By Shelby Freedman Harris, Psy.D. for YouBeauty.com
In our overmedicated culture, popping a pill is often the first resort. Most people only know about pills when it comes to treating insomnia. We hear about them from friends and see commercials on TV. Although medications can be helpful for insomnia, sleep specialists do not consider them to be the first-line, gold standard treatment for insomnia. That's where cognitive behavior therapy for insomnia (CBT-I) comes in.
CBT-I is a non-drug treatment and has benefitted many types of patients who have trouble sleeping: from those with primary insomnia to others who can't sleep due to chronic pain, depression or anxiety. CBT-I consistently produces results that are comparable to, or even exceed, those of sleeping pills! Even one year after ending treatment, many patients continue to sleep well (rates that far outperform sleeping pills).
CBT-I isn't as easy as just popping a pill every night. It takes effort and patients need to be motivated. Treatment generally lasts from 4-12 sessions, with many patients making gains within the first three sessions. The remaining sessions are typically used for medication tapering, if necessary, and relapse prevention.
Although it is ideal to not be taking any sleeping pills at the start, patients do not need to discontinue these medications in order to benefit from CBT-I. Many patients decide to start treatment while on medication and gradually taper off (with the help of their doctor) once they have learned alternative techniques for their insomnia.
The initial stressors that may have caused poor sleep may vary from patient to patient (e.g. divorce, job stress, health issues, etc.), insomnia is thought to be sustained by certain behaviors that many people adopt as sleep worsens. Examples of these behaviors include going to bed early, sleeping in, napping, using alcohol as a sedative, increasing caffeine use, worrying about the amount of sleep being obtained and tossing and turning in bed. CBT-I focuses on changing these behaviors. Although sleep hygiene can help some people sleep better, CBT-I is not simply sleep hygiene. It consists of various components that help target the various behaviors that maintain the problem.
Before the first session, you'll typically be asked to track your sleep times (using a sleep diary) and sleep hygiene. Your clinician will review this in the first session. Sleep diaries are an important part of treatment and help guide progress over the weeks. You'll also be taught about basic sleep hygiene. Examples of this include limiting caffeine and nicotine, avoiding evening alcohol and liquids, exercising 4-5 hours before bedtime, winding down before bed, limiting "screen time" within an hour of bed and avoiding heavy meals at night.
Stimulus control is another key component. Insomnia patients spend increasingly more time in bed awake than asleep. They sometimes try to force sleep to happen by laying there. Others watch TV in bed, read in bed, or lay there worrying and/or thinking. As a result, the bed becomes associated not only with sleep, but also as a place to be awake. The rule is this: "The bed is only for sleep and sex. If you're awake and thinking, get up, go to another room and do something until you're sleepy again." Although tough to do, it works really well.
Patients with insomnia tend to spend more time laying in bed than they are actually sleeping. With the help of your clinician and based on your sleep diaries, you will be asked to limit your time allowed in bed. This technique, called sleep restriction, limits your time in bed and increases your body's drive to sleep. As you sleep more soundly during the times you're allowed in bed, your clinician will teach you how to gradually get more sleep.
Relaxation training is used to help those who are particularly tense at night. Not every patient needs relaxation training, but it can be quite powerful for those who do. There are many different relaxation techniques that can be helpful -- from deep breathing to muscle relaxation to visualization. Find what works best for you.
The cognitive component of CBT-I teaches patients to recognize and modify inaccurate thoughts that affect your ability to sleep. For example, many patients have the thought "I must get eight hours of sleep or else I can't function tomorrow." This thought creates additional pressure to sleep, putting you in a tense and anxious state -- one that does not induce sleep! Your clinician will teach you to challenge the evidence behind these thoughts and break the chain of anxiety that follows.
Clinicians who specialize in CBT-I are typically board certified in Behavioral Sleep Medicine. You can find a listing of these providers at the American Board of Sleep Medicine's website . If you are unable to find someone in your area, contact your local sleep center to see if they provide these services or can recommend someone who does.
Self-help books offering CBT-I are also available. I highly recommend The Insomnia Answer by Paul Glovinsky and Art Spielman and Quiet your Mind and Get to Sleep by Colleen Carney and Rachel Manber.
