CBT for insomnia

Can’t Sleep? Do you find yourself tossing and turning all night and fatigued during the day? Don’t you feel refreshed when waking up from sleeping, either? It’s probably because when you have insomnia you are never really asleep and you’re never really awake. But you need not stress. There are many ways cognitive behavioral therapy for Insomnia (CBT-I) can help you with your sleep problems.

Defining Insomnia

Insomnia is a common sleep disorder. Individuals with insomnia find it difficult to fall asleep, stay asleep, or both. Chronic insomnia occurs in about 10% of the population. Acute insomnia symptoms occur in about 30-35% of the population.

Insomnia can occur in isolation or along with other conditions that can include:

1.Psychological difficulties (such as PTSD, depression, anxiety, bipolar, schizophrenia..)

2.Medical conditions (e.g., chronic pain, diabetes, restless leg syndrome..)

3.Substance abuse (e.g., cocaine, caffeine, or nicotine)

People can experience insomnia in distinct ways. Many people experience short-term (acute) insomnia, which lasts for days or weeks.  Some experience long-term (chronic) insomnia that lasts for a month or more. Chronic insomnia is usually a result of traumatic life events or habits that disturb sleep.

How a person is affected by insomnia varies greatly. It depends on its cause, severity, and how it is influenced by underlying health conditions.

What are the Potential Causes of Insomnia?

There are many potential causes of insomnia. The risk factors include:

  • Unhealthy lifestyle, and sleep habits
  • Life stressors and Traumatic life events
  • Anxiety disorders/ mood disorders and other mental health conditions. A high number of psychiatric patients also suffer from insomnia. Approximately 50% to 80% of patients with mental illnesses have difficulty with falling or staying asleep. Research shows that insomnia is strongly associated with psychiatric disorders. It can be primary or secondary to a mental disorder.
  • Medical conditions
  • Comorbidity (Fibromyalgia, Diabetes or Arthritis)
  • Medication or Substance abuse

What are the signs and symptoms of Insomnia?

Following are the common signs and symptoms of insomnia.

  • Difficulty falling asleep or waking up at the middle of the night
  • Difficulty returning to sleep
  • Waking up too early in the morning
  • Daytime lethargy and sleepiness
  • Fatigue
  • Mood changes, irritability, and anxiety
  • Low on energy or motivation
  • Poor concentration and lack of focus

Consider speaking with your GP regarding any of the symptoms you experience that might indicate insomnia. They can put you in touch with an Austrian accredited psychologist or psychiatrist. Our psychiatrists and psychologists are experienced in treating insomnia and other sleep disorders. They are here to provide caring, professional support to those in need.

How is Insomnia diagnosed?

Your healthcare provider will conduct a physical exam. He may ask questions to learn more about your sleep difficulties. He will review your sleep history, medical history, and medications.

You may get a clinical diagnosis if:

  1. You have difficulty falling or staying asleep.
  2. It has adverse effects on your daily functioning.
  3. This happens at least three nights a week for 3 months, despite sufficient opportunity for sleep.

How can Insomnia affect you?

  • Firstly, insomnia can have adverse implications on you in terms of your emotional, mental health. and quality of life.
  • Secondly, it impacts your daily functioning.
  • Thirdly, it decreases your work productivity.
  • Daytime effects including increased risks of accidents.
  • Furthermore, it can lead to higher severity of symptoms in patients with mental disorders.
  • In addition, it leads to the development of certain chronic diseases such as heart diseases and strokes.

What is CBT-I?

CBT-I is a brief, highly effective, and safe behavioral health treatment for patients with chronic and acute insomnia. It is a form of CBT tailored specifically to address insomnia. CBT-I is a collection of skills or techniques that can effectively retrain you to trust your sleep system again. It helps correct any unrealistic thoughts or expectations that you might have around sleep. The thoughts that end up putting extra pressure on you. For example,’ I must get this many hours of sleep’. Hence, it makes sleep more difficult.

CBT-I typically involves 4 to 12 customized sessions. Patients are encouraged to modify their beliefs about insomnia.

Is CBT an Evidence-based Treatment for Insomnia?

 Cognitive-behavioral therapy for insomnia is an effective treatment and can be given in a primary care setting by psychologists.

It is proposed that Cognitive behavioral therapy should be the first-line treatment for adults having chronic insomnia (American College of Physician ACP, 2016).  

Research also suggests that there is a good deal of evidence for applying CBT as an initial treatment for chronic insomnia.

Likewise, a comparative meta-analysis of 21 studies showed similar short-term outcomes for CBT and pharmacotherapy. While CBT produced greater long-term benefits.

