Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders

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Abstract

Insomnia is a pervasive problem for many patients suffering from medical and psychiatric conditions. Even when the comorbid disorders are successfully treated, insomnia often fails to remit. In addition to compromising quality of life, untreated insomnia may also aggravate and complicate recovery from the comorbid disease. Cognitive behavior therapy for insomnia (CBT-I) has an established efficacy for primary insomnia, but less is known about its efficacy for insomnia occurring in the context of medical and psychiatric conditions. The purpose of this article is to present a rationale for using CBT-I in medical and psychiatric disorders, review the extant outcome literature, highlight considerations for adapting CBT-I procedures in specific populations, and suggest directions for future research. Outcome studies were identified for CBT-I in mixed medical and psychiatric conditions, cancer, chronic pain, HIV, depression, posttraumatic stress disorder, and alcoholism. Other disorders discussed include: bipolar disorder, eating disorders, generalized anxiety, and obsessive compulsive disorder. The available data demonstrate moderate to large treatment effects (Cohen's d, range = 0.35–2.2) and indicate that CBT-I is a promising treatment for individuals with medical and psychiatric comorbidity. Although the literature reviewed here is limited by a paucity of randomized, controlled studies, the available data suggest that by improving sleep, CBT-I might also indirectly improve medical and psychological endpoints. This review underscores the need for future research to test the efficacy of adaptations of CBT-I to disease specific conditions and symptoms.

Section snippets

General rationale, indications, and contraindications for CBT-I in comorbid insomnia

It has been argued that cognitive-behavioral models of insomnia are particularly relevant to patients with medical and psychiatric diseases (e.g., Morin et al., 1989, Smith et al., 2000). Cognitive-behavioral conceptualizations of insomnia posit that as insomnia transitions from an initial acute symptom and/or stress reaction to a chronic problem, maladaptive compensatory strategies and behavioral contingencies begin to play a role in maintaining the sleep disturbance, independent from the

Cognitive behavior therapy for insomnia in mixed samples of medical and psychiatric disorders

Before reviewing the outcome literature for CBT-I in specific medical and psychiatric disorders, we will briefly review four studies that have evaluated the efficacy of CBT-I in patients with heterogeneous medical and/or medical/psychiatric conditions. Two of these studies were randomized clinical trials (Lichstein et al., 2000, Rybarczyk et al., 2002) and the other two were case series (Morin et al., 1994, Perlis et al., 2001).

Lichstein et al. (2000) used a randomized, waitlist control design

Cancer

Given the tremendous emotional and physical burden associated with cancer, it is not surprising that studies have found greater prevalence of self-reported and objectively documented difficulties initiating and maintaining sleep compared with healthy controls (Kaye et al., 1983, Silberfarb et al., 1993). Rates of self-reported sleep disturbance in mixed cancer populations range between 30% and 50%, with highest prevalence (37–38%) among breast and lung cancer patients (Davidson et al., 2002,

Cognitive behavior therapy for insomnia occurring in psychiatric conditions

Disturbed sleep is listed as a diagnostic symptom of mood and anxiety disorders and is an associated symptom of most other psychiatric disorders. A report on the patterns of symptomatic recovery in psychotherapy indicates that sleep complaints do not change as a result of general psychotherapy (Kopta, Howard, Lowry, & Beutler, 1994). This implies that the sleep complaints of psychiatric patients need to be specifically targeted if they are to be improved. In addition to difficulties initiating

Conclusions and future directions

In summarizing the existing outcomes literature for CBT-I, the preliminary data regarding the efficacy of CBT-I for chronic insomnia when it occurs in patients with various medical and psychiatric conditions are encouraging (see Table 1). Effect sizes across most of the studies are quite large and consistent with effect sizes reported in the outcomes literature for primary insomnia. The possibility that improvements in sleep might reciprocally feedback and impact the primary disease processes

References (222)

  • W. Breitbart et al.

    Fatigue in ambulatory AIDS patients

    Journal of Pain and Symptom Management

    (1998)
  • K.J. Brower

    Insomnia, alcoholism and relapse

    Sleep Medicine Reviews

    (2003)
  • D.J. Buysse et al.

    Electroencephalographic sleep correlates of episode and vulnerability to recurrence in depression

    Biological Psychiatry

    (1997)
  • D.J. Buysse et al.

    Electroencephalographic sleep studies in depressed outpatients treated with interpersonal psychotherapy: II. Longitudinal studies at baseline and recovery

    Psychiatry Research

    (1992)
  • D.J. Buysse et al.

    The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research

    Psychiatry Research

    (1989)
  • J. Cannici et al.

    Treatment of insomnia in cancer patients using muscle relaxation training

    Journal of Behavior Therapy and Experimental Psychiatry

    (1983)
  • C. Colombo et al.

    Rate of switch form depression into mania after therapeutic sleep deprovation in bipolar depression

    Psychiatry Research

    (1999)
  • M.G. Craske et al.

