DEPLOYMENT-RELATED INSOMNIA AND 

COGNITIVE BEHAVIORAL TREATMENTS

Adam Bramoweth, PhD

Advanced Fellow, Mental Illness Research & Treatment

Mental Illness Research, Education and Clinical Center

VA Pittsburgh Healthcare System

Visiting Instructor

Department of Psychiatry

University of Pittsburgh

HSR&D Cyberseminar

March 20, 2014
DISCLOSURE

• Financial Support

– VA Advanced Fellowship in Mental Illness Research and Treatment

 VISN 4 Mental Illness Research, Education and Clinical Center

 (Director, D. Oslin; Site Director, G. Haas)

 VA Pittsburgh Healthcare System

– Department of Psychiatry, University of Pittsburgh

• This presentation does not represent the views 

of the Department of Veterans Affairs or the 

United States Government.
DEPLOYMENT RELATED INSOMNIA

• Outline/Goals:

1. Review insomnia, including common risks and consequences

2. Provide an overview of deployment-related factors/mTBI and 

impact on insomnia

3. Briefly describe cognitive behavioral treatment for insomnia + 

case example

4. Discuss dissemination and implementation efforts for CBTI
SURVEY 1 

• What is your primary position?

– Clinician – Primary Care Provider (MD/DO, NP, PA)

– Clinician – Behavioral Health (Psychologist, Psychiatrist, Social Worker)

– Clinician – Other Medical/Behavioral Health provider

– Research – Physician

– Research – Psychologist

– Research – Other
SURVEY 2 

• What is your experience with insomnia?

– I treat many Veterans with insomnia

– I occasionally treat Veterans with insomnia

– I rarely treat Veterans with insomnia

– I do not currently treat Veterans with insomnia
DSM-5 INSOMNIA DISORDER1

• Difficulty initiating sleep, maintaining sleep, and/or early morning 

awakenings

• Clinically significant distress or impairment

• ≥ 3 nights per week

• ≥ 3 months

• Occurs despite adequate opportunity for sleep 

• Specify if:

– Comorbid with non-sleep psychiatric disorder

– Comorbid with medical disorder

– Comorbid with sleep disorder

• Episodic (<3 months), Persistent (> 3 months), Recurrent (>2 episodes in 

1 year)
INSOMNIA IN VETERANS – ADAPTED 3P 

MODEL

Predisposing Factors Precipitating Factors Perpetuating Factors

• Baseline factors 

• Bio/Psych/Social traits 

• Stable

• Initial cause of 

insomnia

• Behavioral 

• Cognitive 

• Target and modify

Bramoweth & Germain, 20132 
INSOMNIA IN VETERANS – 3P MODEL

Predisposing Factors Precipitating Factors Perpetuating Factors

• Adverse childhood 

events

• Pre-military/ 

deployment problems

Bramoweth & Germain, 20132 
INSOMNIA IN VETERANS – 3P MODEL

Predisposing Factors Precipitating Factors Perpetuating Factors

• Adverse childhood 

events

• Pre-military/ 

deployment problems

• Deployment

• Combat exposure

• Shift work/irregular 

scheduling

• Hyper-vigilance

Bramoweth & Germain, 20132 
INSOMNIA IN VETERANS – 3P MODEL

Predisposing Factors Precipitating Factors Perpetuating Factors

• Adverse childhood 

events

• Pre-military/ 

deployment problems

• Deployment

• Combat exposure

• Shift work/irregular 

scheduling

• Hyper-vigilance

• Nightmares

• Energy drink 

consumption

• Psychopathology

• Sleep schedule 

adjustment 

• Unemployment/

 financial stress

• Family responsibilities

• Coping mechanisms: 

alcohol/substance use

Bramoweth & Germain, 20132 
INSOMNIA IN VETERANS

• Prevalence rates higher in Veterans vs. general adult population

– 24-54% in Veterans vs. 10-22% in general adult population2 

• Sleep disturbance3,4

– Iraq Veterans: ~30% 

– Head injury: ~58%

– Vietnam Veterans: ~94% 

• PTSD + sleep disruption: 70-87%5 

• Among the most frequent complaints of recently deployed Veterans3 

• Most common initial complaint of those referred for mental health 

services6 
RISKS & CONSEQUENCES

• 40% - 57% of people with insomnia have a comorbid psychiatric 

disorder7,8,9

• Depression10

– Insomnia vs. Good Sleepers: 10x more likely to have depression (BDI > 18)

