In this article, clinical psychologist Dr. Vilija Ball presents on the barriers to and consequences of chronic sleep difficulties as well as how they might be treated. Specifically, Dr. Ball:
Describes the emotional, financial, and health consequences associated with chronic insomnia
Provides an overview of how Cognitive-Behavioral Therapy for Insomnia (CBT-I), an evidenced-based psychological treatment considered a first-line treatment by the American Academy of Sleep Medicine, might be helpful for an individual suffering from chronic sleep problems.
Educates about what one might expect while participating in this form of treatment.
Contact Dr. Ball at 833-710-7770 ext. 3 for more information
Insomnia is costly – how much has it been costing you?
With all the important things competing for attention in our lives, why would one listen to my fussing about sleep? Who has enough time to sleep with all the demands calling out our names anyway? Some high achievers might even want to find out how to get rid of sleep all together, so they can accomplish more. On the other hand, others might already be feeling the effects of neglecting this basic need of the body to complete its adequate maintenance, strengthen its immune system, and provide for its restorative functions.
Increased knowledge among professionals about the impact of sleep deprivation is prompting the education and equipping individuals to prevent or overcome a number of negative health risks associated with insomnia and other sleep disorders. In a research study on the effects of insomnia, about half of the individuals who participated were never asked by their primary care physician about sleep. Is this reflective of your situation? This data suggests not only that many people are impacted and suffering because of a lack of knowledge, but also that other health care professionals should contribute to filling this gap and raising awareness about this issue. This is because it deprives affected individuals of help and even exposes them to a number of potential risks, which can result in lost health, productivity, and creativity and a poorer quality of life.
Research studies also show that untreated insomnia can be related to and intensify depression, anxiety, suicide, the development of substance use disorders, and PTSD after experiencing a traumatic event. Finally, if your insomnia is not adequately addressed by your therapist or a sleep specialist, it may mean that you will not achieve optimal treatment gains and it predisposes you to a greater likelihood of relapse down the road. Moreover, studies have linked sleep disorders to detriments of our physical wellbeing such as high blood pressure, heart disease, and diabetes.
Chronic insomnia can also disrupt hunger hormones, which leads to weight gain and potentially other health issues. Insomnia has been associated with increased work-related injuries and overall dissatisfaction with one’s work. If this litany of mental and physical health issues grabs your attention and makes you at least a little bit hesitant in your assumption that you cannot afford to pay attention to your sleep, it is time to check and see whether your sleep patterns, duration, and quality warrant closer attention and assessment for available treatment options.
Taking that first step involves identifying the causes that might generate and maintain symptoms of insomnia, such as difficulty initiating and maintaining sleep. One may also experience early-morning awakening with unsuccessful re-initiation of sleep, and this may occur multiple nights during a week and might have persisted for at least three months. Assuming that this is happening in the context of adequate opportunities for sleep, it should get our attention. Reaching out to a psychologist, a sleep specialist, or a physician would initiate screening and/or assessment of the type of sleep disorder that afflicts us and ensures our symptoms are treated appropriately. For example, if a psychological screening identifies that we have sleep issues stemming from suspected sleep apnea, we will be referred to a sleep clinic or a sleep specialist who would likely order a sleep study to competently diagnose obstructive sleep apnea, determine its severity, and rule out other possible issues. Since obstructive sleep apnea is a potentially deadly condition, it must be prioritized before work on insomnia with a psychologist begins. Sleep issues can also be related to circadian rhythm disorders, narcolepsy, movement-related sleep disorders, parasomnias, and other conditions. Individuals with these concerns should be assessed by a sleep specialist and may need to be observed at a clinic in order to identify effective treatment.
Many may wonder how a psychologist would be able to help them with an insomnia disorder because they have tried to improve their sleep hygiene and exhausted many different strategies, but ended up relying on medication, which has not been a panacea either. It is no wonder that has been our experience because it is possible the answer is waiting for us somewhere else.
CBT-I is the best currently available treatment for insomnia disorder.
