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Cognitive Behavioral Therapy (CBT or CBTI) for Insomnia in Jacksonville, Florida

Posted by: Dr. Justin D'Arienzo, Psy.D., ABPP

Cognitive Behavioral Therapy (CBT or CBTI) for Insomnia in Jacksonville, Florida

Handout: Cognitive Behavioral Therapy (CBT or CBTI) for Insomnia in Jacksonville, Florida

Dr. D’Arienzo specializes in CBT and CBTI in Jacksonville, Florida. CBTI is the use of specific CBT techniques to alleviate sleep problems or insomnia.  CBT is often the first line treatment for insomnia and is a nonpharmacological method  often generating  quick results. The treatment helps you to change your relationship with sleep and behaviors and thoughts that are not conducive to sleep problems. I often use simple biofeedback devices to teach relaxation techniques that can be rapidly learned by the first appointment. Often psychological testing is performed as well to determine whether there are personality factors or other psychological problems or obstacles to sleep that are not identified during the initial evaluation. Please disclose about your use of any medications, sleep aids, and caffeine and any recent major life changes or health changes during your first appointment.

Below are two great articles about CBT or CBTI and its effectiveness with sleeping problems. If you are having difficulty with sleep, please read the articles and let us know if you would like us to help you improve your sleep hygiene.

 

Getting A Good Night’s Sleep With the Help of Psychology

Cognitive behavioral therapy is becoming the “treatment of choice” for many people with insomnia.

Findings

More sleep would make most people happier, healthier and safer. But for people with sleep disorders, trying to get more sleep can be a nightmarish experience. Surveys conducted by the National Sleep Foundation reveal that at least 40 million Americans suffer from over 70 different sleep disorders and 60 percent of adults report having sleep problems a few nights a week or more. Sleep disorders and sleep disturbances comprise a broad range of problems, including sleep apnea, narcolepsy, insomnia, jet-lag syndrome, and disturbed biological and circadian rhythms.

For the estimated one in 10 people who suffer from chronic insomnia, psychologists are helping them get a good night’s sleep through the benefits of cognitive behavioral therapy (CBT). In a 2001 study published in the Journal of the American Medical Association (JAMA), psychologist Jack Edinger, PhD and colleagues found the CBT worked better than either progressive muscle relaxation or a placebo treatment for people with insomnia. Another JAMA study two years earlier by psychologist Charles Morin, PhD, found that behavioral and pharmacological therapies, alone or in combination, are effective in the short-term management of late life insomnia. But those who received CBT had the best long-term results and the participants rated the behavioral therapy as more effective and satisfying. A 2001 German study by Jutta Backhaus and colleagues found that the benefits of short-term CBT had long-term effects. After therapy the participants improved their total sleep time and sleep efficiency and reduced their sleep latency and negative sleep-related cognitions, and those improvements were sustained during the three-year follow-up period.

How does cognitive behavioral therapy help people sleep better? Research shows that CBT reduces false beliefs about sleep (the cognitive part) and also addresses the behavioral aspect, such as what to do when you are lying in bed and can’t fall asleep. A 2002 study by Dr. Morin highlighting people’s misconceptions about sleep found those that who received CBT reduced their false beliefs, which resulted in increases in the amount of time they spend in bed actually sleeping. Misconceptions regarding sleep can involve unrealistic expectations about sleep (“I must get 8 hours of sleep every night”), exaggeration of the consequences of not getting enough sleep (“If I don’t get a full 8 hours of sleep tonight a catastrophe will happen”), faulty thinking about the cause of your insomnia (“My insomnia is completely caused by a biochemical imbalance”), and misconceptions about health sleep practices.

A 2004 study by psychologist Célyne Bastien, PhD, and colleagues found that group therapy and telephone consultations using cognitive-behavioral therapy was a cost-effective alternative to individual therapy for the management of insomnia. All three CBT treatment methods produced improvements in sleep that were maintained for six months after the treatment period ended.

Significance

Up to 40 percent of adults report at least occasional difficulty sleeping, and the National Institutues of Health reports that chronic and severe forms of insomnia affects between 10 to 15 percents of adults. Even small disruptions in sleep can wreak havoc on human safety and performance. Estimates by the National Highway Traffic Safety Administration indicate that drowsy or fatigued driving leads to more than 100,000 motor vehicle crashes per year.

Practical Application

Findings from controlled clinical trials indicate that 70 to 80 percent of insomnia patients benefit from cognitive-behavioral interventions. Although CBT is now considered the treatment of choice for chronic insomnia, no single treatment method is effective for all insomnia patients, so behavioral and pharmacological approaches sometimes need to be integrated.

