Sleep Medicine · Supplementary · from Sleep Medicine

Case 3: Chronic Insomnia Disorder with CBT-I

Patient Presentation

Demographics: 42-year-old female hospital nurse (night shift), divorced mother of two

Chief Complaint: "I haven't had a good night's sleep in over a year. I'm exhausted, but when I lie down I just can't fall asleep. I need something to help me sleep."

History of Present Illness: The patient presents to the sleep medicine clinic reporting chronic insomnia that has progressively worsened over the past 14 months. Her insomnia began during a stressful period involving her divorce, a custody dispute, and a transition from day shifts to rotating night shifts at the hospital. Initially, she had difficulty falling asleep on nights after her ex-husband's custody weekends, but the insomnia has generalized to nearly every night regardless of the circumstances.

She describes a typical pattern of going to bed at various times (ranging from 22:00 to 02:00 depending on shift schedule), lying awake for 1-3 hours with a "racing mind" reviewing the day's events, worrying about finances, and anticipating the next day's responsibilities. Once asleep, she wakes 2-3 times per night and often cannot return to sleep for 30-60 minutes. She estimates her total sleep time on most nights is 3.5-5 hours. She reports that insomnia occurs on both work nights and nights off, though it is worse after night shifts.

She has developed significant anxiety about sleep itself, describing a sense of dread as bedtime approaches. She reports lying in bed watching the clock, calculating how many hours of sleep she can get "if I fall asleep right now." She has tried multiple strategies on her own, including melatonin (up to 10 mg, "doesn't work"), diphenhydramine (provides drowsiness but leaves her groggy), chamomile tea, lavender aromatherapy, and alcohol (a glass of wine before bed, which helps her feel drowsy but leads to awakenings later in the night).

She spends 9-10 hours in bed most nights in an attempt to "catch up" on sleep. She uses her bed for reading, watching television, phone scrolling, eating snacks, and working on her laptop in addition to sleeping. She reports daytime fatigue, irritability, difficulty concentrating at work (she has made two minor medication errors in the past month), poor memory, and decreased motivation. She is worried about her job performance and patient safety.

Her primary care physician prescribed zolpidem 10 mg three months ago, which initially helped but has become less effective. She is now requesting a higher dose or a different sleeping pill. She denies any symptoms of sleep apnea, restless legs, or parasomnia.

Past Medical History:

• Generalized anxiety disorder (chronic, worsened since divorce)
• Mild depression (PHQ-9 score: 14, moderate)
• Tension headaches (2-3 times per week)
• Iron deficiency anemia (resolved with supplementation 2 years ago)
• No surgical history
• No known drug allergies

Medications:

• Zolpidem 10 mg at bedtime (started 3 months ago, diminishing effectiveness)
• Escitalopram 10 mg daily (started 6 months ago for anxiety/depression)
• Melatonin 10 mg at bedtime (OTC, self-prescribed, inconsistent use)
• Diphenhydramine 50 mg PRN (uses 3-4 nights/week when zolpidem "doesn't work")
• Acetaminophen 500-1000 mg PRN for headaches
• Multivitamin daily

Social History:

• Registered nurse in a hospital ICU; works rotating shifts (mix of 12-hour day shifts and 12-hour night shifts)
• Shift pattern: typically 3 night shifts in a row, then 4 days off; sometimes switches to day shifts
• Divorced 14 months ago; shares custody of two children (ages 8 and 11)
• Lives in a townhouse; bedroom faces a busy street with traffic noise and streetlight through the window
• Drinks 4-5 cups of coffee per day, last cup typically at 16:00 (but sometimes later on night shifts)
• One glass of wine most evenings
• No tobacco or recreational drug use
• Limited exercise; previously attended yoga classes (stopped after the divorce)
• Screen time before bed: 1-2 hours (phone scrolling, social media, texting)
• Has not been on vacation in over a year

Family History:

• Mother: chronic insomnia (takes benzodiazepines nightly for 20 years)
• Father: no sleep issues
• Sister: anxiety disorder

Physical Examination

• Vital Signs: BP 128/82 mmHg, HR 82 bpm, RR 16/min, Temp 36.7°C, Weight 68 kg, Height 165 cm, BMI 25.0 kg/m²
• General: Appears fatigued with dark periorbital circles; slightly anxious; makes good eye contact; oriented and coherent
• Epworth Sleepiness Scale (ESS): Score 10/24 (borderline — insomnia patients often report fatigue rather than sleepiness, distinguishing insomnia from hypersomnia)
• Insomnia Severity Index (ISI): Score 22/28 (severe clinical insomnia; 0-7 none, 8-14 subthreshold, 15-21 moderate, 22-28 severe)
• Pittsburgh Sleep Quality Index (PSQI): Global score 16 (poor sleep quality; >5 indicates poor quality)
• Fatigue Severity Scale: 5.8/7 (significant fatigue)
• GAD-7: 14 (moderate anxiety)
• PHQ-9: 14 (moderate depression)
• HEENT: Normal; Mallampati class II; no tonsillar hypertrophy
• Cardiovascular: Regular rate and rhythm; no murmurs
• Neurological: Intact cranial nerves; no restless legs symptoms elicited; no peripheral neuropathy; normal reflexes
• Two-week sleep diary review (completed prior to visit):
• Average time in bed: 9.5 hours
• Average sleep onset latency: 75 minutes
• Average number of awakenings: 2.8 per night
• Average wake after sleep onset (WASO): 68 minutes
• Average total sleep time: 4.6 hours
• Average sleep efficiency: 48% (severely reduced; normal >85%)
• No consistent circadian pattern due to rotating shifts