    Reactivity to interoceptive cues in nocturnal panic

    Journal of Behavior Therapy and Experimental Psychiatry

    (2001)
  • D.G. Cruess et al.

    Sleep disturbance mediates the association between psychological distress and immune status among HIV-positive men and women on combination antiretroviral therapy

    Journal of Psychosomatic Research

    (2003)
  • J.R. Davidson et al.

    Sleep disturbance in cancer patients

    Social Science & Medicine

    (2002)
  • D.F. Dinges et al.

    Sleep deprivation and human immune function

    Advances in Neuroimmunology

    (1995)
  • H.M. Dreher

    The effect of caffeine reduction on sleep quality and well being in persons with HIV

    Journal of Psychosomatic Research

    (2003)
  • A.G. Harvey

    Insomnia symptom or diagnosis

    Clinical Psychology Review

    (2001)
  • P. Hauri et al.

    Alpha-delta sleep

    Electroencephalography and Clinical Neurophysiology

    (1973)
  • J.A. Haythornthwaite et al.

    Development of a sleep diary for chronic pain patients

    Journal of Pain and Symptom Management

    (1991)
  • G.D. Jacobs et al.

    Home-based central nervous system assessment of a multifactor behavioral intervention for chronic sleep-onset insomnia

    Behavior Therapy

    (1993)
  • W. Jernajczyk

    Latency of eye movement and other REM sleep parameters in bipolar depression

    Biological Psychiatry

    (1986)
  • B. Krakow et al.

    Imagery rehearsal treatment for chronic nightmares

    Behavior Research and Therapy

    (1995)
  • J. Adamson et al.

    Sleep of dry alcoholics

    Archives of General Psychiatry

    (1973)
  • H. Allain et al.

    Effects on postural oscillation and memory functions of a single dose of zolpidem 5 mg, zopiclone 3.75 mg and lormetazepam 1 mg in elderly healthy subjects. A randomized, cross-over, double-blind study versus placebo

    European Journal of Clinical Pharmacology

    (2003)
  • American Psychiatric Association

    Diagnositic and Statistical Manual of Mental Disorders (DSM-IV)

    (1994)
  • American Sleep Disorders Association

    The International Classification of Sleep Disorders: Diagnostic and Coding Manual—Revised

    (1997)
  • S. Ancoli-Israel et al.

    Characteristics of insomnia in the United States: Results of the 1991 National Sleep Foundation Survey, I

    Sleep

    (1999)
  • F. Arriaga et al.

    EEG sleep characteristics in dysthymia and major depressive disorder

    Neuropsychochobiology

    (1995)
  • G.M. Asnis et al.

    Zolpidem for persistent insomnia in SSRI-treated depressed patients

    Journal of Clinical Psychiatry

    (1999)
  • J.A. Astin

    Mind–body therapies for the management of pain

    Clinical Journal of Pain

    (2004)
  • J.H. Atkinson et al.

    Subjective sleep disturbance in chronic back pain

    The Clinical Journal of Pain

    (1988)
  • D. Avery et al.

    Bright dawn simulation compared with bright morning light in the treatment of winter depression

    Acta Psychiatrica Scandinavica

    (1992)
  • D. Avery et al.

    REM latency and temperature in affective disorder before and after treatment

    Biological Psychiatry

    (1982)
  • D.H. Avery et al.

    REM latency and core temperature relationships in primary depression

    Acta Psychiatrica Scandinavica

    (1986)
  • A.T. Beck et al.

    Cognitive Therapy for Depression

    (1979)
  • G. Belenky et al.

    Patterns of performance degradation and restoration during sleep restriction and subsequent recovery: A sleep dose–response study

    Journal Sleep Research

    (2003)
  • R.M. Benca et al.

    Eating disorders

  • R.M. Benca et al.

    Sleep and psychiatric disorders: A meta analysis

    Archives of General Psychiatry

    (1992)
  • M. Berger et al.

    Sleep deprivation combined with consecutive sleep phase advance as a fast-acting therapy in depression: An open pilot trial in medicated and unmedicated patients

    American Journal of Psychiatry

    (1997)
  • T.K. Birkenhager et al.

    Benzodiazepines for depression? A review of the literature

    International Clinical Psychopharmacology

    (1995)
  • M.H. Bonnet et al.

    Heart rate variability in insomniacs and matched normal sleepers

    Psychosomatic Medicine

    (1998)
  • Bootzin, R. R. (1972). Stimulus Copntrol Treatment. Paper presented at the American Psychological Association Annual...
  • N. Breslau et al.

    Sleep in lifetime posttraumatic stress disorder: A community-based polysomnographic study

    Archives of General Psychiatry

    (2004)
  • K.J. Brower et al.

    Insomnia, self-medication, and relapse to alcoholism

    American Journal of Psychiatry

    (2001)
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