I am frequently referred patients with insomnia. In fact, insomnia is the most common of all sleep disorders. In many cases, these patients have been on medications for years that no longer work. Others express a strong desire to avoid taking medications or want to discontinue medications for myriad reasons such as daytime sleepiness or fear of “getting hooked” and want to know if there are alternatives. The answer is yes and it is called CBT (Cognitive Behavioral Therapy).
Most people with chronic insomnia develop sleep-preventing behaviors and associations with the bedroom that make it more difficult to sleep. They stay in bed and try to make themselves fall asleep when they are wide awake. They look at the alarm clock all night. They try to make up for lack of sleep with naps during the day. They consume excessive caffeine to compensate for their sleepiness. They bring their work into the bedroom such as laptops or work-related reading material. Eventually, as the insomnia persists and worsens, they develop significant anxiety about sleep. This causes higher levels of stress hormones such as cortisol to be produced and exacerbates the problem even further.
In CBT, we attempt to reverse sleep-preventing behaviors and restructure attitudes about sleep. Patients are told to eliminate caffeine, avoid naps, and put the alarm clock where it can be heard in the morning but not seen. We also try to maintain a stable sleep/wake schedule with the emphasis on a set wake time as we work through their insomnia.
We use a technique called Stimulus Control to try to break negative associations with the bedroom environment. Patients are instructed to go to bed only when sleepy. If they are in bed for 20 minutes and are wide awake, to get out of bed and do something relaxing in another room and when sleepy return to the bedroom.
Finally, we work on negative cognitions such as “If I don’t get to sleep I’ll be miserable tomorrow” or “I know I’m going to lose my job if I don’t sleep” or “I know that this is ruining my health if I don’t get some sleep.” We want people to be aware of these negative thoughts and how they make falling asleep more difficult. We work on replacing them with more positive and realistic cognitions such as”I’ve been through this before and I’m able to function” or” I know that most people with insomnia tend to underestimate the amount of sleep they actually get.” In the end, combining behavioral and cognitive treatments is by far the most successful and lasting therapy available. There are some excellent books available such as Peter Hauri’s No More Sleepless Nights and if that fails, seek out a board certified sleep specialist. This is a treatable condition.