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• Actigraphy (2-week recording): Confirms highly irregular sleep-wake pattern; low sleep efficiency consistent with diary; rest-activity rhythms are fragmented with no consistent circadian pattern
• PSG: Not indicated — clinical history is classic for chronic insomnia disorder without features suggestive of sleep apnea, periodic limb movements, or parasomnia; PSG is not recommended for routine insomnia evaluation per AASM guidelines
• Sleep diary analysis: Sleep efficiency 48% (target for CBT-I: >85%); time in bed far exceeds actual sleep time (9.5 hours in bed, 4.6 hours sleeping); classic "conditioned arousal" pattern

Clinical Image

Educational diagram illustrating the 3P (Predisposing, Precipitating, and Perpetuating factors) model of chronic insomnia and the components of Cognitive Behavioral Therapy for Insomnia (CBT-I). Source: Educational illustration.

Diagnosis

Chronic Insomnia Disorder (ICSD-3) with Comorbid Shift Work Disorder and Generalized Anxiety Disorder

Key Diagnostic Criteria (ICSD-3):

• Difficulty initiating sleep (sleep onset latency >30 minutes) AND difficulty maintaining sleep (WASO >30 minutes) — both present
• Occurs despite adequate opportunity for sleep (she spends 9.5 hours in bed)
• Results in daytime impairment: fatigue, impaired concentration, mood disturbance, occupational dysfunction (medication errors)
• Occurs at least 3 nights per week for at least 3 months (present for 14 months)
• Not better explained by another sleep disorder (no evidence of OSA, RLS, or circadian rhythm sleep-wake disorder as primary diagnosis; shift work disorder is comorbid)

Perpetuating Factors Identified (3P Model):

• Predisposing: Family history of insomnia (mother), trait anxiety, hyperarousal phenotype
• Precipitating: Divorce, custody dispute, shift work transition
• Perpetuating: Excessive time in bed (conditioned arousal), irregular sleep schedule, bedroom used for non-sleep activities, clock-watching, caffeine use, alcohol before bed, diphenhydramine dependence, anxiety about sleep ("psychophysiological" insomnia), blue light exposure from screens, zolpidem tolerance development

Treatment Plan

1. Cognitive Behavioral Therapy for Insomnia (CBT-I) — first-line treatment: CBT-I is recommended as the first-line treatment for chronic insomnia disorder by the AASM, ACP, and European Sleep Research Society, superior to pharmacotherapy for long-term outcomes.

Component 1 — Sleep Restriction Therapy (most potent behavioral component):

• Reduce time in bed to match actual total sleep time: prescribe a sleep window of 5 hours initially (e.g., 00:00 to 05:00 on nights off)
• Do not go to bed until the prescribed bedtime, regardless of how tired she feels
• Set a fixed wake time (05:00) every day — including days off and weekends — to anchor the circadian rhythm
• When sleep efficiency reaches >85% for 5 consecutive days, increase time in bed by 15-minute increments
• Minimum prescribed time in bed: never below 5 hours (safety threshold)
• Warning: Sleepiness will initially worsen — critical to ensure patient safety, especially given her nursing duties; may need temporary shift modification

Component 2 — Stimulus Control Therapy:

• Bed is for sleep and sex only — remove the TV, laptop, phone, and reading materials from the bedroom
• Go to bed only when sleepy (not just tired)
• If unable to fall asleep within approximately 20 minutes (do not clock-watch — estimate by feeling), get out of bed, go to another room, engage in a quiet, non-stimulating activity (reading a physical book under dim light), and return to bed only when sleepy
• Repeat the above rule for middle-of-the-night awakenings
• No napping (with exception for shift work safety — see below)

Component 3 — Cognitive Therapy:

• Identify and challenge dysfunctional beliefs about sleep: "I need 8 hours or I can't function," "If I don't fall asleep soon, tomorrow will be ruined," "My insomnia is destroying my health"
• Cognitive restructuring: replace catastrophic thoughts with realistic appraisals
• Address the paradox of effort: trying harder to sleep increases arousal and worsens insomnia
• Reduce clock-watching behavior: turn clocks away from the bed, remove the phone from the bedroom

