Guided internet-based cognitive behavioral therapy for insomnia in patients with borderline personality disorder: Study protocol for a randomized controlled trial

Applying therapist-guided digital cognitive behavioral therapy for insomnia in psychiatry: a mixed-methods process evaluation

INTRODUCTION

Insomnia is prevalent, particularly among individuals with mental health complaints. However, Cognitive Behavioral Therapy for Insomnia (CBT-I), the first-line treatment, is underutilized in care settings. This study evaluated a therapist-guided digital CBT-I (i-Sleep), gathering insights from participants and therapists to optimize the intervention and inform implementation strategies.

METHODS

A mixed-methods process evaluation, guided by the RE-AIM framework, was conducted alongside an effectiveness trial. Data were collected from i-Sleep participants with clinically relevant insomnia and various mental health complaints across all care levels, ranging from pre-clinical (unattended), to those referred to general or specialized care. Additionally, data were collected from i-Sleep therapists.

RESULTS

A total of 181 i-Sleep participants (mean age = 46.7 years, SD = 13.2) enrolled, with an attrition rate of 21.6%. Participants reported benefits including faster sleep onset, fewer nighttime awakenings, increased daytime energy, and positive lifestyle changes, though some experienced minimal gains or adverse effects. Satisfaction with the intervention ranged from 7.1 to 7.3 across care levels. Post-intervention, 89.4% of all participants indicated they would recommend iCBT-I. Satisfaction with therapist guidance was high (M = 7.7-8.3), though preferences for format and frequency varied. Therapists (n = 15, mean experience = 0.8 years, SD = 1.1) suggested addressing practical constraints and enhancing training for better integration into routine care.

CONCLUSION

Our findings highlight the feasibility and potential of therapist-guided iCBT-I to improve sleep in individuals with mental health complaints across all care settings. Universal implementation could offer significant benefits, while adaptable content and flexible guidance may better meet individual needs.

TRIAL REGISTRATION

Netherlands Trial Register (NL9776) registered on 07/10/2021.

Clinical predictors of insomnia in borderline personality disorder: a polysomnographic and subjective examination

BACKGROUND

Sleep disturbances are common in patients with borderline personality disorder (BPD) and are associated with a poor prognosis and symptom severity. Research findings on sleep abnormalities in individuals with BPD have been inconsistent, with limited evidence linking subjective and objective measures.

METHODS

We compared 44 women with BPD with 41 healthy controls. We examined differences (using ANCOVAs and ordinal logistic regression) and associations (using correlations) between objective sleep assessment (polysomnography) and subjective measures (Consensus Sleep Diary, Insomnia Severity Index, Pittsburgh Sleep Quality Index). We explored predictors of insomnia in BPD patients, including BPD severity, symptomatology, comorbid conditions, and medication use, via standard least squares regressions and ANOVAs.

RESULTS

A total of 22% of patients with BPD had clinically significant insomnia (cut-off ≥ 15), 85% reported mild (subthreshold) insomnia (cut-off > 10) (Insomnia Severity Index; ISI), and 94% reported sleep quality disturbances (PSQI > 5). Compared with those in HC, PSG results in individuals with BPD revealed a longer duration in bed, longer sleep period, REM latency, wake after sleep onset latency, Stage N1 sleep duration, shorter N2 sleep duration, and, with age, more arousals and awakenings. The correlations between objective and subjective sleep measures were weak in both groups. In patients with BPD, a greater degree of insomnia predicted a reduction in total sleep time and increased awakenings and arousals on PSG. Clinical BPD severity, emotional reactivity and dysregulation, depression symptoms, posttraumatic stress symptoms, alexithymia, and presleep arousal were associated with greater insomnia in BPD patients.

CONCLUSIONS

Our study confirmed high rates of insomnia and sleep disturbances in individuals with BPD, which contrasted with relatively minor PSG alterations. Clinical BPD severity and symptomatology are associated with sleep abnormalities in individuals with BPD. Insomnia is a neglected yet important characteristic of the BPD phenotype, warranting more attention in future research and clinical guidelines.