You might be surprised to know that in 2016 the American College of Physicians recommended Cognitive Behavioral Therapy for Insomnia (CBT-I) as the first-line treatment for adults with chronic insomnia. CBT-I recognizes the importance of our beliefs and behaviors that might present as obstacles to good sleep, and even have a direct relationship with our insomnia by adding to sleep problems and sustaining them. Therefore, psychologists trained in CBT-I will educate you about psychological and biological processes that help regulate your sleep and can start changing unhelpful habits to facilitate a desirable outcome. Moreover, understanding the philosophy behind what a psychologist might ask you to do will help you to be more compliant because some treatment interventions may seem counterintuitive and conflict with what you want to continue doing. For example, a psychologist’s prescription to reduce your time in bed if it is not associated with sleeping might be met with some resistance. While it might not be a popular intervention, embracing it helps to reduce cognitions and habits that tend to reinforce insomnia. Cognitive and behavioral models assert that our thoughts and beliefs about sleep have a direct impact on our sleep-related behaviors. CBT-I also seeks to reduce physiological hyperarousal associated with our sympathetic nervous system and our cognitions.
Psychologists practicing CBT-I will introduce very specific terminology to you when explaining these treatments, which address behavioral components contributing to sleep difficulties. This entails Stimulus Control (SC), Sleep Restriction Therapy (SRT), and Conditioned Arousal (CA). Stimulus Control (SC) refers to a situation when we tend to react and function differently in the presence of a certain stimulus, but our behaviors change when that thing or situation is removed. The role of SC for insomnia treatment is closely intertwined with CA, which appears to be present in the majority of insomnia treatment scenarios. CA points to the activities that overtime have been associated with our bed and bedroom and which tend to increase and maintain our arousal instead of helping to relax and sleep when we go to bed. If our bed and bedroom are used for activities that increase wakefulness, our brain becomes stimulated instead of relaxed every time we enter our bedroom, or it might be in a state of dysregulation with no clear expectation and preparation to be either relaxed or alert. Therefore, CBT-I treatment requires us to inventory our bed and bedroom activities and leave behind a closed door all those that are not associated with sleeping or sex. The same goes with unhelpful mental activities. You might find it surprising that even “trying to sleep” is counterproductive. It tends to increase worries, arousal, and contribute to insomnia. Moreover, it conditions us to rely on some kind of aid and weakens our body’s sleep drive and ability to initiate and sustain sleep independently.
After a CBT-I therapist collects 1-2 weeks’ worth of data about your sleep patterns with the help of sleep diaries, SRT may be used temporarily to reduce the amount of time in bed to build up your sleep drive, if the data shows that it has been weakened. While it might be somewhat difficult for you to embrace, it can have a positive impact and reduce unwanted wakefulness throughout the night. After this goal is achieved, the amount of time in bed is increased gradually to the optimal amount of sleep time to meet the sleep needs of your respective chronotypes.
Regarding the cognitive component of CBT-I, it will be important to identify, explore, and modify thoughts, perceptions, and interpretations associated with your sleep concerns that tend to generate bodily arousal, sleep anxiety, and poorer sleep. For example, we all have had some important exams or job interviews to face. We desperately wanted to be rested, relaxed, and in our best state of mind. These expectations and desire for a successful outcome would most likely trigger some performance anxiety, but if strong rules and beliefs surrounding our performance in association with sleep were to be added into this equation, that might stack even more obstacles against having decent sleep and performing well. If we went to bed with a strong belief that we absolutely must have at least eight hours of sleep to be successful during an interview, this might present a significant obstacle to our performance, if we get only four hours of sleep. How would this scenario most likely play out? We might start awfulizing the situation and more strongly embrace the conviction that with only four hours of sleep we will fail. Of course, this mindset would be a significant obstacle during the interview, if we even dare to proceed because this belief would be harassing and intimidating us – weakening our focus, concentration, and confidence. We would end up being flooded with anxiety-producing automatic thoughts, which are absolute performance spoilers. These types of beliefs tend not just to deprive us of putting our best efforts forward, but reinforce more cognitive errors associated with sleeping, which support the envisioning of catastrophic outcomes and most likely overestimating them. This would start and continue a cycle of building pressure, stress, anxiety, and more difficulties with falling and staying asleep in the future.