More and more sleep disorder clinics are popping up across the country – there are now more than 300, with most hospitals offering sleep clinics. Look for those that offer more than just pharmacological treatment options.

Here are some tips for anyone, including those without serious sleep problems, that is looking for ways to get a good night’s sleep:

  • Restrict the amount of time spent in bed as close as possible to the actual sleep time
  • Go to bed only when sleepy, not just fatigue but sleepy
  • If unable to sleep (e.g., within 20 min), get out of bed and go to another room and return to bed only when sleep is imminent
  • Use the bed and bedroom for sleep (and sex) only; no eating, TV watching, radio listening, planning or problem solving in bed
  • Maintain a regular sleep schedule, particularly a strict arising time every morning regardless of the amount of sleep the night before
  • Avoid daytime napping

Cited Research

Backhaus, J., Hohagen, F., Voderholzer, U., Riemann, D. (2001). Long-term effectiveness of a short-term cognitive-behavioral group treatment for primary insomnia. European Archives of Psychiatry & Clinical Neuroscience, Vol. 251, No. 1, pp. 35-41.

Bastien, C.H., Morin, C.M., Ouellet, M., Blais, F.C., Bouchard, S. (2004). Cognitive-behavioral therapy for insomnia: Comparison of individual therapy, group therapy, and telephone consultations. Journal of Consulting and Clinical Psychology, Vol. 72, No. 4, pp. 63-659.

Edinger, J.D., Wohlgemuth, W.K., Radtke, R.A., Marsh, G.R., Quillian, R.E. (2001). Cognitive behavioral therapy for treatment of chronic primary insomnia: A randomized controlled trial. Journal of the American Medical Association, Vol. 285, No. 14, pp. 1856-1864.

Morin, C.M. (2002). Contributions of cognitive-behavioral approaches to the clinical management of insomnia. Primary Care Companion, Journal of Clinical Psychiatry (suppl 1), pp. 21-26.

Morin, C.M., Blais, F., Savard, J. (2002). Are changes in beliefs and attitudes about sleep related to sleep improvements in the treatment of insomnia? Behaviour Research & Therapy, Vol. 40, No. 7, pp. 741-752.

Morin, C.M., Colecchi, C., Stone, J., Sood, R., Brink, D. (1999). Behavioral and pharmacological therapies for late-life insomnia: A randomized controlled trial. Journal of the American Medical Association, Vol. 281, No. 11, pp. 991-999.

American Psychological Association, September 15, 2004

The article can be viewed at http://www.apa.org/research/action/sleep.aspx

Cognitive Behavioral Therapy (CBT) for Insomnia and Sleep Hygiene in Jacksonville, Florida

 

Cognitive Behavioral Therapy (CBT) for Insomnia

Cognitive behavioral therapy guides patients through a series of changes in sleep-related behaviors. The focus is on addressing the three factors that contribute to the persistence of insomnia:

  1. conditioned arousal,
  2. identifying and eliminating habits that were developed in an effort to improve sleep but have become ineffective, and
  3. reducing sleep-related worry and other sources of heightened arousal.

The therapist identifies the most relevant targets for behavior changes, and helps patients overcome obstacles to making the necessary and often difficult changes in sleep-related behaviors. This means that individual patients can concentrate their energy on changes that are most likely to produce improvements in their sleep. Sometimes the therapist helps patients re-evaluate beliefs about sleep that might be causing unnecessary anxiety.

The majority of patients respond to this treatment fairly quickly. Some experience significant changes after only two therapy sessions. Most improve after four to six sessions, but some might need more. Both group and individual treatments are effective.

Below is a list of some of the instructions and procedures used in this therapy:

Stimulus Control

This set of instructions addresses conditioned arousal. It was developed by Richard Bootzin. They are designed to strengthen the bed as a cue for sleep and weaken it as a cue for wakefulness. The key instructions are:

  • Establish a regular morning rise time. This will help strengthen the circadian clock regulating sleep and wakefulness. Ideally, bedtime should also be regular, but for people with insomnia it is impossible to actually fall asleep around the same time nightly. When insomnia resolves, regular bedtime can further strengthen the circadian rhythm.
  • Go to bed only when sleepy. This will increase the probability that you will fall asleep quickly. It is important to distinguish between fatigue and sleepiness. Fatigue is a state of low energy, physical or mental. Sleepiness is a state of having to struggle to stay awake. Dosing off while watching TV or as a passenger in a car involve sleepiness. People with insomnia often feel tired but “wired” (i.e. not sleepy) at bedtime.
  • If unable to fall asleep, either at the beginning or in the middle of the night, get out of bed and return to bed only when sleepy again.
  • Avoid excessive napping during the day. A brief nap (15 to 30 minutes), taken approximately 7 to 9 hours after rise time, can be refreshing and is not likely to disturb nocturnal sleep.