• Anxiety10

– Insomnia vs. Good Sleepers: 17x more likely to have anxiety (STAI > 70 T score) 

• Risk factor: Depression, Substance Abuse Disorders, and CardioMetabolic Disorders11,12,13
RISKS & CONSEQUENCES

• Increased healthcare utilization15,16

– Office visits + Medication usage

• Increased insomnia-related costs14

– Insomnia Syndrome ≈ $5,000/year vs. Good Sleeper ≈ $400/year

• Insomnia associated with significant economic burden14

– Total costs (treatment + indirect) ≈ $250 billion annually
COMORBIDITY

Insomnia

PTSD

Depression

Substance 

Use

mTBI Adjustment 

Disorder

Anxiety 
COMORBID INSOMNIA – MILITARY/VETERANS

• PTSD17,18

– Insomnia symptoms at post-deployment (time 1), significantly linked to 

increased PTSD symptoms at time 2

• Suicide19

– Veterans who committed suicide—those with a sleep complaint died 

closer to their last office visit than Veterans without a sleep complaint

• Insomnia can be a target for treatment/intervention of psychiatric 

disorders
MILD TRAUMATIC BRAIN INJURY + SLEEP

• 5 – 22% soldiers have mTBI

– Majority report >1 mTBI20

• 50% civilians with mTBI have a sleep disturbance21

– 25 – 30% have diagnosed sleep disorder

• 97% of military with chronic mTBI (>3 months) report sleep 

problems22

– Per PSG findings23,24: 85% hypersomnia, 55% insomnia, 54% sleep 

fragmentation, 35% sleep apnea
MILD TRAUMATIC BRAIN INJURY + SLEEP22

• Blast-related injuries

– Insomnia

– Anxiety

• Blunt-related injuries

– Obstructive sleep apnea
Summary

• Insomnia

– Prevalent

– Comorbid

– Significant risks and consequences
COGNITIVE BEHAVIORAL TREATMENT FOR

INSOMNIA
SURVEY 3

• What is your experience/exposure to CBT for Insomnia?

– I am not at all familiar with CBT for Insomnia

– Heard of it but don’t know much about it

– Heard of it and have referred Veterans

– I use it occasionally

– I use it regularly
CBT FOR INSOMNIA

• Multi-Component Evidence-Based Therapy

– Education 

– Stimulus Control

– Sleep Restriction

– Cognitive Therapy

– Relaxation

• All vs. select components

• Recommended first-line of treatment

• 4-6 sessions (30-60 minutes)
CBTI – LANGUAGE OF ITS OWN

• Sleep Diary – self monitoring tool to measure sleep behaviors

• Time in Bed – amount of time spent in bed

• Total Sleep Time – amount of time sleeping

• Sleep Onset Latency – how long does it take to fall asleep

• Wake After Sleep Onset – time awake after initially falling asleep

• Sleep Efficiency – Total Sleep Time / Time in Bed
ASSESSMENT/OUTCOME MEASURES

• Sleep Diary – measure/track sleep behaviors

• Insomnia Severity Index – 7-items, insomnia symptoms

• Epworth Sleepiness Scale – 8-items, likelihood to fall asleep in 

situations 

• Dysfunctional Beliefs About Sleep – rate 16 common sleep 

beliefs

• Morningness/Eveningness – identify chronotype (owl vs. lark)

