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James Pretzer October 7th, 2004 02:07 PM

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

Medscape has several other articles on insomnia available. One at covers the assessment and management of insomnia. The other at 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).

JustBen October 14th, 2004 03:53 PM

Re: CBT for Insomnia
An excellent article, thank you. Do you have any suggestions for books that address CBT treatment of insomnia?

James Pretzer October 19th, 2004 09:22 AM

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.

JustBen October 25th, 2004 03:55 PM

Re: CBT for Insomnia
I've done a little reading in this area since the topic was posted, and I thought I'd pass along another recommendation.

"Beliefs About the Utility of Presleep Worry: An Investigation of Individuals with Insomnia and Good Sleepers."
Harvey, Allison, G.
Cognitive Therapy & Research; Aug2003, Vol. 27 Issue 4, p403, 12p

A very interesting read. Here's the short version: Patients with insomnia seem to believe that presleep worrying has more utility than those without insomnia. In other words, insomniacs are more likely to believe that worrying about things in bed before sleeping will have a good outcome (i.e. sort things out, prepare for the future, emotionally process things, etc.). According to the author, "The results of the present study suggest that positive beliefs about the benefits of worrying during the presleep period are characteristic of insomnia and may serve to maintain the disorder."

I think the gut-reaction of a CB therapist might be to look at the cognitive distortions of the patient's thoughts before they go to sleep. I could be off-the-mark here, but this article would seem to suggest that it might be more effective to actually deal with the client's thoughts about those thoughts. In other words, to challenge the patient's belief that entertaining those thoughts actually does them good, regardless of their content.

James Pretzer October 30th, 2004 09:53 PM

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.

Joel Pomerantz December 22nd, 2004 04:12 PM

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???

roland rogiers December 22nd, 2004 07:18 PM

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.

JustBen December 23rd, 2004 10:56 AM

Re: CBT for Insomnia
Raises another interesting question: Can we conceptualize insomnia in purely behavioral terms? Has anyone had a case where cognitive factors seemed irrelevant to the problem?

roland rogiers December 23rd, 2004 04:55 PM

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.

Joel Pomerantz December 24th, 2004 02:57 PM

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!

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