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Chapter 4

Cognitive Behavior Therapy for Insomnia:

Treatment Considerations

Abstract
Sleep is a process that is heavily influenced by a number of psychological

factors including daytime activities and overall schedules. While it may seem

intuitively obvious that engaging in such routine practices as allowing oneself to

wind down or relax prior to bed or following a routine sleep schedule should benefit

sleep, the systematic use of such psychological strategies for insomnia manage-

ment did not emerge until the latter 1950s. We discuss the rationale and theoretical

basis of early strategies (e.g., relaxation training and stimulus control therapy)

originally developed for other psychological and behavioral disorders but adapted

for use in insomnia. We also describe the rationale, theoretical basis, and treatment

components of strategies that evolved out of the field of sleep disorders medicine

(e.g., sleep hygiene and sleep restriction therapy). We discuss the development

of more omnibus insomnia therapies (e.g., multi-component Cognitive-Behavior

Therapy (CBT) for insomnia) that emerged in the mid-1980s and early 1990s.

Finally, we review the evidence for CBT as a well-established front-line therapy

for management of chronic insomnia in adults (Sleep 29:1398–1414, 2006; Sleep

28:1049–1057, 2005).

There is a time for many words, and there is also a time for sleep……(Ecclesiastes 3:7)

A well-spent day brings happy sleep…(Leonardo Da Vinci, circa 1500)

Early to bed and early to rise makes a man healthy, wealthy, and wise…(Benjamin

Franklin, circa 1735)

What is Cognitive Behavior Therapy and Who Can

Benefit from It?

As implied by these few quotations, we have long recognized that our sleep is a

process that is heavily influenced by a number of psychological/behavioral factors,

including our daytime activities and overall schedules. When our sleep becomes

problematic and unpredictable, it then seems reasonable to question whether there

C.E. Carney and J.D. Edinger,
Insomnia and Anxiety
, Series in Anxiety and Related Disorders,

51

DOI 10.1007/978-1-4419-1434-7_4, © Springer Science+Business Media, LLC 2010

52

4 Cognitive Behavior Therapy for Insomnia: Treatment Considerations

are psychological and behavioral strategies that can be employed to “right the ship”

again and reestablish a normal and reliable sleep pattern. While it may seem intui-

tively obvious that engaging in such routine practices as allowing oneself to wind

down or relax prior to bed or following a routine sleep schedule should benefit

sleep, the systematic use of such psychological and behavioral strategies for insom-

nia management did not emerge until the latter 1950s. Between that time and the

mid-1980s, a number of psychological and behavioral therapies, described briefly

in Table 4.1, were proposed for insomnia management. Some of these, such as

relaxation training and stimulus control therapy, were therapies originally devel-

oped for other psychological and behavioral disorders, but adapted for the use in

insomnia. Others, such as sleep hygiene and sleep restriction therapy, evolved in the

then emerging field of sleep disorders medicine and were specifically developed for

insomnia management. As indicated in Table 4.1, each of these therapies is

Table 4.1
Common behavioral therapies

Type of treatment

Treatment description

Sleep hygiene

Education about healthy sleep behaviors and sleep-conducive

environmental conditions. Treatment focuses on: (1) encouraging

daily exercise, (2) reducing/eliminating caffeine, alcohol, and

nicotine, (3) eating a light bedtime snack at bedtime, and (4)

ensuring that the bedroom is quiet, dark, and comfortable.

Relaxation therapy

Various techniques including progressive muscle relaxation, autogenic

training, biofeedback, imagery training, meditation, and hypnosis.

This treatment targets sleep-disruptive physiological (e.g., muscle

tension) and/or cognitive (e.g., racing thoughts) arousal.

Stimulus control

Based on the assumption that both the timing (bedtime) and sleep

therapy

setting (bed/bedroom) become conditioned cues for arousal that

perpetuate insomnia as a result of their repeated association with

unsuccessful sleep attempts. The goal of this treatment is that of

re-associating the bed and bedroom with successful sleep attempts.

Therapy instructions include: (a) go to bed only when sleepy; (b)

establish a standard wake-up time; (c) get out of bed whenever