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Cognitive-Behavioral Therapy for Insomnia in Patients With Cancer

Susan Crump Woodward
CJON 2011, 15(4), E42-E52 DOI: 10.1188/11.CJON.E42-E52

Sleep-wake disturbances, particularly insomnia, are among the most prevalent and distressing symptoms experienced by patients with cancer. As a result of extensive interdisciplinary research conducted since 2000, cognitive-behavioral therapy now is considered the standard of care for the treatment of insomnia in the general population and also has been upgraded to "likely to be effective" in the Oncology Nursing Society Putting Evidence Into Practice weight of evidence category. Cognitive-behavioral therapy is a multicomponent psychological and behavioral treatment designed to eliminate the perpetuating factors of insomnia. The most frequently used strategies are stimulus control, sleep restriction and relaxation therapies, paradoxical intention, sleep hygiene, and cognitive restructuring. Although this insomnia treatment recommendation has been well publicized, the nursing literature has not effectively translated the theories and principles of cognitive-behavioral therapy into practical guidelines or considerations for use by oncology staff nurses and advanced practitioners. This article attempts to demystify cognitive-behavioral therapy and provide nurses at different levels of practice a foundation from which to evaluate and potentially deliver this promising insomnia intervention.


Arving, C., Sjoden, P., Bergh, J., Hellbom, M., Johansson, B., Glimelius, B., & Brandberg, Y. (2007). Individual psychosocial support for breast cancer patients: A randomized study of nurse versus psychologist interventions and standard care. <i>Cancer Nursing, 30</i>, E10-E19. doi:10.1097/01.NCC.0000270709.64790.05

Arving, C., Sjoden, P., Bergh, J., Lindstrom, A.T., Wasteson, E., Glimelius, B., & Brandberg, Y. (2006). Satisfaction, utilisation, and perceived benefit of individual psychosocial support for breast cancer patients—A randomised study of nurse versus psychologist interventions. <i>Patient Education and Counseling, 62</i>, 235-243.

Babson, K.A., Feldner, M.T., & Badour, C.L. (2010). Cognitive behavioral therapy for sleep disorders. <i>Psychiatric Clinics of North America, 33</i>, 629-640. doi:10.1016/j.psc.2010.04.011

Bastien, C.H., Morin, C.M., Ouellet, M., Blais, F.C., & Bouchard, S. (2004). Cognitive-behavioral therapy for insomnia: Comparison of individual therapy, group therapy, and telephone consultations. <i>Journal of Consulting and Clinical Psychology, 72</i>, 653-659.

Beck, S.L., Dudley, W.N., & Barsevick, A. (2005). Pain, sleep disturbance, and fatigue in patients with cancer: Using a mediation model to test a symptom cluster [Online exclusive]. <i>Oncology Nursing Forum, 32</i>, E48-E55. doi:10.1188/05.ONF.E48-E55

Beersma, D.G. (1998). Models of human sleep regulation. <i>Sleep Medicine Reviews, 2</i>, 31-43.

Beersma, D.G. (2002). Insomnia and the two-process model of sleep regulation: Etiopathogenic considerations. <i>Journal of Clinical Psychiatry, 4</i>(Suppl. 1), 13-16.

Belanger, L., Savard, J., & Morin, C.M. (2006). Clinical management of insomnia using cognitive therapy. <i>Behavioral Sleep Medicine, 4</i>, 179-202.

Berger, A.M. (2009). Update on the state of the science: Sleep-wake disturbances in adult patients with cancer [Online exclusive]. <i>Oncology Nursing Forum, 36</i>, E165-E177. doi:10.1188/09.ONF.E165-E177

Berger, A.M., Farr, L.A., Kuhn, B.R., Fischer, P., & Agrawal, S. (2007). Values of sleep/wake, activity/rest, circadian rhythms, and fatigue prior to adjuvant breast cancer chemotherapy. <i>Journal of Pain and Symptom Management, 33</i>, 398-409.

Berger, A.M., Kuhn, B.R., Farr, L.A., Lynch, J.C., Agrawal, S., Chamberlain, J.G., & VonEssen, S.G. (2009). Behavioral therapy intervention trial to improve sleep quality and cancer-related fatigue. <i>Psycho-Oncology, 18</i>, 634-646. doi:10:1002/pon.1438

Berger, A.M., & Niedfelt, F. (2005). <i>Measuring oncology nursing-sensitive patient outcomes: Measurement summary: Sleep-wake disturbances</i>. Retrieved from <a target="_blank" href='http://ons.org/Research/PEP/media/ons/docs/research/measurement/sleep-di...

