Cognitive Behavioral Therapy for Insomnia Part 1
Thorough self evaluation is the first step in overcoming insomnia.
Posted May 11, 2009
In previous posts I discussed the problem of insomnia and its treatment with medication and cognitive behavioral therapy. In the next several posts I will review in greater depth a number of the techniques used by behavioral sleep specialists to effectively treat insomnia. These methods have been tested in rigorous clinical research and are used daily through out the country, either as part of a self-help program or in formal therapy to manage and overcome insomnia for many weary people seeking relief from this persistent and potentially debilitating sleep disorder.
The major components of a cognitive behavioral treatment of insomnia are stimulus control, sleep scheduling, sleep restriction, cognitive therapy, relaxation therapy and sleep hygiene education. A number of other techniques are also effective in managing insomnia and will be reviewed in future posts.
Before reviewing each of these techniques it is important to note that insomnia takes different forms in different people or may affect the same person in different ways over time. Insomnia can involve difficulty falling asleep, difficulty staying asleep, non-restorative sleep or some combination of all of these. It is therefore a good idea to take stock of your sleep pattern and do a careful self-evaluation prior to implementing a plan for conquering insomnia. For example, if the primary problem leading to insomnia is the presence of negative thoughts about sleep that result in over-arousal and thus prevent sleep onset, then it will be more effective to focus efforts on challenging these negative thoughts and replacing them with more accurate, positive sleep thoughts sleep than to focus on sleep hygiene issues that may not be the problem. Changing these thoughts will reduce over-arousal and make it easier to fall asleep.
So the first step in evaluating one's insomnia is to do a careful self-analysis of one's sleep pattern and the factors that affect it. This will help rule out potential other sleep disorders and help identify behaviors and cognitions that are negatively affecting sleep.
First, note the possible presence of other psychological, medical or sleep disorders. Major psychological problems that can negatively affect sleep include mood disorders (e.g., major depression), anxiety disorders (e.g. generalized anxiety or post traumatic stress disorder) and abuse of substances (e.g. alcohol). Medical problems that can affect sleep include thyroid disorders (hyperthyroidism), chronic pain and diabetes. In addition, women may experience significant sleep disruption due to the hormonal changes associated with menopause. It is also possible that the side effects of certain medications used in the treatment of medical conditions, including those purchased over the counter, may interfere with sleep. A number of other sleep disorders can also significantly contribute to poor quality sleep including sleep apnea and restless legs. If any of these are suspected it is important to have them evaluated and properly treated by your health care providers. Even if these conditions are contributing to insomnia, cognitive behavioral techniques may still be very helpful in correcting problems related to behaviors and thoughts that may be maintaining insomnia.
Second, learn more about your sleep pattern. Keep a sleep journal for a week or two to get a better idea of your sleep pattern and factors affecting it. It may be helpful to note such factors as the use of caffeine, tobacco and alcohol, naps taken, timing of meals, time of getting into bed, time of turning out lights to go to sleep, awakenings during the night, time of waking in the morning and time of getting out of bed. The journal helps identify areas that may need to be changed. For example, are you spending a lot of time in bed reading or working on bills before turning out the lights to go to sleep? Are you taking long late afternoon naps and how does this affect falling asleep at night? Does having a cup of coffee with dinner seem to make a difference in your sleep?
Third, carefully note your thoughts about sleep. These thoughts can occur while lying awake in bed at night or during the day while at work. When these thoughts occur at night and prevent falling asleep they are referred to as "excessive nocturnal mentation" and are a primary cause of insomnia. These thoughts often take the form of "if I don't get to sleep I will not be able to function tomorrow." This is upsetting, causes arousal and makes it virtually certain that sleep will not come easily. When they occur during the day they often are along the lines of "I got a terrible night of sleep last night and so today I am going to feel terrible." This line of thinking contributes to the negative mood often associated with insomnia.
Fourth, look at your life style and how it may be affecting sleep. For example, do you have a very heavily scheduled day and so are going to the gym to exercise vigorously at 8 p.m. in the evening, hoping to be able to come home and fall asleep by 9:30 p.m.? Are you eating heavy meals right before bed time and then not being able to sleep because of gastric reflux? Do you stay up until 1:00 a.m. playing action packed video games knowing that you have to fall asleep quickly so that you can be up by 6:00 a.m. to go to work? These life style and behavioral issues may be a primary contributor to insomnia.
Finally, consider your stress level. Does the tension and pressure of your job or relationship continue to affect you as you are trying to fall asleep? The over-arousal resulting from a stressful life situation may significantly contribute to insomnia. Reducing general stress can help improve sleep. Stress management techniques can help greatly in this regard.
After you have a better idea of what your sleep pattern is and what factors are contributing to your insomnia you are prepared to start working actively on getting better sleep. If it is clear that you are going to need professional help to move forward, make an appointment to discuss this with your primary health care provider and ask for a referral to a behavioral sleep specialist. If it seems that some basic changes in life style or outlook can do the trick, then prepare to move forward. More techniques will be reviewed next time. If you want to get more in depth information about these methods I recommend reading Gregg Jacobs' Say Good Night to Insomnia or Peter Hauri and Shirley Linde's No More Sleepless Nights. A good reference for women dealing with issues such as menopause is Meir Kryger's A Woman's Guide to Sleep Disorders.