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CHEST Postgraduate Education Corner CONTEMPORARY REVIEWS IN SLEEP MEDICINE Cognitive Behavioral Treatment of Insomnia Jacob Williams , MS ; Alicia Roth , MA ; Karlyn Vatthauer , BS ; and Christina S. McCrae , PhD Chronic insomnia (symptoms for 6 months) is the most common sleep disorder, affecting 6% to 10% of adults in the general population, with even higher rates in patients with comorbid condi- tions (eg, hypertension, 44%; cardiac disease, 44.1%; breathing problems, 41.5%).
Traditionally, chronic insomnia occurring with another condition has been considered secondary and rarely received direct treatment because treatment of the primary condition was expected to improve the insomnia.

However, this approach often failed because chronic insomnia is maintained by behaviors, cognitions, and associations that patients adopt as they attempt to cope with poor sleep but that end up backﬁ ring (eg, increasing caffeine, spending more time in bed, trying harder to sleep).
Cognitive behavioral treatment of insomnia (CBTi) targets those behaviors, cognitions, and associations and is effective across a variety of populations, including those with medical and psychologic comorbidities.
Thus, in 2005, a National Institutes of Health expert consensus panel on chronic insomnia recommended dropping the term ”secondary insomnia” in favor of the term ”comorbid insomnia.” Because CBTi does not carry the risks associated with some sleep medica- tions (eg, dependency, polypharmacy, cognitive and psychomotor impairment), it is an attractive option for patients with other conditions.

Through the Society of Behavioral Sleep Medicine ( www .

behavioralsleep .
behavioralsleep .

org ) and the American Board of Sleep Medicine ( www .

absm .

org ), it is possible to ﬁ nd practitioners with expertise in CBTi (as well as other aspects of behavioral sleep medicine) and other behavioral sleep resources.
Given the currently limited number of trained practi- tioners, exploration of alternative delivery methods (eg, briefer protocols, self-help, Internet) to improve access to this highly effective treatment and expanded training in these treatments are CHEST 2013; 143 ( 2 ): 554 – 565 warranted.
Abbreviations : CBTi 5 cognitive behavioral treatment of insomnia ; ICD 5 implantable cardioverter-deﬁ brillator ; NIH 5 National Institutes of Health ; SDB 5 sleep-disordered breathing Insomnia is deﬁ ned as complaints of difﬁ culty ini- tiating sleep, maintaining sleep, waking too early, and nonrestorative sleep despite adequate opportu- nity plus a complaint of impaired daytime functioning (eg, fatigue, depressed mood, poor concentration).
1 Acute insomnia lasts , 4 weeks and can be linked to a speciﬁ c cause, 1 whereas chronic insomnia lasts for at least 6 months and may not have an easily identiﬁ able Manuscript received March 19 , 2012 ; revision accepted October 8 , 2012 .

Afﬁ liations: From the Department of Clinical and Health Psy- chology, University of Florida, Gainesville, FL.
Correspondence to: Christina S. McCrae, PhD, Department of Clinical and Health Psychology, University of Florida, Box 100165, Gainesville, FL 32610-0165; e-mail: csmccrae@phhp.uﬂ .edu © 2013 American College of Chest Physicians.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians.

See online for more details.

DOI: 10.1378/chest.12-0731 cause.


2 Instead, chronic insomnia is believed to be perpetuated over time by changes in behaviors, cog- nitions, and associations that patients make as they attempt to compensate for poor sleep.

(See “Etiology” section for more details.)

Comorbid insomnia accounts for the majority of chronic insomnia cases.

Thus, this review focuses on comorbid chronic insomnia with special emphasis on medical comorbidities (hyper- tension, cardiac disease, and breathing disorders).
3 , 4 Prevalence General estimates vary depending on the criteria used to deﬁ ne insomnia, and prevalence rates tend to decrease as the stringency of the criteria increases.

5 Thirty percent of adults have insomnia when deﬁ ned as reporting at least one insomnia symptom.

6 When 554 Postgraduate Education Corner Downloaded From: http://journal.publications.chestnet.org/ by a Landspitali University Hospital User on 05/29/2013 daytime impairment or distress is a required criterion, prevalence drops to 10%.
1 When the most stringent diagnostic criteria are applied, 7 prevalence remains substantial, but further drops to about 6% of adults.

5 , 8 The few studies examining racial differences in prev- alence have reported rates of 16.4% to 28.3% in whites, 15.3% to 23.7% in blacks, and 13.4% to 17.1% in Hispanics.
9 When separated into age categories, blacks appear to have a greater prevalence of insom- nia in middle age (30-59 years), whereas whites have a greater prevalence of insomnia across the life span ( Table 1 ).

10 Overall, sex, age, and health and mental conditions appear to be the most signiﬁ cant risk fac- tors for insomnia.

1 , 15 Older age has been associated with increased risk of insomnia.
15 , 16 However, research suggests that age itself is not the risk; instead, the risk is related to inactivity, sleep changes, decreased social activities, and increases in health conditions associ- ated with aging.

17 , 18 Women are at least two times more likely to have insomnia than age-matched men, 10 and an increased prevalence of insomnia has been seen in adolescent girls compared with age-matched boys ( Table 1 ).
11 The presence of a health or mental condition increases the risk, with insomnia seen in 37.8% of individuals with a comorbid condition but in only 8.4% of those without a comorbid condition.

