Cognitive-Behavioral

Treatment of Insomnia
Martita Lopez, Ph.D.
Department of Psychology
University of Texas at Austin
Sleep stages
 We cycle through the stages of sleep about
every 90 minutes during the night, in the same
order
 Most dreaming occurs during the second half of
the night, as REM sleep lasts longer and longer
 Stage 1: Very light sleep
 Stage 2: Light sleep
 Stage 3: Deeper sleep
 Stage 4: Very deep sleep, most restorative
 Stage 5: REM sleep, when we dream
Sleep throughout life
 Childhood and adolescence
 Sleep needs range from 18 hrs a day for infants to
about 9 hrs a day for teenagers
 Adulthood
 Amount of deep sleep drops dramatically between
age 20 and 40, and average sleep time is 7.5 hours
 Women’s reproductive cycles affect sleep
 Especially pregnancy (sleepier first trimester)
 Also affected by menstrual cycle (sleepier second half of
cycle)
Sleep in middle age
 Sleep becomes lighter and nighttime
awakenings become more frequent and last
longer
 Often wake up after 3 hours of sleep
 Menopause may lead to hot flashes that
interrupt sleep repeatedly
 Breathing problems may begin, especially
among overweight people
 Physically active adults sleep more soundly than
their sedentary peers.
 About 20% of sleep time is spent in dreaming
Sleep among older adults
 Little deep sleep, but dreaming still 20%
 Dozens of awakenings during the night
 Falling asleep takes longer
 Despite the above, over a 24-hour period older
adults accumulate the same amount of total
sleep as younger people
 Older adults more likely to nap during the day
 Older adults do need the same amount of sleep
as they did when they were younger
Insomnia:
A common sleep problem
 People with insomnia may have
 Trouble falling asleep
 Many awakenings during the night, with difficulty
going back to sleep
 Fitful sleep
 Daytime drowsiness
 During the day, people with insomnia may be
 Anxious and irritable
 Forgetful, with difficulty concentrating
Types of Insomnia
 Transient: Less than 2 weeks
 Intermittent: Repetitive episodes of
transient insomnia
 Chronic: Continuing difficulty with sleep
Chronic insomnia
 Complaint of poor sleep causing distress or
impairment for 6 months or longer
 Average less than 6.5 hours sleep per day
 Or 3 episodes per week of:
 Taking longer than 30 minutes to fall asleep
 Waking up during the night for at least an hour
 Not accounted for by another sleep disorder,
mental disorder, medical condition or substance
use.
How common is insomnia?
 More than half of adults in the U.S. said they
experienced insomnia at least a few nights a
week during the past year
 Nearly one-third said they had insomnia nearly
every night
 Increases with age
 The most frequent health complaint after pain
 Twice as common in women as in men
Conditions that can cause
insomnia
 Hyperthyroidism
 Arthritis or any other painful condition
 Chronic lung or kidney disease
 Cardiovascular disease (heart failure, CAD)
 Heartburn (GERD)
 Neurological disorders (epilepsy, Alzheimer’s,
headaches, stroke, tumors, Parkinson’s
Disease)
 Diabetes
 Menopause
Common drugs that can cause
insomnia
 Alcohol  Corticosteroids
 Caffeine/chocolate  Decongestants
 Nicotine/nicotine  Antidepressants
patch  Thyroid hormones
 Beta blockers  Anticonvulsants
 Calcium channel  High blood pressure
blockers medications
 Bronchodilators
Additional Causes
 Psychiatric disorders
 Especially phobias and panic attacks, bipolar disorder,
depression, and schizophrenia
 Poor sleep habits
 Shift work
 Other sleep disorders
 Circadian rhythm disorders
 Restless legs syndrome
 Periodic limb movement disorder
 Sleep apnea
Consequences of insomnia
 Decreases in mental performance and
motor functioning
 Accidents
 Inability to accomplish daily tasks
 Mood disturbance
 More sadness, depression, and anxiety
 Interpersonal difficulties
 With families, friends, and at work
Sleeping pills
 Most common treatment approach
 Drowsiness common the next day
 NOT meant for chronic insomnia
 Effective for short-term (a couple weeks) insomnia
only
 Tolerance and dependency may develop
 Withdrawal, rebound, relapse may occur
 But commonly used, despite the above
 5-10% of adults have used a benzodiazepine in past
year as a sleep aid
 10-20% of those over age 65 use sleeping pills
Non-drug treatments
 Cognitive-behavioral therapy (CBT)
 Stimulus control
 Cognitive therapy
 Sleep restriction
 Relaxation training
 Sleep hygiene
How to keep track of your sleep
 Daily sleep diary or sleep log
 Bedtime
 Falling asleep time
 Nighttime awakenings
 Time to get back to sleep
 Waking up time
 Getting out of bed time
 Naps
Cognitive Therapy
 Identify beliefs about sleep that are
incorrect
 Challenge their truthfulness
 Substitute realistic thoughts
False beliefs about insomnia
 Misconceptions about causes of insomnia
 “Insomnia is a normal part of aging.”