Sleep Restriction

This procedure, developed by Arthur Spielman, is designed to eliminate prolonged middle of the night awakenings. It doesn’t aim to restrict actual sleep time but rather to initially restrict the time spent in bed. Subsequent steps consist of gradually increasing the time spent in bed. The initial time in bed is usually the average nightly total sleep time over the last week. However, the time allowed in bed should not be less than 5.5 hours, even for people who sleep less than 5.5 hours per night.

For example, consider a person who goes to bed at 11:00 p.m. and gets out of bed at 8:00 a.m. but sleeps on average only 6 hours per night. During the first step of this procedure this person will be in bed only 6 hours (e.g., 12:00 am to 6:00 am). This sounds harsh but after a week or so there will be a marked decrease in time spent awake in the middle of the night.

Usually people experience marked improvement in the quality of sleep after a week of restricted time in bed, but they also realize that that they are not getting enough sleep. In this case, the next step is to gradually extend the time spent in bed by 15 to 30 minutes, as long as wakefulness in the middle of the night remains minimal.

Each new extension of the time in bed is followed for at least a week before progressing to the next extension. The decision as to when to extend the time in bed is based on the percent of the time slept relative to the time spent in bed. This is called sleep efficiency. If the average sleep efficiency is 85% or more, then the time in bed is extended. If it is below 80% then the time is bed is further restricted. Otherwise the time in bed remains unchanged. There are several variants of this procedure, and the therapist chooses the one that best fits an individual patient. In all variants, the procedure continues until one reaches a point after which no further extension is necessary because the amount of sleep obtained is sufficient for optimal daytime function.

Reducing Sleep-Interfering Arousal/Activation

This includes a variety of relaxation techniques, stress management skills, and reducing sleep-related worries. The behavioral sleep medicine specialist uses cognitive therapy to reduce arousal by helping patients shift from “trying hard to sleep” to “allowing sleep to happen.” In addition, the following can also facilitate sleep:

  • Use the hour before bedtime to unwind from the day’s stresses. This down time will allow sleepiness to come to the surface and will therefore facilitate sleep onset. This is a time to engage in activities that are enjoyable yet calming.
  • Avoid clock watching. Turn the clock around so you cannot see the time yet you can still use it as an alarm. A recent study showed that volunteers who were asked to monitor a digital clock at bedtime took longer to fall asleep than those monitoring a similarly looking device that displayed random digits.
  • Avoid exercise within four hours before bedtime.
  • Make sure that the sleep environment is safe, quiet and pleasant.

About Foods and Substances

  • Alcohol: Alcohol speeds sleep onset but this positive effect is counteracted by increased wakefulness in the second half of the night.
  • Stimulants: Caffeine has a rather long half-life (about 6 to 8 hours). People’s sensitivity to the effects of caffeine vary. Those with caffeine sensitivity should be particularly careful to avoid caffeine after lunch. (The amount of caffeine in different drinks and recommendations regarding caffeine consumption can be found on the National Sleep Foundation website.) Certain prescription and non-prescription drugs contain caffeine and when feasible should be avoided close to bedtime. Nicotine and nicotine withdrawal can also interfere with sleep.
  • Eating at night: Digestion slows down during sleep and indigestion, caused by undigested food, can disrupt sleep. Eating in the middle of the night sends the body an alerting signal.

Taking the Biological Clock Into Account

Bed time and rise time should be congruent with one’s circadian clock. When the desired bed time and rise time are not aligned with the circadian clock the therapist can use procedures to shift the circadian clock, such as properly timed exposure to bright light.

Professional help should be sought by people who find it impossible to follow the above recommendations consistently. For example, some people say they never get sleepy. Others find it too hard to get out of bed at the same time every day.

Therapists with special training in sleep disorders and behavioral sleep medicine are best suited to help people with insomnia because they possess knowledge in the science of sleep and the science of behavior change. The American Academy of Sleep Medicine has established a certification in Behavioral Sleep Medicine and maintains a list of certified specialists and their geographic location on its web site.

 

To locate this article go to The Stanford Center for Sleep Sciences and Medicine at http://stanfordhospital.org/clinicsmedServices/clinics/sleep/treatment_options/cbt.html

 

Both providers, Dr. D’Arienzo and Mr. Alan Lipzin, LMHC, provide CBTI in Jacksonville, Florida.

Handout: Cognitive Behavioral Therapy (CBT or CBTI) for Insomnia in Jacksonville, Florida