Clinical guidelines for the Evaluation and Management of Chronic Insomnia in Adults also suggest that :

  • CBT is effective and recommended in the treatment of primary and secondary insomnia.
  • This treatment is effective for adults of all ages including older adults.
  • It should be utilized as an initial treatment when appropriate and when conditions permit.

CBT-I vs Pharmacotherapy

Usually, people with chronic insomnia reach out to doctors for drug therapies that have serious side effects. CBT is likely to have very fewer side effects as compared to sleep medications. FDA only approves sleep medications for short-term use, ideally no longer than four to five weeks. This explains the paramount role of applying CBT in practice.

 Skills learned in CBT provide long-term effectiveness. But, there is a degree of effort and self-discipline needed to commit to therapy as it is far more challenging than taking a pill. It offers many advantages over present-day pharmacotherapies. That’s not to say there’s never a place or time for sleep medications.

When CBT-I alone is not successful in improving the symptoms, it is recommended to go for sleep medications alongside CBT-I.

Does CBT Work for Insomnia?

CBT-I works because it addresses the cause that drives insomnia

  • According to conferences on the management of chronic insomnia, CBT is equally successful as drugs for treating chronic insomnia in the short run.
  • Meanwhile, a Harvard Medical School study found that CBT was more beneficial than sleep medicine in treating chronic insomnia.
  • The beneficial effects of CBT may last well beyond the termination of active treatment than drugs.
  • CBT-I leads to increased daytime functioning as well as greater sleep quality with persistence.
  • CBT-I improves the lives of 70% to 80% of people who suffer from primary insomnia.
  • Less time to fall asleep, more time spent asleep, and waking up less during sleep are all benefits.
  • Patients learn useful sleep routines that they can use if insomnia strikes again.
  • It also has a number of advantages over medications in terms of safety, efficacy and durability. Pharmacological treatments for insomnia, on the other hand, have been linked to tolerance, reliance, and negative side effects.

What are the Core Components of CBT-I?

CBT-I is a multicomponent treatment because it combines several different approaches. Sessions may include cognitive, behavioral, and educational components

Behavioral Treatments:  The behavioral component of CBT-I helps you identify and address any behaviors that may be perpetuating or worsening your sleep problems.

CBT for insomnia consists of five distinct components that work together to alter a patient’s sleep-related beliefs and behaviors, as well as their sleep environment

In terms of how these components are implemented, all practitioners generally follow a similar pattern, although they can be somewhat changed to meet your own needs. The following are the essential elements:

  • Sleep education/ Understanding Sleep
  • Cognitive therapy/ Changing dysfunctional thinking patterns, beliefs and attitudes that interfere with sleep
  • Sleep restriction
  • Stimulus control
  • Relaxation Training
  • Sleep hygiene

Sleep Education:

CBT-I includes several educational treatments aimed at improving sleep quality. A therapist may educate a client about

  • What a good sleep is
  • What sleep is not
  • Sleep cycle
  • 4 stages of sleep NI, N2, N3 and REM
  • Sleep quality vs quantity
  • Healthy sleep-related behaviors

Cognitive therapy

Cognitive therapy uses cognitive restructuring to target problematic beliefs and attitudes about sleep. For instance, needing 8 hours each night or napping to catch up on sleep loss. It builds up sleep anxiety for you, if you believe you should be sleeping in a certain way or that some part of your sleep is not normal when it quite is.

Additionally, you can also keep a sleep diary or a sleep log to have an overview of where you currently are in regards to your sleep. It helps you see your progress.

Sleep restriction:

I sometimes suffer from Insomnia, and when I can’t fall asleep, I play what I call the alphabet game

~Roz Chast

Sleep restriction is not about restricting sleep, it’s all about sleep efficacy and restricting time in bed. Many persons who suffer from chronic insomnia report sleeping for an average of four hours per night. The rest of the hours are spent tossing and turning in bed. Also, they are spent feeling anxious, worried, and frustrated. Sleep restriction is about reducing this sleep window.

The goal here is to consolidate sleep. Instead of spreading out tiny little snippets of sleep over a very long sleep, you get nice, strong, deeper, and more restorative sleep. It helps create and strengthen the association between bed and sleep.

People with insomnia associate bed with being awake and anxious. With bedtime restriction, you spend all your time in bed asleep. It retrains you to see the bed as time for sleep.

Stimulus Control

Stimulus control helps to associate bed with sleep and nothing else. Ongoing insomnia creates a negative learned association between bedtime and sleep. Stimulus control eliminates this association between bedtime and arousal. The technique ensures that you are not doing any activity in bed apart from sleep. Some habits include:

  • Start with your bed time routine
  • Only go to bed when sleepy
  • Get up if not asleep in 20-30 minutes
  • Do some relaxing, enjoyable activity
  • Go to bed again when sleepy
  • Wake up same time, no naps

Relaxation Training:

Above all, CBT-I also includes some kind of relaxation component. CBT-I therapists also suggest many relaxation techniques. The goal of relaxation techniques is not falling asleep, but the relaxation of mind and body.

