DESCRIPTION:
DBT-I – the most effective therapy for the most common sleep disorders: Cognitive behavioural therapy for insomnia and other sleep disorders

Sleep disorder (insomnia): Why cognitive behavioural therapy CBT-I is the first choice for non-organic insomnia

Brief introduction:
Millions of people in the United Kingdom suffer from sleep-wake disorders (insomnia) – and the number is rising. The form formerly known as "non-organic insomnia" is one of the most common sleep disorders. Many sufferers initially turn to medication, which alleviates symptoms in the short term but does not offer a long-term solution. According to studies and professional associations, cognitive behavioural therapy for insomnia (CBT-I) is the treatment of choice – even for insomnia associated with psychiatric disorders. Read this comprehensive overview to find out why this form of therapy is so effective and how you can benefit from it.

1. What is insomnia – and how does the non-organic form differ?

Insomnia is a persistent sleep disorder that causes difficulty falling asleep and staying asleep – sometimes for weeks, often for months, and many sufferers develop serious insomnia. The diagnosis is made when the sleep problems lead to impairments in everyday life: difficulty concentrating, irritability, decreased performance or increased emotional vulnerability are among the typical accompanying symptoms. In the International Classification of Sleep Disorders (ICSD-3), non-organic insomnia is listed as a separate disorder. This means that there is no underlying organic cause such as a respiratory disorder or neurological disease – the cause is rather psychological, behavioural or situational.

According to the German Society for Sleep Research and Sleep Medicine (DGSM), non-organic insomnia is one of the most common sleep disorders. It affects not only older people – young adults, parents of young children, people with busy jobs or those with depressive symptoms also frequently develop chronic insomnia. Particularly common are difficulties falling asleep and staying asleep, i.e. delayed sleep onset and waking up during the night with problems getting back to sleep. For many sufferers, the symptoms persist for years and significantly impair physical and mental health.

2. How common is insomnia – and who is particularly affected?

Epidemiological studies show that around 15% of adults develop chronic insomnia – and the trend is rising. Even more people experience temporary sleep problems during their lifetime. The GoodNight Study and controlled studies from Lancet Psychiatry and the Journal of Clinical Psychology show that non-organic insomnia is widespread in Western societies, with a particularly high prevalence among women, shift workers and people with a history of mental illness.

Patients with so-called psychiatric comorbid insomnia – such as childhood trauma, depression, anxiety disorders or post-traumatic stress disorder – often develop non-organic insomnia, which is perpetuated by unhealthy sleep habits and worries. Sleep problems are also often exacerbated in older people by an irregular daily routine, less exercise or spending too much time in bed. Studies on dysfunctional beliefs about sleep also show that negative expectations further exacerbate the severity of insomnia.

3. Why sleeping pills are not a long-term solution

Many sufferers initially turn to medication, usually in the form of valerian, tryptophan, benzodiazepines or so-called Z-substances. These drugs can make it easier to fall asleep in the short term, but they do not combat the causes of non-organic insomnia. The effect often wears off after just a few weeks, and there is a risk of dependence with many medications. In addition, controlled studies (including Riemann et al. and Griffiths et al.) show that sleeping pills often only slightly improve sleep efficiency – while increasing the risk of dependence, memory problems and falls.

Current guidelines for the treatment of sleep disorders therefore emphasise that cognitive behavioural therapy for insomnia (CBT-I) is preferable to medication. CBT-I has no side effects, is effective and leads to long-term improvements in insomnia symptoms in the majority of patients – even those with comorbid conditions. According to a meta-analysis (van Straten et al.), the effects of therapy often remain stable for years – an advantage that no medication offers.

4. What exactly is cognitive behavioural therapy for insomnia (CBT-I)?

Cognitive behavioural therapy for insomnia (CBT-I) is currently the most widely researched and effective psychotherapeutic treatment for chronic insomnia. It is internationally recognised as the treatment of choice, both by the American Academy of Sleep Medicine and according to European guidelines. In the new ICD-11, chronic insomnia is listed under diagnosis code 7A00 in the chapter "Sleep-Wake Disorders," which underscores its importance. The new classification not only increases the visibility of the condition, but also emphasises that it is a distinct disorder – independent of psychiatric or somatic comorbidities.

