
[Patient response]
117
“The reason you don’t fall asleep as easily or sleep
as well or as long during the day is that there is a
second process regulating sleep – our body's
internal biological clock, also called the circadian
rhythm. This process controls sleep timing so we
sleep best at night and function best during the
day. Our internal biological clocks are naturally
‘set’ to promote sleep at night and wakefulness
during the day. Ideally, the sleep drive and the
biological clock – the two processes that regulate
sleep – would work together. Ideally, at the end of
the day, you’d be ‘hungry’ for sleep at the same
time your internal biological clock is saying, “This is
the best time to get a good sleep.”
118
119
“However, many times, work life and
home life demand that we do things
that work AGAINST either our natural
sleep drive or our internal biological
clock and can eventually result in
insomnia. Let me explain…”

“One way to look at how insomnia gets
started is called the ‘3P model’. The
idea is there are some things that may
make you vulnerable to sleep problems
- the predisposing factors - like genetics
or a tendency to worry. Then
something triggers some bad nights -
the precipitating factor(s) - like stress, a
PCS or deployment, etc.”
120
“But what really causes those bad
nights to turn into insomnia is the last
‘P’, the perpetuating factors. These are
behaviors someone starts doing in
response to the bad nights that can
unintentionally make sleep even worse.
The good news is there are changes you
can make in order to get better sleep,
and that's exactly what this treatment is
designed to do. Make sense?”
121
2) Introduce “4 Rules”: Adapted sleep restriction and
stimulus control
The “Four Rules” of BBTI

i. Reduce time in bed
ii. Wake up at the same time every day
iii. Do not go to bed unless sleepy
iv. Do not stay in bed unless you are asleep
122
Sleep Restriction in BBTI
https://www.flickr.com/photos/kubina/2159447099
123123
Sleep Restriction
• Based on the principle that people with
insomnia often use sleep extension
• When sleep __________ exceeds sleep
_______, wakefulness is the result - less
efficient sleep
• Restricting time in bed leads to an
increase in sleep efficiency by using sleep
deprivation as a tool
Spielman et al, 1987

124
124
Sleep Restriction
• Based on the principle that people with
insomnia often use sleep extension
• When sleep opportunity exceeds sleep
ability, wakefulness is the result - less
efficient sleep
• Restricting time in bed leads to an
increase in sleep efficiency by using sleep
deprivation as a tool

125
125
Sleep Restriction
• Determine average sleep time with sleep

logs (sleep ability)
• Limit time in bed (TIB) (sleep opportunity) to
average sleep time plus 30 minutes
– Start with desired wake time and count
backwards
– 5-5.5 hours TIB as a minimum for most people*
– Plan activities to fill extra time
• Continue with sleep logs
Spielman et al, 1987 126

126
Sleep Restriction
• Can be difficult to follow for some
individuals
• Need to prepare clients for extra sleep
deprivation
– Extra caution when driving or other potentially
dangerous situations
– May be contraindicated for some (ex: epilepsy)
– Can coincide with time off during first 1-2 weeks
– Modafinil 100-200 mg in AM may be used for
extreme daytime sleepiness
• Assess motivation and potential barriers

127
127
Stimulus Control
Ramon Snellink – https://www.flickr.com/photos/rcsnellink/4680013894 Labeled for non-commercial reuse with attribution 128128
Appt 2: Stimulus Control Instructions
• Based on operant conditioning principles
– The bed and bedroom lose their stimulus value
as a cue for sleep because of non-sleep activities
in bed
• Classical conditioning also explains the idea
of conditioned hyperarousal
– “Alert and aroused” is associated with the bed
and becomes a conditioned response to the
bedroom
• Overall principles:
The bed is for sleep, and sleep is for the
bed.
Bootzin, 1972 129

Appt 2: Good Stimulus Control
Sleep Sex
ODDS = 1 In 2
130
Appt 2: Poor Stimulus Control
Bedroom/Bedtime
Eat in Bed
Exercise in
ODDS = 1 in 10
Bedroom
Read in Bed
Watch TV in Bed
Worry in Bed
Clean Bedroom
Work in Bed
131
• The bed is for sleep…
• Avoid sleep-incompatible activities in bed*
• Ex: TV, homework, reading, paying bills
• Don’t worry, think, plan, etc., in bed
• Go to bed only when sleepy
• If unable to sleep, get out of bed
• Maintain a regular sleep schedule and get
up at the same time every morning
• And sleep is for the bed…
• Avoid sleeping outside of the bed/napping
Bootzin, 1972 132

