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Our lives in the modern age have changed quite a lot. We are always in a rush, working too much, and stressing about everything, while being bombarded with different stimuli all around. Whether those are screens that emit blue light, which messes with our internal clock, or simply noise from the urban environment.
As a result, our sleep is often suffering. It is no wonder that we have a pandemic of sleep disorders. One of the most common sleep disorders is insomnia, and it is estimated to affect around 30% of people at some point in their lives.
Treating insomnia is a challenging task, and it can be different depending on the individual. Cognitive behavioral therapy (CBT) is the first option for treating insomnia. It is supposed to be a long-lasting solution, in contrast to medication that is used to help manage short-term symptoms of insomnia.
Research done so far has shown that CBT is an effective way of lessening and eliminating symptoms of insomnia. Let’s dig in into different aspects of CBT, how it works, what are the benefits, and why you should try CBT if you are struggling with insomnia.
What Is Insomnia?
Insomnia is one of the most common sleep disorders, where an affected person is either not able to fall or stay asleep. Depending on that, a person is diagnosed with either sleep onset or sleep maintenance insomnia.
Everyone experience a sleepless night now and then, and if it just one night, you probably shouldn’t worry about it. Maybe you had an afternoon nap, or you got too excited about some event, and your nightly rest suffered a little bit.
If the symptoms persist for some time, it is probably best to seek professional medical help. Some people may experience a condition called transient insomnia, which can last up to three months. It can usually be connected to a stressful period, some acute illness, hospitalization, or a significant life event. It can even be caused by a rebound effect when a person stops using sleep medication. The important thing is that the situation usually resolves when the conditions go back to normal.
Chronic insomnia is a little different. Environmental factors can trigger it, but genetic factors and underlying conditions play a significant role as well.
Some people have a naturally low threshold for nighttime arousals, which is why their sleep is often fragmented, and they are more prone to developing insomnia. Others might have a condition like restless legs syndrome, chronic pain, depression, anxiety, kidney disease, arthritis, Alzheimer’s, or some other medical condition that is affecting their sleep.
If that is the case, besides standard insomnia treatment, doctors also focus on eliminating the underlying causes and managing the disease that is responsible for sleep disruption.
What Is Cognitive Behavioral Therapy for Insomnia (CBT-I)?
CBT-I is a go-to treatment when it comes to insomnia. It consists of a series of visits to a psychologist who specializes in this type of treatment. The goal of CBT-I is to address problems surrounding sleep and to create a more peaceful sleep environment, as well as a positive attitude towards your nightly rest.
CBT-I is used for treating chronic insomnia since people usually develop negative thoughts and behaviors connected to their sleep. It is understandable that after tossing and turning in bed for a long time, people tend to get a bit frustrated. And if this persists for weeks or months, you might go to bed every night expecting to get inadequate rest.
That is where CBT-I steps in and tries to turn these negative associations into positive ones. That takes time, and CBT-I is often viewed as a long term solution for sleep problems. Standard CBT-I program involves regular sessions for 6 to 12 weeks, and it includes different approaches based on each case.
The CBT-I can include stimulus control, sleep restriction, biofeedback, relaxation training, and sleep hygiene education. The treatment usually consists of a combination of these approaches, and sometimes you can even be prescribed medication for short term relief if the symptoms are severe. It is all closely watched by a sleep specialist, who evaluates your condition with each weekly session, and they adjust the treatment accordingly.
People with insomnia often have a lot of negative thoughts about sleep. They get frustrated with the inability to fall asleep, which can later develop into anxiety. That results in a negative attitude towards going to sleep, as people are already expecting a negative outcome.
Stimulus control aims to reinforce positive associations with sleep and to get rid of any distracting thoughts. That usually means using your bed only for nightly rest and intimacy and leaving all electronics, and other distractions from your bedroom. All other activities like watching TV, reading, catching up with news, or looking up social networks should be left outside the bedroom.
When you get rid of distractions, it should be easier to fall asleep. However, if you have been in your bed for 20 minutes, and you haven’t fallen asleep, it is time to get up. Doing some relaxing activity should wear you out, and then you can return to bed when you feel tired again.
After some time, your brain learns to recognize the bedroom as a place for relaxation, and nightly rest. That means that it takes less time for you to fall asleep, and all the negative thoughts surrounding sleep will slowly go away.
Most people think that going earlier to bed should result in more sleep. However, that is not true in most cases, since more time in bed doesn’t necessarily mean more rest. Our internal clocks dictate our sleep and wake cycles, and the best thing you can do for your internal clock is consistency. Going and getting out of bed at the same time every day is one of the most important things when it comes to good sleeping habits.
Sleep restriction limits the time spent in bed each night in an attempt to cut down the time needed to fall asleep. For instance, if you usually spend 7 hours in bed each night, but you only get 4 hours of sleep, the initial limit is set at 4 hours.
Sleep restriction seems to have an opposite of the desired effect in the beginning, since you are spending less time in bed, you are not getting enough sleep. But with time, falling asleep becomes more comfortable, and your sleep efficiency increases. After that, you start gradually increasing your time spent in bed until you can regularly get sufficient amount of sleep without prolonged sleep onset and nocturnal disturbances.
