Stephanie Livingston–Psychologist

CONQUERING INSOMNIA—A Cognitive Behavioral Approach

Are you having problems sleeping? Insomnia is a health problem that will affect most Americans at some point in their lives. There are three major types of sleep disturbance. Onset and maintenance insomnia, and early morning awakening. Onset insomnia has to do with difficulty falling asleep; maintenance insomnia is related to staying asleep and EMA, means waking up earlier that one’s usual wake up time. Anxiety is usually related to onset insomnia. Have you ever found yourself lying awake at night, unable to sleep, because you cannot turn your mind off. You may be replaying the days’ events in your head or worrying about an important meeting tomorrow. EMA, on the other hand, is related to depression. If you find yourself awakening at three or four am, when your usual wake up time is six or seven you may have EMA. Many things can cause depression, but most often it is related to some type of loss—loss of a job, marriage, loved one, pet, or disability. These environmental events can lead to negative or distorted thinking patterns which in turn can lead to depression. Sleep disturbance is one of many symptoms of depression, be it hypersomnia (sleeping too much) or hyposomnia (sleeping too little). And then there are complications with sleep due to pain, disability, medication side effects, sleep apnea and environmental conditions such as temperature, and light.
Another group of people who may have sleep problems is shift work individuals. People who have been night owls all their lives, may have difficulty working during the day and sleeping at night. And conversely, people who are used to sleeping at night and working during the day, like most of us, may have trouble sleeping during the day and working at night. However, most people can adjust to a routine as long as it remains constant. Their body will likely eventually adjust to the new schedule. Unfortunately, those who are on rotating shifts, find It difficult to keep up with a constantly changing schedule. Their body never learns when It is supposed to sleep. It has been my experience that this group is the hardest to treat.
So you might ask, why is sleep so important. One of the most important reason is health. Studies have shown that when people are sleep deprived they tend to eat more, have higher blood pressure, and lowers immune functioning, which can lead to many illnesses. From a cognitive perspective, reaction time, attention and concentration, and memory are all affected by sleep deprivation. Slowed motor skills and mood changes are also side effects. Unlike, substance abuse, which can cause similar symptoms and the person is aware that the substance (ie, alcohol) may be causing their problem, most people are not aware of the impact of sleep deprivation on these different areas of their lives. Consequently, a person who is sleep deprived may have no problem getting behind the wheel of a car or operating potentially dangerous machinery. It takes only a moment of nodding off for a sleep deprived truck driver to cause a major accident. Most studies have shown that individuals need approximately eight hours of sleep per night, in order to feel rested and rejuvenated, irrespective of your age.
The good news is that there is effective treatment for insomnia that does not involve drugs. Cognitive Behavioral Therapy or CBT, involves changing thinking patterns and habits. The sleep hygiene rules listed below may help you get a handle on your sleep problems. A first course of action is to visit your primary care physician to rule out any medical reasons for having a sleep disturbance. Sometimes medications will be prescribed to help with sleep, especially in acute situations of severe stress or chronic illness. Over the counter medications can have mixed results. They often help initially, but if used for long periods of time, they may actually become ineffective and even interfere with your sleep.
Sleep hygiene rules
Regulate sleep wake cycle
Go to bed at the same time (within a 30 minute before and after bedtime window) and get up at same time every day. On weekends, do not sleep in more than one hour later than your normal wake up time.
Do not take naps. If you are severely sleep deprived, get up at your normal wake up time and if necessary take a short cat nap (15-30 min) and force yourself to stay awake until your bedtime.
Do not stay in bed for more than 15 minutes lying awake. Get up, go to another part of the house and do quiet things to make yourself sleep (TV, music, reading). Do not start cleaning the house, surfing the web, or doing work. And most of all to do not eat, because you may actually condition yourself to awaken during the night feeling hungry.
Avoid stimulants in evening
Do not smoke, drink caffeine, eat sweets, or exercise in the evening. However, if evening is the only time you have to exercise, it is better to exercise than not.
Relaxation techniques
Learning diaphragmatic breathing, imagery, or progressive muscle relaxation are ways of activating your parasympathetic nervous system (PNS) and facilitating asleep. Sleep is a passive activity, that requires you to let go. The sympathetic nervous system (SNS) is the alarm system, that kicks in when the body into fight or flight (increase blood pressure, respiration and heart rate). Think of the SNS as the accelerator and the PNS as the brake. When you are in an emergency situation you want to press the accelerator. But, if you are trying to go to sleep you want to put on the brake. Taking control and trying to force yourself to go to sleep rarely works. Tossing and turning and looking at the clock only makes the situation worse. Doing something that helps you slow down will help you to fall asleep.
Associate the bed with sleep not wakefulness
You should only sleep and have sex in bed. No TV, working, talking on the phone, or any other activity in bed. These behaviors require you to be awake and alert and contradict the calming down process for going to sleep. If you are doing activities that require you to be alert, you may begin to associate the bed with wakefulness not sleep.
Make your sleep environment conducive to sleep. Make sure you have a comfortable mattress, room temperature, and lighting.
Develop a pre-sleep routine
Signal to your body that it is time to go to bed by developing a routine just before bed. Activities such as showering, saying prayers/meditation, brushing teeth, or reading can all indicate to your body that sleep is imminent. Eventually, your body adapts to a schedule just like an infant whose parents maintain a rigorous feeding and sleeping schedule with them. After some training the infant will expect to eat and sleep at a certain time no matter where they are. The same can be true for adults. Good night and sweet dreams.