Cognitive Behavioral Treatments for Insomnia
June 26, 2013
People with insomnia have trouble falling asleep or staying asleep. Insomnia can cause one or more of the following symptoms:
- Difficulty falling asleep
- Waking up often during the night and having trouble going back to sleep
- Waking up too early in the morning
- Having sleep that is not refreshing
Approximately 50 percent of adults experience occasional bouts of insomnia, and one in 10 complain of chronic insomnia. Insomnia is almost twice as common in women as in men, and is more common in those who are older.
Behavior therapy is commonly used to treat insomnia. It is a technique that requires some effort, but it is a proven method to help people return to more normal sleep patterns. Behavioral treatments, in general, are found to be more effective and longer lasting than treating insomnia with medication.
Cognitive Behavioral Therapy for Insomnia, or CBT-I, is an approved method for treating insomnia without the use of medication. This type of therapy is aimed at changing sleep habits and schedules. CBT-I techniques may include sleep hygiene, relaxation exercises, stimulus control, sleep restriction and cognitive restructuring.
CBT-I includes regular physician visits to examine your sleep/wake habits and pinpoint the actions that may be preventing you from sleeping soundly.
About the Speaker
Ketan Deoras, MD, is an associate staff physician with the Department of Psychiatry and Psychology in Cleveland Clinic’s Sleep Disorders Center in the Neurologic Institute. Dr. Deoras is board certified in psychiatry. He sees patients at Cleveland Clinic’s main campus, Beachwood Family Health & Surgery Center and Hillcrest Hospital. Dr. Deoras has a joint appointment in Cleveland Clinic’s Center for Behavioral Health and practices outpatient psychiatry in Westlake. He has many specialty interests including sleep disorders, insomnia, sleep apnea, psychiatric disorders and mood and anxiety disorders.
Dr. Deoras completed his fellowship in sleep medicine at Cleveland Clinic following completion of his residency in psychiatry at the University of Arizona Medical Center, Tucson, Ariz. He received his medical degree from the University of Toledo College of Medicine, Toledo, OH.
Let’s Chat About Cognitive Behavioral Treatments for Insomnia
Moderator: Welcome to our Cognitive Behavioral Treatments for Insomnia online health chat with Dr. Ketan Deoras. We are very excited to have him with us today!
Overview of Cognitive Behavior Therapy for Insomnia (CBT-I)
jellyb: What exactly is meant by cognitive behavioral treatments?
_Ketan_Deoras,_MD: Cognitive behavioral treatments in general refer to therapies that are aimed at examining and changing thoughts, behaviors and emotions. For sleep, cognitive behavioral therapy for insomnia (CBT-I) actually refers to a variety of modalities, including sleep hygiene, relaxation methods, examination of sleep patterns, formulation of sleep restriction plans, and thought records.
BDD: I often have a horrible time falling asleep. My physicians have tried both sleep medications and off-label medications, I end up with adverse reactions with all after both short- and long-term use. Now I am taking the muscle relaxers Soma® (carisoprodol) and Flexiril® (cyclobenzaprine hydrochloride) and alternate them each night, which does allow me to sleep. I want to transition away from prescription medications, but I do not know how. I have a job that requires that I'm sharp, so I don't want to be experimenting and going without sleep. Do you have any suggestions?
_Ketan_Deoras,_MD: You may be an ideal candidate for looking into some of the behavioral treatments employed in Cognitive Behavioral Treatment for Insomnia (or CBT-I), which has shown sustained long-term benefits in several studies. Many patients come to us having tried a variety of medications with limited or no success, or with intolerable side effects. We often work with patients using CBT-I to help transition off of sleep medications. Ideally, working with a CBT-I practitioner in person may be a good starting point. In addition a full assessment could determine whether there may be any other potential contributing sleep or medical disorders that might also be involved.
suecorey: In order to implement cognitive behavior therapy for insomnia (CBT-I), how many sessions are planned and how long is each session?
