Who Should Not Try Cognitive Behavioral Therapy for Insomnia (CBTI)?

By Brandon Peters, MD

It is a question that comes up fairly often: Who should not try cognitive behavioral therapy for insomnia (CBTI) to resolve chronic difficulty sleeping? It really comes down to a simpler question: Is CBTI right for me? Although there are a few relative contraindications to pursuing a CBTI program, most people will actually benefit from the education. Let’s review some of the considerations in deciding whether CBTI is the right treatment for you.

Understanding the Nature of CBTI

First, let it be known that cognitive behavioral therapy for insomnia (CBTI) is the best treatment for chronic insomnia. It is recommended by the American College of Physicians to be used as the initial treatment, even before the prescription of sleeping pills. But what is chronic insomnia and what exactly is CBTI?

If someone has difficulty getting to sleep (typically more than 20 to 30 minutes), frequent awakenings, difficulty getting back to sleep (again, more than 20 to 30 minutes awake at night in total), or poor quality sleep in the absence of another sleep disorder, this is insomnia. If it occurs 3 nights per week and lasts for at least 3 months, it is by definition chronic insomnia. It may occur every night and last for decades.

CBTI is a structured, educational program that helps to identify and resolve the causes of insomnia. It typically lasts 6 weeks, and may be accomplished one-on-one with the help of a trained psychologist, through a workshop or class, via an online course (such as Insomnia Solved), or with the help of a self-directed book. Each week, lessons present incremental changes that eliminate unhelpful thoughts and behaviors. These changes build the sleep drive and strengthen circadian patterns.

Some people are more likely to struggle with these changes. Others may have conditions that make it impossible to comply with the treatment recommendations. Who should not participate in a CBTI program?

Specific Conditions to Consider

Before engaging in a CBTI program, it may be helpful to reflect on specific conditions that may make it harder to be successful. Consider these:

Anxiety and Depression

Mood and sleep walk hand in hand. Poor sleep often worsens mood conditions, including anxiety and depression. Untreated anxiety or depression may likewise contribute to insomnia. When both insomnia and a mood disorder are present, research tells us it is better to focus on improving sleep to help both. If anxiety or depression are impacting your life in other ways, it may be necessary to seek treatment of these conditions to be most successful in a CBTI program.

Bipolar Disorder

CBTI should be pursued cautiously in those with bipolar disorder. One part of CBTI, sleep consolidation, involves reducing the total time in bed to better reflect the sleep need. This may result in a restriction in the total hours of sleep. In those predisposed to bipolar disorder, this may incite either hypomania or mania. It is recommended that those with bipolar consider participating in CBTI with careful follow up with their psychiatrist to ensure that the mood disorder remains stable.

Chronic Pain (Fibromyalgia)

Pain can impact the ability to fall asleep. After awakenings, it may also be hard to get back to sleep. Optimal pain control may ease the transition to sleep. Sleep deprivation may worsen pain. This is often a temporary change, and over the long term, improved sleep quality can provide relief. Ensure that your pain condition is addressed to ensure successful completion of the CBTI program.

Chronic Fatigue Syndrome

Though not fully understood, the nature of chronic fatigue syndrome (CFS) is the debilitating impacts it has on both sleep and wakefulness. There is a high degree of overlap between CFS and other sleep disorders, including insomnia and sleep apnea. Participation in CBTI is possible, but it may be necessary to ease some of the recommendations to accommodate the disorder.

Hypothyroidism

Untreated hypothyroidism can cause fatigue and sleep disturbances. It is typically associated with other symptoms, including weight gain, dry skin or hair, and fatigue. If you have not been evaluated by your primary care provider, consider a visit and a blood test to check your thyroid-stimulating hormone (TSH).

Obstructive Sleep Apnea

Untreated sleep apnea commonly overlaps with insomnia characterized by frequent awakenings, especially towards morning. It may be associated with snoring, witnessed pauses in breathing, gasping, frequent urination at night, teeth grinding (bruxism), heartburn at night, night sweats, palpitations, morning headaches, unrefreshing sleep, daytime sleepiness, memory problems, and mood disorders like anxiety and depression. Over time, it may contribute to high blood pressure, diabetes, atrial fibrillation, heart failure, heart attack, stroke, dementia, and sudden death. It should be evaluated by a board-certified sleep physician with a consultation and appropriate testing and treatment. If ignored, or left untreated, frequent awakenings will persist.

Restless Legs Syndrome

Difficulty getting to sleep at the beginning of the night may occur due to a sense of restlessness in the legs. This uncomfortable feeling, associated with an urge to move, typically comes on in the evenings when sitting or lying down. As with sleep apnea, treatment may be required to ease the associated insomnia.

Drug or Substance Use or Withdrawal

Insomnia may lead to the abuse of alcohol, illicit drugs, over-the-counter sleep aids, and prescription medications. The use of these substances, or the withdrawal that occurs after stopping them, may interfere with sleep and the response to CBTI. If you have substance use issues, discuss these with a medical professional and seek appropriate treatment.

Why You May Still Pursue CBTI

Ignoring a coexisting problem will not make it go away. Instead, striving to complete CBTI while ignoring a contributing cause is like running a race with a broken leg. These conditions should be optimally managed to succeed at CBTI.

It should be noted that many people still benefit from CBTI when these issues are present. A diagnosis, a label, does not consign you to a fate of interminable poor sleep. Just because you have been diagnosed with one of these problems does not mean that you cannot participate in the program.

Reflect on how much the condition may be interfering with your sleep, and whether sleeping better may actually help the condition. If in doubt, participate with the supervision of your healthcare provider. If you struggle to make progress with CBTI, revisit its influence on your efforts.

CBTI can be a powerful tool to optimize sleep, even in those with these common coexisting conditions. Give it a try and you may discover how good sleep affects both health and well-being.

Brandon Peters, MD, is the writer on sleep for Verywell.com, a neurology-trained sleep medicine specialist at Virginia Mason Medical Center in Seattle, and adjunct lecturer at the Stanford Center for Sleep Sciences and Medicine.