CBT for insomnia

Cognitive behavioral therapy for insomnia is the recommended first treatment for chronic insomnia in adults. The American College of Physicians said so in its 2016 guideline, written by Amir Qaseem and colleagues, which recommends CBT-I as the initial treatment for chronic insomnia disorder. The American Academy of Sleep Medicine’s 2021 guideline, by Jack Edinger and colleagues, strongly recommends multicomponent CBT-I. It conditionally recommends stimulus control, sleep restriction, and relaxation as treatments on their own, and it recommends against sleep hygiene used alone. The European Insomnia Guideline, updated in 2023, also puts CBT-I first.

Those recommendations are about the method as clinicians deliver it. Sleep Toolbox follows the method’s parts, but it isn’t a treatment and hasn’t been tested as one. It describes and organizes, and it leaves diagnosis and treatment to clinicians.

The sleep diary

In 2012, Colleen Carney and colleagues published the Consensus Sleep Diary, an agreed set of core questions for tracking sleep night by night. Sleep Toolbox’s diary covers the same core questions, worded closely to the consensus diary without copying it. It also adds optional questions about the day before, and it doesn’t call itself the Consensus Sleep Diary. Total sleep starts when the person fell asleep, which is the time they tried to sleep plus how long it took. It ends at the final waking, with time awake in the night taken out. Time in bed runs from getting into bed to getting up, and sleep efficiency is total sleep divided by time in bed.

Stimulus control

Richard Bootzin described stimulus control in 1972. Its rules ask the person to go to bed only when sleepy, keep the bed for sleep and sex, get up when sleep won’t come and return when sleepy, get up at the same time every day, and avoid napping. The idea is that after many bad nights the bed itself becomes a cue for being awake, and the rules teach it to mean sleep again.

Sleep restriction and the sleep window

Arthur Spielman and colleagues described sleep restriction in 1987. Shortening time in bed to match the sleep a person is actually getting is meant to build sleep drive, so sleep tends to come faster and hold together, and time in bed then grows back. Sleep Toolbox calls it the sleep window and follows the protocol taught in most treatment manuals.

• A baseline of one to two weeks of diary. The window opens after 7 complete nights, and 14 give a steadier average.
• One wake time, the same all seven days.
• Time in bed set to the average total sleep from the baseline, never below 5 hours and 30 minutes. Clinician-led protocols often use 5 hours, and Spielman’s original used 4.5. A self-guided tool should be more careful.
• A weekly check on pooled sleep efficiency. At 90% or higher, bedtime moves 15 minutes earlier. From 85 to 89%, it stays the same. Under 85%, it moves 15 minutes later, never below the floor. The person confirms every change.
• No suggestion for a week with fewer than 5 complete nights. When most nights were spent outside the window, a plain note says so and the window stays the same that week.

These thresholds are a common version, not the only one. Clinicians sometimes adjust them, for example moving bedtime earlier at 85% for older adults.

Simon Kyle and colleagues measured more daytime sleepiness and slower reactions in the early weeks of sleep restriction, which is why the “Before you start” page asks people who drive or use machinery for work to talk with a provider first. Sleep compression, studied by Kenneth Lichstein and colleagues in older adults, shrinks time in bed more gradually and is offered as the gentler start.

A busy mind

Allison Harvey’s cognitive model of insomnia describes how worry and attention to sleep keep people awake. Constructive worry, which Colleen Carney and William Waters tested in 2006, sets the day’s concerns down early in the evening with a next step for each. Nicole Tang and colleagues found that watching a clock at night raised worry and lengthened the time it took to fall asleep.

Sleep habits

Caffeine, alcohol, light, and a comfortable bedroom matter, and the Learn article covers them. The evidence for habits on their own as a treatment for insomnia is weak, and the 2021 guideline recommends against using them alone. Sleep Toolbox offers them as information, not as a treatment.

The Sleep Condition Indicator

The app’s optional check-in is the Sleep Condition Indicator, published by Colin Espie and colleagues in 2014. It shows the score from 0 to 10 with one line, “Higher means better sleep,” and never shows the cutoff for probable insomnia disorder.

The Sleep Condition Indicator is © Sleepio Limited and is used under a Creative Commons Attribution-NonCommercial 4.0 International license, creativecommons.org/licenses/by-nc/4.0. Everyday Insight shows the questions on one page, writes the ranges out in words, and moved the note on the second question below it. Espie, C. A., Kyle, S. D., Hames, P., Gardani, M., Fleming, L., & Cape, J. (2014). The Sleep Condition Indicator: A clinical screening tool to evaluate insomnia disorder. BMJ Open, 4(3), e004183. https://doi.org/10.1136/bmjopen-2013-004183

References

Named as background and further reading. None of these authors or organizations is affiliated with Everyday Insight or has reviewed this site.