12 Although there are numerous epidemiologic studies of insomnia, criteria for insomnia classiﬁ cation are highly varied among these studies.

Therefore, the sum- mary of prevalence data in Table 1 relies heavily on data collected from a single epidemiologic study by Lichstein 10 in 2004.
Some of the data generated by that study have appeared in the peer-reviewed litera- ture, 12 but the bulk of ﬁ ndings to date have been pub- lished in Lichstein’s book.

Thus, it is important to note that the methodology used in Lichstein’s study was highly rigorous and provides one of the best sources of information currently available on the prevalence of insomnia.

In terms of methodology, Lichstein 10 used random-digit dialing to sample 50 men and women in each age decade from 20 to 80 years.
Additionally, unlike the bulk of studies in this area, Lichstein’s study used prospective data collection methods (2 weeks of sleep diaries) and stringent criteria for diagnosing insomnia.

10 , 12 The other studies in Table 1 were also selected because they used the strongest methodology and most stringent criteria available.

Etiology Prior to a 2005 National Institutes of Health (NIH) state of the science conference, insomnia was deﬁ ned as primary or secondary.
1 , 4 If insomnia symptoms were related to another physical or psychologic condition, that condition was considered the primary diagnosis and insomnia the secondary diagnosis.

4 Thus, treatment focused on the primary diagnosis, and it was assumed that successful treatment of the primary condition would resolve the secondary insomnia.

Currently, no evidence supports this assumption, and some evi- dence suggests that treating the primary condition of depression does not result in remission of insomnia.
19 Table 1 —Prevalence of Insomnia by Sex, Age, Race, Health Condition, and Mental Disorder Grouping Men Women Blacks Whites Prevalence of Insomnia, % Age Adolescents (13-16 y; n 5 1,014) 11 20-29 y (n 5 772) 10 30-39 y (n 5 772) 10 40-49 y (n 5 772) 10 50-59 y (n 5 772) 10 60-69 y (n 5 772) 10 70-79 y (n 5 772) 10 80-89 1 y (n 5 772) 10 Health condition Hypertension (n 5 772) 12 Cancer (n 5 772) 12 Heart disease (n 5 772) 12 Diabetes (n 5 772) 12 Chronic pain (n 5 772) 12 Breathing problems (n 5 772) 12 Urinary problems (n 5 772) 12 GI problems (n 5 772) 12 Sleep-disordered breathing (n 5 225) 13 Neurologic disorders (n 5 772) 12 Mental disorder Depressive (n 5 14,915) 14 Anxiety (n 5 14,915) 14 8.9 6.0 22.0 11.0 10.0 9.0 23.0 23.0 … … … … … … … … … … … … 12.4 12.0 12.0 20.0 21.0 17.0 26.0 41.0 … … … … … … … … … … … … … 2.4 23.4 20.6 21.9 11.1 18.8 22.2 … … … … … … … … … … … … … 9.8 11.1 12.7 13.1 13.9 25.3 35.1 … … … … … … … … … … … … All … … … … … … … … 44 41.4 44.1 47.4 48.6 59.6 41.5 55.4 54.9 7.3 64.6 43.6 journal.publications.chestnet.org CHEST / 143 / 2 / FEBRUARY 2013 555 Downloaded From: http://journal.publications.chestnet.org/ by a Landspitali University Hospital User on 05/29/2013 However, there is a critical need for additional research on the effects of nonsleep interventions across the variety of presenting comorbid conditions.
Preva- lence studies have estimated that secondary insomnia accounts for up to 90% of insomnia cases.

15 , 20 The NIH conference recommended that the term “sec- ondary” be dropped in favor of the term “comorbid.” This recommendation was made for several reasons.

First, when insomnia co-occurs with another con- dition, it can be difﬁ cult to establish which condition is causing the other.
Additionally, the relationship between insomnia and some conditions is likely recip- rocal in nature (eg, pain contributes to poor sleep and vice versa).

Second, the factors that perpetuate insom- nia over time often are different from those that pre- cipitated it in the ﬁ rst place.
For example, poor sleep may begin in response to cardiac disease but is main- tained over time by the behaviors (increased caffeine use) and thought patterns (worrying about one’s abil- ity to get a good night’s sleep) that patients develop in an attempt to cope with their sleep difﬁ culties.

Finally, when insomnia is conceptualized as secondary, it is unlikely to receive direct treatment.
This is unfor- tunate because effective treatment of chronic insom- nia often requires direct intervention to correct the behaviors, thought patterns, and associations that maintain it.

Spielman 3-P Model of Insomnia The most commonly used model in understanding the development of chronic insomnia includes pre- disposing conditions, precipitating circumstances, and perpetuating factors (3-P model) ( Fig 1 ).
21 In this theoretical model, predisposing conditions do not produce chronic insomnia but precede its onset and increase the likelihood for its occurrence.

For example, anxiousness personality traits may result in hyper- arousal, predisposing a person to sleep problems.

Pre- Figure 1.

