NU671 Unit 10 CBT-I Proposal for Chronic Insomnia Example

Nine Hours in Bed for Five and a Half of Sleep: An Integrated Therapy Proposal Joining the Insomnia Cycle, CBT-I and Its Evidence for a 57-Year-Old Guidance Counselor

[Student Name]

Purdue University Global

NU671: PMHNP Psychopathological Disorders and Psychotherapy

Unit 10 Integrated Therapy Proposal

[Instructor Name]

[Date]

The patient is composite; sleep diary values are bracketed.

The Patient

Ms. [D.] is a [57]-year-old high school guidance counselor. Two years ago her husband was hospitalized for [six] weeks after a heart attack. During that time she slept poorly, lying awake waiting for calls. He recovered fully, but her sleep did not. She now goes to bed at [21:30] to "give herself a chance," lies awake for about an hour, wakes two or three times a night and gets up at [06:30]. On weekends she stays in bed until [08:30]. She naps after work on bad days. She worries in bed about how she will function the next day and checks the clock repeatedly. She has no symptoms of sleep apnea, restless legs or depression beyond fatigue and irritability.

Her two-week sleep diary shows an average time in bed of [9.0] hours and total sleep of [5.5] hours, a sleep efficiency of [61] percent. Normal sleep efficiency is above about [85] percent. She meets criteria for chronic insomnia disorder.

Part One: The Cycle That Holds It in Place

Spielman and colleagues proposed a three-factor model of insomnia (Spielman et al., 1987). Predisposing factors make a person vulnerable. Precipitating factors trigger the acute insomnia. Perpetuating factors, usually the person's own attempts to cope, keep insomnia going after the trigger has passed.

For Ms. [D.]:

1. Predisposing: she has always been a light sleeper and describes herself as a worrier.

2. Precipitating: her husband's hospitalization and the weeks of waiting for news.

3. Perpetuating: going to bed early, staying in bed longer on weekends, napping, lying awake in bed, clock-watching, and the belief that she must get eight hours or she will not cope.

The hospitalization started her insomnia, but it is her sensible-seeming efforts to catch up on sleep that keep it alive two years later. Each perpetuating behavior makes sense on its own. But spending nine hours in bed for five and a half hours of sleep spreads her sleep thin and teaches her body that the bed is a place for lying awake. Naps and weekend lie-ins weaken her sleep drive at night. Clock-watching and worry keep her alert.

Part Two: The Therapy, Matched to the Cycle

Cognitive behavioral therapy for insomnia combines several components. Each targets a part of her cycle.

1. Sleep restriction. Her time in bed is limited to her average sleep time plus a small margin, about [6] hours, from [00:15] to [06:15], to consolidate her sleep and increase her sleep drive. When her sleep efficiency rises above [85] percent for a week, her time in bed will be extended by [15] minutes. This targets the time spent lying awake.

2. Stimulus control. She goes to bed only when sleepy, gets out of bed if she cannot sleep within about [20] minutes, returns only when sleepy, gets up at the same time every day including weekends, and does not nap. This rebuilds the link between bed and sleep.

3. Cognitive therapy. She examines the belief that she needs eight hours or she will not function, using her own diary data: on some days after five hours she functioned well at work. This targets the worry in bed.

4. Sleep hygiene and relaxation. The clock is turned away, caffeine is stopped after noon, and she practices a brief wind-down routine. These are supportive rather than central.

The plan runs over [six] weekly sessions:

1. Week one: assessment, sleep diary review, the three-factor model explained with her own history.

2. Week two: sleep restriction and stimulus control begin; expect more daytime sleepiness at first.

3. Week three: review adherence, adjust the window; address the fear of the first difficult days.

4. Week four: cognitive work on the eight-hour belief and on catastrophic predictions about the next day.

5. Week five: continue titrating the window; relaxation and wind-down routine.

6. Week six: relapse prevention; what to do if insomnia returns after a stressful event.

Part Three: The Evidence

The American College of Physicians recommends cognitive behavioral therapy for insomnia as the initial treatment for all adults with chronic insomnia disorder, a strong recommendation based on moderate-quality evidence, with medication considered through shared decision making only if therapy alone is unsuccessful (Qaseem et al., 2016). A meta-analysis of [20] trials with [1,162] participants, whose mean age of [56] matches Ms. [D.]'s, found that the therapy shortened the time to fall asleep by about [19] minutes, reduced time awake after sleep onset by about [26] minutes and raised sleep efficiency by about [10] percent, with improvements that appeared to be sustained (Trauer et al., 2015). The same analysis found only a small, nonsignificant increase in total sleep time at the end of treatment, which is worth telling her in advance: early gains come in the quality and efficiency of sleep, not always in hours.

Why the Three Parts Belong Together

The cycle explains why her insomnia persists, the therapy targets each perpetuating factor in that cycle, and the evidence shows that targeting them works for people like her. Without the cycle, sleep restriction would seem cruel to a patient who already sleeps too little. Without the evidence, the plan would be one clinician's opinion. Without the therapy, the model would describe her insomnia but not change it. The integration is what makes the proposal persuasive to her, since she is being asked to spend less time in bed, which runs against everything she has tried.

How Success Will Be Judged

Success will be measured with her own sleep diary, which she will keep throughout, and by two outcomes she chose herself: falling asleep within [30] minutes on most nights, and no longer dreading bedtime. Sleep efficiency above [85] percent is the clinical marker the window is built around. Total sleep time is expected to rise more slowly, and she has agreed not to judge the therapy on hours alone in the first month.

Risks and Adjustments

Sleep restriction causes daytime sleepiness in the first weeks, which matters because she drives to work. She will be advised not to drive if she feels drowsy and to keep her window no shorter than [5.5] hours. If her diary shows loud snoring or witnessed pauses, she will be referred for a sleep study before continuing. If her mood worsens, depression will be reassessed.

References

Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., Denberg, T. D., & Clinical Guidelines Committee of the American College of Physicians. (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. https://doi.org/10.7326/M15-2175

Spielman, A. J., Caruso, L. S., & Glovinsky, P. B. (1987). A behavioral perspective on insomnia treatment. Psychiatric Clinics of North America, 10(4), 541-553. https://doi.org/10.1016/S0193-953X(18)30532-X

Trauer, J. M., Qian, M. Y., Doyle, J. S., Rajaratnam, S. M. W., & Cunnington, D. (2015). Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis. Annals of Internal Medicine, 163(3), 191-204. https://doi.org/10.7326/M14-2841