CBT-I was specifically developed to treat the underlying mechanisms of insomnia: unfavourable sleep habits, dysfunctional thoughts about sleep and an overactive mind at bedtime. The goal is not to force sleep, but to "let it happen" again by identifying and systematically changing disruptive patterns. Unlike drug therapy, which only suppresses symptoms, CBT-I changes the interaction between behaviour, thinking and biological activation in the long term.

CBT-I comprises several components: sleep restriction, stimulus control, cognitive restructuring, relaxation techniques and strategies to improve sleep efficiency (see glossary at the end). Together, these components stabilise the sleep-wake cycle, re-associate time in bed with actual sleep and continuously reduce the severity of insomnia. Studies show that many patients experience significant improvement after just a few sessions – without medication and with stable effects even after the end of therapy (a meta-analysis, journal of clinical psychology).

5. How does stimulus control work for chronic insomnia?

Stimulus control is a central component of cognitive behavioural therapy for insomnia. It is based on a simple principle: the bed and the bedroom should be associated exclusively with sleep – not with brooding, lying awake or screen time. People with chronic insomnia often spend a lot of time in bed but only sleep for a few hours. This creates a paradoxical connection in the brain: the bed is not experienced as a place of rest, but as a place of tension and frustration.

The aim of stimulus control is to actively break this faulty association. In therapy, patients learn to only go to bed when they are actually sleepy – and to get out of bed immediately if they lie awake for longer than 15–20 minutes. Activities such as reading, watching television or ruminating in bed are also consistently avoided. This re-establishes a clear, conditioned association between bed and sleep – and sleep efficiency improves step by step.

This method may seem inconvenient at first glance, but clinical studies have shown it to be highly effective. Riemann et al. and Edinger J. show that stimulus control has a particularly significant effect on people with long-standing sleep problems. Consistent application is essential, especially in the first two weeks of therapy. Many sufferers report that this targeted intervention makes them feel tired when they go to bed for the first time in years. Insomnia is not suppressed, but actively relearned.

6. What does sleep restriction mean – and why is it so effective?

Sleep restriction is another core technique of cognitive behavioural therapy for insomnia – and at first glance, it seems counterintuitive. Many people with chronic insomnia spend eight to nine hours in bed, hoping to get at least a little sleep. In fact, however, this strategy leads to a mismatch between time spent in bed and actual sleep duration, resulting in greatly reduced sleep efficiency. The result: dissatisfaction, frustration and an even more disturbed sleep-wake rhythm.

This is exactly where sleep restriction comes in. The first step is to record the average amount of sleep in a sleep diary – for example, four hours of actual sleep during eight hours in bed. In therapy, the time allowed in bed is then reduced to this actual sleep duration. This time restriction increases sleep pressure, stabilises the circadian rhythm and leads to deeper and more continuous sleep. As soon as sleep efficiency improves (e.g. above 85%), the sleep window is gradually extended.

Numerous studies – for example, from the Journal of Clinical Psychology and Lancet Psychiatry – show the high efficacy of sleep restriction in patients with insomnia. In the GoodNight Study, over 70% of participants also reported a significant improvement. Particularly noteworthy is that this technique also works for patients with psychiatrically comorbid insomnia, such as those with accompanying depression or anxiety disorders. Individual adaptation and careful therapeutic support are crucial – then sleep restriction proves to be a highly effective remedy for years of sleep problems.

7. How does CBT-I change negative thoughts about sleep?

In addition to behavioural methods such as sleep restriction and stimulus control, cognitive behavioural therapy for insomnia specifically addresses the thought patterns that negatively influence sleep. People with insomnia often develop dysfunctional beliefs about their sleep over a long period of time, such as: "I absolutely need eight hours of sleep, otherwise I can't function," or: "If I sleep badly tonight, the whole day will be a disaster." Such beliefs and attitudes about sleep create internal pressure and promote a state of cognitive hyperarousal – exactly the opposite of what promotes restful sleep.

The cognitive restructuring within CBT-I aims to make these automated thought patterns conscious, question them and develop more realistic alternatives. Learn to identify your thoughts and attitudes towards sleep, check their validity and break away from rigid expectations. For example, the thought "I'm going to fail tomorrow" can be replaced with the statement "I've functioned well with less sleep before – my body will get the rest it needs." This reduces the level of mental arousal, especially before falling asleep.