The 3-Ps model of the development of chronic insomnia.

cipitating circumstances co-occur with the onset of acute insomnia (eg, stressful personal events, declines in health).
According to this theory, insomnia is main- tained by perpetuating factors, which include the changes in daytime behaviors, cognitions, or sleep/wake schedules that patients adopt to compensate for poor sleep.

The development of chronic insomnia is con- ceptualized as related to a combination of predisposing (anxious personality type) and precipitating factors (eg, cardiac disease).
However, over time, a positive feedback loop of perpetuating factors (eg, compensa- tory behaviors, cognitions) may develop that maintain or even exacerbate the sleep problem.

Predisposing and precipitating factors of insomnia decline as the perpetuating factors exert a more direct impact on a nightly basis.

These perpetuating factors are the tar- gets of cognitive behavioral treatment of insomnia (CBTi), which, as will be discussed later, has exten- sive empirical support.
Less well researched is the direct relationship of the 3-P model in the develop- ment and maintenance of insomnia.

Perpetuating Factors Behaviors Compensatory changes in behavior, such as daytime naps, excessive time in bed, and consuming stimulants, maintain insomnia over the long term.

22 , 23 Speciﬁ cally, daytime naps may meet some of a patient’s sleep needs and as a result, disrupt the natural daytime increase in the homeostatic sleep drive.
24 As a result, the patient’s drive for sleep is weakened, and he or she may take longer to fall asleep that night.

Stimulants (eg, caf- feine, nicotine) act on the CNS and reduce sleep drive.

Reduced daytime activity among patients with chronic illness 25 could lead to a number of potential consequences, including modiﬁ cation of the circadian rhythm due to reduced light exposure and increased opportunity for napping with increased time in bed.
However, the role of daytime activity in insomnia needs more extensive research.

Associations As patients experience sleep problems over time, they may begin to associate bed, bedtime, and the bedroom environment with difﬁ culty falling asleep.

26 After repeated negative experiences, the bed and bedroom become cues for arousal rather than sleep.
Spending an excessive amount of wakeful time in bed (during the night, while attempting to sleep in during the morning, or during the day) is a common response to poor sleep.

Intuitively, this makes sense, but unfor- tunately, it may backﬁ re because the additional wake time strengthens the association between the bed/bed- room and wakefulness, anxiety, and frustration.
556 Postgraduate Education Corner Downloaded From: http://journal.publications.chestnet.org/ by a Landspitali University Hospital User on 05/29/2013 Cognitions Cognitive distortions related to sleep are related to elevated emotional arousal and worsening sleep prob- lems.

27 Negative beliefs, attitudes, and interpretations related to sleep problems exacerbate and maintain insomnia by stimulating the sympathetic nervous system and increasing arousal.
Worries about sleep, physical health, or other stressors may increase both cognitive and physiologic arousal.

28 Chronic Comorbid Insomnia As mentioned previously, chronic insomnia is com- monly comorbid with other conditions.

Comorbidity between chronic insomnia and depression or anxiety is high, 29 and insomnia is a risk factor for both.

30 , 31 Controlling for psychologic disorders and other sleep disorders, chronic insomnia is also highly comor- bid with most major medical conditions ( Table 1 ).
12 This review focuses on chronic insomnia comorbid with hypertension, cardiovascular events, and sleep- disordered breathing (SDB).

The literature pertain- ing to insomnia in these speciﬁ c medical conditions is limited but does indicate an increased rate of insom- nia among these conditions when compared with the general population.

Hypertension and Cardiovascular Disease Comorbidity between insomnia and hypertension ranges from 25% to 44%, depending on the measure- ment tools and deﬁ nitions used.
12 , 32 Table 2 summa- rizes the data of recent epidemiologic studies on the interaction among hypertension, cardiovascular dis- ease, and insomnia.

Schwartz and colleagues 35 and, more recently, Spiegelhalder and colleagues 36 con- ducted reviews of the literature.

Unfortunately, the studies to date have used a wide range of deﬁ nitions from unvalidated questionnaires that assessed sleep complaint and not daytime complaints, which are necessary for an insomnia diagnosis.
Thus, it is difﬁ cult to determine the true rates of insomnia among patients with hypertension and cardiovascular disease.

Consistently sleeping , 6 h a night is associated with an increased risk for hypertension.

37 Although some research suggests that insomnia does not increase mortality risk, 38 other data indicate that increased frequency of insomnia symptoms is associated with an increased risk for all-cause mortality and cardio- vascular events.
39 Frequent difﬁ culty in initiating and maintaining sleep may be related to increased risk for acute myocardial infarction and coronary cardiovas- cular disease-related death.

35 , 40 The biologic mecha- nisms for this link remain uncertain but may be related to increased sympathetic nervous system activity or increased inﬂ ammatory activity in the hypothalamic- pituitary-adrenal axis.
41 , 42 Patients with implantable cardioverter-deﬁ brillator (ICD) devices also show clinically signiﬁ cant levels of sleep disruption.

34 Patients with ICDs are at an increased risk for clinically signi- ﬁ cant anxiety, which is related to hypervigilance, shock anxiety, and fear of device malfunction, 34 , 43 , 44 placing these patients at increased risk for insomnia.

