CBT-I Patient Assessment & Treatment Planning 3 — Questions and Answers
Question 1: A patient's two-week sleep diary shows a highly variable sleep schedule with bedtimes ranging from 10 PM to 2 AM. What does this pattern primarily suggest for treatment planning?
- Irregular sleep-wake rhythm requiring circadian stabilization as part of CBT-I (Correct answer)
- Paradoxical insomnia with no objective sleep disturbance
- Primary hypersomnia masking as insomnia
- Adequate sleep that does not require intervention
Correct answer: Irregular sleep-wake rhythm requiring circadian stabilization as part of CBT-I
Highly variable sleep timing indicates a disrupted circadian anchor, so consistent wake time is established first in CBT-I to stabilize the sleep-wake cycle.
Question 2: Which sleep diary variable is used as the primary metric when making week-to-week adjustments in sleep restriction therapy?
- Sleep efficiency (SE) averaged over the preceding week (Correct answer)
- Total sleep time (TST) on the best night of the week
- Sleep onset latency (SOL) on the worst night
- Number of awakenings per night
Correct answer: Sleep efficiency (SE) averaged over the preceding week
Weekly average SE guides TIB titration: SE ≥90% expands the window; SE <85% maintains or contracts it.
Question 3: A 72-year-old patient reports waking at 3 AM and being unable to return to sleep. Which assessment consideration is most age-specific for this presentation?
- Advanced sleep phase, which is more common in older adults and alters target bedtime recommendations (Correct answer)
- Higher likelihood of idiopathic insomnia than in younger patients
- Circadian rhythm disorder requiring melatonin before CBT-I
- Sleep restriction is absolutely contraindicated in patients over 65
Correct answer: Advanced sleep phase, which is more common in older adults and alters target bedtime recommendations
Older adults commonly experience an advanced sleep phase with earlier natural sleep and wake times, which must be incorporated into sleep window scheduling.
Question 4: During the assessment phase, a patient scores 16 on the PHQ-9 alongside an ISI of 19. What is the recommended CBT-I planning approach?
- Address both disorders concurrently using an integrated CBT protocol (Correct answer)
- Treat depression fully before initiating any CBT-I components
- Defer depression treatment until insomnia resolves
- Refer solely to psychiatry and discontinue CBT-I planning
Correct answer: Address both disorders concurrently using an integrated CBT protocol
Evidence supports treating comorbid insomnia and depression concurrently because improvement in sleep often amplifies antidepressant response.
Question 5: What information from a patient interview would most support a diagnosis of psychophysiological insomnia rather than another insomnia subtype?
- Sleeping better away from home and heightened arousal at bedtime in the home environment (Correct answer)
- Consistently sleeping fewer than 4 hours regardless of setting
- Sleep diary showing long sleep latency only on weekdays
- Reports of no difficulty falling asleep but frequent nightmares
Correct answer: Sleeping better away from home and heightened arousal at bedtime in the home environment
Psychophysiological insomnia is characterized by conditioned arousal; sleeping better in novel environments (e.g., hotels) is a hallmark diagnostic feature.
Question 6: A clinician notes that a patient has been prescribed zolpidem for 3 years. How does this affect the initial CBT-I treatment plan?
- Plan for gradual medication tapering coordinated with the prescriber as CBT-I progresses (Correct answer)
- Discontinue medication abruptly before starting CBT-I
- Avoid sleep restriction because benzodiazepine receptor agonists preclude it
- Begin CBT-I only after the patient has been medication-free for 6 months
Correct answer: Plan for gradual medication tapering coordinated with the prescriber as CBT-I progresses
Current guidelines recommend a coordinated, gradual taper alongside CBT-I rather than abrupt discontinuation or prolonged delay of behavioral therapy.
Question 7: Which of the following best describes the purpose of a prospective sleep diary (rather than retrospective questionnaires) in CBT-I assessment?
- It captures night-to-night variability and minimizes recall bias for accurate baseline and outcome data (Correct answer)
- It replaces actigraphy because it provides objective physiological measurements
- It is used solely to increase patient motivation for treatment
- It measures sleep architecture across sleep stages
Correct answer: It captures night-to-night variability and minimizes recall bias for accurate baseline and outcome data
Prospective daily recording minimizes retrospective recall bias and reveals variability patterns essential for setting prescriptive sleep windows in sleep restriction.
CBT-I Patient Assessment & Treatment Planning 3
A patient's two-week sleep diary shows a highly variable sleep schedule with bedtimes ranging from 10 PM to 2 AM.
What does this pattern primarily suggest for treatment planning?