The effectiveness of this approach is well documented scientifically. In numerous studies, Insomnia Severity Index scores decrease significantly as soon as cognitive techniques are integrated. A meta-analysis by van Straten et al. shows that the combination of cognitive and behavioural elements in particular produces particularly lasting therapeutic effects. These strategies are also particularly helpful for people with psychiatric comorbid insomnia, as rumination, catastrophising and fear of sleep are particularly pronounced in these cases. CBT-I breaks this cycle and leads step by step to a more relaxed, realistic approach to sleep.

8. What do clinical studies say about the effectiveness of CBT-I?

Cognitive behavioural therapy for insomnia (CBT-I) is considered the best-studied method for treating chronic sleep disorders. There are now over 100 randomised controlled studies that prove its high effectiveness – not only in comparison to placebo, but also to drug therapy. A meta-analysis by van Straten et al. shows that CBT-I significantly increases sleep efficiency, shortens sleep latency and improves sleep duration – and does so in the long term. The improvements often last for months or years after the end of therapy (efficacy of long-term CBT-I).

In addition, several studies have shown that CBT-I also reduces depressive symptoms – even when these were not explicitly the focus of therapy. This shows that treating insomnia has a positive effect on physical and mental health beyond sleep itself. The results are particularly convincing in cases of co-occurring mental illness. The effectiveness of CBT-I for psychiatric comorbid insomnia has been positively assessed in all systematic reviews.

Another advantage is that the dropout rate for CBT-I is low compared to other psychotherapeutic methods. In the GoodNight Study, less than 20% of participants discontinued therapy – a figure that is well below the average for many long-term interventions. The individual response to CBT-I is crucial to the success of the therapy and is facilitated by a good therapeutic relationship, structured implementation and realistic expectations. Whether in individual or group settings, digitally or in person, CBT-I has proven itself in clinical studies through its clarity, effectiveness and sustainability.

9. How does CBT-I work in practice – digitally or in a clinic?

Classic cognitive behavioural therapy for insomnia usually comprises six to eight sessions, which take place weekly or biweekly. In therapeutic practice, CBT-I begins with a structured medical history, the assessment of sleep behaviour using a sleep diary and the setting of individual therapy goals. Key components then include sleep restriction, stimulus control, cognitive restructuring and relaxation techniques. Patients are given specific tasks to complete between sessions and reflect on their effects in therapeutic dialogue. This approach corresponds to the specialist field of behavioural therapy – goal-oriented, transparent and practical.

With the advancement of digital healthcare, CBT-I is now also available as an online programme. Several digital health applications (DiGA) that have been reviewed by the Federal Institute for Drugs and Medical Devices (BfArM) offer structured, scientifically based treatment programmes for chronic insomnia. These programmes also include sleep logs, video instructions, cognitive exercises and feedback on sleep efficiency – some even with integrated support from specialists. Initial results show that digital CBT-I formats are just as effective as face-to-face therapy, especially for tech-savvy, motivated users.

Regardless of the format, a medical examination is recommended before starting therapy to rule out other causes of insomnia, such as sleep-related breathing disorders (e.g. obstructive sleep apnoea), circadian rhythm disorders or parasomnic phenomena. If the diagnosis of chronic insomnia (ICD-11: 7A00) is confirmed, CBT-I is an evidence-based, guideline-compliant treatment that can lead to a profound improvement in sleep behaviour in many cases after just a few weeks.

10. Who is CBT-I particularly suitable for – and who benefits most?

Cognitive behavioural therapy for insomnia is suitable for all adults with chronic insomnia, regardless of age, gender or occupation. However, patients whose sleep disorder is not caused by organic factors such as a neurological disorder or sleep apnoea syndrome benefit particularly. Studies show that CBT-I is also effective in cases of long-term suffering, even when previous drug therapies have been unsuccessful or caused side effects. CBT-I can be a liberating turning point, especially for people with high levels of suffering, professional responsibilities or family stress.

CBT-I is also ideal for people with psychiatric comorbid insomnia, i.e. those who suffer from insomnia alongside depression, anxiety disorders or post-traumatic stress disorder. Unlike many other psychotherapeutic methods, CBT-I does not show reduced effects in these cases. On the contrary, the improvement in sleep has a stabilising effect on overall mental balance. People with chronic stress, high perfectionism or dysfunctional beliefs about sleep also often experience a significant reduction in their insomnia symptoms through CBT-I.

