Cognitive-Behavioral Self-Help Treatment for Nightmares and Insomnia

Abstract

Nightmares and insomnia are sleep disorders with serious consequences. Both sleep disorders can effectively be treated with cognitive-behavioral therapy (CBT). Because of its cost-effectiveness and promising effects, self-help CBT has been proposed as a first option within a stepped-care framework. CBT for insomnia and nightmares primarily consists of psycho-education about sleep and exercises to improve sleep-wake habits. Therefore, the use of CBT self-help manuals for sleep problems within a stepped care approach framework seems promising. This dissertation describes three large randomized controlled trials concerning self-help CBT for nightmares or insomnia. In the first nightmare RCT, 399 participants were randomized into Imagery Rehearsal Therapy - IRT (n = 103), exposure (n = 95), recording (n = 106) or waiting-list condition (n = 95). Results showed that nightmares can successfully be treated with self-help and that effectiveness is sustained in the long run. IRT alleviated nightmare frequency faster, but, unexpectedly, was equally effective to exposure. It seems thus that the desensitization to the feared image is the crucial element in nightmare treatment. In the second nightmare RCT, 278 participants were randomized into IRT (n = 70), IRT+ (with sleep hygiene; n = 76), Lucid Dreaming Therapy - LDT (n = 70), or waiting-list condition (n = 62). Results showed that in addition to IRT, sleep hygiene or lucid dreaming did not have a beneficial effect. For insomnia, a self-help CBT protocol was developed and its effectiveness was evaluated in a large RCT (N = 623) which compared Internet delivered self-help CBT to bibliotherapy and a waiting-list condition. We found that insomnia can effectively be treated with unsupported self-help CBT. Internet and bibliotherapy were equally effective at 4-week follow-up. However, the Internet condition had a higher dropout. Effects were sustained at 48-week follow-up, but surprisingly, symptoms of insomnia and secondary complaints decreased more in the Internet compared to the bibliotherapy condition. In conclusion, in this dissertation we found that unsupported self-help CBT can successfully ameliorate nightmares and insomnia. Sleep disorders can be specifically targeted and self-help treatments have an effect on primary sleep complaints. The nightmare studies demonstrated that self-help CBT decreased nightmare frequency. The insomnia study showed that CBT increased total sleep time, and decreased sleep onset latency as well as waking time after sleep onset. Moreover, indirect effects were found on affective complaints such as depression and anxiety. The effects were sustained in the long run, suggesting that not only face-to-face but also self-help CBT has better long-term effects than sleep medication. The unsupported self-help format is promising because it appears to be a cost-effective way to reach a large number of people with sleep disorders.