_Ketan_Deoras,_MD: CBT-I is administered differently by different practitioners. Most often, four to six sessions are planned. They last one to one and one half hours.
jack-0: If I decided to try this treatment (CBT-I), what exactly could I expect during the sessions?
_Ketan_Deoras,_MD: During a group session, we usually start by reviewing patient's sleep logs (sheets which the patient has used to track the past week of his or her sleep patterns). We try to identify obstacles to falling and staying asleep, and possible interventions. Afterwards, we might engage in examining ways to deal with stress, or examining the automatic thoughts that come up during the night when people are unable to sleep. We typically end the sessions with a relaxation exercise.
suecorey: Do you find that secondary sleep disorders are as responsive to cognitive behavior therapy for insomnia (CBT-I) as primary sleep disorders?
_Ketan_Deoras,_MD: CBT-I is designed to work in a variety of circumstances, including the presence of other sleep disorders. In addition, the psychiatric literature has made a move to the idea of co-morbid insomnia rather than primary or secondary insomnia. Regardless, I've found CBT-I to be helpful in both cases.
BDD: Are there any books that you can recommend to help me learn more about cognitive behavior therapy for insomnia (CBT-I)?
_Ketan_Deoras,_MD: For people interested in administering CBT-I, I recommend ‘Cognitive Behavioral Treatment of Insomnia: A Session By Session Guide’ by Michael L. Perlis, Carla Junqquist, Michael T. Smith and Donna Posner, which is a good starting point. For more patient information, there are multiple options, including ‘The Insomnia Workbook” A Comprehensive Guide to Getting the Sleep You Need' by Stephanie Silberman and Charles Morin’ among others.
suecorey: I have enjoyed this opportunity hearing Dr. Deoras speak about sleep disorders. I would love to spend one to two weeks at Cleveland Clinic with Dr. Deoras to further my understanding of this very common problem.
_Ketan_Deoras,_MD: You are very welcome. We do have a physician observer program that might interest you.
suecorey: Could you please further define thought records? Is it the thoughts that one has prior to sleep?
_Ketan_Deoras,_MD: Thought records are a tool used in most types of cognitive behavioral therapy. These look at the immediate thoughts that arise during certain situations, the emotions associated with them, and then trying to counterbalance these with supporting and contradicting evidence. After the exercise, the emotional response to the thought is rated again.
Overnight Sleep Studies (Polysomnograms [PSG])
BDD: Since I live in Toledo, how would this evaluation and treatment work? Should I plan on spending a few days in Cleveland? Is any of the testing over night, over several days. I had a sleep study a few years ago which was not significant, but my insomnia is chronic, enduring more than 20 years.
_Ketan_Deoras,_MD: Overnight sleep studies called polysomnograms (or PSGs) are not routinely indicated for insomnia by itself. If there is strong suspicion for other sleep disorders such as sleep apnea, then a PSG would be warranted. Also when multiple treatments have been tried for insomnia without any success, PSGs are sometimes obtained to confirm there are no other sleep disorders contributing to the insomnia.
The evaluation and treatment do not require overnight stays. Here at Cleveland Clinic, we offer either individual or group appointments using CBT-I. The group format goes for one session a week for four weeks in a row, whereas individual appointments are usually spaced out a little further.
Maintenance Insomnia Treatment
efpat: I wake up in the middle of the night, three to five hours after falling asleep. I use a CPAP (continuous positive airway pressure) machine. I have tried most of the standard advice, including maintaining a dark room, having no clock in the room, going to bed tired, etc., but I usually can't fall back asleep. Do you have any advice on how to address middle-of-the-night insomnia?
_Ketan_Deoras,_MD: Most patients, like you, have either heard of or employed sleep hygiene principles (including having a dark environment without noise and not looking at the clock). Often we refer to this as being ‘necessary, but not sufficient’, meaning that it is required to intervene in the cycle of insomnia, but is often not enough on its own. This is why we often combine it with the other modalities used in CBT-I.
