CBT for insomnia

• A. Sleeping more than 10 hours per night on a regular basis
• B. Persistent difficulty falling asleep, staying asleep, or waking too early, with daytime impairment
• C. Occasionally feeling tired after a late night out
• D. Needing naps during the day despite a full night of sleep

• A. The person feels fully rested and sleeps better the next night without intervention
• B. Worry about sleep increases, leading to heightened arousal and further difficulty sleeping
• C. The body automatically compensates by reducing the need for sleep
• D. Daytime alertness improves, which naturally reduces sleep anxiety

• A. Consistent wake times across the week
• B. Spending excessive time in bed trying to force sleep
• C. Regular daytime physical activity
• D. Keeping a stable bedtime routine

• A. The physical exercise done in the evening to tire the body
• B. Deliberately trying harder to fall asleep, which typically increases arousal and wakefulness
• C. The number of hours a person spends in bed each night
• D. Relaxation techniques practiced before bed

• A. They increase sleep pressure so strongly that sleep becomes deeper
• B. They often lead to daytime napping, extra caffeine, or reduced activity, which can disrupt the next night's sleep
• C. They cause the body to produce more melatonin during the day
• D. They have no measurable effect on subsequent nights of sleep

• A. The bed and bedroom can become associated with wakefulness and frustration rather than sleep
• B. Arousal is only a problem for people who exercise late at night
• C. Insomnia is caused solely by an imbalance of brain chemicals
• D. People with insomnia are unable to learn new associations with sleep

• A. Going to bed earlier than usual to make up for lost sleep
• B. Keeping a consistent wake-up time every day, including weekends ✓
• C. Napping for at least two hours in the afternoon to recover energy
• D. Staying in bed until you feel sleepy, even if you are awake for hours

Why: A consistent wake-up time helps regulate the body's circadian rhythm, which strengthens the internal sleep-wake cycle. Going to bed early or taking long naps can disrupt this rhythm, and staying in bed while awake for long periods can weaken the association between bed and sleep.

• A. Caffeine causes dehydration, which wakes people during the night
• B. Caffeine has a half-life of several hours and can interfere with falling asleep and sleep quality ✓
• C. Caffeine raises body temperature to a level that prevents any sleep
• D. Caffeine permanently reduces the brain's ability to produce melatonin

Why: Caffeine has a half-life of roughly 5 to 6 hours, meaning a large portion remains in the body long after consumption. This can delay sleep onset and reduce deep sleep, even if the person does not feel strongly stimulated.

• A. Keep the room warm, bright, and quiet to feel safe and comfortable
• B. Use the bed for work and television so the body feels relaxed in it
• C. Keep the room cool, dark, and quiet, reserving the bed for sleep and intimacy ✓
• D. Leave a bright light on all night to reduce anxiety about waking up

Why: A cool, dark, and quiet environment supports the body's natural drop in core temperature and melatonin release. Limiting the bed to sleep and intimacy strengthens the mental association between the bed and sleep.

• A. Reading a physical book under dim light before bed
• B. Taking a warm bath about an hour before bedtime
• C. Using bright screens or doing intense exercise right before bed ✓
• D. Practicing a relaxing breathing exercise in bed

Why: Bright screen light, especially blue-enriched light, can suppress melatonin production and signal wakefulness. Intense exercise close to bedtime raises heart rate and body temperature, which can delay sleep onset. Dim reading, warm baths, and relaxation exercises generally promote sleepiness.

• A. Remain in bed and keep trying harder to fall asleep
• B. Check the clock frequently to track how much time has passed
• C. Get out of bed and do a quiet, low-light activity until feeling sleepy ✓
• D. Eat a large snack to make the body feel tired enough to sleep

Why: Staying in bed while frustrated and awake can create negative associations with the bed and increase arousal. Getting up and doing a calm, low-light activity until sleepy helps restore the link between bed and sleep. Clock-watching and large meals tend to increase anxiety or discomfort.