• American Academy of Sleep Medicine. (2023). International classification of sleep disorders (3rd ed., text rev.). American Academy of Sleep Medicine.
• Bootzin, R. R. (1972). Stimulus control treatment for insomnia. Proceedings of the 80th Annual Convention of the American Psychological Association, 7, 395–396.
• Borbély, A. A. (1982). A two process model of sleep regulation. Human Neurobiology, 1(3), 195–204.
• Carney, C. E., & Waters, W. F. (2006). Effects of a structured problem-solving procedure on pre-sleep cognitive arousal in college students with insomnia. Behavioral Sleep Medicine, 4(1), 13–28. doi.org/10.1207/s15402010bsm0401_2
• Carney, C. E., Buysse, D. J., Ancoli-Israel, S., Edinger, J. D., Krystal, A. D., Lichstein, K. L., & Morin, C. M. (2012). The Consensus Sleep Diary: Standardizing prospective sleep self-monitoring. Sleep, 35(2), 287–302. doi.org/10.5665/sleep.1642
• Edinger, J. D., Arnedt, J. T., Bertisch, S. M., Carney, C. E., Harrington, J. J., Lichstein, K. L., Sateia, M. J., Troxel, W. M., Zhou, E. S., Kazmi, U., Heald, J. L., & Martin, J. L. (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 17(2), 255–262. doi.org/10.5664/jcsm.8986
• Espie, C. A., Kyle, S. D., Hames, P., Gardani, M., Fleming, L., & Cape, J. (2014). The Sleep Condition Indicator: A clinical screening tool to evaluate insomnia disorder. BMJ Open, 4(3), e004183. doi.org/10.1136/bmjopen-2013-004183
• Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40(8), 869–893. doi.org/10.1016/S0005-7967(01)00061-4
• Irish, L. A., Kline, C. E., Gunn, H. E., Buysse, D. J., & Hall, M. H. (2015). The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep Medicine Reviews, 22, 23–36. doi.org/10.1016/j.smrv.2014.10.001
• Kyle, S. D., Miller, C. B., Rogers, Z., et al. (2014). Sleep restriction therapy for insomnia is associated with reduced objective total sleep time, increased daytime somnolence, and objectively impaired vigilance: Implications for the clinical management of insomnia disorder. Sleep, 37(2), 229–237. doi.org/10.5665/sleep.3386
• Lichstein, K. L., Riedel, B. W., Wilson, N. M., Lester, K. W., & Aguillard, R. N. (2001). Relaxation and sleep compression for late-life insomnia: A placebo-controlled trial. Journal of Consulting and Clinical Psychology, 69(2), 227–239. doi.org/10.1037/0022-006X.69.2.227
• Miller, C. B., Espie, C. A., Epstein, D. R., et al. (2014). The evidence base of sleep restriction therapy for treating insomnia disorder. Sleep Medicine Reviews, 18(5), 415–424. doi.org/10.1016/j.smrv.2014.01.006
• Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. (2005). Cognitive behavioral treatment of insomnia: A session-by-session guide. Springer.
• Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165(2), 125–133. doi.org/10.7326/M15-2175
• Riemann, D., Espie, C. A., Altena, E., et al. (2023). The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. Journal of Sleep Research, 32(6), e14035. doi.org/10.1111/jsr.14035
• Sack, R. L., Auckley, D., Auger, R. R., Carskadon, M. A., Wright, K. P., Jr., Vitiello, M. V., & Zhdanova, I. V. (2007). Circadian rhythm sleep disorders: Part I, basic principles, shift work and jet lag disorders. Sleep, 30(11), 1460–1483. doi.org/10.1093/sleep/30.11.1460
• Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307–349. doi.org/10.5664/jcsm.6470
• Spielman, A. J., Saskin, P., & Thorpy, M. J. (1987). Treatment of chronic insomnia by restriction of time in bed. Sleep, 10(1), 45–56. doi.org/10.1093/sleep/10.1.45
• Tang, N. K. Y., Schmidt, D. A., & Harvey, A. G. (2007). Sleeping with the enemy: Clock monitoring in the maintenance of insomnia. Journal of Behavior Therapy and Experimental Psychiatry, 38(1), 40–55. doi.org/10.1016/j.jbtep.2005.07.004