• Other: Depression, Anxiety, PTSD
CASE EXAMPLE
CASE: MTBI + INSOMNIA

• TB was referred by his PCP for insomnia/sleep disruption

• 25 y/o, Caucasian, Veteran of Marine Corps (medical 

retirement/honorable discharge)

• Service Connected: TBI, PTSD, Migraines, Tinnitus

• Afghanistan 7 months, 2009-2010
CASE: MTBI + INSOMNIA

• Combat exposure (sniper fire), 4 IED blasts (1 LOC)

– Vehicle triggered detonation of IED

– Explosion caused Veteran hit head on vehicle door: 30-60 sec LOC

– Headache with dizziness and photophobia

– 60 min of “dazed and confused”

– Cervical/thoracic/lumbar injury

• Other blast-related injuries: headaches resolved <60 min 
CASE: MTBI + INSOMNIA

• Bedtime: 3:00am

• Sleep latency: up to 3 hours

• 2-3 nighttime awakenings with minimal wake after sleep onset

• Up time: 12:00 – 3:00pm

• Unrefreshed upon awakening

• Chronic back pain contributing to sleep latency

• Denied significant worry, rumination, fear

• Sleep with TV on to help reduce tinnitus

• Daytime: fatigue, poor concentration, poor memory, irritability
CASE: MTBI + INSOMNIA

• Insomnia Severity Index: 20/28 (clinical insomnia)

• Epworth Sleepiness Scale: 6 (not excessively sleepy)

• PHQ-9: 12 (moderate depression)

• Highly rated dysfunctional beliefs about sleep:

– After a poor night’s sleep, I need to catch up the next night

– I am worried I will lose control over my sleep

– Poor sleep will interfere with next day activities

– Medication is probably the only solution
EDUCATION

• Normal sleep vs. Abnormal sleep

• 3P model of insomnia: predisposing, precipitating, and 

perpetuating 

• Other sleep disorders (e.g., apnea, restless legs syndrome)

• Behaviors/Lifestyle: substances, diet, and exercise

Sleep-Related 

Anxiety

Thoughts/Beliefs 

about Sleep

Sleep-Related 

Behaviors 
CBTI

• The sleep diary is your best friend...

3/19/2014 

How long did you nap/doze yesterday? 0 min

What time did you get into bed? 10:15pm 

What time did you try to go to sleep? 10:45pm 

How long did it take you to fall asleep? 1 hour 15 minutes

How many times did you wake up, not 

counting your final awakening?

3 

In total, how long did these awakenings last? 1 hour 10 minutes

What was your final awakening?

 Did you wake up earlier than desired?

 How many minutes earlier?

6:30am 

Yes

30 min

What time did you get our of bed for the day? 7:00am 

How would you rate the quality of your sleep? 

(1=very poor to 5=very good)

2 
STIMULUS CONTROL

Strengthen the relationship between the act of sleeping and the bed/bedroom

• Wake up at the same time every day

• Go to bed only when sleepy (not when tired or because its bedtime)

• Use the bed and bedroom only for sleep (and sex)

• If unable to sleep, get out of bed and return to bed only when sleepy

• Do not nap (or keep it brief and early)

• Create a “buffer zone” and avoid stressful activities in bed
SLEEP (TIME IN BED) RESTRICTION

• Reduce Time in Bed

– Match to current total sleep time + 30 minutes

– No less than 5-6 hours

– Contraindicated: seizure disorder, bipolar disorder

• Prescribe Wake Time (stable) 

• Work backwards to establish a new, flexible bedtime

• As sleep efficiency increases (TST/TIB >90%), slowly extend bedtime

15-20min/week 

• Sleep compression: slowly reduce time in bed until sleep efficiency 

>90%, then extend time in bed
COGNITIVE THERAPY

• Identify maladaptive/dysfunctional beliefs about sleep (DBAS 

scale)

• General worries related to insomnia/disrupted sleep

• Guided discovery to challenge/change thoughts 

– Where is the evidence for that?

– What is the worst that could happen? Most realistic?

– Do you know for certain _____ will happen?

– What would you tell a friend in a similar situation?

– How have you dealt with this in the past? 
RELAXATION

• Progressive Muscle Relaxation

• Passive Relaxation

• Guided Meditation

• Mindfulness 
EVIDENCE
Dolan et al., 201025

0

20

40

60

80

100

2 (baseline) 3 4 5 6 7

SOL

WASO

Minutes

Sessions

N=32; 4+ sessions CBTI

 p < .05
60

65

70

75

80

85

90

95

2 (baseline) 3 4 5 6 7

Sleep Efficiency (TST/TIB x 100)

% 

Sleep Efficiency

Sessions

Dolan et al., 2010

N=32; 4+ sessions CBTI

 p < .05

Dolan et al., 201025
CASE: MTBI + INSOMNIA

• Session 1: 

– TIB: 10h 30m 

– TST: 7h 38m

– SOL: 2h 9m (129m) 

– WASO: 16m 

– SE%: 75%

• OTC sleep aid helped reduce sleep latency

• Hesitant to set early wake time but willing to try

• Rx TIB: 12:00am – 8:00am
CASE: MTBI + INSOMNIA

• Session 2: 

– No sleep diary

– Without sleep aid, inconsistent sleep; with sleep aid, consistent 

and good quality sleep

• Plan:

– Use OTC sleep aid and establish structured sleep schedule

– Taper sleep aid while maintaining/adjusting sleep schedule

• Rx TIB: 2:00am – 10:00am
CASE: MTBI + INSOMNIA

• Session 3: 

– TIB: 6h 57m 

– TST: 6h 8m

– SOL: 40m

– WASO: 4m

– SE%: 87%

• Good sleep with OTC sleep aid (1 bad night without aid)

• Shift Rx TIB: 1:00am – 9:00am

• If sleep remains stable, begin taper of sleep aid
CASE: MTBI + INSOMNIA

• Session 4: No Show

• Plan: TB trying to participate in an outpatient 

multidisciplinary pain program + continued CBTI

• Never rescheduled for CBTI
CBTI - SUMMARY

• Multi-component evidence-based treatment

– Brief: 4-6 sessions

• Collaborative partnership with patient

• Adapt treatment to the patient

– Patient goals: ideal vs. realistic

– Adherence issues

– Comorbid disorders
DISSEMINATION
VHA NATIONAL DISSEMINATION

• Nationwide training in CBTI through Evidence-Based 

Psychotherapy Program

– http://vaww.mentalhealth.va.gov/ebp/insomnia.asp

• ~400 clinicians have been trained (goal: 1000)

– Psychologists

– Psychiatrists

– Social Workers

– Psychiatric Nurses
http://vaww.mentalhealth.va.gov/ebp/insomnia.asp
http://vaww.mentalhealth.va.gov/ebp/insomnia.asp
Karlin et al., 201326

Outcome Measure (scale) Baseline

Mean

Last Session 

Mean

Significant 

Change

Insomnia Severity Index (0-28) 20.5 (4.4) 11.0 (6.9) + 

Beck Depression Inventory-II (0-63) 23.8 (11.3) 17.1 (12.3) + 

WHOQOL-BREF (4-20)

 Physical 10.8 (2.7) 13.2 (3.0) + 

 Psychological 11.4 (2.7) 13.0 (3.1) + 

 Social 11.4 (3.4) 12.8 (3.8) + 

 Environmental 14.1 (2.4) 14.9 (2.6) + 

VA CBTI Rollout: Patient Outcome Measures at Baseline and Last CBTI Session

WHOQOL-BREF: abbreviated version of WHO Quality of Life 100
Locally: Insomnia Consult Service (check CPRS)
OTHER FORMS OF CBTI

• VA Tele-health – Rural Veteran

– Inconsistent transportation

– Not a CBTI provider in the VISN

• VA mobile application: 

CBT-i Coach 

• Brief Behavioral Treatment 

for Insomnia (University of Pittsburgh)

– 2 in-person sessions (week 1 & 3)

– 2 phone sessions (week 2 & 4)

– Delivery by non-psychologist


Summary

• Insomnia is highly prevalent, especially among 

Military/Veterans

• Insomnia is comorbid with psychiatric and medical disorders

• Risk factor for development of disorders

• Linked to significant increases in healthcare utilization and costs

• Evidence-based treatments available

• Treatment is brief, effective, and adaptable

• Dissemination efforts in place and ongoing
MENTORS/COLLABORATORS

• Pittsburgh VAMC/ 

University of Pittsburgh

– Anne Germain, PhD

– Matt Chinman, PhD

– Charles Atwood, MD

– Ada Youk, PhD

– Barbara Hanusa, PhD

– Gretchen Haas, PhD

– Jon Walker, MSIS

– Melissa Gregory, BA

• Philadelphia VAMC

– Gala True, PhD

• Stanford University

– Rachel Manber, PhD
COMMENTS & QUESTIONS

adam.bramoweth@va.gov
RESOURCES

– http://vaww.mentalhealth.va.gov/ebp/insomnia.asp

• www.afterdeployment.org

• Treatment Manuals

– Cognitive Behavioral Treatment of Insomnia: A Session-by-Session 

Guide (Perlis, Junquist, Smith, and Posner, 2008)

– Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach 

Workbook (Edinger & Carney, 2008)

– Insomnia: A Clinical Guide to Assessment and Treatment (Morin and 

Espie, 2003)
RESOURCES

• Papers

– Buysse et al. Recommnedations for a standard research assessment of 

insomnia. SLEEP 2006;29(9):1155-1173.

– Manber et al. Dissemination of CBTI to the non-sleep specialist: Protocol 

development and training issues. J Clin Sleep Med 2012;8(2):209-218.

– Morgenthaler et al. Practice parameters for the psychological and 

behavioral treatment of insomnia: An update. SLEEP 2006;29(11):1415-

1419.

– Schutte-Rodin et al. Clinical guideline for the evaluation and management 

of chronic insomnia in adults. J Clin Sleep Med 2008;4(5):487-504.
REFERENCES

1. Diagnostic and statistical manual of mental disorders. 5th ed. American Psychiatric Press; 2013.

2. Bramoweth AD & Germain A. Deployment-related insomnia in military personnel and veterans. 

Curr Psychiatry Rep. 2013;15(10):401.

3. Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in U.S. 

soldiers returning from iraq. N Engl J Med. 2008;358:453-463.

4. Lewis V, Creamer M, & Failla, S. Is poor sleep in veterans a function of post-traumatic stress 

disorder? Mil Med. 2009;174:948-951.

5. Maher MJ, Rego SA, & Asnis GM. Sleep disturbances in patients with post-traumatic stress 

disorder: epidemiology, impact and approaches to management. CNS Drugs. 2006;20:567-590.

6. Cozza S, Benedek D, Bradley J, Grieger T, Nam T, Waldrep,. Topics specific to the psychiatric 

treatment of military personnel. The Iraq war clinician guide. 2004.

7. Ford DE & Kamerow DB. Epidemiologic study of sleep and psychiatric disturbances. An 

opportunity for prevention? JAMA. 1989;262:1479-84.
REFERENCES

8. McCall W. A psychiatric perspective on insomnia. J Clin Psychiatry. 2001;62 Suppl 10:27-32.

9. Skaer, T.L., Robison, L.M., Sclar, D.A., Galin & Richard S. (1999) Psychiatric comorbidity and 

pharmacological treatment patterns among patients presenting with insomnia: An assessment 

of office-based encounters in the USA in 1995 and 1996. Clinical Drug Investigation, 18, 161-

167.

10. Taylor DJ, Lichstein KL, Durrence HH, Reidel BW, Bush AJ. Epidemiology of insomnia, 

depression, and anxiety. SLEEP. 2005;28:1457-1464.

11. Baglioni C, Battagliese G, Feige B, et al. Insomnia as a predictor of depression: A meta-analytic 

evaluation of longitudinal epidemiological studies. J Affect Disord. 2011;135:10-19.

12. Roane BM, Taylor DJ. Adolescent insomnia as a risk factor for early adult depression and 

substance abuse. SLEEP. 2008;31:1351-1356.

13. Troxel W, Buysse D, Matthews K, et al. Sleep symptoms predict the development of the 

metabolic syndrome. SLEEP. 2010;33:1633-40.

14. Daley M, Morin CM, LeBlanc M, Gregoire J, Savard J. The economic burden of insomnia: Direct 

and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good 

sleepers. SLEEP. 2009;32:55-64.
REFERENCES

15. Leger D, Guilleminault C, Bader G, Levy E, Paillard M. Medical and socioprofessional impact of 

insomnia. SLEEP. 2002;25:625-9.

16. Roy AN, Smith M. Prevalence and cost of insomnia in a state Medicaid fee-forservice

population based on diagnostic codes and prescription utilization. Sleep Med 2010;11:462-9.

17. Wright KM, Britt TW, Bliese PD, Adler AB, Picchioni D, Moore D. Insomnia as predictor versus 

outcome of PTSD and depression among Iraq combat veterans. J Clin Psychol. 2011;67:1240–

58.

18. McLay RN, Klam WP, Volkert SL. Insomnia is the most commonly reported symptom and 

predicts other symptoms of post-traumatic stress disorder in U.S. service members returning 

from military deployments. Mil Med. 2010;175:759–62.

19. Pigeon WR, Britton PC, Ilgen MA, Chapman B, Conner KR. Sleep disturbance preceding suicide 

among veterans. Am J Public Health. 2012;102 Suppl 1:S93–7.

20. Wilk JE, Herrell RK, Wynn GH, Riviere LA, Hoge CW. Mild traumatic brain injury (concussion), 

posttraumatic stress disorder, and depression in U.S. soldiers involved in combat deployments: 

association with postdeployment symptoms. Psychosom Med. 2012;74:249–57.

21. Mathias JL, Alvaro PK. Prevalence of sleep disturbances, disorders, and problems following 

traumatic brain injury: ameta-analysis. Sleep Med. 2012;13:898–905.
REFERENCES

22. Collen J, Orr N, Lettieri CJ, Carter K, Holley AB. Sleep disturbances among soldiers with combatrelated traumatic brain injury. Chest. 2012;142:622–30.

23. Wallace DM, Shafazand S, Ramos AR, Carvalho DZ, Gardener H, Lorenzo D, et al. Insomnia 

characteristics and clinical correlates in Operation Enduring Freedom/Operation Iraqi Freedom 

veterans with post-traumatic stress disorder and mild traumatic brain injury: an exploratory 

study. Sleep Med. 2011;12:850–9.

24. Rao V, Spiro J, Vaishnavi S, Rastogi P, Mielke M, Noll K, et al. Prevalence and types of sleep 

disturbances acutely after traumatic brain injury. Brain Inj. 2008;22:381–6.

25. Dolan D, Taylor D, Bramoweth AD, Rosenthal L. Cognitive-behavioral therapy of insomnia: A 

clinical case series study of patients with co-morbid disorders and using hypnotic medications. 

Behav Res Ther. 2010;48(4):321-7.

26. Karlin BE, Trockel M, Taylor CB, Gimeno J, & Manber R. National dissemination of cognitive 

behavioral therapy for insomnia in veterans: therapist- and patient-level outcomes. J Consult 

Clin Psychol. 2013;81:912-7.