Cognitive Behavioral Therapy for Insomnia

Cognitive Behavioral Therapy, or 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 makes the proper committment, lead to long-lasting elimination of insomnia. The therapy does not work for everyone and it is expensive and time-consuming, but so far CBT has made a tremendous impact in providing lasting relief for many sleep loss sufferers.

CBT addresses a person’s behavior through providing education and establishing better sleep habits. Usually, this is provided to an individuals through several sessions (varying from 4 to 12) usually lasting about 30 minutes by 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 is developed.

Whether poor sleep ideas are developed intuitively or through other sources of 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, this has the opposite effect 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 7.5-8 hours of sleep each evening, the range is from 4 hours to 10 hours for various individuals. If someone that requires only 5 hours of sleep continues to try and obtain 8 hours, there can be unnecessary stress associated with this perceived sleep loss.

CBT first targets accurate information about an individual’s sleep and sleep needs and educates them on factual aspects about sleep in general. After a detailed sleep history is obtained, some of these discrepancies are brought to light and corrected through discussion and examples. Then at each subsequent session, these areas are again discussed to reinforce adherence to the newly learned concepts.

Secondly, 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 ability. 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, timing of exercise, and many others. A common example of this is that many sufferers try and 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 if sleep is not obtained, and then participating in a sleep-promoting behavior like reading. Once you are feeling drowsy again, another attempt to fall asleep is tried. By continuing to lie in bed, anxiety builds thus making sleep even less likely to occur. Once again, educating an insomniac about positive and negative effects of behaviors on sleep provides an understanding upon which to change the behavior, thus establishing a long lasting therapy for their insomnia.

Sleep medication with CBT?

Some CBT regimens incorporate sleeping pills, but only to get the patient started sleeping. Eventually, as the insomniac learns sleeping skils, 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.

It also depends on whether the patient has other conditions that may require medications. Studies on CBT vs 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 is a condition that 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.

Scientific article:

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

Sleep Disorders

Dyssomnias

Parsomnias