• A. To increase the total number of hours spent in bed
• B. To strengthen the association between the bed and sleep, and weaken associations between the bed and wakefulness
• C. To eliminate all daytime naps regardless of sleep need
• D. To encourage watching television in bed to promote relaxation

• A. Remain in bed and keep trying harder to fall asleep
• B. Drink a large glass of water and check the clock frequently
• C. Get out of bed and go to another room to do a quiet, relaxing activity until sleepy
• D. Stay in bed and watch a stimulating movie to distract the mind

• A. Use the bed for reading, eating, and working so the body gets comfortable there
• B. Go to bed only when sleepy, and use the bed only for sleep and sex
• C. Keep a consistent bedtime only on weekdays and sleep in as much as desired on weekends
• D. Check the clock often to monitor how long it has been since lying down

• A. It allows the person to catch up on lost sleep by sleeping in later the next day
• B. It helps regulate the circadian rhythm and strengthens the sleep-wake cycle
• C. It prevents the person from feeling tired during the day regardless of sleep quality
• D. It replaces the need for any other sleep hygiene practices

• A. Nap for long periods in the afternoon to make up for lost sleep at night
• B. Avoid napping, or keep naps brief and early in the day, to protect nighttime sleep drive
• C. Nap in bed whenever feeling tired to reinforce the bed-sleep connection
• D. Take frequent long naps in the evening just before going to bed

• A. To increase the total amount of time spent in bed
• B. To consolidate sleep by temporarily limiting time in bed to match actual sleep time ✓
• C. To eliminate all daytime napping permanently
• D. To force the body to sleep during the day

Why: Sleep restriction therapy limits time in bed to roughly the amount of sleep a person actually gets. This builds sleep pressure (the drive to sleep), which helps consolidate fragmented sleep and improve sleep efficiency.

• A. The total hours slept in a 24-hour period
• B. The percentage of time in bed actually spent asleep ✓
• C. The speed at which a person falls asleep after lights out
• D. The number of times a person wakes during the night

Why: Sleep efficiency is calculated as total sleep time divided by total time in bed, multiplied by 100. Sleep restriction aims to raise this value, typically toward 85% or higher, before gradually expanding time in bed.

• A. 8 hours, to ensure adequate rest
• B. 10 hours, to compensate for the poor sleep
• C. Approximately 5 hours, matching average actual sleep time ✓
• D. 3 hours, to create maximum sleep pressure

Why: The initial sleep window is set close to the patient's average actual sleep time, often with a minimum floor (commonly around 5 hours). Setting it too low, such as 3 hours, risks excessive sleepiness and safety concerns, so clinicians aim for a moderate restriction.

• A. Increased energy and alertness throughout the day
• B. Temporary daytime sleepiness and fatigue ✓
• C. Immediate elimination of all nighttime awakenings
• D. Weight loss due to increased metabolism

Why: Because total time in bed is reduced, patients often feel tired during the day initially. This typically improves as sleep consolidates and sleep pressure becomes balanced, but clinicians should monitor for safety, especially with driving.

• A. Reduce the sleep window further by one hour
• B. Increase time in bed by about 15 to 30 minutes ✓
• C. Stop the therapy and discontinue all sleep schedule guidance
• D. Begin taking sleep medication nightly

Why: Once sleep efficiency reaches the target threshold of about 85%, the sleep window is gradually expanded, usually by 15 to 30 minutes at a time, until the patient reaches a sufficient and comfortable amount of sleep while maintaining good efficiency.

• A. Eliminating all thoughts before bed
• B. Reducing the emotional intensity and sleep-disrupting impact of worrying thoughts ✓
• C. Replacing sleep with relaxation exercises entirely
• D. Avoiding any discussion of daytime problems

Why: CBT for insomnia does not aim to stop all thinking, which is unrealistic. Instead, it helps people change how they relate to worrying thoughts so those thoughts interfere less with falling and staying asleep.

• A. Worrying as intensely as possible so the mind becomes exhausted
• B. Setting aside a fixed time earlier in the day to write down and address worries, so they are less likely to intrude at bedtime ✓
• C. Worrying only while lying in bed to keep the mind active
• D. Ignoring all concerns until the morning

Why: Scheduled worry time contains worrying to a specific, limited window earlier in the day. Writing worries down with possible next steps often reduces the sense that they must be resolved immediately at night.

