1. Introduction to Behavioral Sleep Medicine (CBT-I)
Copyright 2014 by Nancy J. Lin
treatment of insomnia through cognitive Behavioral therapy
Nancy J. Lin, Ph.D.
Go to Sleep San Diego

2. What is Sleep? Definition of sleep (n)
state of not being awake: a state of partial or full unconsciousness in people and animals, during which voluntary functions are suspended and the body rests and restores itself, or a period spent in this state
associated with decreased mobility, closed eyes, a characteristic species-specific sleeping posture, reduced response to external stimulation, quiescence, increased reaction time, elevated arousal threshold, impaired cognitive function, and a reversible unconscious state.
Copyright 2014 by Nancy J. Lin

3. What is Insomnia?
Inability to obtain an adequate amount or quality of sleep.
Types of Insomnia:
Early insomnia – increased sleep latency (trouble falling asleep)
Middle insomnia – disrupted sleep (trouble staying asleep)
Late insomnia – insufficient duration of sleep (waking up too early)
Copyright 2014 by Nancy J. Lin

4. Chronic Insomnia
Less than 4.5 of sleep per night for prolonged periods is associated with:
Increased urge to fall asleep
Irritability
Slowed thinking
Increased reaction time
Symptoms similar to ADHD
Impaired growth hormone secretion
Increased risk of obesity and type 2 diabetes
Impaired immune function
Copyright 2014 by Nancy J. Lin

5. How does insomnia develop?
Predisposing factors
Genetics
Environment
Social influences
Precipitating factors
Stressful or life-changing events
Perpetuating factors
Behavioral compensation for lost sleep
Conditioned arousal
Entrenched conscious or unconscious sleep-sabotaging habits
Copyright 2014 by Nancy J. Lin

6. Behavioral Sleep Medicine (BSM) Overview
Evaluation
Is this Primary Insomnia?
Rule-out other conditions
Possible co-occurring conditions
Referrals
What is the nature of this person’s insomnia?
CBT-I
Primary Components
Stimulus Control Therapy (SCT)
Sleep Restriction (SRT)
Sleep Hygiene Education
Second-Line Interventions
Cognitive Therapy
Relaxation Training
Phototherapy
Sleep Compression
Imagery Rehearsal Therapy for Nightmares
Copyright 2014 by Nancy J. Lin

7. Stimulus Control Therapy (SCT)
Indication
Recommended for sleep initiation and maintenance problems
Rationale
Chronic insomnia is often characterized by a breakdown of the healthy association of the bed/bedroom with rapid, well- consolidated sleep
SCT’s mode of action
Limits the amount of a time a person may spend in bed
Limits the types of behaviors in which a person may engage in bed/ the bedroom
Efficacy
Most effective component of CBT-I. Can be effective as a stand-alone therapy for many insomnia sufferers.
Copyright 2014 by Nancy J. Lin

8. Sleep Restriction Therapy (SRT)
Indication
Recommended for sleep initiation and maintenance problems
Rationale
Chronic insomnia sufferers are unable to get the appropriate amount of consolidated sleep at the appropriate time of day. They may benefit from a “hard reset” of their sleep schedule.
SRT’s mode of action
Limits the amount of a time a person may spend in bed to their average sleep time.
Sets a sleep schedule that is more adaptive to the person’s lifestyle.
Efficacy
Very effective. Generally not used alone but considered a critical component of CBT-I.
Copyright 2014 by Nancy J. Lin

9. Sleep Hygiene Education
Indication
Recommended for sleep initiation and maintenance problems
Rationale
Chronic insomnia sufferers often overcompensate for lost sleep by engaging in behaviors that over time become sleep-sabotaging habits.
Sleep Hygiene Education’s mode of action
Bring to awareness about habits that can contribute to chronic insomnia
Empower the person to engage in actions that are healthy and sleep- promoting
Effectiveness
Not considered an effective stand-along therapy for chronic insomnia
Increases the effectiveness of treatment when combined with SCT and SRT
Copyright 2014 by Nancy J. Lin