Sleep-Disordered Breathing SDB disorders are highly comorbid with insom- nia, with prevalence estimates ranging from 22% to 54.9%.
45 As with cardiovascular disease, the wide range in prevalence rates of comorbid insomnia and SDB is likely related to the diversity of deﬁ nitions and mea- surement tools used.

For a review of the prevalence and interaction of comorbid insomnia and SDB, see Al-Jawder and BaHammam.

45 SDB is most often related to increased rates of sleep maintenance insom- nia, and higher apnea-hypopnea indices are risk fac- tors for sleep maintenance problems.
46 , 47 Older adults with insomnia, patients with long-term medication- resistant insomnia, and women with insomnia have elevated rates of comorbid SDB, 45 , 48 highlighting the importance of polysomnographic screening for patients with insomnia and symptoms of SDB.

The overlap between the conditions may render identiﬁ cation of SBD in these patients more difﬁ cult for the nonsleep specialist.
Despite a lack of empirical links between SDB and insomnia, possible mechanisms include increased nighttime awakenings due to nocturia, sleep fragmentation due to oxygen desaturation-related arousals, and decreased neck and throat muscle tone due to sleep deprivation.

45 Assessment The standard assessment of insomnia should include a thorough review of current insomnia symptoms, including nighttime complaints and daytime conse- quences ( Table 3 ).
49 A sleep history should be taken to identify other conditions that may lead to poor sleep, such as psychologic factors, other sleep disor- ders, substance abuse, and current medications.

For an example of a structured sleep history, see Morin and Espie.

53 Anxiety and depression are common in the context of chronic insomnia but do not necessarily preclude the separate treatment of insomnia symp- toms because signiﬁ cant improvements in insomnia have been found without direct treatment of mood symptoms.
54 The use of sleep diaries is essential for documenting sleep/wake patterns and tailoring treat- ments to the patient’s symptoms.

Although assessment tools for documenting sleep quality and symptom severity exist, none are independently adequate for making a differential diagnosis.
49 The use of actigraphy journal.publications.chestnet.org CHEST / 143 / 2 / FEBRUARY 2013 557 Downloaded From: http://journal.publications.chestnet.org/ by a Landspitali University Hospital User on 05/29/2013 Table 2 —Prevalence and Symptoms of Insomnia in Hypertension and Cardiovascular Disease Authors/Year Insomnia Deﬁ nition Measures Sample Results Taylor et al 12 /2007 Research diagnostic criteria for chronic insomnia (consistent with DSM-IV criteria) Sleep diary for 14 d; health survey Redeker et al 33 /2010 Difﬁ culty initiating and maintaining sleep or waking too early; frequency of problem often or almost always Sleep Habits Questionnaire; Pittsburgh Sleep Quality Index 772 community-dwelling individuals in Tennessee contacted through stratiﬁ ed random sampling.
Sampled at a rate of 50 men and 50 women for each decade of life from 20 to 80 y 173 patients with stable heart failure from the northeastern United States.

Mean age, 60.3 y; 65% men Cross et al 34 /2010 Not deﬁ ned Actigraphy; self-report diary 30 patients with ICDs; 30 patients with CAD.
Mean age, 66.9 y; 61.5% men Budhiraja et al 32 /2011 DSM-IV criteria for insomnia Self-report sleep questionnaire; polysomnography 3,247 community-dwelling adults in Michigan with a variety of comorbid medical conditions.

Mean age, 41.7 y; 49.2% men Hypertension: 44% met criteria for insomnia; 43% of patients with insomnia had hypertension.

Heart disease: 44% met criteria for insomnia; 22% of patients with insomnia had heart disease.
Fifty-one percent of sample met insomnia deﬁ nition (47% maintaining sleep, 42% falling asleep, 24% waking too early).

No effect of demographic or medical characteristics was found.

Both groups had an average of .

31 min of self-report sleep onset latency; patients with ICDs averaged .

31 min of self-report wake after sleep onset.

Both groups had an average of .

31 min of actigraphic wake after sleep onset; patients with CAD averaged .

31 min on actigraphic sleep onset latency.


Hypertension: 24.7% met criteria for insomnia; 42.4% had a sleep efﬁ ciency , 25th percentile of healthy individuals.

Heart disease: 26.8% met criteria for insomnia; 62.8% had a sleep efﬁ ciency , 25th percentile of healthy individuals.

CAD 5 coronary artery disease; DSM-IV 5 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ; ICD 5 implantable cardio- verter-deﬁ brillator.
(wrist-worn activity monitoring) is not a standard assessment tool for insomnia but can be a useful com- plement to sleep diaries, particularly when circadian rhythm disorders are suspected.

55 Polysomnography and multiple sleep latency testing use electrophysi- ological measurement of neurologic and muscular activity and are standard assessments for SDB and narcolepsy.
These tests are not recommended in the routine assessment of insomnia but should be con- sidered when another sleep disorder is suspected or when treatment of the insomnia is unsuccessful.

Treatment Overview Insomnia treatments fall into two categories: pharmacologic and cognitive behavioral.

Medications typically are indicated for short-term use, although CBTi may be more beneﬁ cial for chronic insomnia.
Although a range of classes of medications are indi- cated for the treatment of insomnia (eg, sedating antidepressants, melatonin, benzodiazepine receptor agonists), there is no single reliable pharmacologic method to treat insomnia 56 ; however, hypnotic medi- cations are the most commonly prescribed medication.

