Insomnia is one of the primary presenting complaints in the primary care setting. It can be the only symptom the patient is reporting or it can be part of a constellation of symptoms related to a medical cause or mood or anxiety disorder. That, of course, has to be investigated first. Once that has been done, and treatment options are being discussed, a primary care provider could consider recommending Cognitive Behavioral Therapy (CBT) for insomnia. When comparing it to medication options, it has a high rate of long-term efficacy and there are no side effects to be concerned about. It 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. There are cases where patients have been able to taper off of sleep medications after participating in CBT for insomnia.
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.
While this article will not go into the specific details of how CBT for insomnia is conducted, there are several consistent components for any program. The program starts with a sleep assessment for a particular patient. There is a discussion about the rationale for the treatment and basic education about sleep, including sleep norms, circadian rhythms, effects of aging on sleep and effects of sleep deprivation.
Some of the CBT techniques that are used to treat insomnia include cognitive restructuring, sleep scheduling, stimulus control, relaxation, sleep hygiene, and medication tapering techniques. While the specifics can vary based on the particular program, the general behavioral treatment regimen uses stimulus control and sleep restriction strategies to standardize the patient’s sleep/wake schedule, eliminate sleep incompatible behaviors that occur in the bed and bedroom, and restrict time in bed (TIB) in an effort to force the development of an efficient, consolidated sleep 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) have worked for short periods of time but then cease to be helpful. He denies other mood or anxiety symptoms and has been able to maintain working. A recommendation was made to refer for a sleep study and, if that is normal, then to refer for CBT for insomnia.
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