Last but not least, CBT-I is also interesting in the context of prevention. People who suffer from acute insomnia repeatedly – for example, during stressful phases of life – can specifically counteract chronicity through the early application of CBT-I elements (e.g. stimulus control, sleep hygiene, cognitive self-instruction). In this sense, CBT-I is not only a therapy, but also training in healthy sleep culture. Teaching everyday strategies strengthens self-efficacy and reduces dependence on external sleep aids, whether pharmacological or external stimuli.

11. Conclusion: Why CBT-I is recommended for insomnia

CBT-I – cognitive behavioural therapy for insomnia – is currently the most scientifically proven method for treating chronic sleep disorders. It is recommended as the first-line treatment in all current guidelines, regardless of whether insomnia occurs alone or in combination with other mental illnesses. Unlike drug therapy, which often leads to tolerance, side effects and dependence, CBT-I addresses the root causes of the disorder: dysfunctional behaviour, stressful thought patterns and disturbed sleep-wake regulation.

Thanks to the new classification in the ICD-11 somnology, which lists sleep-wake disorders in a separate chapter (Chapter 7) for the first time, the importance of chronic insomnia is also being recognised more widely at the diagnostic level. The more specific coding – e.g. as 7A00 for chronic insomnia – enables more targeted referral, more accurate choice of therapy and a better basis for research. This not only strengthens sleep medicine, but also raises awareness that insomnia is not merely a symptom, but a distinct disorder with serious implications for physical and mental health.

Cognitive behavioural therapy for insomnia combines the best of both worlds: scientific evidence and practical applicability. Whether in therapeutic practice or as a digital health application, the methods are clearly structured, effective and adaptable to individual needs. People report not only better sleep, but also more energy, emotional stability and a new confidence in their own ability to regenerate. CBT-I thus offers not only a treatment for sleep disorders, but also a sustainable path to a more restful life.

Key findings at a glance

Insomnia is one of the most common sleep disorders and affects up to 15% of adults on a permanent basis.

The new ICD-11 no longer treats sleep disorders as secondary diagnoses, but lists them as separate disorders.

CBT-I is the first-line treatment for chronic insomnia – effective, free of side effects and scientifically proven.

The core elements are stimulus control, sleep restriction, cognitive restructuring and improving sleep efficiency.

The therapy is particularly suitable for people with high levels of suffering, psychiatric comorbidities and for those who want to improve their sleep skills.

Digital offerings such as certified health apps open up new avenues for CBT-I.

Meta-analyses and controlled studies prove the long-term effectiveness of CBT-I, even in severe cases.

Frequently asked questions about the treatment of insomnia (Q&A)

What is insomnia?

Insomnia is a persistent sleep disorder that manifests itself in difficulty falling asleep, waking up during the night or waking up very early – usually over a period of weeks or months. The decisive factor is that the sleep problems noticeably impair everyday life – for example, through exhaustion, concentration problems or irritability. In the new ICD-11, chronic insomnia is listed as a separate disorder (code 7A00) in the chapter on "Sleep and wakefulness disorders" and is no longer classified as a mere symptom of mental disorders. The disorder is one of the most common sleep disorders in Western societies.

What psychotherapy is available for sleep disorders?

The scientifically recommended psychotherapy for insomnia is cognitive behavioural therapy for insomnia (CBT-I). It is the first-line treatment for chronic insomnia and is recommended by professional associations such as the German Society for Sleep Research and Sleep Medicine (DGSM) and in international guidelines. The treatment of sleep disorders with CBT-I targets the causes of sleep problems: entrenched behaviour patterns, dysfunctional thoughts about sleep and poor sleep hygiene.

What is the best therapy for sleep problems?

According to current studies, cognitive behavioural therapy for insomnia (CBT-I) is the most effective method for treating chronic sleep problems. Unlike medication, which only alleviates symptoms, CBT-I changes the behaviour and thoughts that disrupt sleep. It improves sleep efficiency, strengthens sleep-wake regulation and reduces suffering in the long term – without side effects or the risk of dependency. In controlled studies, CBT-I showed significantly better results than any other single measure, including medication.

Does CBT-I really work?

Yes – cognitive behavioural therapy for insomnia (CBT-I) has been proven in numerous clinical studies. Meta-analyses show that over 70% of patients experience a significant improvement in their sleep behaviour. The effectiveness of CBT-I is particularly long-lasting: the positive effects often last for years, even in patients with psychiatric comorbid insomnia. Even depressive symptoms often improve within the framework of successful CBT-I. It works in individual therapy as well as in groups or in digital formats.

