Cognitive Behavioral Therapy for Insomnia in Veterans Therapist Manual Rachel Manber, Ph.D. Leah Friedman, Ph.D. Allison T. Siebern, Ph.D. Colleen Carney, Ph.D. Jack Edinger, Ph.D. Dana Epstein, RN, Ph.D. Patricia Haynes, Ph.D. Wilfred Pigeon, Ph.D. Bradley E. Karlin, Ph.D. Cognitive Behavioral Therapy for Insomnia in Veterans Therapist Manual Suggested Citation: Manber, R., Friedman, L., Siebern, A.T., Carney, C., Edinger, J., Epstein, D., Haynes, P., Pigeon, W., & Karlin, B. E., (2014). Cognitive Behavioral Therapy for insomnia in Veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. Table of Contents Table of Figures and Exhibits ............................................................................................................................................................. 7 Acknowledgments ................................................................................................................................................................................9 Preface ................................................................................................................................................................................................10 Introduction ........................................................................................................................................................................................ 11 Rationale for CBT-I .................................................................................................................................................................... 11 Evidence for Efficacy of CBT-I ..................................................................................................................................................12 Safety ..........................................................................................................................................................................................13 Dosing and Modality ..................................................................................................................................................................13 Outline of This Manual ...............................................................................................................................................................13 Complementary Training Materials ............................................................................................................................................14 Further Reading ..........................................................................................................................................................................14 Cases ...........................................................................................................................................................................................14 Chapter 1: Sleep Education and Overview of Insomnia ...................................................................16 A. Basic Information About Sleep ...........................................................................................................................................16 A1. Why We Sleep..............................................................................................................................................................16 A2. Sleep Stages .................................................................................................................................................................16 A3. Sleep Regulation ..........................................................................................................................................................18 B. Substances and Medications that Impact Sleep ...................................................................................................................21 B1. Alcoholic Beverages ....................................................................................................................................................22 B2. Caffeine ........................................................................................................................................................................22 B3. Nicotine ........................................................................................................................................................................22 B4. Medications ..................................................................................................................................................................22 C. Exercise and Diet .................................................................................................................................................................23 D. Sleep and Aging ...................................................................................................................................................................23 E. Sleep Disorders ....................................................................................................................................................................25 F. Overview of Insomnia .........................................................................................................................................................28 Chapter 2: Assessment and Case Conceptualization ......................................................................31 A. The Assessment Interview ..........................................................................................................................................................31 A1. Assessing the Patient’s Current Sleep Pattern .............................................................................................................31 A2. Assessing Circadian Rhythm Chronotype (Tendency) ................................................................................................32 A3. Assessing Day and Wake Time Behaviors That Can Impact Sleep .............................................................................43 A4. Assessing Factors That Contribute to Hyperarousal, Hyperactivation or Both ...........................................................35 A5. Assessing Cognitions ...................................................................................................................................................35 A6. Assessing Possible Comorbidities ...............................................................................................................................36 A7. Treatment Goal ............................................................................................................................................................36 A8. Insomnia Symptom Severity .......................................................................................................................................37 B. Sleep Diary ..........................................................................................................................................................................37 C. Case Conceptualization .......................................................................................................................................................37 Chapter 3: CBT-I Treatment Components and Implementation ......................................................39 A. Behavioral Components ......................................................................................................................................................39 A1. Stimulus Control (SC) ...................................................................................................................................................9 A1.1 Enhancing Adherence to SC ...............................................................................................................................39 A1.2 Safety ..................................................................................................................................................................41 A2. Sleep Restriction Therapy (SRT) .................................................................................................................................42 A2.1 Determining Time in Bed for SRT .....................................................................................................................43 Therapist Manual 5 A2.2 Determining Waketime and Bedtime for SRT ...........................................................................................................44 A2.3 Collaboration .............................................................................................................................................................43 A2.4 Enhancing Adherence to SRT ....................................................................................................................................45 A2.5 Safety and Side Effects ..............................................................................................................................................46 A2.6 Instructions for Subsequent Time in Bed Alteration .................................................................................................48 B. Addressing High Arousal or Activation ..............................................................................................................................51 C. Scripts for presenting Behavioral Interventions to the Patient ............................................................................................52