Middle-of-the-night insomnia (or what is sometimes referred to as maintenance insomnia) can be due to a variety of issues. Conditions, such as sleep apnea, restless legs syndrome and various other sleep disorders, can contribute to this. Additionally, this type of insomnia can exist as its own entity. Given that what you're experiencing is happening in the context of sleep apnea, it may be good to follow up with your physician to ensure that your sleep apnea treatment is truly optimized. You will need to make sure other conditions are not contributing. For maintenance insomnia in the absence of other conditions, there are a variety of medications or CBT-I that could be used.
asgalian: What is the best recommendation for someone who has no trouble falling asleep, but has difficulty staying asleep. I first wake up after about four hours and then every hour thereafter? Sometimes I easily falling back asleep and other times I am awake for 30 minutes or more.
_Ketan_Deoras,_MD: The first step in assessing your maintenance insomnia would usually be a comprehensive sleep evaluation. You would be asked questions to determine whether any other sleep disorders might be contributing to waking up during the middle of the night. From a CBT-I standpoint, one of the primary principles employed is ‘stimulus control.’ This involves not remaining in bed awake for long periods of time. For example, after awakening in the middle of the night, we would recommend that people get up out of bed if it feels like they have been awake 20 to 30 minutes (again, not advising patients to monitor by looking at the clock). During this time, we recommend a non-stimulating or relaxing activity outside of bed, and then returning to bed when feeling drowsy (as if you could fall asleep in the next 20 to 30 minutes).
Continuous Positive Airway Pressure (CPAP) Alternatives
tom50: Part of my problem for sleeping is the cumbersome CPAP (continuous positive airway pressure) machine. What alternatives are there if the CPAP is not working because of being uncomfortable?
_Ketan_Deoras,_MD: There are several alternatives to CPAP available, including surgery, oral appliances, and Provent® among others. Often the first steps are looking into how the experience with PAP therapy can be improved—troubleshooting and trying to optimize delivery of this treatment. Oftentimes simple changes such as trying a different CPAP mask can lead to significant improvement. Otherwise, I would recommend speaking with your physician about the alternatives, and whether you're a candidate based on the severity of your sleep apnea.
Goodnight: I use a CPAP machine for severe sleep apnea, and I receive no perceived benefit. With or without the machine I wake up about every two and one half to three hours. Sometimes, I go back to sleep and other times, I remain awake for hours. I have had three sleep studies with the pressure on my machine increased each time. Would cognitive behavior therapy for insomnia (CBT-I) be helpful for better sleep maintenance?
_Ketan_Deoras,_MD: CBT-I can certainly be a helpful augmenting strategy to other sleep disorders, and aside from a very few circumstances (such as bipolar disorder), can be used without worry about serious adverse effects.
asgalian: Are there any long-term concerns with taking a very low dose of Klonopin® (clonazepam) to help in prolonging sleep time for someone who wakes up often (every hour to one and one half hours) at night?
_Ketan_Deoras,_MD: Klonopin® (clonazepam), like other benzodiazepines, is ideally suited for short-term treatment. The benzodiazepines in general have been shown to have effects on sleep architecture. The primary long-term concerns include risks for tolerance, dependence, and withdrawal/rebound insomnia— among others. Patients on benzodiazepines for long periods of time should be following with their physicians regularly to monitor and assess for these and other effects.
nutzy: Do you recommend melatonin, maybe the slow release Circadin® 2 mg, for people who are 65 years old,? I am speaking about people in whom sedatives aren’t already helping with sleeping problems. If not, what else do you recommend?
_Ketan_Deoras,_MD: I and other practitioners have sometimes used higher doses of melatonin closer to bedtime to try to facilitate sleep. Cognitive behavior therapy for insomnia (CBT-I) is designed to work in adult patients of all ages, so it is certainly something to be considered.
songcanary: Do you think that magnesium at bedtime is helpful for sleep? If so, what dose would you recommend and what type of magnesium.