Although effective for short-term use, some hypnotic medications can lose effectiveness over time while retaining the potential for dependence and rebound insomnia.
57 More recently formu lated medications retain effectiveness over a longer period; however, these drugs can still lead to tolerance, physical and psy- chologic dependence, and hypnotic-dependent insom- nia.
Nevertheless, hypnotic medications should be 558 Postgraduate Education Corner Downloaded From: http://journal.publications.chestnet.org/ by a Landspitali University Hospital User on 05/29/2013 Table 3 —Insomnia Assessment 49 Category Recommended for all patients Supplementary information Not recommended for standard assessment of insomnia Assessments Review of current nighttime symptoms and daytime complaints In-depth sleep history, related medical and psychologic conditions, and current medications Sleep diaries to determine daily patterns of sleep problems Sleep questionnaires (eg, Epworth Sleepiness Scale, 50 Pittsburgh Sleep Quality Index) Mood questionnaires (eg, Beck Depression Inventory, 51 State Trait Anxiety Inventory 52 ) Actigraphy Polysomnography (recommended when sleep-disordered breathing is suspected) Multiple sleep latency tests (recommended when narcolepsy is suspected ) considered for acute bouts of insomnia or when behav- ioral treatments are unsuccessful.
CBTi comprises several well-established therapeutic strategies that target a broad range of symptoms and etiologic factors, 56 including sleep education, sleep hygiene, stimulus control, sleep restriction, relaxation training, and cognitive therapy.
The efﬁ cacy of CBTi is well documented ( Table 4 ), and given that it offers several signiﬁ cant advantages over hypnotic medica- tions, both researchers and clinicians, including the NIH, consider it to be a, if not the, ﬁ rst-line treatment of chronic insomnia.

4 Older adults 58 and patients with chronic comorbid insomnia (eg, insomnia with concurrent SDB, cardiac disease, hypertension, or other breathing disorder) can signiﬁ cantly beneﬁ t from CBTi ( Table 5 ).
An added beneﬁ t of CBTi for these populations is that unlike medications, behavioral treatments do not contribute to polypharmacy and are unlikely to cause side effects or exacerbate the comorbid diagnosis.
Additionally, Table 4 —Average Effect Sizes Across 18 CBTi Trials Outcome Effect Size Self-report sleep onset latency Objective sleep onset latency Self-report wake after sleep onset Objective wake after sleep onset Self-report total sleep time Objective total sleep time Subjective sleep efﬁ ciency Objective sleep efﬁ ciency Mood (depression, anxiety) CBTi 5 cognitive behavioral treatment of insomnia.

a Interpretation of large effect size using Cohen 8 standards.
b Interpretation of small effect size using Cohen 8 standards.

0.90 a 0.33 b 1.05 a 0.46 b 0.24 b 0.13 0.99 a 0.44 b 2.31 a remediating insomnia may result in improvements in the comorbid condition.

Cognitive Behavioral Treatments Sleep Education Education regarding normative sleep practices often is helpful.

In patients with an associated med- ical or psychologic condition, information regard- ing sleep disturbances is important.
For example, patients with ICDs and coronary artery disease may be informed that insomnia is a highly comorbid condi- tion.

27 More general education would inform patients that sleep needs vary from person to person and from night to night and that taking 30 min to fall asleep or awakening for 30 min during the night is normal.
57 Sleep Hygiene Sleep hygiene aims to increase behaviors and envi- ronmental conditions that promote improved quality or quantity of sleep while reducing or eliminating practices that interfere with sleep ( Table 6 ).

For some behaviors, sleep hygiene recommendations may focus less on reducing and eliminating the behavior than on limiting those behaviors to certain times of the day (eg, avoiding liquids within 2 h of bedtime).
57 There may be individual differences in sensitivity and adher- ence to sleep hygiene rules that need to be tailored to individuals (eg, differential sensitivity to caffeine use ).

Although sleep hygiene is widely prescribed, the Standards Practice Committee of the American Academy of Sleep Medicine suggests that there is insufﬁ cient evidence to conclude that it should be used as a standalone treatment.
54 Stimulus Control Stimulus control therapy is based on learning theory and the underlying premise that sleep difﬁ culties may be due to the bed and bedroom becoming conditioned cues for anxiety and arousal associated with unsuc- cessfully trying to fall asleep.

56 This technique aims to strengthen the association between the bed/bed room and sleep and to weaken the associations between the bed/bedroom and arousing activities that interfere with sleep.
There are six primary instructions for stimulus control ( Table 7 ).