Component 4 — Sleep Hygiene Education:

• Stop caffeine after 12:00 noon (caffeine half-life 5-7 hours)
• Eliminate alcohol as a sleep aid (alcohol fragments sleep architecture, suppresses REM, and causes rebound awakenings)
• Blackout curtains for the bedroom (critical for daytime sleep after night shifts and to block streetlight)
• White noise machine or earplugs for traffic noise
• Cool bedroom temperature (18-19°C / 65-67°F)
• Avoid screens for 60 minutes before bed (blue light suppresses melatonin); use blue-light-blocking glasses if screen use is unavoidable
• Regular exercise (resume yoga or walking) — but not within 3 hours of bedtime

Component 5 — Relaxation Training:

• Progressive muscle relaxation (PMR) — 20 minutes before bed
• Diaphragmatic breathing exercises
• Option: mindfulness-based stress reduction (MBSR) — particularly helpful given comorbid anxiety

1. Shift Work Disorder Management:

• Advocate for a fixed shift schedule (preferably permanent night shift or permanent day shift) rather than rotating shifts — rotating shifts make circadian entrainment impossible
• Strategic light exposure: bright light (10,000 lux light box) during the first half of the night shift to promote alertness; dark sunglasses on the commute home to avoid morning light-induced circadian reset
• Melatonin 0.5-1 mg (not 10 mg — physiological dose) taken 30 minutes before desired daytime sleep after night shifts
• Strategic napping: 20-minute nap before night shifts (prophylactic napping) is evidence-based for shift worker safety

1. Medication management:

• Taper zolpidem gradually (reduce by 5 mg every 1-2 weeks) — prolonged use leads to tolerance, dependence, and worsens insomnia long-term (rebound insomnia); zolpidem also impairs next-day psychomotor performance (FDA black box warning at 10 mg in women)
• Discontinue diphenhydramine — anticholinergic effects, cognitive impairment, tolerance development, and associated with increased dementia risk with chronic use
• Continue escitalopram 10 mg — may consider dose optimization to 20 mg if anxiety and depression do not improve with CBT-I and improved sleep
• Melatonin: Reduce dose to 0.5-1 mg (physiological dose; 10 mg is supratherapeutic and may cause morning grogginess); use specifically for shift work circadian realignment, not as a hypnotic

1. Occupational safety:

• Discuss medication errors with occupational health in a supportive framework
• Request temporary schedule accommodation during initial sleep restriction therapy (most sleep-deprived period)
• Document sleep disorder diagnosis for workplace protections

1. CBT-I delivery:

• Structured 6-8 session program (weekly sessions, 50 minutes each) with a trained CBT-I therapist
• Option: digital CBT-I (e.g., Somryst/Pear Therapeutics FDA-cleared platform, or Sleepio) if in-person sessions are inaccessible due to work schedule
• Ongoing sleep diary completion throughout treatment (essential for monitoring progress and titrating the sleep window)

1. Follow-up schedule:

• Weekly during active CBT-I (6-8 weeks)
• Biweekly during zolpidem taper
• Monthly for 3 months after completing CBT-I
• Sleep diary and ISI score at each visit
• Reassess at 3 months: if ISI <8 (remission), transition to maintenance; if ISI remains >14, consider adjunctive pharmacotherapy (low-dose doxepin 3-6 mg — FDA-approved for sleep maintenance insomnia, or suvorexant 10-20 mg — dual orexin receptor antagonist)

Key Learning Points

• CBT-I is the recommended first-line treatment for chronic insomnia disorder in all major guidelines (AASM, ACP, ESRS), with response rates of 70-80% and sustained benefit at 1-year follow-up, unlike hypnotic medications which lose efficacy and carry risks of dependence and cognitive impairment.
• Sleep restriction therapy — the most potent component of CBT-I — works by building homeostatic sleep pressure through mild sleep deprivation, consolidating sleep into a shorter, more efficient window, and breaking the conditioned association between the bed and wakefulness. Initial worsening of sleepiness is expected and must be managed with safety precautions.
• Chronic use of sedative-hypnotics (zolpidem, benzodiazepines, diphenhydramine) for insomnia is associated with tolerance, dependence, rebound insomnia on discontinuation, cognitive impairment, falls (especially in elderly), complex sleep behaviors (sleep-driving, sleep-eating), and potential association with dementia; guidelines recommend limiting use to 2-4 weeks.
• The physiological dose of melatonin for circadian entrainment is 0.5-1 mg, not the 5-10 mg doses commonly available OTC; higher doses may paradoxically worsen sleep through morning grogginess, desensitization of melatonin receptors, and disruption of endogenous melatonin rhythm.
• Rotating shift work is a significant independent risk factor for chronic insomnia, and circadian misalignment cannot be adequately treated with CBT-I alone; workplace schedule modification, strategic light/dark exposure, and properly timed low-dose melatonin are essential adjuncts for shift workers with insomnia.

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