Cognitive Behavioral Therapy for Insomnia

Cognitive Behavioral Therapy (CBT) is arguably the best form of treatment for primary insomnia because it does not include medicines and can, if done right and the patient sticks with it, lead to long-lasting elimination of insomnia. The therapy does not work for everyone, and it is expensive and time-consuming, but for many who have tried it CBT has made a tremendous impact in providing lasting relief.

CBT addresses a person’s behavior through providing education and establishing better sleep habits. Usually, patients attend several sessions (from 4 to 12) lasting about 30 minutes with a qualified sleep professional. Most commonly this is a psychologist with special interest in insomnia, but nurse practitioners, physicians, psychiatrists, and others that direct patient care can also provide CBT if specially trained. In the process, misconceptions and misinformation about sleep in general are eliminated, and better sleep hygiene habits are developed.

CBT is structured and directive and participants are given homework – things they have to work on before the next meeting with their therapists.  Patients are usually encouraged to keep a sleep diary.

Whether poor sleep ideas develop organically or through incorrect information, detrimental beliefs about sleep can promote and perpetuate insomnia. For instance, some people may believe that if they go to bed earlier, they have a better chance of getting more sleep. In actuality, however, the opposite is true as going to bed earlier only decreases the chance of falling to sleep. This is because the body’s circadian rhythm, or daily bio-rhythm, has a window of time that is optimal for sleep onset and trying to fall asleep outside of this window only creates frustration and anxiety further worsening insomnia. Another example is that many people may hold a belief that they need at least 8 hours of sleep to feel rested. While the majority of us need about 7-8 hours of sleep every night, the range is from 4 hours to 10 hours. If a person whose body requires only 5 hours of sleep continues to try and obtain 8 hours, he or she there can experience unnecessary stress associated with this perceived sleep loss.

When a person goes through CBT, the practitioner first collects information about the patient’s sleep history and norms and educates him/her on factual aspects about sleep in general. Problems and bad habits are brought to light and corrected through discussion and examples. At each subsequent session, these areas are again discussed to reinforce adherence to the newly learned concepts.

Different therapists may have their preferences, but CBT for insomnia may include

• Sleep restriction
• Stimulus control
• Relaxation training
• Biofeedback

CBT also looks at general sleep habits, which are usually referred to as sleep hygiene. Sleep hygiene describes beneficial behaviors and negative routines that can affect one’s sleep. Areas covered include the sleep environment, sleep schedules at night, daytime napping, amounts of stimulating foods and beverages consumed, overly rigid bedtime routines, general health behaviors, and timing of exercise. For instance many sufferers try to fall asleep, but despite being unable to do so, continue to lie in bed hour after hour watching the clock. Positive sleep hygiene encourages you to get out of bed after 20 minutes or so, and to engage in a sleep-promoting behavior like reading. Once you feel drowsy again, you get back into bed for another try. Continuing to lie in bed increases anxiety and makes sleep even less likely. As the insomniac learns about the positive and negative effects of specific behaviors on sleep quality and length, good habits can be formed.

Studies have shown CBT is better than other medical interventions for insomnia, as measured by changes in sleep-onset latency and the percentage of patients who could be classified as normal sleepers following treatment.(http://archinte.ama-assn.org/cgi/content/full/164/17/1888).

CBT has also been found to be particularly effective in dealing with sleep disturbances associated with post-traumatic stress disorder, (http://www.ncbi.nlm.nih.gov/pubmed/16777060)

Sleep medication with CBT?

Some CBT regimens incorporate sleeping pills, but only to get the patient started sleeping. Eventually, as the insomniac learns sleeping skills, he or she is weaned off the medicine. Psychologists who practice this type of therapy tend to focus not so much on insomnia as waking life. You might hear the term "stimulus control"; with respect to CBT this means telling patients to go to bed when sleepy, and getting out of bed when they are not sleeping.

There is some debate among CBT practitioners as to whether hypnotic medications should be used at all by their patients. A recent study showed that CBT helps patients whether or not they use sleep aid pills. This suggests that a good strategy for ending insomnia may be for the doctor to give the patient a sleeping pill along with the CBT and for the two to work together to taper medication levels over time. A mild sleep aid like melatonin or ramelteon sometimes is the best option.

It also depends on whether the patient has other conditions that may require medications. Scientific studies set up to compare CBT with medicine tend to exclude people with depression, apnea, and recent use of hypnotic medicines. There may be other factors that the doctor has to keep in mind when advising on an insomnia treatment.

Insomnia becomes more common with age as the brain’s mechanisms for falling asleep and staying asleep become less robust. In addition, some people have an in-born tendency to be "hyper-alert", and have greater difficulty sleeping regardless of age. These people are in some sense natural insomniacs. Even in some insomniacs who do require supplemental medication for sleep, CBT can provide the best template upon which these can be effective. CBT has been shown in controlled studies to be effective. Cognitive Behavioral Therapy also can identify concurrent problems with depression, anxiety, and other physical problems that may need separate attention through other measures. If other conditions do exist, these will need to be addressed concurrently. In this regard, CBT offers the most comprehensive approach to date for addressing insomnia long term by providing a foundation of knowledge and direction for behavior that enables the insomniac to maintain good quality sleep.

Brief Behavioral Therapy Intervention

Researchers at the University of Pittsburgh and the Cleveland Clinic recently found good results from using a shorter form of CBT: brief behavioral therapy intervention (BBTI) for addressing insomnia in older people. This program consisted of only two in-person sessions and two phone sessions. They found the people who underwent this therapy had success in 67% of cases versus 25% in the control group.

The National Center for Biotechnology Information - http://www.ncbi.nlm.nih.gov/books/NBK64948/ - has more on BBTI.

Why go to Cognitive Behavioral Therapy?

But, you might ask, if CBT is just a matter of learning the facts and adopting the correct practices, why do I have to pay a therapist for it?  Why can’t I just read the facts in a book or on the internet and starting changing my behavior?  You can, of course, and that’s partly why websites like Sleepdex exist – to get the word out about sleep myths and best practices.  Many people need another person involved for coaching and to hold them accountable – which is why CBT services exist.

A pilot program at the University of Virginia to test internet-based CBT found good results. http://archpsyc.ama-assn.org/cgi/content/full/66/7/692

Maybe in the future the Internet or other forms of delivery will be widely used to deliver CBT for insomnia.

Scientific article:

Cognitive Behavioral Therapy for Insomnia Enhances Depression Outcome in Patients with Comorbid Major Depressive Disorder and Insomnia

Sleep Disorders

Dyssomnias

Parsomnias

Insomnia Medications