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Eye On Therapy: Learning to Sleep


doi: 10.1097/01.NNN.0000370192.75912.fe

Cognitive-behavioral therapy can eliminate insomnia—if you do the homework.

Cognitive-behavioral therapy can eliminate insomnia without drugs—if you do the homework.

Mike Smolinsky is the managing editor of Neurology Now. He has a Ph.D. in English Literature from the University of Iowa and has been a medical editor for 10 years.

For more information on insomnia, see RESOURCE CENTRAL on page 36.



More than one-third of American adults report having insomnia, and 10 to 15 percent report chronic insomnia, according to the National Institute of Neurological Disorders and Stroke. Sleep deprivation can be dangerous: According to the American Academy of Sleep Medicine, an estimated 20 percent of all serious injuries on the nation's highways are sleep-related.

Increasing numbers of Americans are seeking a pharmaceutical solution to their sleepless nights. But cognitive behavioral therapy (CBT)—a short-term psychotherapy—is proving to be an effective alternative.

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If you have trouble falling and/or staying asleep, or you wake up early, then you have insomnia. According to the Mayo Clinic, most adults need seven to eight hours of sleep per night in order to feel their best.

Some of the common causes of insomnia are stress, anxiety, and depression; prescription drugs, including several heart and blood-pressure medications; caffeine, alcohol, and nicotine; underlying medical conditions, such as Alzheimer's, Parkinson's, or diabetes; poor sleep habits; and aging.

Inadequate sleep can have a wide range of negative consequences, beyond potentially lethal auto accidents and millions of dollars in lost productivity. In the short term, insomnia can cause memory impairment and an increased risk of on-the-job injury. In the long term, untreated sleep disorders—obstructive sleep apnea, restless leg syndrome, insomnia—have been linked to high blood pressure, heart failure, depression, and obesity.

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“In our sleep center, we do use hypnotics in some patients,” says Donna Arand, Ph.D., sleep medicine specialist, clinical director of the Kettering Medical Center Sleep Disorders Center in Dayton, OH, and assistant professor of neurology at Wright State University School of Medicine in Dayton. So-called hypnotics—such as zolpidem and eszopiclone—are one of the most commonly prescribed classes of drugs for insomnia; benzodiazepines, a type of tranquilizer that includes lorazepam and clonazepam, are another. “Sometimes you need to intervene immediately, and meds work faster than behavioral treatments,” Dr. Arand says.

Marika Kyrimis, Ph.D., agrees: “They have their place.” Dr. Kyrimis is a clinical psychologist in private practice in New York, NY, and clinical instructor of psychology at the Weill Medical College of Cornell University, also in New York City. “Sleep drugs can be effective in the short term. However, they do have side effects—many people feel drowsy the day after taking them,” she observes.

In addition, medication may interfere with the quality of your sleep. “These drugs seem to negatively impact ‘sleep architecture,’ which is how much time we spend in various sleep stages,” says Ryan Wetzler, Psy.D., a certified behavioral sleep medicine specialist with Sleep Medicine Specialists in Louisville, KY, and lead author of a new study on the effectiveness of CBT for insomnia presented at the 2009 Annual Meeting of the Associated Professional Sleep Societies. “Although sleep medications may increase total sleep time, the quality of that sleep may be poor.”

Finally, not all patients can or want to take sleep drugs. “Medication is not the treatment of choice for patients who have a tendency to drug dependency, or for those taking other medications that may interact with sleep meds,” Dr. Arand notes. Many of the people who come to Dr. Kyrimis for help are women who want to stop using sleep drugs before getting pregnant. Data on the reproductive safety of hypnotics and benzodiazepines is limited; as a result, many doctors and patients try to limit their use during pregnancy.