 Unrealistic expectations re: sleep needs
 “I must have 8 hours of sleep each night.”
 Faulty beliefs about insomnia consequences
 “Insomnia can make me sick or cause a mental
breakdown.”
 Misattributions of daytime impairments
 “I’ve had a bad day because of my insomnia.”
 I can’t have a normal day after a sleepless night.”
More common myths about
insomnia
 Misconceptions about control and
predictability of sleep
 “I can’t predict when I’ll sleep well or badly.”
 Myths about what behaviors lead to good
sleep
 “When I have trouble getting to sleep, I should
stay in bed and try harder.”
Sleep Restriction - best if done
with a professional
 Cut bedtime to the actual amount of time
you spend asleep (not in bed), but no less
than 4 hours per night
 No additional sleep is allowed outside
these hours
 Record on your daily sleep log the actual
amount of sleep obtained
Sleep Restriction (cont’d)
 Compute sleep efficiency (total time
asleep divided by total time in bed)
 Based on average of 5 nights’ sleep
efficiency, increase sleep time by 15
minutes if efficiency is >85%
 With elderly, increase sleep time if
efficiency >80% and allow 30 minute nap.
Stimulus Control - You can do
this on your own
 Go to bed only when sleepy
 Use the bed only for sleeping
 If unable to sleep, move to another room
 Return to bed only when sleepy
 Repeat the above as often as necessary
 Get up at the same time every morning
 Do not nap
Relaxation training
 More effective than no treatment, but not as
effective as sleep restriction
 More useful with younger compared with older
adults
 Engage in any activities that you find relaxing
shortly before bed or while in bed
 Can include listening to a relaxation tape, soothing
music, muscle relaxation exercises, a pleasant image
Healthy sleep habits
(sleep hygiene)
 Avoid alcohol, nicotine, caffeine, chocolate
 For several hours before bedtime
 Cut down on non-sleeping time in bed
 Bed only for sleep and satisfying sex
 Avoid trying to sleep
 You can’t make yourself sleep, but you can set the
stage for sleep to occur naturally
 Avoid a visible bedroom clock with a lighted dial
 Don’t let yourself repeatedly check the time!
 Can turn the clock around or put it under the bed
More healthy sleep habits
 Expose yourself to bright light at the right time
 Morning, if you have trouble falling asleep at night
 Night, if you want to stay awake longer at night
 Establish a regular sleep schedule
 Get up at the same time 7 days a week
 Go to bed at the same time each night
 Exercise every day - exercise improves sleep!
 Deal with your worries before bedtime
 Plan for the next day before bedtime
 Set a worry time earlier in the evening
More healthy sleep habits
 Adjust the bedroom environment
 Sleep is better in a cool room, around 65 F.
 Darker is better
 If you get up during the night to use the bathroom,
use minimum light
 Use a white noise machine or a fan to drown out
other sounds
 Make sure your bed and pillow are comfortable
 If you have a partner who snores, kicks, etc., you may
have to move to another bed (try white noise first)