A Cognitive Theory and Therapy for Chronic Insomnia

Abstract

The aim of this article is to review progress toward developing a cognitive theory of and therapy for chronic insomnia. The article will begin with a brief overview of cognitive behavior therapy for insomnia (CBT-I), the current treatment of choice, which devotes approximately one session to cognitive therapy. On the basis of (a) the conclusion from a recent review of psychological treatments for insomnia that cognitive therapy has received insufficient attention and evaluation and (b) the evidence that cognitive therapy for a range of other psychological disorders has improved treatment outcome, the remainder of the article describes another approach to the treatment of insomnia: cognitive therapy for insomnia (CT-I). This treatment is derived from a cognitive model that specifies five processes that function to maintain insomnia: worry (also known as cognitive arousal), selective attention and monitoring, distorted misperception of sleep and daytime deficits, unhelpful beliefs about sleep, and counterproductive safety behaviors. The aim of the treatment is to reverse all five maintaining processes during both the day and the night. Keywords: cognitive therapy; insomnia; sleep; attention; beliefs Since the groundbreaking work of Aaron T. Beck and his colleagues (e.g., 1976), cognitive theories and therapies have led to a much enhanced understanding of a wide range of psychological disorders (see Salkovskis, 1996). The aim of the present article is to review progress toward developing a cognitive theory of, and therapy for, chronic insomnia. The article will begin with a brief overview of what is currently regarded as the treatment of choice for insomnia; cognitive behavior therapy for insomnia or CBT-I. CBT-I is a multicomponent treatment that is conducted over 4 to 10 weekly sessions (Morin & Espie, 2003), with one of these sessions typically devoted to cognitive therapy. The remainder of the article will describe a different approach to the treatment of insomnia. This will be referred to as cognitive therapy for insomnia, or CT-I. CT-I is driven by one cognitive model of the maintenance of insomnia and every session is devoted to using core cognitive therapy skills to reverse the cognitive maintaining processes specified by the cognitive model. WHAT Is INSOMNIA? Insomnia is a chronic difficulty that involves problems getting to sleep, maintaining sleep, or waking in the morning not feeling restored. It is one of the most prevalent psychological health problems, reported by 10% of the population (Ancoli-Israel & Roth, 1999). The consequences for the sufferer are severe and include functional impairment, work absenteeism, impaired concentration and memory, and increased use of medical services (Roth & Ancoli-Israel, 1999). Further, there is evidence that insomnia significantly heightens the risk of having an accident (Ohayon, Caulet, Philip, Guilleminault, & Priest, 1997) and the risk of subsequently developing another psychological disorder, particularly an anxiety disorder, depression, or substance-related disorder (Harvey, 2001; McCrae & Lichstein, 2001). It is therefore regarded as a serious public health problem. In this paragraph a distinction is drawn between the original cause/s or precipitant/s of insomnia (i.e., the distal cause/s) and the causes that are active at the time the client is seeking treatment (i.e., the proximal cause/s). The former will be referred to as precipitant/s and the latter as maintaining process/es. Although in this paper we are primarily concerned with the processes that maintain insomnia, rather than the precipitating factors, it is emphasized that the precipitants are likely to be heterogeneous and may include physical disorders, substances, circadian rhythm disturbances, psychological factors, and poor sleep habits (Bootzin, Manber, Perlis, Salvio, & Wyatt, 1993). The reason for focusing on the maintaining processes is that the relative contribution of precipitating and maintaining processes is likely to vary over the course of a disorder with the precipitating processes (e. …