Berger, A.M., Parker, K.P., Young-McCaughan, S., Mallory, G.A., Barsevick, A.M., Beck, S.L., … Hall, M. (2005). Sleep/wake disturbances in people with cancer and their caregivers: State of the science [Online exclusive]. <i>Oncology Nursing Forum, 32</i>, E98-E126. doi:10.1188/05.ONF.E98-E126

Berger, A.M., VonEssen, S., Kuhn, B.R., Piper, B.F., Agrawal, S., Lynch, J.C., & Higginbotham, P. (2003). Adherence, sleep, and fatigue outcomes after adjuvant breast cancer chemotherapy: Results of a feasibility intervention study. <i>Oncology Nursing Forum, 30</i>, 513-522. doi:10.1188/03.ONF.513-522

Berger, A.M., VonEssen, S., Kuhn, B.R., Piper, B.F., Farr, L., Agrawal, S., … Higginbotham, P. (2002). Feasibility of a sleep intervention during adjuvant breast cancer chemotherapy. <i>Oncology Nursing Forum, 29</i>, 1431-1441. doi:10.1188/02.ONF.1431-1441

Bonnet, M.H., & Arand, D.L. (2010). Treatment of insomnia. Retrieved from <a target="_blank" href='http://www.uptodate.com/contents/treatment-of-insomnia?source=search_res...

Borbely, A.A., & Achermann, P. (2005). Sleep homeostasis and models of sleep regulation. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.), <i>Principles and practice of sleep medicine</i> (pp. 405-417). Philadelphia, PA: Elsevier Saunders.

Buysse, D.J. (2003). Diagnosis and classification of insomnia disorders. In M.P. Szuba, J.D. Kloss, & D.F. Dinges (Eds.), <i>Insomnia principles and management</i> (pp. 3-22). Cambridge, England: Cambridge University Press.

Chen, M.L., Yu, C.T., & Yang, C.H. (2008). Sleep disturbances and quality of life in lung cancer patients undergoing chemotherapy. <i>Lung Cancer, 62</i>, 391-400. doi:10.1016/J.lungcan.2008.03.016

Clark, J., Cunningham, M., McMillan, S., Vena, C., & Parker, K. (2004). Sleep-wake disturbances in people with cancer part II: Evaluating the evidence for clinical decision making. <i>Oncology Nursing Forum, 31</i>, 747-771. doi:10.1188/04.ONF.747-771

Dy, S.M., & Apostol, C.C. (2010). Evidence-based approaches to other symptoms in advanced cancer. <i>Cancer Journal, 16</i>, 507-513.

Ebben, M.R., & Spielman, A.J. (2009). Non-pharmacological treatments for insomnia. <i>Journal of Behavioral Medicine, 32</i>, 244-254. doi:10.1007/s10865-008-9198-8

Edinger, J.D. (2009). Is it time to step up to stepped care with our cognitive-behavioral insomnia therapies? <i>Sleep, 32</i>, 1539-1540.

Edinger, J.D., & Means, M.K. (2005). Cognitive-behavioral therapy for primary insomnia. <i>Clinical Psychology Review, 25</i>, 539-558.

Engstrom, C.A., Strohl, R.A., Rose, L., Lewandowski, L., & Stefanek, M.E. (1999). Sleep alterations in cancer patients. <i>Cancer Nursing, 22</i>, 143-148.

Epstein, D.R., & Dirksen, S.R. (2007). Randomized trial of a cognitive-behavioral intervention for insomnia in breast cancer survivors [Online exclusive]. <i>Oncology Nursing Forum, 34</i>, E51-E59. doi:10.1188/07.ONF.E51-E59

Espie, C.A. (2009). "Stepped care": A health technology solution for delivering cognitive behavioral therapy as a first-line insomnia treatment. <i>Sleep, 32</i>, 1549-1558.

Espie, C.A., Fleming, L., Cassidy, J., Samuel, L., Taylor, L.M., White, C.A., … Paul, J. (2008). Randomized controlled clinical effectiveness trial of cognitive behavior therapy compared with treatment as usual for persistent insomnia in patients with cancer. <i>Journal of Clinical Oncology, 26</i>, 4651-4658. doi:10.1200/JCO.2007.13.9006

Espie, C.A., MacMahon, K.M., Kelly, H., Broomfield, N.M., Douglas, N.J., Engleman, H.M., … Wilson, P. (2007). Randomized clinical effectiveness trial of nurse-administered small-group cognitive behavior therapy for persistent insomnia in general practice. <i>Sleep, 30</i>, 574-580.