What are CBT exercises?

CBT exercises for insomnia include various therapeutic techniques used in cognitive behavioural therapy. These include:

Sleep restriction: limiting the time spent in bed to the actual amount of time spent sleeping in order to increase sleep pressure

Stimulus control: Only go to bed when you are sleepy; do not lie awake or brood in bed

Cognitive restructuring: Recognising and changing stressful thoughts about sleep ("I have to sleep!" → "My body knows what it needs")

Relaxation techniques: e.g. progressive muscle relaxation, breathing techniques, body scan

Improve sleep hygiene: Optimise lighting, temperature, media consumption and evening routines

These exercises are structured, practical and proven to be effective – they strengthen your confidence in your own ability to sleep.

Does behavioural therapy help with insomnia?

Yes – behavioural therapy is currently the most successful treatment method for chronic insomnia. Cognitive behavioural therapy for insomnia offers a multimodal approach that changes both behavioural habits and thought patterns. Studies show that CBT-I works even when other approaches have failed – and that it often leads to better results than medication. Particularly convincing: the method is also highly effective and well tolerated in severe cases of insomnia, in older people and in cases of insomnia with psychiatric comorbidities.

Glossary of key terms related to insomnia & CBT-I

Sleep competence
Sleep competence describes the learnable ability to deal constructively with sleep problems. This includes knowledge about sleep-promoting behaviour, realistic ways of dealing with lying awake at night and the use of effective strategies such as sleep restriction or cognitive techniques. The aim is to be able to "rely" on your own sleep again, independently of external aids such as medication.

Sleep hygiene
Sleep hygiene encompasses all behaviours and environmental factors that have a positive or negative impact on sleep. Good sleep hygiene means, for example: no screen time before bed, a quiet, dark bedroom, regular bedtimes, no caffeine in the late afternoon. It creates the foundation for other measures – such as cognitive behavioural therapy – to work more effectively.

Sleep pressure
Sleep pressure is a biological mechanism that causes the body to become sleepy after prolonged periods of wakefulness. It is caused by the messenger substance adenosine, which accumulates during the course of the day. Spending a lot of time in bed without sleeping reduces this pressure. Sleep restriction specifically increases sleep pressure and thus helps with chronic insomnia.

Sleep efficiency
Sleep efficiency describes the ratio between actual sleep time and the total time spent in bed. It is considered a key measurement in sleep medicine. For example, someone who spends eight hours in bed but only sleeps for four hours has a sleep efficiency of 50%. The aim of CBT-I is to increase this efficiency – usually to over 85%.

Stimulus control
Stimulus control is a behavioural element of CBT-I. Its aim is to re-associate the bed exclusively with sleep. Patients learn to only go to bed when they are genuinely tired ( ) and to leave the bed immediately if they lie awake for a long time. Activities such as brooding, watching television or scrolling on devices in bed are also consistently avoided.

Sleep restriction
Sleep restriction does not mean that people should "sleep less", but rather that the time spent in bed is temporarily limited to the time actually spent sleeping. This increases sleep pressure, makes it easier to fall asleep and reduces fragmented sleep. The time spent in bed is then gradually increased again.

Cognitive restructuring
This CBT-I component aims to identify and change stressful or exaggerated thoughts about sleep. Many people develop catastrophic thoughts ("If I don't sleep tonight, nothing will work anymore") that make it difficult to fall asleep. These thought patterns are defused through reflection and counterevidence.

Circadian rhythm
The circadian rhythm (sleep-wake cycle) is an internal biological clock that is controlled by light, social routines and activity patterns. A stable rhythm supports healthy sleep. Imbalances – caused by jet lag or shift work, for example – can exacerbate insomnia.

Parasomnias
Parasomnias are unusual behaviours during sleep, such as sleepwalking, nightmares or talking in your sleep. They usually occur during certain phases of sleep and are not always consciously perceived. CBT-I does not generally target parasomnias, but they are part of the extended diagnosis of sleep disorders.

Digital health applications (DiGA)
DiGA are digital therapy programmes – such as apps or online courses – that have been tested by official bodies. Some of these applications offer structured CBT-I programmes and can be prescribed by a doctor under certain conditions.

Insomnia Severity Index (ISI)
The Insomnia Severity Index is a standardised questionnaire for assessing the severity of insomnia. It is used at the beginning, during and after therapy to measure progress.

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