Cognitive Behavioral Therapy for Insomnia
Cognitive Behavioral Therapy (CBT) is arguably the best way to address primary insomnia because it does not use 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.
Proper CBT is structured 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.
Some long-term insomniacs have deep mistaken beliefs or emotions revolving around sleep. Therapists use conversation and coaching to correct these mental blocks. Therapists also attempt to set realistic expectations for how much sleep and the quality of sleep the patient should expect.
Whether poor sleep beliefs develop organically or through incorrect information, detrimental ideas 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.
CBT is a training method for your mind. In day-to-day life, when things happen to you, your mind generates a response whether it be happiness, frustration, anger, and these responses can affect the ability to fall and stay asleep. You mind has habits and regular patterns and the path it wants to take, and will take unless you know how to mitigate it. CBT teaches you how and makes it easier to override the process. Small defects in sleep quality or duration can sometimes spiral to a long-term problem and CBT can help nip the problem in the bud.
Different therapists may have their preferences, but CBT for insomnia may include
- Sleep restriction
- Stimulus control
- Relaxation training
- Paradoxical intention (the patient tries to stay awake as long as possible)
CBT works. Like other therapies, it works for some people than others and some individuals find it ineffective.
Studies have shown CBT can on average shorten sleep latency by 30 to 45 minutes and increase total sleep time 30 to 60 minutes. A recent meta-study found CBT is "at least as effective for treating insomnia when compared with sleep medications, and its effects may be more durable than medications." The evidence is not all that strong. The study authors classified it as "low-to-medium quality" evidence, meaning CBT works as well or slightly better, on average, than medicines across all people who participated in the random trials considered.
Previous studies had 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)
As a practical matter for insomniacs and their doctors need to consider CBT on a case-by-case basis. For secondary insomnia where the underlying cause of the sleep problem can be identified, treatment of the cause is the first thing to go after. For severe acute insomnia, drugs may be called for.
The downside of CBT is the expense and time requirements the patient needs to spend with the therapist. The doctor and patient need to consider the trade-offs and insurance coverage. But the proven effectiveness of CBT and competitiveness with drug therapy are reasons to give it a shot.
Relaxation training includes meditation with instruction on abdominal breathing, repetitive focus (like a mantra), and paced respirations. Guided imagery and autogenic training have been used. Biofeedback and hypnosis can be employed if the practitioner is capable in these techniques. Muscle relaxation techniques such as those employed by physical therapists can also be used.
If insomnia is a product of hyperarousal (rather than too little propensity to sleep), and this is certainly the case for some percentage of the population, then relaxation should help. People who demonstrate signs of stress or tension during the day should be good candidates for relazation.
This s a bit of reverse psychology the insomniac can play on himself. The person lies in bed and practices good sleep hygiene but tries to remain awake. This can help the sleeper get around a mental block to drifting off to sleep. It works for some people.
CBT for Patients with Chronic Pain
Pain causes insomnia and sleeplessness can increase the subjective level of pain. This is almost always secondary insomnia and the patient will likely be on other medication, but a recent study has found CBT is particularly effective in alleviating insomnia in those with chronic pain. The improvements in sleep duration persisted six months after therapy even when the pain continued.
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. Indeed, practitioners sometimes CBT to alleviate insomnia with the ulterior goal of treating depression.
A meta study (study of other studies) published in the journal Sleep found that behavioral techniques have been effective in alleviating insomnia in patients who do not use drugs, and in facilitating tapering off of drug use in long-term hypnotic users. Of course the studies considered were ones that had professionals applying CBT in controlled situations.
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.
Behavioral therapy is used in many areas of life – think of Pavlov who conditioned dogs to expect food when they heard a bell. You can use it to make your life better.
A pilot program at the University of Virginia to test internet-based CBT found good results. Maybe in the future the Internet or other forms of delivery will be widely used to deliver CBT for insomnia An internet-based system called Sleepio has been introduced which uses CBT principles to coach people to get better sleep. It costs $25/week.
Related: New developments in cognitive behavioral therapy as the first-line treatment of insomnia http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218784/