Biofeedback and Relaxation Techniques
These two usually go hand in hand as the ultimate goal is for you to calm down, and enter a relaxed state that should make it easier to fall asleep.
Biofeedback refers to using a small device that tells you about the state of your body. This device tracks your heart rate, blood pressure, muscle tension, or body temperature, and can tell you when these parameters change. The device alerts you when these parameters increase, which is an indicator that you are getting restless. Using these devices comes naturally for some people, while others need time to get used to them. Either way, don’t worry and take your time.
After you learn to recognize the signs of restlessness, it is essential to know how to reverse your mind and body into a calm state. That is when relaxation techniques come into play, and the most common ones include meditation and breathing exercises.
With biofeedback and relaxation techniques, you will learn to recognize when you are getting frustrated with the inability to fall asleep, and also to calm yourself. That is useful not just for sleep, but for other aspects of your life as well.
Sleep Hygiene Education
One of the first things a sleep specialist does is examining your lifestyle habits. People often do certain things that disrupt their nightly rest, without them even realizing. That is why it is crucial to learn about good sleep hygiene and make some adjustments to help you sleep better. That includes:
- Sticking to a regular sleeping schedule. Going to sleep and waking up at the same time every day helps your internal clock realize when is the time to be active, and when you should go to sleep. Staying up late and sleeping in on weekends is tempting, but you should avoid it and stick to your schedule.
- Making your bedroom sleep-friendly. You should remove all the distractions from your bedroom, including all electronics and anything that can wake you up. Keep your sleep environment dark, and set the room temperature to mid 60 Fahrenheit, as it appears to be the best sleeping temperature.
- Avoid screen time at least 45 minutes before bedtime. Screens emit blue light that can make your brain think that it is daytime, and it stops the production of melatonin. Melatonin is a sleep-inducing hormone that is produced at night, and it is vital for our sleep/wake cycles. If your brain stops producing melatonin before bedtime, it becomes more difficult to fall asleep.
- Create a relaxing bedtime routine. You can try reading, taking a hot bath, listening to relaxing music, yoga, meditation, breathing exercises, or tending to a hobby. Just remember to do it outside the bedroom, as the bed should be reserved only for sleep related activities.
- Eat a balanced diet, with a lot of fruit and vegetables. You should also stay away from stimulants like nicotine, alcohol, and caffeine at least 6 hours before going to bed, as they can disrupt your sleep.
- Exercise regularly. Staying active is essential to proper rest, and experts recommend at least 150 minutes of moderate activity each week for full long term health benefits. However, don’t exercise too close to bedtime, as it can be counterproductive and make it harder to fall asleep. You should also spend some time outdoors in daylight each day, to help your biological clock understand when active hours are happening.
On top of all of these techniques and education, a sleep specialist will discuss everything with you during weekly sessions. They can discover underlying sleep problems, tell you where you go wrong and point you in the right direction. Even though it may seem like all of these different techniques aren’t complicated, having a professional guide you makes it much easier.
Is CBT-I Effective?
It all means nothing if CBT is not effective for treating insomnia. Luckily, there has been a lot of research, where scientists investigated aspects of CBT and how it compared to sleep medication.
This 2002 meta-analysis tried to discover how effective sleep medication and behavioral therapy were in treating chronic insomnia. The review looked at different parameters, including total sleep time, sleep latency, number of nighttime arousals, wake time after sleep onset, and sleep quality. All of these were assessed before and after the treatment was conducted. The results showed that both pharmacotherapy and behavioral therapy are an effective way of treating short term effects of primary insomnia. There was no difference in effectiveness between those two, except in sleep latency, where CBT showed a more significant reduction in sleep latency.
A 2004 study looked at different treatment approaches for insomnia. The results showed that CBT was the most effective intervention, and it also produced the most persistent improvement in sleepers. That was another step in proving the effectiveness of CBT, and placing is as the number one treatment for insomnia.
The results of later research followed the same trend. This meta-analysis also highlighted that CBT-I is at least as effective as pharmacotherapy in the short term, and it is superior in the long term. Because of the long-lasting effects of CBT-I, it is considered a first-line treatment for insomnia.
Besides insomnia, CBT has been proven effective for some other conditions, like anxiety, depression, and chronic pain. A 2012 study showed some long term effects of CBT on patients with chronic pain. There was a 23-minute improvement in total sleep time recorded six months after the treatment. That showed that CBT was valid and that it also had long-lasting effects.
When to See a Professional
If you occasionally experience a night of poor sleep, there is probably nothing to worry about. However, if your problems persist for some time, you might need to see a professional. If your everyday life and work performance are affected, it is time to book an appointment.
Medical professionals will help discover the cause of your sleep problems, and prescribe you the needed therapy. Depending on what’s causing your sleep problem, it could even be CBT.
If you have been advised to try CBT-I, it is vital to remember that it has been proven effective time after time. Stick to it even though it might not seem like it’s working in the beginning, it will definitely pay off in the long run.
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Dusan is a biologist, a science enthusiast and a huge nature lover. He loves to keep up to date with all the new research and write accurate science-based articles. When he’s not writing or reading, you can find him in the kitchen, trying out new delicious recipes; out in the wild, enjoying the nature or sleeping in his bed.