Cognitive-Behavioral Treatment of Insomnia

By Dr. Gregg D. Jacobs

The most significant advance in the treatment of insomnia has been the evolution of cognitive-behavioral therapy (CBT), which is based on the idea that chronic insomnia is learned and can be unlearned. CBT focuses on four areas in the treatment of insomnia: modifying stressful, inaccurate thoughts about sleep; modifying maladaptive sleep behaviors; improving relaxation skills; and, improving lifestyle practices that affect sleep.

Over 20 years of research on CBT for insomnia indicates that it is highly effective in the treatment of insomnia. For example, recent meta-analyses involving 60 peer-reviewed empirical studies indicate that CBT is more effective than no-treatment and placebo treatments for insomnia. Furthermore, treatment effect sizes are large, are maintained at long-term follow-up, and are cost-effective. At least one-third of insomniacs become normal sleepers after CBT and 70-80% derive benefit from treatment.

In a study that I conducted at Harvard Medical School, 100% of insomnia patients reported improved sleep as a result of the CBT intervention that I have developed. In contrast, sedative-hypnotics produce moderate treatment effect sizes, and, in several federally funded randomized controlled trials that directly compared the efficacy of CBT to sleep medication, CBT was superior. For example, a study conducted by Dr. Charles Morin that was also funded by the NIH also found that, in a direct comparison, CBT was more effective than sleeping medication in the long run and maintained gains more effectively at long-term follow-up.

The success of CBT is based on a central theme: insomnia can only be treated by addressing all of the underlying causes. In most instances, the causes of insomnia are thoughts (cognitions) and behaviors (habits) which are learned and can be unlearned. Some examples include:

• Negative, distorted thoughts and beliefs about insomnia and the effects of sleep loss
• Feelings of loss of control over sleep
• Spending excessive time in bed relative to actual sleep time
• Inadequate exercise or exposure to sunlight
• Going to bed too early or sleeping too late
• Trying to control sleep rather than letting it happen
• Negative responses to stress
• Lying awake in bed, frustrated and tense