• A. Checking the clock frequently to track how much sleep is being lost
• B. Using a 'cognitive shuffle' or focusing on neutral, unrelated images or words to gently redirect attention ✓
• C. Trying harder and harder to force yourself to fall asleep
• D. Reviewing every unresolved problem in detail to find a solution

Why: Cognitive shuffling uses random, neutral words or images to reduce the effort of trying to sleep and interrupt goal-directed problem solving. Clock-checking and forced effort tend to increase arousal and worsen insomnia.

• A. Because such beliefs are always completely accurate and should be accepted
• B. Because catastrophic beliefs about sleep loss increase anxiety, which in turn makes sleep harder to achieve ✓
• C. Because challenging beliefs guarantees immediate sleep
• D. Because beliefs about sleep have no effect on how a person feels

Why: Catastrophic thoughts about sleep create anxiety and performance pressure, which maintain insomnia. Examining the evidence and recognizing that one night of poor sleep is usually manageable reduces this cycle.

• A. Turn on bright lights and start working on the problem
• B. Remain in bed without forcing sleep, use a calm mental focus technique, and get up only if unable to rest for an extended period, returning to bed when sleepy ✓
• C. Stay in bed and check your phone for information about your worries
• D. Stop all relaxation efforts and worry until morning

Why: CBT for insomnia recommends avoiding stimulation, not forcing sleep, and using calm focus techniques. Getting up after prolonged wakefulness and returning only when sleepy helps the brain re-associate the bed with sleep.

• A. To eliminate all nighttime awakenings permanently
• B. To help the patient recognize early warning signs of returning sleep difficulties and respond with skills already learned ✓
• C. To replace sleep restriction therapy with sleep medication
• D. To ensure the patient never experiences a poor night of sleep again

Why: Relapse prevention focuses on equipping patients to identify early warning signs of sleep problems and apply the CBT-I skills they have learned, rather than expecting perfect sleep at all times. Occasional poor nights are normal and expected.

• A. Immediately return to sleeping in longer time-in-bed periods
• B. Stop using all previously learned strategies until sleep normalizes
• C. Recognize the situation as a temporary stressor, apply stimulus control and cognitive strategies, and avoid catastrophizing about the setback ✓
• D. Begin taking sleep medication nightly to prevent further disruption

Why: Effective relapse prevention teaches patients to view isolated setbacks as expected and manageable. Applying learned skills calmly, while avoiding catastrophic thinking about the setback, helps prevent a minor disruption from becoming a full relapse.

• A. Keeping a detailed sleep diary indefinitely at the same intensity as during treatment
• B. Avoiding all contact with the therapist for the rest of the patient's life
• C. Continuing to maintain a consistent wake time and stimulus control habits ✓
• D. Gradually increasing time in bed each week regardless of sleep efficiency

Why: Maintaining a consistent wake time and stimulus control habits are core behavioral components that sustain improvements. Sleep diaries can be used selectively, and time in bed should remain guided by sleep efficiency rather than increased arbitrarily.

• A. So they can avoid sleeping altogether during those periods
• B. So they can plan ahead to use coping strategies before sleep problems develop ✓
• C. So they can request additional sedating medications from their physician
• D. So they can document every possible cause of insomnia for future diagnosis

Why: Identifying high-risk situations such as travel, illness, major life stress, or schedule changes allows patients to prepare and apply coping strategies proactively. This reduces the likelihood that temporary disruptions will progress into chronic sleep difficulties.

• A. Yes, sleep restriction must be followed rigidly for life without any adjustment
• B. No, the patient should abandon all CBT-I principles once treatment concludes
• C. Sleep restriction is typically liberalized gradually as sleep efficiency improves, and the patient should follow a planned maintenance schedule with their therapist ✓
• D. The patient should double their time in bed immediately upon completing treatment

Why: Sleep restriction is usually adjusted gradually as sleep efficiency improves, with a planned approach to liberalizing time in bed. Core habits like consistent wake times are maintained, but rigid restriction is not required indefinitely, and abruptly abandoning or doubling time in bed risks relapse.