Insomnia: Talk Beats Sleeping Pills
Cognitive Behavioral Therapy Better Than Pills for Chronic Insomnia
How CBT Cures Insomnia
The CBT used by Sivertsen and colleagues consists of six hour-long sessions one week apart. The sessions incorporate five principles:
- Sleep hygiene. Patients learn how lifestyle habits (such as diet and alcohol use) and environmental factors (such as light, noise, and temperature) affect sleep.
- Sleep restriction. Patients keep to a strict schedule of bed times and wake times that at first increases their sleepiness by depriving them of sleep.
- Stimulus control. Patients learn to associate being in bed with going to sleep. They learn not to do anything in the bedroom that does not help them sleep.
- Cognitive therapy. "The thoughts people with insomnia have about sleep are a bit skewed," Sivertsen says. "Cognitive therapy gives patients control over what is going on. They become their own co-therapists."
- Progressive relaxation technique. Patients learn to recognize and control muscular tension.
"It is not a deep therapy," Sivertsen says. "What is most efficient is sleep restriction and telling the patient not to stay in bed while awake. We think it is not that important for a patient to see a trained therapist in order to get an effect. Even a self-help program based on these principles is almost as efficient."
Simon says many patients don't need the whole six-week program tested by Sivertsen and colleagues. By tailoring the CBT to the needs of individual patients, he is often able to relieve their insomnia after only two sessions.
Staying Awake to Sleep
"I do the sleep hygiene first, and for most patients I do sleep restriction," he says. "They typically have been going to bed for eight or nine hours, and sleeping five hours. If they are driving to work in the morning, I restrict them to six hours in bed. But if not, bedtime is 3 a.m. and wake time is 8 a.m. You may go to bed later, but you can't go to bed earlier. The only bed time they get is time for sleeping. No naps in the daytime." Once patients' sleep diaries show they've slept 90% of their time in bed, Simon increases bed time by 30 minutes -- a bit longer than the 15-minute increments many specialists recommend.
Simon also offers cognitive therapy. "This is the gentle debate between a therapist and a patient to change the patient's conceptions about sleep," he says. "When they wake at night they think, 'Omigod, what if I don't get to sleep.' I try to get them to change it to, 'This is great, I get to fall asleep again.'"
Simon estimates that about half of his patients get over their insomniainsomnia within two or three sessions -- and he is a sleep specialist who sees only hard cases. Primary care providers, he says, would get much better results.