Q &A: INSOMNIA TREATMENT

What is Insomnia?

Difficulty initiating sleep, difficulty maintaining sleep, or sleep that is non-restorative are the common complaints that people with insomnia experience. Fatigue, difficulty with attention and concentration, low mood, and irritability are common daytime complaints. 

How are insomnia and sleep deprivation different?

The definition and diagnosis of insomnia relies on a person having adequate sleep opportunity. That is, a person who routinely sets aside a nine-hour window for sleep and can only manage to get about five hours of sleep during that window of opportunity is a person with insomnia. A person, who routinely “burns the candle” at both ends and consequently only allows for a sleep window of five hours and sleeps five hours is likely very sleep deprived but is not suffering from insomnia. There are naturally short sleepers but people reporting that they get along fine with less than six hours is very rare.

I know that there are sleeping pills but are there non-medication approaches that can be used to treat insomnia.

Yes! Non-medication psychological approaches such as Cognitive Behavioral Therapy for Insomnia (CBT-I) has proved to be a very effective treatment for insomnia. Scientific support for this treatment model has developed over 30 years of high quality research and clinical implementation. A major benefit of the CBT-I approach is that the improvements in sleep gained during formal treatment are routinely maintained after treatment ends. One drawback to the psychological approach is that it takes longer to see improvements but, again, this is balanced by the durability of the gains.

How much time is needed for CBT-I

The model is 4 to 8 sessions. Typically, the first 2 sessions are for assessment, sleep education, and treatment planning. The next 2 to 6 sessions are dedicated to implementing the treatment plan.

What are the basic components of CBT-I

As the name implies there are both cognitive and behavioral components that can be used to help you improve your sleep. The cognitive or thinking component includes addressing the following issues: catastrophic thinking about lack of sleep itself, daytime worry about the upcoming night’s sleep, perfectionism about sleep (I need x hours or sleep is ruined), impatience (I need it “fixed” right now), worry about daytime consequences of sleep loss, any other counterproductive (untrue assumptions) about sleep that only serve to increase anxiety, arousal, worry, tension.

The behavioral component includes sleep efficiency training and stimulus control. Sleep efficiency training makes your time in bed more efficient by limiting your opportunity to sleep to roughly your reported total sleep time. That means that if you feel that you only get 4 hours of sleep during an 8 hour opportunity, your sleep opportunity is limited to that 4* hours. *However, for safety reasons, we generally ensure that sleep opportunity is not restricted to less than 5 hours. Stimulus control eliminates behaviors that are incompatible with the intended use of the bedroom – that is, sleep (sexual activity is the exception). For example, laying in bed “trying to sleep” for hours on end, working in bed, eating in bed, watching TV in bed, having stress-laden talks with your bed partner in bed, all lead to having the bed and bedroom be a cue or stimulus for many behaviors other than sleep. Stimulus control tightens the association of the bed and bedroom with the behavior of sleep and this is reinforced by better more satisfying sleep.

What should I look for in a CBT-I clinician.

Ideally, your CBT-I clinician should have good psychotherapy skills, good psychiatric diagnostic skills, dedicated training in insomnia models and diagnosis, dedicated training in the delivery of CBT-I (with case consultation), and enough knowledge about other sleep disorders so that patients who present with these symptoms can be referred for further evaluation. Knowledge of sleep physiology and polysomnography is helpful but not often a requirement for good service.

Is certification in Behavioral Sleep Medicine from either the American Board of Sleep Medicine and/or the Board of Behavioral Sleep Medicine something I should look for in a clinician.

Yes, but finding a certified clinician in your area may be difficult given the limited number of clinicians across the country. The benefit of certification is knowing that the clinician who is treating you has met the educational, training, and examination requirements of the American Board of Sleep Medicine and/or the Board of Behavioral Sleep Medicine.