Gregg Jacobs is an insomnia specialist at the Sleep Disorders Center at the UMass Memorial Medical Center and the author of Say Good Night to Insomnia. In answer to my questions, he shared his insights on how human sleep patterns have changed over time, healthier and more effective alternatives to sleeping pills, and how to reverse our worst sleep habits and behaviors.
Describe your research on insomnia.
I have a longstanding interest in the relationship between the mind and health. My doctoral research, which assessed the ability of the mind to control physiology, showed that it was possible to use deep relaxation techniques to voluntarily produce brain wave patterns that were identical to the initial stages of sleep. My postdoctoral research at Harvard Medical School included research on the meditative practices of Tibetan monks. This research, conducted in a Tibetan monastery in Sikkim under the auspices of the Dalai Lama, revealed that advanced Tibetan monks possess remarkable control over their brain waves and physiology. This led to my efforts to develop a safe, drug-free intervention for insomnia, called cognitive behavioral therapy for insomnia (CBT-I), over the past 30 years at the Harvard and University of Massachusetts medical schools. This research culminated in a landmark study, funded by the National Institutes of Health, showing that CBT-I is more effective than Ambien. Because few people have access to CBT-I, my more recent efforts have focused on making CBT-I widely available in an inexpensive, practical format through my website, cbtforinsomnia.com. Numerous studies have recently demonstrated that internet-based CBT-I can be delivered as effectively as face-to-face CBT-I and is more practical and cost-effective.
You've discussed the history of segmented sleep. Do you believe we have evolved past this pattern, or are our bodies struggling against us when we try to sleep in one chunk of time? How does insomnia relate to this?
Research suggests that we may have displayed a polyphasic (i.e., multiple periods) sleep pattern for virtually all of our evolution until the recent advent of nighttime lighting. Prior to that, humans likely went to sleep soon after dusk and awakened at dawn in longer sleep periods that consisted of alternating bouts of sleep and wakefulness. This non-continuous sleep pattern is characteristic of virtually all mammals and is also the pattern we experience early and late in life. It is only in adult life, and the last 350 years of human history, that a more consolidated nocturnal sleep pattern is apparent. However, many adults still experience polyphasic sleep in the form of insomnia, and regular intervals of waking are still experienced in normal sleepers today, as evidenced by six to 12 brief awakenings per night (which most of us don't recall, for they are too short). Evidently, this polyphasic sleep pattern lies dormant in our physiology, met an evolutionary need, and therefore may be adaptive rather than a sleep disorder.
In segmented sleep, how was waking time between the two sleeps spent?
In prehistoric times, it may have been spent tending to the fire, being vigilant for predators, in deep relaxation, for creativity and problem solving, and a channel of communication between dreams and waking life. Historical accounts suggest it was used for sexual activity and socializing, reading and writing, praying, meditating on dreams, or tending to the fire in the cold months.
Tell me about cognitive behavioral therapy, or CBT. How does this treatment for insomnia compare with other methods like sleeping pills? What successes have you seen among your patients, and how can others incorporate the strategies into their sleep habits?
CBT-I is the most effective psychology-based treatment for a health problem and has consistently been proven to be the most effective first-line treatment for chronic insomnia. It improves sleep in 75 to 80 percent of insomnia patients and reduces or eliminates sleeping pill use in 90 percent of patients. It is so effective that I am surprised if my patients do not report improvement in sleep, or a reduction or elimination of sleeping pills, from CBT-I. And in three studies published in major medical journals that directly compared CBT with sleeping pills, including my study at Harvard Medical School, CBT-I was more effective than sleeping pills. CBT-I also has no side effects and maintains improvements in sleep long-term, and new research shows that CBT-I doubles the improvement rates of depression compared with antidepressant medication alone in depressed patients with insomnia.
In contrast to CBT-I, sleeping pills do not greatly improve sleep. Objectively, newer-generation sleeping pills such as Ambien are no more effective than a placebo. Subjectively, they only increase total sleep time, and reduce the time it takes to fall asleep, by about 10 minutes. Furthermore, these small to moderate short-term improvements in sleep are often outweighed by significant side effects and risks, particularly in older adults. These include impairment of alertness, driving, and learning and memory (including sleep-dependent memory consolidation); increased mortality risk, as shown in almost two dozen scientific studies; and dependence, addiction, and activation of the same neurobiological pathways involved in drugs of abuse.
CBT-I is based on the idea that some individuals react to short-term insomnia (usually caused by stress) by worrying about sleep loss. After a few weeks of lying awake at night, frustrated and anxious about insomnia, they start to anticipate not sleeping and become apprehensive about going to bed. They soon learn to associate the bed with sleeplessness and frustration; consequently, the bed quickly becomes a learned cue for wakefulness and insomnia. As a result, they begin to engage in these types of maladaptive sleep habits, thoughts and behaviors that exacerbate insomnia that must be changed with CBT-I (sleeping pills are marginally effective because they do not change these behaviors):
- Negative, distorted thoughts and beliefs about insomnia such as "I must get eight hours of sleep" or "I did not sleep a wink last night."
- Going to bed too early or sleeping too late and spending excessive time in bed.
- Irregular arising times.
- Trying to control sleep rather than letting it happen.
- Lying awake in bed, frustrated and tense.
- Using the bed and bedroom for activities other than sleep.
- Use of electronic devices before bedtime.