Cognitive restructuring techniques might help us to identify and challenge fears associated with catastrophic and low probability consequences. This can open the door for a different scenario, if we embrace a more flexible attitude toward sleep and its direct impact on our performance. We would be more prone to encouraging ourselves to do our best under circumstances resulting in less than optimal sleeping time. The psychologist might challenge us to recall when we managed to succeed in the past even with less than eight hours of sleep and to identify times when our performance was not optimal even with the full eight hours. This scenario would help us channel our anxiety and increase our performance instead of hindering it. This approach would also allow us to avoid counterproductive efforts of “trying to sleep” in order to function well and failing because, like someone once said, trying to sleep is the same as trying to fall in love – it does not work that way, but it starts when we do not seek or try at all.
Finally, understanding and addressing the role of our physiological and cognitive hyperarousal in CBT-I treatment would entail determining a good fit and practicing those relaxation techniques, scheduling time to worry, and finding effective ways to unwind before sleep time. The psychologist’s approach to the major relaxation targets in treatment would involve letting go of sleep efforts and attempts to control relaxation. Paradoxically for some of us, relaxation efforts may induce more anxiety and increase hyperarousal if controlled and used as a means to an end in order to generate sleep. Therefore, with the help of the psychologist you would learn to disassociate pre-bed or bed-time activities from your efforts to produce sleep – trying too hard to sleep – which can be a big challenge for some. Creating a “buffer zone” before bedtime might be one of the tools that can help to reduce sleep-interfering arousal by engaging in pleasant activities for your enjoyment and without the intention to bring on sleep. Used in this way, a buffer zone can help facilitate sleep. Many of us have already been advised by our physicians or have familiarized ourselves with some sleep hygiene routines or relaxation strategies with an intent to reduce pre-bed physiological or cognitive hyperarousal. However, this does not seem to be sufficient when we are dealing with chronic insomnia. It is important to stress that treating insomnia can be problematic because of the subjective experiences and nature of this disorder as well as the complexity of the interaction of many factors contributing to chronic sleeplessness.
Overall, CBT-I’s conceptualization of insomnia draws on Arthur Spielman’s 3P Model that incorporated research findings on the major factors contributing to the development and maintenance of insomnia. It acknowledges and addresses our biological sensitivities and vulnerabilities and considers our chronotype, which can all be predisposing factors to insomnia. Precipitating factors have a tendency to appear in the context of life stressors or mental health issues that might become salient triggers in the development of insomnia disorder. The model also identifies the role of perpetuating factors such as bedtime worry, spending too much time in bed, conditioning ourselves to be awake in bed, and our need to deal with them effectively to ensure successful treatment outcomes.
There are other strengths of CBT-I to consider. It is an empirically supported, first-line, brief treatment for insomnia disorder, but it has also been shown to be effective even among individuals diagnosed with psychological and medical comorbidities. Data also shows that its positive effects are sustained and remain long after completing treatment. The treatment is nonpharmacological and so avoids the side effects of medication. CBT-I is risk free and safe in most cases, but its application where comorbid, unstable medical or psychiatric conditions are involved should be evaluated carefully. Environments where individuals cannot control their sleep and wake time as well as their sleep environment, might present difficulties implementing CBT-I components. Otherwise, it should be underscored that CBT-I has been found to be effective in a wide range of populations.
There is a good reason why we tend to smirk at someone who is enjoying sleep and is protective of it, and we say that these people are getting their beauty sleep. I would like to end with adding that sleep is not only for our beauty, but it is an important element in our overall health and life quality, and it serves as a protective factor against mental and physical disorders. Therefore, there is always a good reason to improve our sleep. Knowing the costs and impact of insomnia disorder on our health, performance, and relationships, we should never tolerate it.
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