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CBT is a short-term, symptom-focused psychotherapy that has been proven successful in treating insomnia, anxiety disorders, and mood disorders such as depression. For insomnia, the treatment typically entails five to 10 sessions, each one about an hour. “It's structured and focused on the present, as opposed to the patient's past,” Dr. Kyrimis explains. “CBT involves working directly on beliefs and behaviors that are getting in the way of sleep.”

Beliefs about insomnia can be downright cataclysmic. Although getting eight hours of sleep on a regular basis is ideal, people can and do survive on less without the world coming to an end. “One typical catastrophic belief is, ‘If I don't get eight hours of sleep, I'll go crazy.’ These kinds of thoughts make people incredibly anxious, which interferes with sleep,” Dr. Kyrimis says. “To combat them, we'll first show people the evidence—that not getting eight hours of sleep doesn't cause insanity. Next, we show the person how these negative thoughts get in the way of their sleeping. Finally, we help the person modify their thoughts, replace them with rational ones. That's the cognitive aspect of the therapy.”

In the sleep-education component, the therapist will explain the basics of “sleep hygiene”—for example, the importance of sticking to a regular sleep- and wake-time and making sure one's bedroom is cool, dark, and clutter-free. Another element of sleep education is helping people establish a sleep regimen, which includes a time to decompress from the stresses of the day.

The behavioral component involves actively changing your sleep habits, which takes willpower—especially when it's 3 A.M. and you aren't thinking clearly, or it's 7 A.M. and you're finally falling asleep.

“For many people with insomnia, their compensatory strategy is to increase the amount of time they spend in bed,” says Dr. Kyrimis. For example, they might lie in bed during the night without sleeping and/or push their wake time forward in the morning. Unfortunately, this can forge an association between the bed and sleeplessness. It can also “disrupt the homeostatic ‘sleep pressure’ we all have and trick the brain into thinking you've gotten enough sound sleep,” Dr. Kyrimis explains. “If you get out of bed instead, you build sleep pressure.”

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“In a word, yes,” says Dr. Arand. “By comparison, in almost every category, CBT is superior to other forms of treatment. It has no side effects. It's been proven effective in trials lasting a year and slightly longer, so it doesn't lose effectiveness over time like many pharmaceutical compounds can. And once a person knows the techniques, even if the insomnia comes back in the future, he can apply them.”

Although CBT has been studied before, Dr. Wetzler's research is an important step forward. “I undertook what is known as an effectiveness study, to find out if CBT works in a clinical setting with real-world patients,” says Dr. Wetzler.

Dr. Wetzler and his colleagues looked at the records of 115 patients they had seen at their clinic. For entrance criteria, participants either had to have sleep-onset latency (trouble falling asleep) of more than 30 minutes, or sleep-maintenance insomnia (waking up after being asleep) that lasted for more than 30 minutes. The number of treatment sessions varied from two to 10. Participants were between the ages of 14 and 81 years, and 65 percent were female.

The results showed that CBT is indeed an effective treatment for chronic insomnia. “For people who had sleep-onset insomnia, 57.8 percent had remission of symptoms. For those who had sleep-maintenance insomnia, 50 percent had remission of symptoms. Of patients who had both types of insomnia, 66 percent had their sleep onset normalized, and 56 percent had their sleep maintenance normalized,” Dr. Wetzler says.

In addition, one of Dr. Wetzler's graduate students looked at the group of patients taking sleep drugs of all types—many of them hypnotics—three or more days per week. “After four sessions of CBT, 78 percent were off sleep drugs completely and actually sleeping better,” Dr. Wetzler notes. “Their sleep-onset latency and awakenings decreased and their total sleep time increased.”

However, CBT does work better for some people than others. Most of the work is actually done outside of the sessions and includes maintaining a sleep log that is regularly reviewed with the therapist.

“The treatment is time-intensive, and it requires effort and self-discipline. As a result, you need a really motivated client, in my experience,” Dr. Kyrimis says. “A lot of people would rather lie in bed or take a pill than work to get their insomnia under control.”

©2010 American Academy of Neurology