Appt 2: Sleepy vs Tired
Sleepy means having to almost
struggle to stay awake, maybe
dozing off
Tired and fatigue reflect low energy

level but maybe unable to fall
asleep – “Tired but Wired”
Sleep naturally unfolds when we are sleepy

133
• If unable to sleep, get out of bed***
• After about 10 minutes, or whenever
mental or emotional arousal sets in
• Engage in relaxing activities until ready
for sleep
• Have activities planned in advance
• Get back into bed, but repeat as often
as necessary
• Establishing new patterns of
conditioning usually takes _________
Bootzin, 1972 134

• If unable to sleep, get out of bed***
• After about 10 minutes, or whenever
mental or emotional arousal sets in
• Engage in relaxing activities until ready
for sleep
• Have activities planned in advance
• Get back into bed, but repeat as often
as necessary
• Establishing new patterns of
conditioning usually takes 3 to 4 weeks
Bootzin, 1972 135

Difficulties with Stimulus Control
Adherence
• Difficulty identifying sleepiness
• Trouble getting out of bed
• Bed partner-related obstacles
• Different bedtimes
• Disturbing the partner
• Difficulty with the scheduled
wake-up time
136
2) Introduce “4 Rules”: Adapted sleep restriction and
stimulus control

137
3) Set Prescribed Sleep Schedule:
Determine time in bed using
baseline sleep time + 30 minutes
• Recommended wake-up time

• Recommended bedtime (work
backwards)
• Activities prior to going to bed and
in middle of the night if awake
• Medication timing and dose (if
applicable)
138
138
3) Prescribed sleep schedule
should not reduce time in bed
below 5-5.5 hours
 This can trigger excessive daytime

sleepiness and other problems
 Consider 5 hours as minimum for patients
in good health
 Consider 5.5 hours as minimum for
patients with sleep-related comorbidities
such as OSA and those with high existing
levels of sleepiness, older adults, etc.
139
139
4) Behavior Change Plan
• Discuss precautions to temporary

increase in sleepiness
• Provide materials with 4 Rules,
prescribed sleep schedule
• Plan for appointments 3 and 4
140
140
Appointment 3 (20 min.)
• ISI
I. Assessment • Review sleep log (broadly)
• Assess and address adherence

difficulties
II. Intervention
• Provide sleep hygiene information
Remember: This appointment can be

accomplished in person or via phone
141
142
142
2) Review sleep log for sleep patterns
− Broad review, do not need to

calculate averages or input in AHLTA
− Focus on adherence to prescribed
sleep schedule
− Share your observations with patient
143
143
Questions to review the log (if via phone):
 Did you nap? How many days of the week?
 What time did you go to bed?
 What time did you wake up?
 Were there any days that differed?
 Did it take you more than 30 minutes to fall
asleep on any of the nights? How many?
 What about waking up in the middle of the
night?
144
144
1) Assess and address adherence
difficulties
− Brief check-in with patient on

experience with new sleep
schedule
• Point out and reinforce positives
• Problem solve challenges
145
145
Questions you may ask:
 Did you notice any changes in your sleep?
 How would you rate your sleep quality (0-
100 scale)?
 How would you rate your daytime function?
 Did you find it difficult to follow the
schedule?
 What was helpful for you in sticking with
your schedule?
 What challenges did you have with the
schedule, and what did you try to tackle
those?
146
146
Address any of the patient’s

questions about the handouts, the
4 Rules, or anything from last
appointment
147
147
2) Provide sleep hygiene information
− Provide or review sleep hygiene
handout
Bosland Corp. https://www.flickr.com/photos/145362038@N02/41522888305
148
148
Sleep Hygiene Handout
• The handout provides

information on basic sleep
hygiene principles
• Adherence to good sleep hygiene
practices is generally poor among
insomniacs
• Outcome studies show that sleep
hygiene education alone is
insufficient for chronic insomnia
149
Sleep Hygiene
• Environment
− Light, noise,
temperature
• Role of regular exercise
− Avoid 1-2 hours
before bed because
of increase in core
temperature
• Avoid looking at the clock
− NEVER helps!
150
Sleep Hygiene
• Caffeine
− Sources (more than just
coffee)
− Half-life 5-7 hours
− Avoid after lunch
• Tobacco & other
substances
• Alcohol
− Common military sleep aid
− Helps with sleep initiation Image by Bill Brim, CDP
− Ultimately leads to
fragmented sleep
151
• ISI
I. Assessment • Review sleep log (broadly)
• Provide instructions on the

II. Intervention 30/30 Rule
• Prescribe new sleep schedule
• PCM/AHLTA
III. Feedback/
Recommendations
152
153
153
2) Review sleep log for sleep patterns
− Broad review, do not need to

calculate averages or input in AHLTA
sleep schedule
154
154
1) Provide instructions on the 30/30 Rule
The 30/30 Rule in BBTI