This facilitates sleep and decreases physiological and cognitive arousal. The hour before sleep can be for relaxing and doing enjoyable activities.  

Here are a few relaxation techniques commonly taught in CBT-I that serve as ways to elicit the relaxation response and help fall asleep:

Progressive muscle relaxation (PMR):

PMR is a deep relaxation technique that involves tensing and relaxing different muscle groups one by one. This helps reduce muscle tension that leads to sound sleep.

Deep Breathing and Visualization Exercises:

Another way to engage the body’s natural relaxation response is through deep breathing and visualization exercises. Deep breathing exercises are also helpful tools have that can calm your mind.

These exercises involve taking slow deep breaths and rely on using mental images to create a sense of well-being in the body. This reduces stress and transition you to sleep.

Underlying stress and anxiety often result in insomnia. These simple exercises can help relieve the stress and tension that is stored in the body.

Hypnosis:

Hypnosis is a useful tool for enhancing sleep. In a deep hypnotic state, your subconscious is receptive to thoughts and ideas. During hypnosis, you can verbally repeat or listen to a relaxing thought such as ‘I fall asleep as soon as I lie in my bed’ or ‘I am relaxed and calm’.

Mindfulness Meditation:

Mindfulness meditation is about focusing on the present moment. It increases awareness of your breathing and body and makes you more conscious.

If a thought or emotion pops up during meditation, you just have to observe it without judgment, always returning the focus to your body and breath.

Additionally, guided and body scan meditations can also be of great help for insomnia. The act of focusing and increased awareness promotes relaxation, which helps you sleep.

Biofeedback:

Biofeedback teaches you to identify and master your body’s stress response. It can also use sensors to measure your physiological health such as heart rate, breathing, and muscle tension.

Sleep hygiene:

Strong sleep hygiene means having both a bedroom environment and daily routines that promote consistent, uninterrupted sleep. Following are some sleep hygiene rules:

  • Reduce time in bed
  • Using bed only for sex and sleep
  • Keep a regular sleep schedule
  • Erase the bedroom clock
  • Exercise in the afternoon/ early evening
  • Avoid caffeine, nicotine and alcohol
  • Limit your room light and screen time as they can also affect your sleep drive and circadian rhythms

Educating clients about the importance of good sleep hygiene is a core component of CBT-I. However, it is not an effective stand-alone treatment for insomnia.

Hence, CBT-I coaches engage patients to be active participants in their sleep health. They teach cognitive and behavioral skills that resolve chronic insomnia in 70% to 80% of patients often without medication.

 Who Provides CBT-I?

CBT-I is often provided by a counselor, therapist, doctor, or psychiatrist trained in this form of treatment. Unfortunately, there aren’t enough CBT-I coaches despite the widespread call for its demand. To respond to this widespread call digital CBT-1 (DCBT-I) offers the benefits of CBT-I to a far and wider audience and is also as effective.

How long does CBT take to work for insomnia?

CBT for insomnia involves anywhere between 4 to 12 weekly 1-hour sessions by a qualified sleep therapist. The length of therapy also depends on the severity of your sleep disorder.

Does CBT-I have any Risks?

The risks of CBT are likely to be mild, but they may be uncomfortable at times.  Although this treatment has demonstrated great efficacy in treating insomnia, it does require a degree of effort and self-discipline needed to commit to therapy.

Talking about painful experiences, thoughts, and feelings can be challenging and may cause temporary stress and discomfort.

Working with practitioners with experience in CBT-I can help manage the discomfort and challenges. Above all, it can take some time to learn and practice the skills.

A Piece of Advice:

CBT is a fantastic long-term solution for insomnia. It is a collection of skills and techniques and if you learn them, they are with you for life. It is not an ongoing prescription for the rest of your life with sleeping pills. Anytime, if your sleep gets disturbed again in the future, you remember all the skills that you’ve learned. You can reintroduce those skills into your routine to get your sleep back on track. As it is rightly said that:

Sleep is the best meditation

~Dalai Lama

It is highly encouraged to look into CBT-I as an initial treatment for insomnia. Usually, patients with insomnia do not view it as a clinically significant disorder that warrants medical attention. Anyone who experiences ongoing trouble sleeping and feels that is affecting his/her daily functioning should see a professional.

Contact our friendly coordination team to book an appointment with one of our clinicians if you are suffering from any sleep disorder. You can reach our friendly support team via webchat, phone, or email. You will need a referral (Mental Health Care Plan) from your GP to see one of our psychologists.