_Ketan_Deoras,_MD: I haven't prescribed magnesium solely for the purpose of helping with insomnia. I have used it in the context of nocturnal leg cramps, or sometimes as an alternative treatment for restless leg syndrome (RLS). For example, as a nonmedical treatment for RLS, I have had patients take it as 250 to 500 mg twice daily—with no specific brand or type.
BDD: I use transcendental meditation for relaxation first thing every morning. Should I be doing this more towards sleep time, and /or use other relaxation modalities?
_Ketan_Deoras,_MD: Any modality which helps to relax you is great to use as a ‘buffer’ before going to bed. This can help to transition from wake to sleep and, hopefully, further delineate the distinction in your mind as well. Common and popular modalities include yoga, meditation, reading, progressive muscle relaxation or even simple deep breathing exercises.
BDD: Are you a fan of herbal supplements? I've tried valerian root with limited success and now I heard on Dr. Oz’ show that passion flower extract should be considered by insomniacs, because of its stress-relaxing properties. What are your thoughts?
_Ketan_Deoras,_MD: The major issue with the herbal treatments is the lack of studies looking at their efficacy. Additionally, herbal supplements are not FDA-regulated, so it's difficult to know the quality and purity of the product. I've only had anecdotal experiences from my patients, and to this point it's been quite a mixed bag. Melatonin is probably used the most frequently.
Effect of Caffeine on Sleep
downtown: What is your opinion of taking caffeine pills to say alert during the day and its effects on night time sleep patterns?
_Ketan_Deoras,_MD: When we're evaluating for insomnia, any form of caffeine invites further review. I don't specifically recommend caffeine pills, and one of the principles of sleep hygiene involves trying to limit the amount or eliminate caffeine consumption. Many patients note feeling that caffeine doesn't affect their ability to fall asleep whatsoever and more research is looking into this. However, as the effects of caffeine can persist for up to seven hours, we would like to try to at the very least to eliminate any late afternoon or evening caffeine, so as not to interfere with sleep.
Amount of Sleep Necessary for Adults
asgalian: Do all folks really need seven to eight hours of sleep? I find that I get about six to six and one half hours due to frequent waking up at night. I am awake for at least 10 to 20 minutes between sleeping.
_Ketan_Deoras,_MD: Everyone's sleep needs are individual. However, the majority of people will require anywhere between six to nine hours of sleep per night.
Moderator: I'm sorry to say that our time with Cleveland Clinic expert Dr. Ketan Deoras is now over. Thank you Dr. Deoras for taking your time to answer our questions today about cognitive behavioral treatments for insomnia.
_Ketan_Deoras,_MD: Thank you very much for joining us today and for your excellent questions.
To make an appointment with Ketan Deoras, MD, or any of the other specialists in Cleveland Clinic’s Sleep Disorder Center, please call 216.636.5860 or call toll-free at 866.588.2264. You can also visit us online at clevelandclinic.org/sleep.
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On Cleveland Clinic
Established in 1978, Cleveland Clinic's Sleep Disorders Center was among the first in the nation dedicated to the diagnosis and treatment of sleep disorders in people of all ages. Accredited by the American Academy of Sleep Medicine, Cleveland Clinic's Sleep Disorders Center is staffed by physicians specializing in sleep disorders from a variety of disciplines, including adult and child neurology, pulmonary and critical care medicine, psychology, psychiatry, and otolaryngology.
In patients with poor quality sleep or daytime sleepiness, the first step toward a better night's sleep is a comprehensive evaluation by a Cleveland Clinic Sleep Disorders specialist. Your physician may recommend testing with an overnight and/or daytime sleep study. Once your disorder is diagnosed, a treatment plan will be designed specifically for you. As part of your sleep disorder treatment, your sleep medicine physician may recommend a consultation with a sleep psychologist, psychiatrist, otolaryngologist (ear, nose and throat specialist), dentist or a physician specializing in weight reduction. In addition to a sleep study, your physician may also recommend treatment with cognitive behavioral therapy for insomnia (CBT-I) or even a positive airways pressure (PAP) device depending on the diagnosis that is causing your insomnia.
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