If SOL and WASO are < 30 minutes on most nights,
patient may add 15 min to TIB (advance bedtime)
If SOL or WASO are > 30 min on most nights, patient

should decrease TIB by 15 min
155
2) Prescribe new sleep schedule
− Use the 30/30 Rule to adjust the

patient’s sleep schedule and assign
for the next week
− Schedule Appointment 5
156
156
• ISI
• Review/score sleep log
I. Assessment
Remember: This
appointment can be
• Prescribe new sleep schedule prn accomplished in person
• Review progress or via phone
II. Intervention • Review “4 Rules”
• Relapse prevention
• PCM/AHLTA
III. Feedback/
Recommendations
157
158
158
2) Review/score sleep log in detail
− If via phone: Broad review, do not

need to calculate averages or input in
AHLTA
− If in person: Score SOL, WASO, TIB,
TST and input in AHLTA
sleep schedule
159
159
1) Prescribe new sleep schedule
prn
− Increase TIB if sleep remains

consolidated
− Review instructions for increasing
or decreasing time in bed with the
30/30 Rule
160
160
2) Review progress
− Discuss patient and BHC

observations about progress
− Address any remaining difficulties
− Emphasize benefit of behavioral
strategies
161
161
3) Review “4 Rules” for better
sleep
− Reduce time in bed

− Wake up at the same time every
day
− Do not go to bed unless sleepy
− Do not stay in bed unless you are
asleep
162
162
2) Review “4 Rules” for better sleep

163
4) Relapse Prevention
− Discuss possible
situations or periods
when patient may be
more likely to have
sleep problems
− Develop strategies in
advance
164
164
• If not on sleep medication  follow-up prn
• If still on sleep medication
• 1 month or earlier follow-up with PCM
• Discuss long-term treatment, plan to reduce
meds with PCM
• Consider BHC continuity follow-up
• If goals not met/inadequate tx response:
• Brief PCM, consider complicating factors
• Collaborate to update plan and consider specialty
referral
165
BBTi – Challenges & Considerations
https://www.flickr.com/photos/purplemattfish/3020016417 166
166
By Matthew Keefe - Flickr: Celebrating Festivus 2, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=16756870
Airing of Grievances
167
BBTI Logistics
• Handouts provided for participants
• Can replace telephone appointments
with brief in-person appointments
• Recommended for less complex
patients
– Contraindications for sleep restriction
– Chronic, severe, or with comorbidities
Troxel, Germain & Buysse, 2012; Troxel et al, 2014

168
168
BBTI Logistics
• Can continue past 5 appointments
based on patient and clinician
judgment
• Continued sleep schedule focus
• May need to incorporate relaxation
component to address hyperarousal
• Consider referral if patient does not
improve after BBTI protocol
169
169
BBTI in PC
• What if patient doesn’t need
BBTI?
• BHCs can address:
 Symptoms of sleep difficulties vs.
insomnia
 Insufficient sleep
 Environmental contributors
• Consider sleep hygiene
171
171
BBTI in PC
• Selling BHC Services to PCMs
• Introduce self
• Brief on how you can assist your
PCM’s patients
• Benefits even in subclinical cases
• Differentiate insomnia vs. general
referrals
• Make cookies
172
172
Questions and Discussion
Thank You 173

173
Recommended Reading
• Troxel, W.M., Germain, A., & Buysse, D.J. (2012). Clinical management of insomnia
with brief behavioral treatment (BBTI). Behavioral Sleep Medicine 10(4): 266‐279.
• Germain, A., Richardson, R., Stocker, R., Mammen, O., Hall, M., Bramoweth, A. D.,
Begley, A., Rode, N., Frank, E., Hass, G. & Buysse, D. J. (2014). Treatment for insomnia
in combat-exposed OEF/OIF/OND military veterans: Preliminary randomized
controlled trial. Behaviour research and therapy, 61, 78-88.
https://doi.org/10.1016/j.brat.2014.07.016
• Morin, C.M. & Espie, C.A. (2003) Insomnia: A clinical guide to assessment and
treatment. Springer.
• Schutte‐Rodin, S., Broch, L., Buysse, D., Dorsey, C. & Sateia, M. (2008). Clinical
guideline for the evaluation and management of chronic insomnia in adults. Journal
of Clinical Sleep Medicine, 4(5): 487‐504.
• http://deploymentpsych.org/provider‐resources/asssessment‐and‐treatment‐sleep‐
disturbance‐cbt‐i
174
174
deploymentpsych.org
• Descriptions and schedules of
upcoming training events
• Blog updated daily with a range of
relevant content
• Articles by subject matter experts
related to deployment psychology,
including PTSD, mTBI, depression,
and insomnia
• Other resources and information
for behavioral health providers
• Links to CDP’s Facebook page and
Twitter feed
175
Other Learning Opportunities
• CDP Presents - Monthly
Webinar Series
• Live and archived
• CEs free for live, small fee
for on-demand CEs
• View archived webinars
free for no CEs
• On-demand Courses
• Military Culture
• Deployment Cycle
• Intro to PE and CPT
• …and more!
176
Provider Support
CDP’s “Provider Portal” is exclusively for individuals trained by CDP
in evidence-based psychotherapies (e.g., CPT, PE, and CBT-I)
• Consultation message
boards
• Hosted consultation calls
• Printable fact sheets,
manuals, handouts, and
other materials
• FAQs and 1:1 interaction
with answers from SMEs
• Videos, webinars, and other
multimedia training aids
Participants in CDP’s evidence-based training will automatically receive an email