10. Cognitive Therapy Catch it Check it Change it Indication Rationale
Recommended for whose insomnia is worsened by excessive or intrusive worry about the negative consequences of sleep problems or other stressors.
Rationale
Chronic insomnia sufferers who have negative thoughts and beliefs about their condition typically do worse than those who feel hopeful and believe they can get better.
Cognitive Therapy’s modes of action
Cognitive Restructuring
Paradoxical Intent
Problem-solving
Efficacy
Gold standard therapy for treatment of anxiety-related problems
Catch it
Check it
Change it
Copyright 2014 by Nancy J. Lin

11. Relaxation Training Indication Rationale
Recommended for insomnia sufferers who view their insomnia as an “inability to relax”
Rationale
Chronic insomnia can arise from an overactive sympathetic nervous system.
Relaxation Training’s modes of action
Progressive Muscle Relaxation (PMR)
Diaphragmatic Breathing
Guided Imagery
Efficacy
Considered effective adjunctive therapy for anxiety-related problems
Copyright 2014 by Nancy J. Lin

12. Phototherapy Indication Rationale Phototherapy’s mode of action
Recommended for insomnia sufferers who experience a phase-delay component (go to bed late, get up late)
Rationale
Chronic insomnia sufferers can experience a disruption in their circadian rhythm and have dysregulation in the timing of melatonin production
Phototherapy’s mode of action
Lightbox therapy
Increased exposure to natural sunlight
Efficacy
Considered effective adjunctive therapy for anxiety-related problems
Copyright 2014 by Nancy J. Lin

13. Sleep Compression Indication Rationale
Recommended for sleep initiation and maintenance problems
Alternative to SRT for those who cannot tolerate sudden reduction in total sleep time
Rationale
Chronic insomnia sufferers are unable to get a healthy amount of consolidated sleep at the appropriate time of day. They may benefit from a “slow reset” of their sleep schedule.
Sleep Compression’s mode of action
Gradually limits the amount of a time a person may spend in bed to their average sleep time.
Over time, sets a sleep schedule that is more adaptive to the person’s lifestyle.
Efficacy
Generally works more slowly than SRT but is equally efficacious.
Copyright 2014 by Nancy J. Lin

14. Typical Course of BSM Components Evaluation
90-minute individual session (more if referral is needed)
Format: Individual or group sessions
5 to 8 x 50-minute weekly individual sessions
8 x 90-minute weekly group sessions
Copyright 2014 by Nancy J. Lin

15. Benefits of BSM Non-addictive, no drug interactions
May be effective in cases where insomnia is resistant to other interventions due to patient’s habits, attitude or other behavioral factors
Patient demands time and resources that are not well served in current treatment setting
Can be used as an adjunct to other treatments
Not recommended for patients also on pharmacological therapy for insomnia.
Can be a less-stigmatizing first step towards further psychological treatment for co-occurring mental health issues
Referrals
Copyright 2014 by Nancy J. Lin

16. About the Clinician
Nancy J. Lin, Ph.D. is a California licensed clinical psychologist (PSY23741) and member of American Academy of Sleep Medicine
Clinical Experience and Training
Staff Psychologist at a military hospital specializing in sleep problems in combat veterans with PTSD
Staff Psychologist at VA San Diego Healthcare System
Assistant Professor at UCSD Medical School Psychiatry Department
Postdoctoral training at VA San Diego Healthcare System
Trained in CBT-I by Sean Drummond, Ph.D., clinical psychologist and BSM Specialist
American Psychological Associated accredited internship training
Education
Ph.D. and MA in Clinical Psychology from UMass Boston
BA in Psychology from UC Berkeley
Copyright 2014 by Nancy J. Lin

17. About the Practice Availability Location
Current openings in the evening
Now accepting new patients for BSM
Location
Convenient Mission Valley location
7860 Mission Center Court, Suite 209, San Diego, CA 92108
Co-located* with Center for Stress and Anxiety Management (CSAM)
Contact info:
Telephone – (619) –
Copyright 2014 by Nancy J. Lin
* Separate entity

18. References
Perlis, M., Aloia, M., & Kuhn, B. (2011). Behavioral Treatments for Sleep Disorders. Elsevier, Amsterdam.
Perlis, M. L., Jungquist, C., Smith, M.T., & Posner, D., (2005). Cognitive Behavioral Treatment of Insomnia. Springer Science + Business Media, LLC, New York.
Copyright 2014 by Nancy J. Lin