One of the primary presenting complaints in the primary care setting is insomnia. It can be a solitary presenting symptom or it can be part of a constellation of symptoms related to a medical cause or mood or anxiety disorder.
A good assessment of onset, extent, duration, onset, severity, triggers of the sleep problem, in conjunction with the standard review of systems, is the first step. Once done, treatment options can be considered.
Cognitive Behavioral Therapy (CBT) interventions have a high rate of long-term efficacy, and CBT should be employed with all patients, even those with health care issues and medication needs. When using CBT, the complications and risks associated with sleep aid medications can be avoided or minimized and for intractable cases, doses may be able to be contained.
CBT has been shown to be helpful as an adjunctive treatment for insomnia in depression when used with antidepressant medication. It has also been helpful with other co-morbid concerns, like chronic pain, fibromyalgia, substance abuse, and anxiety disorders. Some patients may be able to taper off of sleep medications after participating in CBT treatment for insomnia. The central focus of CBT treatment is on improving the patient’s sleep hygiene.
Predisposing factors, precipitating events, and perpetuating mechanisms all contribute to the development of chronic primary sleep difficulties. Some individuals may be particularly predisposed or vulnerable to sleep difficulties because of a dysfunctional biological sleep system. When such individuals are confronted with precipitating circumstances (for example: a stressful life event), they can develop an acute sleep disturbance. This sleep disturbance can be perpetuated if the patient develops poor sleep hygiene practices (for example: daytime napping, spending excessive time in bed, etc) to try to cope with the sleep difficulty.
Therefore, although predisposing and precipitating factors contribute to insomnia, poor sleep hygiene is seen as a critical sustaining element in the sleep disturbance. One key element of CBT for insomnia is to correct those sleep habits that ostensibly sustain or add to the patients’ sleep problems.
Modified CBT intervention can be provided in the primary care office, though referral to a formal program is appropriate for most as well. CBT requires a discussion about the rationale for the treatment and some basic education about sleep norms, circadian rhythms, effects of aging, of medications and drugs and the effects of sleep deprivation. Typical CBT techniques include sleep scheduling, stimulus control, relaxation, cognitive restructuring, sleep hygiene, and medication tapering techniques. Typically the behavioral treatment uses stimulus control and sleep restriction strategies to normalize standardize the patient’s sleep/wake schedule, eliminate sleep incompatible behaviors, and restrict time in bed (TIB) in an effort to force the development of an efficient, consolidated sleep profile and pattern. It is important to maintain and review sleep logs to help with troubleshooting problems that may occur along the way.
Here is a case example to illustrate the role that CBT for insomnia can play in the primary care setting:
35yo male with a history of Type I Diabetes well controlled on insulin and no previous psychiatric history who presents with longstanding (since high school) difficulty with initiating and maintaining sleep. Various medication trials (Benadryl, Ambien, Elavil, OTC agents) have worked for short periods of time but then cease to be helpful. He has been stable, denies other mood or anxiety symptoms and has been able to maintain working. Education and guidance on sleep hygiene is helpful in some respects but medication requests recur. A referral for a sleep study is made with normal findings and a recommendation for referral to a formal CBT sleep treatment group.
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