instructing them how to activate their user name and access the “Provider Portal”
section at Deploymentpsych.org. 177
Center for Deployment Psychology
Department of Medical & Clinical Psychology
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road, Executive Office: Bldg. 11300-602
Bethesda, MD 20813-4768
Contact Us
Email: general@deploymentpsych.org
Website: deploymentpsych.org
Facebook: http://www.facebook.com/DeploymentPsych
Twitter: @DeploymentPsych
178

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Brief Behavioral Treatment

Obstructive Sleep Apnea

Circadian Rhythm Sleep-

Troxel et al. (2015) 6

Insomnia occurs when there are

Insomnia occurs when there are

Caldwell, Knapik, & Lieberman, 2017 10

Sleep deprivation is characterized

Sleep deprivation is characterized

Slide concept courtesy Dr. Anne Germain 13

“We do more before 9 a.m. than

Courtesy of Bill Brim, CDP

Sleep and Insomnia:

Kilduff & Kushida, 1999 23

Mitterling et al, 2015 31

Thomas et al, 2014 32

Ambien (zolpidem) 1.5-2.6 Fast 2.5-10 No

Ambien ER (zolpidem 2.8 Fast 6.25-12.5 No

Belsomra (suvorexant) 12 Slow 5, 10, 15, 20 No

Rozerem (ramelteon) 1-2.6 Fast 4-8 Yes

Silenor (doxepin) 4 Fast 3-6 Yes

Restoril (temazepam) 8-12 Moderate 7.5-30 No

ProSom (estazolam) 12-20 Moderate 1-2 Minimal

Doral (quazepam) 50-200 Fast 7.5-15 Yes

Dalmane (flurazepam) 50-200 Fast 15-30 Yes

– Excessive daytime sleepiness (daily x3 mos)

RLS • Crawling or aching feeing in legs

• Leg twitches or jerks during the night

• Grinding teeth at night/teeth worn down

ICD-10 Diagnostic Codes

Chronic Kidney Neurologic Psychiatric

Roth & Roehrs, 2003 48

• Problems falling asleep at bedtime

• Awakening too early in the morning

• Sleep-onset latency (SOL) > 30 mins

Schutte-Rodin et al, 2008 53

The Etiology of Insomnia

• Worry or rumination • Environmental

• Worry or rumination • Environmental

–For poor sleepers, these stimuli are often associated with

Predisposing Precipitating Perpetuating

• Pre-military/Deployment • Combat exposure • Energy drink consumption

Bramoweth & Germain, 2013; Pruiksma et al, 2018 66

Photo by https://www.flickr.com/photos/mrehan00/. Used with permission via https://creativecommons.org/licenses/by-sa/2.0/

Brief Behavioral Therapy of Insomnia

Bramoweth et al, 2018 7171

0 0.2 0.4 0.6 0.8 1

• ↑ levels of depressed mood, anxiety, and

Germain et al, 2014; Buysse et al, 2011; Troxel et al 2013 72

Appt 2 • Score Sleep Log In Person

Appt 4 • “30/30 Rule” for Sleep Titration In Person

Appt 5 • Score Sleep Log In Person or

Phone vs In-Person Appts

BBTI Appointment-by-Appointment Guide

Is this Insomnia Is BBTI

Behaviors Affecting Sleep

Symptoms of Potential Other Sleep Disorders

Unusual sleep behaviors (sleep paralysis, hallucinations, sleepwalking)?

• 7 items: 0-4 scale, score range 0-28

“After reviewing your medical record and completing the

Please fill in the last three nights’

Did you have trouble recalling all of

• Patient benefits if discontinue during BBTI: