CBT for Insomnia
 

A report regarding a new outcome study of CBT vs Meds for insomnia recommends CBT as the first-line treatment for insomnia. This report can be found on Medscape at http://www.medscape.com/viewarticle/490197.

Medscape has several other articles on insomnia available. One at http://www.medscape.com/viewarticle/470585 covers the assessment and management of insomnia. The other at http://www.medscape.com/viewarticle/470683 discusses CT and benzodiazepines for insomnia.

(To read these articles you'll need to register with Medscape if you haven't already joined but there is no charge).

Re: CBT for Insomnia
 

Re: CBT for Insomnia
 

One book I'd recommend is Bennett-Levy, et al (2004) Oxford Guide to Behavioural Experiments in Cognitive Therapy. The book isn't specifically about insomnia but it is quite good and includes a good chapter on insomnia which outlines a number of useful interventions.

There are also a couple of books on insomnia that I haven't seen but which sound promising: Treatment of Late-Life Insomnia by Kenneth L. Lichstein (Editor), Charles M. Morin (Editor) focuses on late-life insomnia but most of the content would apply to all ages. It includes a chapter on CT with insomnia. Insomnia: Principles and Management by Martin P. Szuba (Editor), Jacqueline D. Kloss (Editor), David F. Dinges (Editor) appears to be a good overview of the current literature on treating insomnia but isn't specifically about CT.

Re: CBT for Insomnia
 

Re: CBT for Insomnia
 

Yes, Harvey's article is very interesting. It makes a lot of sense that individuals who belive that worry is a good idea in some way (i.e. "I'll be prepared," "I won't be taken by surprise," "I'll get to the root of the problem," etc.) will put more time and energy into worrying and will persist with it even if it interfers with sleep.

These beliefs and thoughts about one's own cognitions play an important role in many problems. Adrian Wells discusses their role in GAD and PTSD in an excellent chapter in Contemporary Cognitive Therapy: Theory, Research, and Practice (Guilford, 2004) and has an article coming out in Cognitive and Behavioral Practice that I am looking forward to. By the way, you can impress your friends and relatives by referring to these cognitions about cognition as "metacognitions."

It certainly makes sense to address these metacognitions as part of treating insomnia and I find that it is often quite useful. I'm not sure I'd go as far as predicting that this intervention will be more effective than other interventions because there are many cognitive and behavioral factors that play a role in insomnia and I haven't seen any studies comparing the effectiveness of different interventions.

Other dysfunctional cognitions and behaviors commonly observed in insomniacs include:

a belief that insomnia will have catastrophic consequences,

a tendency to avoid dealing with worries and concerns during the day so that they remain unresolved at bedtime,

a tendency to "try hard" to get to sleep and to quickly become frustrated when they have difficulty falling asleep,

anticipatory anxiety as bedtime approaches,

and dysfunctional strategies for coping with insomnia such as napping which disrupts the sleep cycle or the use of alcohol to make it easier to get to sleep (which suppresses REM sleep)

After a good assessment, there usually are quite a few cognitions and behaviors that are useful to address.

Re: CBT for Insomnia
 

I recently encountered an insomniac client who denies that she is at all anxious. She describes herself as very laid back and easy going! I asked if she has ever had a medical evaluation of the problem and replied that she had not. I asked if she had any history of thyroid dysfunction and she replied that she had recently suffered a miscarriage due to thyroid problems, but isn't being treated... I suggested that she immediately consult a physician etc... but I'm just curious- let's say that the doctor determines that her insomnia is psychogenic and not physiologic... is there an alternative explanation to anxiety in conceptualizing insomnia- or is she fooling herself about being easy going and laid back???

Re: CBT for Insomnia
 

Interesting question.
In order to speak of insomnia, we need to know if these complaints affects her functioning during the day? I think it was really a good idea to suggest physical examination before starting cbt.
I suppose that you have asked for sleep hygiene?
Literature suggests that classical conditioning starts after about three weeks. That could be one reason: being awake in bed became a habit. Stimuluscontrol (or sleep deprivation) can be a help in that case
I"m really interested about further evolution of this case.
roland

Re: CBT for Insomnia
 

Re: CBT for Insomnia
 

I suppose that when someone sees his insomnia as a problem there will always be some (internal) problem talk/cognitions. Otherwise, he would not see it as a problem. Does this make any sense?
I just formulated the classical conditioning hypothesis as a rationale for treatment when a patient resists, denies or does'nt experience any anxiety or tension. I was really wondering if this patient did have any burden (and motivation)? It's not mentioned in the description. So it would be very interesting if the author would supply some more information.
roland

Re: CBT for Insomnia
 

This client is, in fact, experiencing significant life stress... a child with special behavioral needs who often exasperates her, a recent move, employment uncertainty etc... (her presenting problem focused on these issues the sleeplessness was raised as an aside...) she still denies experiencing anxiety or tension and claims that the problem with morning insomnia predated these current stressors. If the medical exam turns up nothing I may want to explore the classical conditioning angle and maybe work to get her to pinpoint relevant thoughts- which she denies that she has except for "noticing that I'm still awake one hour later" and not knowing what to do about it. she also did tell me that her attempts at visualization / relaxation etc. do not seem to help.
Thank you all so much for your input!

Re: CBT for Insomnia
 

and what about her sleep hygiene?
would you please inform us about further evolution
i'm very interested

Re: CBT for Insomnia
 

Yes, very interesting. I agree with the preceeding comments, especially the importance of appropriate treatment for her thyroid problem.

One thought is that when she asserts that she is not anxious and that she is not worrying during the periods when she is having difficulty falling asleep, this does not necessarily prove that anxiety and/or worry is not part of the problem. Not all individuals are skilled at recognizing and reporting their thoughts and feelings and not all individuals are willing to acknowledge all of their thoughts and feelings.

It certainly is possible to have insomnia for reasons other than anxiety. Have you asked about caffeine consumption or medication that can produce insomnia as a side effect? You haven't mentioned if she is having trouble falling asleep, trouble staying asleep, or trouble with early-morning waking. My experience is that difficulty falling asleep is often due to anxiety but also can be due to too much caffeine, to an irregular sleep schedule, to not allowing time to "wind-down" before sleep, or even can be due to anger at one's spouse. Waking during the night often is due to anxiety but also can be due to physical discomfort, nightmares, or concerns that areon the person's mind. Early-morning waking can be due to depression rather than anxiety or can be due to thoughts about all that needs to be done in the coming day.

It could be quite useful to have her write down her thoughts and feelings (1) as bedtime approaches, (2) when she first goes to bed, and (3) when she realizes that time has passed and she is not falling asleep.

Given her long-standing insomnia, it wouldn't be surprising if she has anticipatory cognitions ("Will I be able to get to sleep?") as bedtime approaches. Given the stressors that she is facing, it wouldn't be surprising if some of those issues come to mind as she is lying in bed (especially if she tries not to think about them during the day or tries not to be uspet by them). Once she notices that she is again having difficulty falling asleep, it wouldn't be surprising if she has some cognitions about how frustrating it is to be unable to fall asleep or some cognitions about how terrible it will be if she doesn't sleep well.

Re: CBT for Insomnia
 

Dear Colleague

I was wondering if you had some news about the case of your patient suffering from insomnia? Did you have any news about her possible thyroid problem?
You also wrote: she also did tell me that her attempts at visualization / relaxation etc. do not seem to help. In my experience, one of the greatest problems in practicing CBT for insomnia is that patiënts have great expectations and were hoping for some miracle to happen. Therefore I found it very useful to ask them (and registrate) how many times they have done their homework. This kind of stuff needs some weeks before it brings some solution. And I learned that it is useful to tell the patient that they don't had to learn how to get to sleep, but that the aim is to get relaxed.

Re: CBT for Insomnia
 

Yes,
Where the root of the problem was pain. More specifically bodily pain that i treated using guided visualisation. Then teaching these skills to my client putting her back in control which also had the added affect of reframing her old beliefs around the pain.My client now looks forward to her bedtime to practice her new skill!
All the best Jimmy.

Recent review of treatments for Insomnia
 

Two recent articles, a review of behavioral interventions for insomnia and a discussion of who is a good candidate for CBT for insomnia sound useful (I haven't read them). They are:

Irwin, M. R. (2006). Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychology, 25, 3-14. (Note: I object to referring to indiviuals who are 55+ as "older adults." Never mind why.)

Smith, M. T. & Perlis, M. L. (2006). Who is a candidate for cognitive-behavioral therapy for insomnia? Health Psychology, 25, 15-19.

Re: CBT for Insomnia
 

hypo- or hyperthyroid? i treated somebody whose GP claimed that all symptoms were due to her hyperthyroidism (S&S very close to those of anxiety). However the marked reduction in symptoms following therapy suggested to me that there was a large psychological componant to the problem - not that he was impressed!

Re: CBT for Insomnia
 

Certainly, a physical to rule out medical causes is always a good idea. Thyroid problems can mimic anxiety or depression or can play a role in anxiety or depression. Side-effects of medication can also play a role.

If treatment for her elevated thyroid level took care of the insomnia, then maybe it was a purely medical problem. That certainly isn't the case with most insomnia.

Training in CBT for Insomnia
 

Weekend Training Seminars on CBT for Insomnia
=============================================
When: May 4th-6th
October 19th-21st

Where: The Woodcliff Lodge
http://www.woodclifflodge.com/
Rochester New York

Sponsor: University of Rochester

COURSE DESCRIPTION
This activity is intended for Clinical Psychologists, PhD/NP
level Nurses and Physicians who are interested in the assessment
and treatment of Insomnia. Clinical Trainees are also welcome.

The seminar will provide information on both pharmacologic and
non-pharmacologic treatment. The majority of the course, however,
will be focused on how to conduct Cognitive Behavioral Therapy for
Insomnia (CBT-I)as an evidenced based intervention for Primary
and Secondary Insomnia.

This non-profit activity offers CE and CME credits.

Registration contact: Paul Lambiase
PJLambiase@UR.Rochester.edu

Course Director: Michael Perlis
Michael_Perlis@URMC.Rochester.edu

Web: http://www.urmc.rochester.edu/cpe/CBT-I

Increased concern re Meds for Insomnia
 

Many laypersons (and many MDs) assume that medication is the preferred treatment for insomnia. Not only does CBT seem to be more effective, there also are increased concerns about some commonly used meds. See http://www.medscape.com/viewarticle/553654?src=mp