Cognitive Behavioral Therapy for Insomnia

Sleep problems are becoming increasingly common in the general population. Studies from a range of western countries show that nearly one-third of people report insomnia symptoms, 10% experience additional daytime consequences, and 6% fulfill the diagnostic criteria for insomnia. Insomnia is more frequent in women, older adults, and patients with physical or psychiatric disorders.¹ The core symptoms of insomnia include difficulties initiating or maintaining sleep, or experiencing non-restorative sleep that results in clinically significant distress or an impairment in daytime functioning. People with insomnia are commonly classified as suffering from primary or secondary/ comorbid insomnia. While the diagnosis of primary insomnia is made when the sleep problems are not caused by any known physical or mental condition, secondary insomnia refers to poor sleep that is either caused or worsened by another disorder. Approximately 25% of chronic insomniacs are thought to suffer from primary insomnia with no known secondary etiology.

The adverse consequences of insomnia are well documented. Insomnia is associated with both cognitive and intellectual impairment,^2,3 as well as current and subsequent affective disorders.^4–6 Patients suffering from insomnia commonly report a significant reduction in quality of life⁷ and impaired coping abilities,⁸ and insomnia has also been linked to reduced immune function and mortality.^9,10 Insomniacs also typically report a lower working capacity, and insomnia has been shown to predict both long-term sick-leave and permanent work disability.^11,12 In terms of economic costs, the most recent analysis of the economic burden of insomnia in the US estimated the direct medical costs of insomnia to be $13.9 billion annually,¹³ which increases to $92–107 billion if including indirect costs from sleep-related accidents and lost productivity.¹⁴

The mechanisms underlying the pathophysiology of insomnia are still poorly understood, but whether a person develops chronic insomnia seems to depend on predisposing traits, precipitating events, and perpetuating conditions.¹⁵ For example, acute (adjustment) insomnia is typically precipitated by a physical illness, psychosocial stressor, or other life event, but is usually short-lived as the adverse event or condition alleviates with time. However, some people continue to experience sleep problems long after the evoking factors have disappeared. In chronic insomnia, there is now a general consensus that cognitive and behavioral mechanisms play important roles in maintaining and exacerbating sleep problems.