Psychotherapy for Chronic Insomnia

Most of us have experienced insomnia at one point or another in our lives. We have all experienced the frustration of lying awake in bed for hours waiting for sleep, which then comes too late and is short-lived, leaving us feeling impaired the next day. Lack of sleep becomes distressful when accompanied by beliefs that “everyone needs eight hours of sleep to be healthy” and “there is something wrong with me, why can’t I sleep like a normal person?”

It is normal to experience insomnia once in a while. Insomnia is the impaired ability to fall asleep in less than 30 minutes, frequent prolonged awakenings lasting more than 30 minutes, spending less than 85% of the time spent in bed sleeping, and experiencing related impairments in social/work/family life. Many sleep experts recommend seven to nine hours per night. Some people need less to feel refreshed and some need more.

When sleep disturbance occurs occasionally, as in jet lag or other situational insomnia, it has no long-term impact on daily function. Two full nights of sleep will usually restore deficits in cognition, mood, and behaviour resulting from inadequate sleep. When sleep disturbance is chronic, occurring every night for at least two weeks, or occurring three or more times per week for at least one month, the ensuing low energy, irritability, excessive worry about lack of sleep, memory difficulties, lapses in concentration and attention, mood disturbances, can have a major impact on a person’s enjoyment of life.

Some isolated studies have shown that chronic sleep deprivation is associated with immune system impairments, increased risk of diabetes, cardiovascular disease, cancer and mortality. These studies do not show a causal link but suggest that those with poor health also tend to have poor sleep, thereby worsening the quality of—already—very difficult lives.

As much as 25–60% of the general population suffer from insomnia. 10–15% of the population experience insomnia with distress or impairment. Lost productivity associated with sleep deprivation costs over 100 billion USD annually. Many people do not mention it to their family physician or health care providers. This is not surprising since many of us have never been told that insomnia is a treatable problem. Chronic insomnia is an illness with risk factors and complications that can be screened, diagnosed, and effectively treated. Factors that make a person more prone to sleep disturbance include increasing age, female gender, illness (medical or psychiatric), shift work, unemployment and poverty.

Screening tools for sleep disturbance, including ESAS-r, PROMIS, ESS, ISI, ONS, are available to your health care provides. These were developed to help distinguish those patients/clients needing immediate referral for formal sleep studies, from those needing preventative/supportive non-pharmacologic strategies, from those needing pharmacologic interventions, and/or needing cognitive behaviour therapeutic approaches. Other helpful assessment tools include at-home sleep logs, symptom checklists, and bed-partner survey. Formal testing in sleep labs are generally not recommended for chronic insomnia not related to a physical cause, including sleep disturbance due to a psychiatric condition.

According to most professional guidelines, treatment goals for insomnia are to improve sleep quality, sleep quantity, daytime function, and to reduce sleep-related psychological distress. Hypnotics or medications that induce sleep are considered add-ons to behavioural and psychological interventions. These medications are used in the short term until non-pharmacological interventions take effect. The American Academy of Sleep Medicine recommend the inclusion of at least one behavioural intervention in the initial treatment of uncomplicated insomnia: sleep restriction therapy, stimulus control therapy, paradoxical intention, or relaxation therapy, with or without cognitive behaviour therapy. With the exception of cognitive behaviour therapy, most behavioural interventions for sleep are simple and can be self-administered:

  1. Wake up at the same time everyday
  2. Avoid staying in bed more than 20 minutes if awake
  3. Maintain a consistent bedtime with adjustments to increase efficiency
  4. Exercise regularly (preferably in the late afternoon, but not within two to four hours of bedtime)
  5. Do relaxing activities before bed
  6. Keep the bedroom quiet and cool (extreme temperatures interfere with sleep)
  7. No clock in the bedroom for watching
  8. Avoid caffeine and nicotine for at least six hours before bedtime
  9. Drink alcohol only in moderation
  10. Avoid alcohol at least four hours before bedtime
  11. Avoid napping during the day
  12. Avoid excessive fluid intake before bedtime
  13. No pets in the bedroom
  14. No stressful activities like studying in bed

Cognitive behaviour therapy (CBT) aims to change thought patterns, for example reducing unrealistic expectations and changing overvalued ideas about sleep. Sleep-related cognitive distortions are replaced with positive attitudes and sleep-conducive behaviour. Consistent, good-quality patient-oriented evidence (Grade A) indicates that CBT is superior to medications in the treatment of chronic insomnia. CBT administered by primary care physicians to treat chronic insomnia has limited quality patient-oriented evidence (Grade B). CBT delivered face-to-face by a trained therapist can be unaffordable for many. CBT is not covered by the Canadian universal health care system, and is therefore unavailable to most. If you live in Canada and your family doctor does not offer CBT for insomnia, what are your options?

In the next blog entry, I will discuss a new innovation in the delivery of CBT when in-person face-to-face therapy is unavailable or unaffordable.

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You can find a psychotherapy provider in your area by using the Basic Search and selecting “Help with … Sleep problems”

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References:

American: *mildly OUTDATED*

Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults; Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. J Clin Sleep Med. 2008 Oct 15;4(5):487-504.

Psychological And Behavioral Treatment Of Insomnia: Update Of The Recent Evidence (1998-2004) Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. Sleep. 2006 Nov 1;29(11):1398-414.

Practice parameters for the psychological and behavioral treatment of insomnia: an update; Morgenthaler T, Kramer M, Alessi C, Friedman L, Boehlecke B, Brown T, Coleman J, Kapur V, Lee-Chiong T, Owens J, Pancer J, Swick T; American Academy of Sleep Medicine. Sleep. 2006 Nov 1;29(11):1415-9.

Canadian: *DUE for UPDATE Dec 2015*

Howell D, Oliver TK, Keller-Olaman S, Davidson J, Garland S, Samuels C, Savard J, Harris C, Aubin M, Olson K, Sussman J, Macfarlane J, Taylor C; Sleep Disturbance Expert Panel on behalf of the Cancer Journey Advisory Group of the Canadian Partnership Against Cancer. A Pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer. Support Care Cancer. 2013 Oct;21(10):2695-706.

The views expressed in these blogs are the author’s own and not necessarily reflective of those of Psychotherapy Matters.  Copyright © 2015 PsychotherapyMatters.com

Vicky P.K.H. Nguyen
Vicky P.K.H. Nguyen

Vicky is a psychiatry resident at the Northern Ontario School of Medicine (NOSM). She completed her PhD and MD training at the University of Toronto. Her research interests are directed at promoting innovative practices and policies to address sub-optimal wait times, access, equity, and quality of health care services for disadvantaged populations in Ontario. She is certified to provide IPT and CBT. She is trained to provide other types of therapy including DBT, and Psychodynamic Psychotherapy.

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