Fiorentino, L., & Ancoli-Israel, S. (2007). Sleep dysfunction in patients with cancer. <i>Current Treatment Options in Neurology, 9</i>, 337-346.

Graci, G. (2005). Pathogenesis and management of cancer-related insomnia. <i>Journal of Supportive Oncology, 3</i>, 349-359.

Harvey, A.G. (2010). Insomnia. In D. McKay, J.S. Abramowitz, & S. Taylor (Eds.), <i>Cognitive-behavioral therapy for refractory cases: Turning failure into success</i> (pp. 277-295). Washington, DC: American Psychological Association.

Hearson, B., & Sawatzky, J.V. (2008). Sleep disturbance in patients with advanced cancer. <i>International Journal of Palliative Nursing, 14</i>, 30-37.

Hellbom, M., Brandberg, Y., Kurland, J., Arving, C., Thalen-Lindstrom, A., Glimelius, B., & Sjoden, P. (2001). Assessment and treatment of psychosocial problems in cancer patients: An exploratory study of a course for nurses. <i>Patient Education and Counseling, 45</i>, 101-106.

Hoffman, A.J., Given, B.A., von Eye, A., Gift, A.G., & Given, C.W. (2007). Relationships among pain, fatigue, insomnia and gender in persons with lung cancer. <i>Oncology Nursing Forum, 34</i>, 785-792. doi:10.1188/07.ONF.785-792

Hultman, T. (2006). It's not too late: Insomnia research and palliative care. <i>Journal of the American Psychiatric Nurses Association, 12</i>, 257-261. doi:10.1177/1078390306295069

Kozachik, S.L., & Bandeen-Roche, K. (2008). Predictors of patterns of pain, fatigue, and insomnia during the first year after a cancer diagnosis in the elderly. <i>Cancer Nursing, 31</i>, 334-344.

Kvale, E.A., & Schuster, J.L. (2006). Sleep disturbance in supportive care of cancer: A review. <i>Journal of Palliative Medicine, 9</i>, 437-450.

Lee, K.A., & Ward, T.M. (2005). Critical components of a sleep assessment for clinical practice settings. <i>Issues in Mental Health Nursing, 26</i>, 739-750. doi:10.1080/0161.2840591008320

McMillan, S.C., Tofthagen, C., & Morgan, M.A. (2008). Relationships among pain, sleep disturbances, and depressive symptoms in outpatients from a comprehensive cancer center. <i>Oncology Nursing Forum, 35</i>, 603-611. doi:10.1188/08.ONF.603-611

Morin, C.M., Beaulieu-Bonneau, S., LeBlanc, M., & Savard, J. (2005). Self-help treatment for insomnia: A randomized controlled trial. <i>Sleep, 28</i>, 1319-1327.

National Cancer Institute. (2010). Sleep disorders (PDQ®). Retrieved from <a target="_blank" href='http://www.cancer.gov/cancertopics/pdq/supportivecare/sleepdisorders'>ht...

O'Donnell, J.F. (2004). Insomnia in cancer patients. <i>Clinical Cornerstone, 6</i>(Suppl. 1D), S6-S14.

O'Donohue, W., & Krasner, L. (1995). Theories in behavior therapy: Philosophical and historical contexts. In W. O'Donohue & L. Krasner (Eds.), <i>Theories of behavior therapy: Exploring behavior change</i> (pp. 1-22). Washington, DC: American Psychological Association.

Oncology Nursing Society. (2008). <i>ONS Putting Evidence Into Practice: Sleep-wake disturbances definition list</i>. Retrieved from <a target="_blank" href='http://ons.org/Research/PEP/media/ons/docs/research/outcomes/sleep/defin...

Otte, J.L., & Carpenter, J.S. (2009). Theories, models, and frameworks related to sleep-wake disturbances in the context of cancer. <i>Cancer Nursing, 32</i>, 90-104.

Page, M.S., & Berger, A.M. (2009). Sleep-wake disturbances. In L.H. Eaton & J.M. Tipton (Eds.), <i>Putting Evidence Into Practice: Improving oncology patient outcomes</i> (pp. 285-297). Pittsburgh, PA: Oncology Nursing Society.

