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Chronic Insomnia / Insomnia Disorder

Brief Behavioural Therapy for Insomnia (BBTi)

Brief Behavioural Therapy for insomnia (BBTi) focuses on the provision of education about sleep and on modifying waking behaviours that affect the physiological systems that regulate sleep (i.e. homeostatic and circadian drives).


Therapeutic components of BBTi include:1, 2

BBTi, when compared to Cognitive Behavioural Therapy for insomnia (CBTi), is a program which can be performed in primary practice by GPs or practice nurses, during shorter appointment times delivered over fewer (4-5) sessions.3, 4, 5, 6, 7

GP-administered BBTi treatment sessions with practice nurse support includes the initial appointment, an additional assessment appointment (if required), 4-5 treatment in-person and telephone sessions with a 1-2 week interval, and a review appointment three to six months after the patient has completed the BBTi treatment.1

GPs can use Focussed Psychological Strategies (FPS) sessions (or normal MBS appointment items to deliver BBTi).


BBTi related GP appointments:


  • Initial/assessment appointment(s)

i. Insomnia symptoms

ii. History

iii. Comorbidities

iv. Questionnaires

v. Provide patient with sleep diary

RACGP Handbook of Non-Drug Interventions (HANDI) - Sleep diary American Academy of Sleep Medicine - Sleep diary


  • Session 1 of BBTi

i. Introduce components of BBTi:

° General sleep education

° Bedtime restriction therapy - review diagnostic sleep diary to prescribe new bedtime ‘window’

° Stimulus control therapy

° Relaxation techniques

ii. Discuss comorbid conditions if applicable


  • Sessions 2-5

Review components of BBTi:

° General sleep education

° Bedtime restriction therapy

i. Review sleep diaries to calculate average sleep and wake time

ii. Assess and titrate the new bedtime ‘window’ and discuss any difficulties

iii. Discuss patient’s feelings of sleepiness/fatigue

° Stimulus control therapy

°Relaxation techniques


  • The role of the practice nurse may include:

i. Health history

ii. Insomnia symptoms

iii. Questionnaires

iv. Sleep-diary data



Information for GPs to administer BBTi within the general practice setting

Sweetman 2021 - A step-by-step model to administer BBTi in Australian general practice RACGP Handbook of Non-Drug Interventions (HANDI) - Brief behavioural therapy for insomnia (BBTi) Troxel 2012 - Clinical management of insomnia with brief behavioral treatment (BBTi)
Abbreviations

AHI - Apnoea-Hypopnoea Index
BBTi - Brief Behavioural Therapy for Insomnia
BMI - Body Mass Index (kg/m2)
BQ - Berlin Questionnaire
CBTi - Cognitive Behavioural Therapy for Insomnia
CELL - Coblation Endoscopic Lingual Lightening
COPD - Chronic Obstructive Pulmonary Disease
CVA - Cerebrovascular Accident
CPAP - Continuous Positive Airway Pressure
CSA - Central Sleep Apnoea
DASS - Depression Anxiety Stress Scale
DBAS - Dysfunctional Beliefs and Attitudes about Sleep
DBP - Diastolic Blood Pressure
DIMS - Difficulties Initiating and/or Maintaining Sleep
DISE - Drug-Induced Sleep Endoscopy
DISS - Daytime Insomnia Symptom Scale
ENT - Ear Nose and Throat
ESS - Epworth Sleepiness Scale
FOSQ - Functional Outcomes of Sleep Questionnaire
FSH - Follicle-Stimulating Hormone
FTP - Friedman Tong Position
GP - General Practitioner
HANDI - RACGP Handbook of Non-Drug Interventions
HGNS - Hypoglossal Herve Htimulation
ISI - Insomnia Severity Index
K10 - Kessler Psychological Distress Scale
MAD - Mandibular Advancement Device
MAS - Mandibular Advancement Rplint
MBS - Medicare Benefits Schedule
MMA - Maxillomandibular Advancement Surgery
MRA - Mandibular Repositioning Appliance
ODI - Oxygenation Desaturation Index
OSA - Obstructive Sleep Apnoea
PLMD - Periodic Limb Movement Disorder
PT - Positional Therapy
PTSD - Post-Traumatic Stress Disorder
PSG - Polysomnography
QSQ - Quebec Sleep Questionnaire
REM - Rapid Eye Movement
RFTB - Radiofrequency Thermotherapy of the Tongue Base
SBP - Systolic Blood Pressure
SCI - Sleep Condition Indicator
SE - Sleep Efficiency
SF36 - Short-Form (36) Health Survey
SMILE - Submucosal Minimally Invasive Lingual Excision
SNRIs - Serotonin-Norepinephrine Reuptake Inhibitors
SOL - Sleep Onset Latency
SSRI - Selective Serotonin Reuptake Inhibitors
TFTs - Thyroid Function Tests
TIB - Time In Bed
TORS - Transoral Robotic Surgery
TST - Total Sleep Time
UPPP - Uvulopalatopharyngoplasty
WASO - Wake After Sleep Onset

Bedtime Restriction Therapy

Stimulus Control Therapy

Relaxation Techniques

References

  1. Sweetman A, et al. A step-by-step model for a brief behavioural treatment for insomnia in Australian General Practice. Australian Journal of General Practice 2021
  2. Troxel WM, et al. Clinical management of insomnia with brief behavioral treatment (BBTI). Behavioral sleep medicine 2012;10(4):266-79
  3. Royal Australian College of General Practitioners. Handbook of non-drug interventions (HANDI). Brief behavioural therapy: insomnia in adults. Melbourne: RACGP 2014
  4. Fernando A, et al. A double-blind randomised controlled study of a brief intervention of bedtime restriction for adult patients with primary insomnia. J Prim Health Care 2013;5(1):5-10
  5. Buysse DJ, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med 2011;171(10):887-95
  6. Falloon K, et al. The assessment and management of insomnia in primary care. BMJ 2011;342:2899
  7. Wilson SJ, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol 2010;24(11):1577-601