26 Stimulus control has been identiﬁ ed as a well-established treatment of insomnia, 54 , 64 and CBTi that includes it has been shown to be more effective in improving sleep onset latency, wake time after sleep onset, sleep efﬁ ciency (ratio of time spent asleep to time spent in bed), and slow-wave sleep than pharmacotherapy, 65 , 66 with improvements maintained at 1-year follow-up.
67 journal.publications.chestnet.org CHEST / 143 / 2 / FEBRUARY 2013 559 Downloaded From: http://journal.publications.chestnet.org/ by a Landspitali University Hospital User on 05/29/2013 Authors/Year Study Design Study Sample Intervention Outcome Table 5 —CBTi Trials in Patients With Comorbid Illness SDB Krakow et al 59 /2004 Assessed sequential CBTi and SDB therapy in patients with concurrent chronic insomnia and SDB Guilleminault et al 60 /2008 Evaluated subjective and objective outcomes of different sequences of two treatments for OSA: surgical intervention and CBTi 17 patients (mean age, 42.9 y) with psychophysiologic insomnia who completed CBTi (but did not fully respond to therapy) and received a diagnosis of SDB after CBTi completion 30 patients (mean age, 31.8 y [surgical intervention]; 30.9 y [CBTi]) with both insomnia and OSA Participants randomized to one of two groups: (1) CBTi followed by surgical intervention or (2) surgical intervention followed by CBTi Sequential CBTi and CPAP therapy (following CBTi, PSG was conducted to conﬁ rm SDB and titrate CPAP; SDB treatment of 3 mo) Eight of 17 participants had nonclinical insomnia levels post-CBTi.
Fifteen of 17 participants reached nonclinical insomnia levels post-SDB treatment.

Surgical intervention alone eliminated insomnia complaint in ﬁ ve of 15 patients; no patients receiving CBTi alone were remitted.

Surgical intervention had greater initial improvements in subjective (sleepiness, fatigue), objective (TST, slow-wave sleep, WASO), and respiratory measures (AHI, RDI, Sp o 2 ).
After CBTi, signiﬁ cant improvements were observed in subjective insomnia severity, global sleep quality, SE, WASO, and attitudes about sleep.

Signiﬁ cant improvements in depressed mood were observed after WE.

CBTi signiﬁ cantly improved compared with control on SE, WASO, TIB, global quality of sleep, and beliefs and attitudes about sleep at 4 mo follow-up.

Home relaxation improved SE, WASO, and global sleep quality compared with control at 4-mo follow-up.
Across both treatments, participants experienced moderate to signiﬁ cant clinical changes in sleep that were durable at 1-y follow-up.
COPD Kapella et al 61 /2011 CAD Rybarczyk et al 62 /2002 Rybarczyk et al 63 /2011 Evaluated effectiveness of CBTi in patients with comorbid insomnia and COPD 23 patients (mean age, 65 y [CBTi]; 60 y [WE]) with COPD and concurrent insomnia symptoms (difﬁ culty either initiating or maintaining sleep) Participants randomized to one of two groups: (1) six weekly CBTi sessions or (2) six weekly WE sessions Compared effectiveness of group CBTi to self-guided audio relaxation in older adults with comorbid insomnia and chronic health conditions 35 older adults (mean age, 66.5 y [CBTi]; 65.6 y [home relaxation]; 71.4 y [control]) with comorbid chronic health conditions (either CAD, osteoarthritis, or type 2 diabetes mellitus) Participants randomized to one of three groups: (1) eight weekly group CBTi sessions or (2) home-based audio relaxation program.
Delayed treatment control (given home relaxation intervention later) Evaluated two self-help methods of CBTi with older adults with comorbid insomnia and chronic health conditions, including CHD 106 older adults (mean age, 68 y) with insomnia and either CHD, osteoarthritis, or no health condition Participants randomized to one of two groups: (1) CBTi book or (2) CBTi multimedia AHI 5 apnea-hypopnea index; CHD 5 coronary heart disease; OSA 5 obstructive sleep apnea; PSG 5 polysomnography; RDI 5 respiratory disturbance index; SDB 5 sleep-disordered breathing; SE 5 sleep efﬁ ciency; Sp o 2 5 oxygen saturation as measured by pulse oximetry; TIB 5 time in bed; TST 5 total sleep time; WASO 5 wake after sleep onset; WE 5 wellness education.
See Table 2 and 4 legends for expansion of other abbreviations.

Sleep Restriction and Sleep Compression Sleep restriction and sleep compression both focus on reducing the amount of time a patient spends awake in bed during the night by prescribing a time in bed that more closely resembles the actual amount of time the patient spends sleeping.

The primary dis- tinction between these two approaches is how quickly the amount of time the patient currently spends in bed is reduced.
Sleep restriction sharply reduces the 560 Postgraduate Education Corner Downloaded From: http://journal.publications.chestnet.org/ by a Landspitali University Hospital User on 05/29/2013 Table 6 —Sleep Hygiene Activities That Interfere With Sleep 24 Activity Examples Frequent napping Variable bedtimes and wake times Frequently spending an excessive length of time in bed Use of stimulants near bedtime Stimulating activities too close to bedtime Use of bed for nonsleep-related activities Poor bedroom environment Allowing oneself to persist in sleep-preventing mental activities while in bed … … … Alcohol, tobacco, caffeine Working, talking about stressful topics, paying bills Watching television, reading, snacking Uncomfortable bed, too much light or noise, too cold or too warm Thinking, planning, reminiscing amount of time spent in bed, whereas sleep com- pression takes a more gradual approach; Table 8 pro- vides detailed instructions on how to apply both methods.
Both approaches help patients to achieve a consolidated block of higher-quality sleep and work by (1) weakening the association between the bed/bed- room and being awake and (2) inducing partial sleep deprivation that builds sleep debt and activates the sleep drive, 56 facilitating more-rapid sleep onset, increased slow-wave sleep, and fewer awakenings dur- ing the night.
Following successful consolidation of sleep time (measured by tracking sleep efﬁ ciency), time in bed can be gradually expanded to allow for greater sleep opportunity.

