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Chronic Insomnia / Insomnia Disorder

Cognitive Behavioural Therapy for Insomnia (CBTi)

The evidence based non-drug intervention CBTi is recommended to be used as treatment of insomnia disorder over the long term by international sleep and medical guidelines.


The main therapeutic components of Cognitive behavioural therapy for insomnia (CBTi) are:1, 2


CBTi, when compared to BBTi, is generally delivered over a 6-10 weekly/fortnightly sessions, includes longer appointments (approximately 30-45 minutes), a greater focus on cognitive therapy/restructuring, and is mainly administered by psychologists with specialist training/experience in the management of insomnia (See Referral to a Psychologist).1


Identify patients suitable for CBTi from a ‘sleep’ psychologist, instead of an online program or BBTi:

  • Epilepsy or seizure disorders
  • Co-morbid sleep disorder (e.g., obstructive sleep apnoea, restless legs syndrome, circadian rhythm disorder)
  • Shift workers
  • People who drive or operate heavy machinery for work
  • Previous motor vehicle accident
  • Severe or uncontrolled psychiatric condition (e.g., Bi-polar disorder, Schizophrenia disorder)
  • Currently pregnant or caring for very young children
  • Epworth Sleepiness Scale score > 15
  • Significant or very strongly held maladaptive or dysfunctional sleep-related cognitions (e.g., on the Dysfunctional Beliefs and Attitudes about Sleep Scale)
  • Previously tried BBTi or online program which was not effective



CBTi addresses behaviours that maintain the insomnia and targets specific dysfunctional sleep-preventing attitudes and beliefs including:

  • Anxious and catastrophic thoughts that are associated with sleeplessness
  • Inappropriate expectations about hours of sleep
  • Misattributions regarding the effects of sleeplessness


CBTi is widely recognised in Australian and international sleep, medical, and primary care guidelines to be safer and more effective over time, when compared with pharmacological therapies.3, 4, 5, 6, 7, 8


CBTi therapy has been reported to improve insomnia severity, sleep onset latency (time to first fall asleep), wake after sleep onset (time spent awake during the night after first falling asleep), number of nocturnal awakenings, total sleep time, and sleep efficiency (total sleep time divided by average time spent in bed) over long-term follow-up.9, 10, 11, 12, 13

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

Cognitive Restructuring

Referral to Digital CBTi Programs

Referral to a Psychologist

References

  1. Winkelman JW. Overview of the treatment of insomnia in adults. In UpToDate, Benca R (ed). Waltham, MA: UpToDate 2020
  2. Smith MT, et al. Cognitive behavior therapy for chronic insomnia. Clin Cornerstone 2003;5(3):28–40
  3. Wilson S, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update. Journal of Psychopharmacology 2019;33(8):923-47
  4. Qaseem A, et al. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of internal medicine 2016;165(2):125-33
  5. Royal Australian College of General Practitioners (RACGP). Prescribing drugs of dependence in general practice, Part B: Benzodiazepies 2015
  6. Williams J, et al. Cognitive behavioral treatment of insomnia. Chest 2013;143(2):554–56
  7. Riemann D, et al. The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavioural therapies. Sleep Med Rev 2009;13:205–14
  8. Morin CM, et al. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA 1999; 81(11):991–99
  9. www.racgp.org.au/clinical-resources/clinical-guidelines/handi/handi-interventions/mental-health/cognitive-behavioural-therapy-for-chronic-insomnia
  10. van der Zweerde T, et al. Cognitive behavioral therapy for insomnia: a meta-analysis of long-term effects in controlled studies. Sleep medicine reviews. 2019;48:101208
  11. Cunnington D, et al. Chronic insomnia: diagnosis and non-pharmacological management. BMJ 2016;355:i5819
  12. Trauer M, et al. Cognitive behavioural therapy for chronic insomnia: a systematic review and meta-analysis. Annals of Internal Medicine 2015:163:191-204
  13. Okajima I, et al. A meta-analysis on the treatment effectiveness of cognitive behavioral therapy for primary insomnia. Sleep and Biological Rhythms. 2011;9(1):24-34