Can atypical antipsychotics alleviate Deficits in psychosocial impairments in patients with a diagnosis of Borderline Personality? A systematic review and meta-analysis

Patients with a diagnosis of Borderline Personality Disorder (BPD) often experience difficulties in psychosocial functioning, which reduces the ability of individuals to engage socially. This review seeks to determine whether atypical antipsychotics (AAPs) are more effective than placebo at alleviating these difficulties in adults with a diagnosis of BPD. We identified six Randomized Control Trials, conducted between 1994 and 2024, with 1012 patients that were treated with either: Olanzapine, Quetiapine, Ziprasidone or Aripiprazole. Using a meta-analysis, we found evidence that atypical antipsychotics induce a small improvement treating psychosocial functioning in patients with a diagnosis of border line personality. In particular, AAPs improved General Assessment of Functioning (GAF) more than placebo. Combining GAFs P-values from several studies indicated this effect was significant. AAPs were also superior to placebo at improving quality of interpersonal relationships, occupational functioning and family life. There was a positive improvement tendency in social life and leisure activities. AAPs also induced known secondary effects like weight gain and sedation as previously described. AAPs were beneficial for improving general functioning and its subcomponents. However, the magnitude of the benefit above that of placebo was small and its clinical meaningfulness is thus debatable. More randomised-controlled trials are required.

Interventions to improve the sleep quality of adults with personality disorder: A systematic review

Poor quality sleep is common for people who have a diagnosis of personality disorder (PD). Core cognitive and behavioral features of PD may cause and perpetuate poor sleep, but to date, no review has collated the evidence on the efficacy of interventions to improve sleep quality for people with PD. Structured searches for interventional studies among adults with PD and reporting validated measures of sleep quality were conducted up to November 2022 in multiple databases. Single-case reports were excluded. Study quality was assessed with standardized risk of bias tools. Unreported data was sought systematically from authors. This review was pre-registered with an international prospective register of systematic reviews (PROSPERO) (CRD42021282105). Of the 3503 identified studies, nine met inclusion criteria, representing a range of psychological, pharmaceutical, and other interventions and outcome measures. Meta-analytic methods were not feasible because of the serious risk of bias in all studies, and results were therefore synthesized narratively. There is limited and low-quality evidence of the effects of a variety of interventions to improve the sleep quality of people living with PD. Further research might consider specifically including people diagnosed with PD in trials of sleep interventions and using sleep outcome measures in trials of established PD treatments.

Do better nights lead to better days? Guided internet-based cognitive behavioral therapy for insomnia in people suffering from a range of mental health problems: Protocol of a pragmatic randomized clinical trial

BACKGROUND

Insomnia is the transdiagnostically shared most common complaint in disorders of anxiety, stress and emotion regulation. Current cognitive behavioral therapies (CBT) for these disorders do not address sleep, while good sleep is essential for regulating emotions and learning new cognitions and behaviours: the core fundaments of CBT. This transdiagnostic randomized control trial (RCT) evaluates whether guided internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) (1) improves sleep, (2) affects the progression of emotional distress and (3) enhances the effectiveness of regular treatment of people with clinically relevant symptoms of emotional disorders across all mental health care (MHC) echelons.

METHODS

We aim for 576 completers with clinically relevant symptoms of insomnia as well as at least one of the dimensions of generalized anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder (PD), posttraumatic stress disorder (PTSD) or borderline personality disorder (BPD). Participants are either pre-clinical, unattended, or referred to general- or specialized MHC. Using covariate-adaptive randomization, participants will be assigned to a 5 to 8-week iCBT-I (i-Sleep) or a control condition (sleep diary only) and assessed at baseline, and after two and eight months. The primary outcome is insomnia severity. Secondary outcomes address sleep, severity of mental health symptoms, daytime functioning, mental health protective lifestyles, well-being, and process evaluation measures. Analyses use linear mixed-effect regression models.

DISCUSSION

This study can reveal for whom, and at which stage of disease progression, better nights could mean substantially better days.

TRIAL REGISTRATION

International Clinical Trial Registry Platform (NL9776). Registered on 2021-10-07.