CBT for Insomnia

Cognitive Behavioral Therapy for Insomnia 
by Noah Clyman, LCSW-R

Over 50% of adults now complain of difficulty sleeping, half of these chronically. We now know that sleeping pills are not the solution to insomnia and that it is possible to successfully treat insomnia using cognitive-behavioral therapy (CBT). CBT has been endorsed by the National Institutes of Health as an effective and preferred method for treating insomnia.
Research on CBT shows the following:

• 75% of insomnia patients experience significantly improved sleep
• The majority become normal sleepers
• 85- 90% reduce or eliminate sleeping pills
• CBT is more effective than sleeping pills

Did you know? Sleeping pills fail to treat the causes of insomnia, which are thoughts and behaviors. By treating only insomnia’s symptoms, any improvement in sleep can only be temporary, thereby perpetuating the cycle of insomnia and sleeping pills. This cycle can become a trap that can lead to dependency. Many patients are aware of the drawbacks of sleeping pills and prefer non-drug approaches to managing insomnia but don’t know how to escape their reliance on sleeping pills. Even if the ideal sleeping pill were developed-one that had no side effects and that produced natural sleep-it would still reinforce the belief that the cure for insomnia comes from something external; and, it wouldn’t treat the causes of insomnia, which are thoughts and behaviors. So sleep may improve while taking a sleeping pill, but as the pill is stopped insomnia usually returns.
Did you know? The success of CBT is based on a central theme: insomnia can only be treated by addressing all of the underlying causes. In most instances, the causes of insomnia are thoughts (cognitions) and behaviors (habits) which are learned and can be unlearned. Some examples include:
*negative, distorted thoughts and beliefs about insomnia,
*feeling of loss of control over sleep,
*inadequate exercise or exposure to sunlight,
*going to bed too early or sleeping too late,
*trying to control sleep rather than letting it happen,
*lying awake in bed, frustrated and tense.
5 Sleep Behavioral Skills to DRAMATICALLY Improve Sleep

1. Establish a regular arising time: To promote a regular arising time, pair it with a pleasurable activity: walk the dog, read the newspaper, exercise or take a morning walk, etc. By establishing a consistent arising time, you will fall asleep and stay asleep more easily, and sleep more deeply. This will improve sleep efficiency and make the bed a stronger cue for sleep.
2. Establish a relaxing wind-down routine during the hour before bed (reading, “neutral” television, or a hobby as opposed to problem solving, computer work, finances, work-related activities, phone calls, “negative” tv). However, don’t become so sedentary during the wind-down period that drowsiness occurs. Use physical activity and light to ward off fatigue and drowsiness and don’t be a “couch potato.” Avoid computers the hour before bed and during the night since the light exposure may promote wakefulness.
3. Break habits that make the bed a cue for wakefulness. Poor sleepers have often lain awake for so many nights that the bed and bedroom have become strong cues for sleeplessness! As a result, just getting into bed triggers a learned arousal response and wakefulness. In fact, it is not uncommon for insomniacs to find themselves falling asleep in front of the television in the living room, yet when they get into their bed to go to sleep, they become wide awake because the bed has become such a strong cue for wakefulness.
4. Develop habits to associate the bed with drowsiness: Practice identifying the internal cues for drowsiness (eyelids dropping, head nodding, yawning, reading the same line in a book several times) rather than relying on external cues such as the clock, a bed partner’s bedtime or the end of the evening news.
5. Follow the half hour-half hour rule. If patients don’t fall asleep within 20 or 30 minutes, or if they awaken during the night and don’t fall back asleep within 20-30 minutes, they should not lie in bed tossing and turning (since focusing on the clock only heightens anxiety about falling asleep, the 20-30 minute limit should be estimated). Instead, they can go into another room and engage in a quiet, relaxing activity such as watching television, reading a book, magazine, or catalog until drowsy, then attempt to go to sleep again.

7 Lifestyle Considerations to DRAMATICALLY Improve Sleep

1. Alcohol: suppresses deep sleep and dream sleep and exacerbates snoring. Alcohol in the evening should be limited to two drinks and not after 7 pm.
2. Caffeine: disrupts sleep because it produces stimulant effects (faster brain waves, heart rate, etc.) that can persist for up to eight hours in sensitive people. Caffeine should not be consumed after 3:00 pm; total daytime use should be limited to two cups.
3. The Food-Sleep Connection: Those who desire to fall asleep more easily should eat a high carbohydrate snack and avoid high protein foods the hour or two before bedtime. Those who desire to minimize nighttime awakenings should eat a carbohydrate snack immediately before bedtime, which will increase serotonin levels during the night and help one stay asleep. Having a light carbohydrate snack before bedtime will also ensure that sleep isn’t disturbed due to hunger.
4. Role of exercise: Moderate physical activity (lawn work, taking stairs instead of elevators, walking) and vigorous aerobic activity improve sleep by promoting greater rise and fall in body temperature that persists for up to five hours. This greater rise and fall in temperature can make it easier to fall asleep and stay asleep. The beneficial effect of exercise is greatest when exercise occurs within three to six hours of bedtime. Try to engage in 20-30 minutes of physical activity at least every other day to improve sleep.
5. Room temperature: A cooler room will improve sleep by producing a drop in body temperature. In constrast, a warm room will inhibit the drop in body temperature and impair sleep. (Have a spouse or bed partner use an extra blanket if they prefer a warmer room).
6. Baths: A hot bath before bed will improve sleep. Must be kept hot for 25 minutes and should be taken about two hours before bedtime. (A great way to relax and a good substitute on days when you can’t exercise).
7. Noise: White noise (the sound of a fan, air conditioner, or commercial white noise machine) masks noise, is relaxing to the brain, and can make it easier to fall and stay asleep.

CBT COMPONENTS
Techniques taught in CBT include:

• changing sleep thoughts and behaviors
• lifestyle habits that improve sleep
• relaxation techniques

WHO WOULD BENEFIT

• individuals with problems falling asleep or waking during the night
• individuals who wish to reduce or eliminate sleep medications