Page, M.S., Berger, A.M., & Johnson, L.B. (2006). Putting Evidence Into Practice: Evidence-based interventions for sleep-wake disturbances. <i>Clinical Journal of Oncology Nursing, 10</i>, 753-767. doi:10.1188/06.CJON.753-767

Parker, K.P., Bliwise, D.L., Ribeiro, M., Jain, S.R., Vena, C.I., Kohles-Baker, K.K., … Harris, W.B. (2008). Sleep/wake patterns of individuals with advanced cancer measured by ambulatory polysomnography. <i>Journal of Clinical Oncology, 26</i>, 2464-2472.

Payne, J.K., Held, J., Thorpe, J., & Shaw, H. (2008). Effect of exercise on biomarkers, fatigue, sleep disturbances, and depressive symptoms in older women with breast cancer receiving hormonal therapy. <i>Oncology Nursing Forum, 35</i>, 635-642.

Perlis, M.L., Jungquist, C., Smith, M.T., & Posner, D. (2008). <i>Cognitive behavioral treatment of insomnia: A session-by-session guide.</i> New York, NY: Springer.

Potter, P.A., & Perry, A.G. (2009). Sleep. In P.A. Potter & A.G. Perry (Ed.), <i>Fundamentals of nursing</i> (7th ed., pp. 1028-1049). St. Louis, MO: Mosby Elsevier.

Quesnal, C., Savard, J., Simard, S., Ivers, H., & Morin, C.M. (2003). Efficacy of cognitive-behavioral therapy for insomnia in women treated for nonmetastatic breast cancer. <i>Journal of Consulting and Clinical Psychology, 71</i>, 189-200. doi:10.1037/0022-006X71.1.189

Reeve, K., & Bailes, B. (2010). Insomnia in adults: Etiology and management. <i>Journal for Nurse Practitioners, 6</i>, 53-60. doi:10.1016/nurpra.2009.09.013

Savard, J., & Morin, C. (2001). Insomnia in the context of cancer: A review of a neglected problem. <i>Journal of Clinical Oncology, 19</i>, 895-908.

Savard, J., Simard, S., Ivers, H., & Morin, C.M. (2005). Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part II: Immunologic effects. <i>Journal of Clinical Oncology, 23</i>, 6097-6105. doi:10.1200/JCO.2005.12.513

Savard, J., Villa, J., Simard, S., Ivers, H., & Morin, C.M. (2010). Feasibility of a self-help treatment for insomnia comorbid with cancer. <i>Psycho-Oncology</i>. Advance online publication. doi:10.1002/pon.1818

Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. <i>Journal of Clinical Sleep Medicine, 4</i>, 487-504.

Simeit, R., Deck, R., & Conta-Marx, B. (2004). Sleep management training for cancer patients with insomnia. <i>Supportive Care in Cancer, 12</i>, 176-183. doi:10.1007/s00520-004-0594-5

Tremblay, V., Savard, J., & Ivers, H. (2009). Predictors of the effect of cognitive behavioral therapy for chronic insomnia comorbid with breast cancer. <i>Journal of Counseling and Clinical Psychology, 77</i>, 742-750. doi:10.1037/a0015493

Vena, C., Parker, K., Cunningham, M., Clark, J., & McMillan, S. (2004). Sleep-wake disturbances in people with cancer part I: An overview of sleep, sleep regulation, and effects of disease and treatment. <i>Oncology Nursing Forum, 31</i>, 735-746. doi:10.1188/04.ONF.735-746

Vena, C., Parker, K.P., Allen, R., Bliwise, D.L., Jain, S., & Kimble, L. (2006). Sleep-wake disturbances and quality of life in patients with advanced lung cancer. <i>Oncology Nursing Forum, 33</i>, 761-769. doi:10.1188/06.ONF.761-769

Vincent, N., & Lewycky, S. (2009). Logging on for better sleep: RCT of the effectiveness of online treatment for insomnia. <i>Sleep, 32</i>, 807-815.

Yamamoto, D.S. (2010). Identifying and treating insomnia in the adult cancer patient. <i>Journal of the Advanced Practitioner in Oncology, 1</i>, 107-115.

Young-McCaughan, S., Mays, M.Z., Arzola, S.M., Yoder, L.H., Dramiga, S.A., Leclerc, K.M., … Nowlin, M.U. (2003). Change in exercise tolerance, activity and sleep patterns, and quality of life in patients with cancer participating in a structured exercise program. <i>Oncology Nursing Forum, 30</i>, 441-450. doi:10.1188/03.ONF.441-454