For more home remedies to help you sleep, click through the slideshow below:
Soothing music before bedtime can really do the trick. A 2005 study found that older people who listened to 45 minutes of soft tunes before hitting the hay reported a <a href="http://www.blackwellpublishing.com/nursing/news/news.asp?id=124" target="_hplink">35 percent improvement in their sleep problems</a>. But it doesn't have to be Brahms, if that's not your style. As long as the music was soft and slow -- around 60 to 80 beats per minute -- it can spur <a href="http://news.bbc.co.uk/2/hi/health/4228707.stm" target="_hplink">physical changes known to promote sleep</a>, like a slower heart rate and breathing, the BBC reported. "We know that when a person closes their eyes they induce a certain frequency of brain waves," says Decker. Slow music may have a similar effect, he surmises, leading to sleep onset. <em>Flickr photo by <a href="http://www.flickr.com/photos/llimaorosa/112246369/" target="_hplink">Llima</a></em>
It was once thought that a glass of warm milk at bedtime would help send you off to dreamland because of the tryptophan, <em>The New York Times</em> reported, but milk and other protein-rich foods actually <a href="http://www.nytimes.com/2007/09/04/health/04real.html" target="_hplink">block tryptophan's sleepiness-inducing effects</a>. However, there might still be a psychological benefit to that warm milk, the <em>Times</em> concluded, calling it "as soothing as a favorite old blanket." "There have been some studies showing that when infants receive warm milk before bed, they'll dream a little bit more," says Decker, but the results don't hold true in adults. "It may be one of those myths that because it happens in children, adults think it may be true for them, too," he explains. However, many adults are actually at least slightly lactose intolerant, he says, meaning a warm mlik at bedtime may just lead to discomfort. <em>Flickr photo by <a href="http://www.flickr.com/photos/julianrod/152930252/" target="_hplink">julianrod</a></em>
If your goal is to bore yourself to sleep, you might try counting sheep, or counting backwards by multiples of three or any of a number of other counting-related mind-numbers. But a 2002 study found that <a href="http://www.ncbi.nlm.nih.gov/pubmed/11863237" target="_hplink">imagining a more relaxing scene might be more effective</a>. The study observed 41 people with insomnia over a number of nights and asked them to try a variety of different sleep-inducing techniques, like counting sheep. On the nights they were told to imagine relaxing scenes like a beach, a massage or a walk in the woods, <a href="http://www.mentalfloss.com/blogs/archives/53137" target="_hplink">they fell asleep an average of 20 minutes sooner</a> than on the nights they were told to count sheep or were given no instructions, Mental Floss reported. Decker agrees. "Counting sheep in and of itself may not help," but can act as a ritual that prepares us for sleep, making it not unlike meditation. Counting sheep -- or more relaxing guided imagery -- helps us "focus on something other than life's stressors," he says. "Thinking about a soothing environment may be more restful than the way you spent the last eight hours!" <em>Flickr photo by <a href="http://www.flickr.com/photos/narciss/3716241331/" target="_hplink">Kr. B.</a></em>
Focusing on the breath, whether it's as part of a pre-bed yoga sequence or just a tuned-in awareness, can also have meditation-like effects in preparing for bed, says Decker, like lowering the heart rate. <em>Flickr photo by <a href="http://www.flickr.com/photos/perfectoinsecto/2363255713/" target="_hplink">Perfecto Insecto</a></em>
Your body temp <a href="http://www.health.com/health/condition-article/0,,20189095,00.html" target="_hplink">dips about two hours before bedtime</a>, <em>Health </em>magazine reported, a natural change that "triggers our brain for sleep onset", says Decker. Soaking in a warm bath beforehand boosts your temperature temporarily, but results in a dramatic, rapid cooldown after you get out that relaxes you and eases you into sleep. It's not necessarily the bath that lulls you to sleep, it's that resulting cooling of your body temperature, Decker emphasizes. Research shows that people who take a warm bath before bed not only <a href="http://www.ncbi.nlm.nih.gov/pubmed/2578367" target="_hplink">fall asleep more quickly</a>, but also report better quality of sleep, he says.
Many people swear by a drink to unwind at the end of the day, but alcohol before bed can actually <a href="http://www.huffingtonpost.com/2012/07/04/fourth-of-july-sleep_n_1644627.html#slide=1176662" target="_hplink">disrupt your sleep</a>. You'll be more likely to wake up more often in the early-morning hours, wake up and not be to fall back to sleep or have disturbing dreams. "As alcohol is metabolized by the liver, it has a disruptive effect," says Decker. It takes a few hours to metabolize, he says, so a drink with dinner shouldn't be a problem, but anything too close to bedtime can be counterproductive. <em>Flickr photo by <a href="http://www.flickr.com/photos/rob-qld/2889139445/" target="_hplink">Rob Qld</a></em>
Get Out Of Bed
It sounds crazy -- how will you ever get to sleep if you're not even in bed?! -- but it works, says Decker. "When a person stays in bed and they can't sleep, the bedroom can induce a certain level of anxiety," he says. "We say after 15 or 20 minutes, get out of bed, sit in another part of the house until you feel a little groggy, then go back to sleep," he says. "Staying in bed can condition you to become anxious in bed." A small 2011 study published in the <em>Archives of Internal Medicine</em> found that among the <a href="http://healthland.time.com/2011/01/27/cant-sleep-it-may-help-to-get-out-of-bed/" target="_hplink">adults studied who reported trouble sleeping</a>, those who spent <a href="http://www.thirdage.com/news/insomnia-cant-sleep-get-out-bed_1-26-2011 " target="_hplink">less time in bed had better sleeping habits</a>. <em>Flickr photo by <a href="http://www.flickr.com/photos/perfectoinsecto/3948115802/" target="_hplink">Perfecto Insecto</a></em>
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