Sleep restriction has received greater research attention and is the technique most commonly used in CBTi protocols.

Across various studies, sleep restric- tion alone has been shown to decrease sleep onset latency and wake time during the night as well as to increase total sleep time and sleep efﬁ ciency.
68 , 69 How- ever, sleep restriction may not be appropriate for some patients.

For example, sleep restriction is contrain- dicated for patients with a history of mania or sei- zures because sleep deprivation (even if it is only mild) increases the risk for episodes.
Sleep compres- sion may also be preferred where a drastic reduction in sleep or increase in sleep deprivation is not recom- mended (eg, frail older adults, patients with severe or multiple medical comorbidities, patients resistant to sleep restriction).

70 Relaxation A variety of relaxation techniques can be used in the treatment of insomnia, including diaphragmatic breathing, biofeedback, imagery, and meditation.
The goal of relaxation is to reduce the patient’s levels of physiologic and cognitive arousal.

One approach acknowledged as an empirically supported treatment by the American Academy of Sleep Medicine is pro- gressive muscle relaxation.

This method involves lead- ing patients through a deep-breathing exercise followed by alternating tensing and relaxation of muscle groups (eg, arms, neck, back, legs) throughout the body .
Patients are instructed to pay attention to the feelings of relax- ation after the process compared with feelings of tension before and to practice this technique once during the day and before bedtime.

Relaxation can also be integrated with stimulus control.

Prior to leav- ing the bed during nighttime awakenings, patients can practice a relaxation technique (one time per awak- ening) to see whether it helps them to fall back to sleep.
For patients with concomitant pain or joint dis- orders, a passive relaxation procedure that does not involve tensing and relaxing muscles, which could exacerbate their conditions, may be preferred.

Table 7 —Stimulus Control Instructions 26 Cognitive Therapy Step Instructions Lie down to go to sleep only when you are sleepy.

Do not use the bed for anything except sleep and sex.

Do not eat, read, watch television, or worry in bed.
If you cannot fall asleep within 10 min, get up and go to another room.

Only return to bed when you feel sleepy again.

If you return to bed and still cannot fall asleep, repeat step 3.

Do this as often as necessary throughout the night.

Set your alarm and get up at the same time every morning regardless of how much you slept during the night.

This will help your body to acquire a constant sleep rhythm.

Do not nap during the day.


Patients with insomnia frequently express attitudes and beliefs about sleep that can prompt worry and anxiety about one’s ability to get the sleep he or she needs.

56 , 71 This anxiety and worry contributes to arousal that interferes with sleep, which prompts further anxiety and worry and sets up a self-fulﬁ lling cycle that is difﬁ cult to break in the absence of direct inter- vention.
Cognitive therapy focuses on identifying these beliefs and replacing them with more-adaptive beliefs and attitudes.

57 , 71 Sleep education (discussed previously) assists cognitive therapy because learn- ing about normative sleep patterns can be helpful in address ing mistaken beliefs.
Although cognitive ther apy has not been evaluated as a singular therapy journal.publications.chestnet.org CHEST / 143 / 2 / FEBRUARY 2013 561 Downloaded From: http://journal.publications.chestnet.org/ by a Landspitali University Hospital User on 05/29/2013 Instructions Common Technique speciﬁ c Sleep restriction Sleep compression Table 8 —Sleep Restriction and Sleep Compression Instructions Details Sleep diaries: ask patients to complete daily sleep diaries starting 1-2 wk prior to initiating treatment and throughout treatment.
At a minimum, the diaries should provide daily information on TIB, TST, TWT, and SE.

Avoid daytime napping.

Calculate average TIB and TST for the previous 1-2 wk.

Determine initial TIB prescription, which is the average TIB during baseline 1 30 min.

(Do not go below 5.5 h.) Work with patient to set a regular bedtime and wake time consistent with the TIB prescription.

Monitor TIB prescription during each treatment session and adjust as follows: If average SE .

90%, add 30 min to averaged reported TIB.


If average SE , 85%, subtract 30 min from average reported TIB.

If SE is between 85% and 90%, do not adjust.

Do not go to bed before set bedtime.

Get out of bed at the set wake time every morning.

Avoid daytime napping.

Calculate average TIB and TWT for the previous 1-2 wk.

Divide TWT by number of proposed treatment sessions.

Determine TIB prescription by reducing TIB slowly by the calculated increment above.
Work with patient to set a regular bedtime and wake time consistent with the TIB prescription.

Go to bed and get out of bed at set bedtime and wake time.

See Table 5 legend for expansion of abbreviations.

for insomnia, CBTi with a speciﬁ c cognitive compo- nent has been shown to improve both objectively mea- sured sleep and subjective sleep satisfaction 72 and to decrease dysfunctional sleep-related thoughts.
73 Cognitive Behavioral Therapy for Insomnia Given that multiple factors can contribute to insom- nia, using a multicomponent approach such as CBTi enhances the likelihood that one or more of the treat- ment elements will target the factors contributing to a patient’s poor sleep.

