Cognitive behavioral therapy for the management of poor sleep in insomnia disorder

Figures & data

Table 1 Criteria for insomnia disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition¹ and the International Classification of Sleep Disorders, Third Edition²

	DSM-5: insomnia disorder	ICSD-3: chronic insomnia disorder
Sleep	A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms: 1) difficulty initiating sleep, 2) difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings, and 3) early-morning awakening with inability to return to sleep.	The patient reports (or the patient’s parent or caregiver reports) marked concern about, or dissatisfaction with, sleep comprising one or more of the following: 1) difficulty initiating sleep, 2) difficulty maintaining sleep, 3) waking up earlier than desired, 4) resistance in going to bed on the appropriate schedule, and 5) difficulty sleeping without the parent or caregiver present.
Consequences	The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.	The patient reports (or the patient’s parent or caregiver reports) one or more of the following as being associated with the nighttime sleep difficulty in fatigue; mood disturbance; interpersonal problems; reduced cognitive function; reduced performance; daytime sleepiness; behavioral problems (eg, hyperactivity, impulsivity, aggression); reduced motivation/initiative; proneness to errors/accidents.
Frequency	The sleep difficulty occurs at least 3 nights per week.	The sleep disturbance and associated daytime symptoms occur at least 3 times per week.
Chronicity	The sleep difficulty is present for at least 3 months.	The sleep disturbance and associated daytime symptoms have been present for at least 3 months.
Exclusions	The sleep difficulty occurs despite adequate opportunity for sleep. The insomnia is not better explained by and does not occur exclusively during the course of another sleep/wake disorder (eg, narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep/wake disorder, a parasomnia). The insomnia is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication). Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.	The reported sleep/wake complaints cannot be explained purely by inadequate opportunity (ie, enough time is allotted for sleep) or inadequate circumstances (ie, the environment is safe, dark, quiet, and comfortable) for sleep. The sleep/wake difficulty is not better explained by another primary sleep disorder.

Abbreviations: DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; ICSD-3, International Classification of Sleep Disorders, Third Edition.

Figure 1 Factors contributing to the development of insomnia, according to the 3P framework.

Notes: Threshold refers to the probable intensity of insomnia to be classified as a “case”. Reprinted from Elsevier Health Sciences, Espie CA, Kyle SD, Cognitive and behavioural psychological therapies for chronic insomnia, in: Therapy in Sleep Medicine, Barkoukis TJ, Matheson JK, Ferber R, Dohramji K (Ed.), 161–171, Copyright © 2012, with permission from Elsevier.⁸⁰

Table 2 Psychological and behavioral therapies for insomnia

Treatment (level of endorsement)
Stimulus control therapy (standard)
Behavioural recommendations designed to reinforce the association between the bed or bedroom and sleep, and to strengthen a consistent sleep-wake schedule: (a) go to bed only when sleepy; (b) get out of bed when unable to sleep; (c) use the bed for sleep only (no reading, problem-solving in bed); (d) arise at the same time every morning; (e) avoid napping. Sleep restriction therapy (guideline) A method that limits the time spent in bed as close as possible to the actual sleep time, thereby producing a mild sleep deprivation, which results in more consolidated sleep. The sleep window is gradually increased throughout a few days or weeks until optimum sleep duration is achieved. Relaxation training (standard) Clinical procedures aimed at reduction of somatic tension (eg, progressive muscle relaxation, autogenic training) or intrusive thoughts (eg, imagery training, meditation) interfering with sleep. Most relaxation techniques need professional guidance initially and daily practice for a few weeks. Cognitive therapy (insufficient evidence as single therapy) Psychotherapeutic method aimed at alleviating excessive worries and revising misconceptions about sleep, insomnia, and daytime consequences. Specific targets include unrealistic sleep expectations, fear of the consequences of insomnia, and misconceptions of the causes of insomnia. Sleep hygiene education (insufficient evidence as single therapy) General guidelines about health practices (eg, diet, exercise, substance use) and environmental factors (eg, light, noise, temperature) that might promote or interfere with sleep: (a) avoid stimulants (eg, caffeine, nicotine) for several hours before bedtime; (b) avoid alcohol around bedtime as it fragments sleep during the second half of the night; (c) exercise regularly, it can deepen sleep; (d) do not watch the clock; (e) keep the bedroom environment dark, quiet, and comfortable. Cognitive behavioural therapy (standard) A combination of any of the above behavioural (eg, sleep restriction, stimulus control instructions, relaxation) and cognitive procedures.

Note: Reprinted from The Lancet, 379(9821), Morin CM, Benca R, Chronic insomnia. Lancet, 1129–1141, Copyright © 2012, with permission from Elsevier.⁹

Figure 2 Effect sizes for psychological and behavioral interventions pre-to-post treatment and at follow-up (average of 6 months) for cognitive behavioral therapy for insomnia.

Note: Reprinted from Sleep Medicine Reviews, Vol 13, Issue 3, Riemann D, Perlis ML, The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavioral therapies, Pages 205–214.²⁷ Copyright © 2008, with permission from Elsevier.
Abbreviations: NOA, number of awakenings; SL, sleep latency; TST, total sleep time; WASO, wake time after sleep onset.

Table 3 Treatment modalities of cognitive behavioral therapy for insomnia and key controlled trials

Group therapy	Espie et al^Citation47,Citation76,Citation77
Large group therapy	Jernelov et al^Citation78
Individual therapy	Morin et al^Citation34
Brief therapy	Edinger and Sampson^Citation59
Telephone-delivered	Arnedt et al^Citation79
Internet-delivered	Espie et al^Citation57
Self-help books	Jernelov et al^Citation78
Self-help booklets	Morgan et al^Citation58

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