CBTi has been shown to be more effective than stand-alone treatments 74 and to provide a more durable treatment response than medi- cation.
75 There is considerable evidence for the effec- tiveness of CBTi across patient populations.

For example, CBTi has been found to produce clinically signiﬁ cant improvement in insomnia symptoms in patients with breast cancer, chronic pain, ﬁ bromyal- gia, and other medical comorbidities.
76 - 80 Addition- ally, behavioral interventions have been shown to be effective for middle-aged and older adults and older caregivers, populations in which comorbid medical conditions (eg, SDB, hypertension, cardiac disease) are more likely.

58 patients with dementia and Alzheimer disease have been trained in the application of sleep hygiene, sleep-wake scheduling, early morning bright light exposure, and exercise.
82 There is very limited litera- ture pertaining to the treatment of insomnia in the context of comorbid medical disorders, and far more research is needed in this area.

Some empirical evi- dence 59 , 60 suggests that concurrent medical treatment of SDB and psychologic treatment of chronic insom- nia can result in clinically signiﬁ cant improvements in both conditions ( Table 5 ).

However, these two stud ies had relatively small samples sizes and lacked true control groups.
When addressing insomnia comorbid with symptoms of another psychologic disorder, it may be appropriate to pursue adjunctive treatment of both conditions, but this remains to be thoroughly investi- gated.

Sleep-related education can speciﬁ cally address common symptom patterns.

Within each patient pop- ulation may be speciﬁ c cognitions or emotions that disrupt sleep, and addressing these speciﬁ c concerns is important in tailoring cognitive treatment.
For exam- ple, among patients with ICDs, concerns about receiv- ing a shock in the middle of the night may lead to increased emotional and physiologic arousal, which can interfere with sleep.

34 Tailoring CBTi Finding a Therapist For some populations, the standard CBTi recom- mendations should be tailored.
For example, among caregivers for individuals with dementia, standard CBTi recommendations have been combined with stress management, linkage to community resources, management of problem behaviors in patients with dementia, and communication skills.

81 Caregivers of Presently, the number of patients who could ben- eﬁ t from behavioral sleep treatment far exceeds the current number of certiﬁ ed providers (160 in 2010).
Of these certiﬁ ed providers, 8.6% are doctors of psy- chology, 26.5% are medical doctors, and 64.9% are doctors of philosophy (71 of 103 are conﬁ rmed psy- chologists).
83 , 84 Increasing the number of providers 562 Postgraduate Education Corner Downloaded From: http://journal.publications.chestnet.org/ by a Landspitali University Hospital User on 05/29/2013 Table 9 —Finding a Behavioral Sleep Medicine Therapist or Other Behavioral Specialist Organization American Board of Sleep Medicine Website Address www .

absm .

org American Psychological Association Association of Behavioral and Cognitive Therapies Society of Behavioral Sleep Medicine www .

apa .

org www .

abct .


org www .

behavioralsleep .

org Website Path Behavioral Sleep Medicine Certiﬁ cation Exam, Certiﬁ ed Behavioral Sleep Medicine Specialists Psychology Help Center, Find a Psychologist Find a Therapist Find a Behavioral Sleep Medicine Provider is a major goal of the American Board of Sleep Med- icine and the newly established Society of Behav- ioral Sleep Medicine.
In the meantime, resources are available for providers who may not have sleep-speciﬁ c expertise but who have expertise in related psycho- logic and cognitive behavioral therapies.

Table 9 lists resources for locating a certiﬁ ed behavioral sleep specialist as well as other behavioral specialists who may provide services for patients with insomnia.
Future Directions Given that most studies examine the discrete cogni- tive behavioral treatments as part of a comprehensive treatment package (ie, CBTi), conducting disman- tling trials to evaluate the effectiveness of the spe- ciﬁ c components of CBTi is warranted.

Increased efforts to determine the optimal combination, sequence, and duration of treatments are needed to provide improved care for speciﬁ c conditions (eg, medical or psychologic problems, primary insomnia).
Further- more, because of the lack of trained specialists, alter- native forms of behavioral treatment delivery should be explored, including developing briefer treatments, the use of self-guided treatments, or alternative meth- ods of treatment delivery (eg, therapy sessions deliv- ered through the Internet or by telephone).

Summary Comorbid insomnia accounts for the majority of chronic insomnia cases.
It often requires direct treat- ment to address the behaviors, cognitions, and associ- ations that patients adopt to cope with poor sleep but which backﬁ re (eg, caffeine use, spending more time in bed, trying harder to sleep).

CBTi offers effective treatment of comorbid insomnia and represents a particularly attractive treatment option because it does not carry some of the risks associated with medica- tions (eg, dependency, polypharmacy, cognitive and psychomotor impairment).
Given the currently limited number of trained practitioners, alternative methods of delivery (eg, briefer protocols, Internet, videocon- ferencing) should be explored to improve access to this highly effective treatment.

Acknowledgments Financial/nonﬁ nancial disclosures: The authors have reported to CHEST that no potential conﬂ icts of interest exist with any companies/organizations whose products or services may be dis- cussed in this article .

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