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Cognitive Behavioral Treatments for Insomnia

Approximately 50 percent of adults experience occasional bouts of insomnia, and one in 10 complain of chronic insomnia. Insomnia is almost twice as common in women as in men, and is more common in those who are older.

People with insomnia have trouble falling asleep or staying asleep. Insomnia can cause one or more of the following symptoms:

• Difficulty falling asleep
• Waking up often during the night and having trouble going back to sleep
• Waking up too early in the morning
• Having sleep that is not refreshing

Behavior therapy is commonly used to treat insomnia. It is a technique that requires some effort, but it is a proven method to help people return to more normal sleep patterns. Behavioral treatments, in general, are found to be more effective and longer lasting than treating insomnia with medication.

Cognitive Behavioral Therapy for Insomnia, or CBT-I, is an approved method for treating insomnia without the use of medication. This type of therapy is aimed at changing sleep habits and schedules. CBT-I techniques may include sleep hygiene, relaxation exercises, stimulus control, sleep restriction and cognitive restructuring.
CBT-I includes regular physician visits to examine your sleep/wake habits and pinpoint the actions that may be preventing you from sleeping soundly.

Listen as the experts from Cleveland Clinic help give you a great nights sleep. We're Talking About Your Health with Cleveland Clinic.

Cognitive Behavioral Treatments for Insomnia
Featured Speaker:
Ketan Deoras, MD, Cleveland Clinic Sleep Specialist

Ketan Deoras, MD, is an associate staff physician with the Department of Psychiatry and Psychology in Cleveland Clinic’s Sleep Disorders Center in the Neurologic Institute. Dr. Deoras is board certified in psychiatry. He sees patients at Cleveland Clinic’s main campus, Beachwood Family Health & Surgery Center and Hillcrest Hospital. Dr. Deoras has a joint appointment in Cleveland Clinic’s Center for Behavioral Health and practices outpatient psychiatry in Westlake. He has many specialty interests including sleep disorders, insomnia, sleep apnea, psychiatric disorders and mood and anxiety disorders.
Dr. Deoras completed his fellowship in sleep medicine at Cleveland Clinic following completion of his residency in psychiatry at the University of Arizona Medical Center, Tucson, Ariz. He received his medical degree from the University of Toledo College of Medicine, Toledo, OH.


Transcription:

Melanie Cole (Host): Approximately 50% of adults experience occasional bouts of insomnia and one in ten complain of chronic insomnia. My guest is Dr. Ketan Deoras. He is an associate staff physician with the department of psychiatry and psychology in Cleveland Clinic Sleep Disorder Center in the Neurologic Institute. Welcome to the show Dr. Deoras. Tell us what is insomnia?

Dr. Ketan Deoras (Guest): Insomnia, we just define as difficulty falling asleep or staying sleep or difficulties with consolidating sleep throughout the night, its a very fragmented sleep and then having effects on daytime functioning, that’s kind of the simplest definition of insomnia that we use.

Melanie: Dr. Deoras, I know that many people suffer from insomnia. What are the risk factors and the causes, are there certain things that would predispose us to not getting that night’s sleep.

Dr. Deoras: Yeah, it’s a very good question, so there are we find, you know, when the studies have been done, they typically find that women report insomnia more and they don’t know that just because they reported more, they are actually having that more. One thing that we typically see in the clinic is often patients have had triggers, some sort of stressor that leads to the onset of insomnia so that can be anything from a change in their work responsibility, loss of a loved one, divorce, but that trigger unfortunately can kind of turn into a long term chronic insomnia problem and the other studies have shown that risk factors for insomnia also include kind of a lot of mood disorder, so depression, anxiety and also kind of lower socioeconomic class have a higher incidence of insomnia as well.

Melanie: How do you know when it gets bad enough that you would come to see a doctor such as yourself, what would send us to see you?

Dr. Deoras: Though, the most common reason that people come in to see us is that they have noticed that it’s really affecting their daytime functioning. You mentioned that 10% have chronic insomnia, when it starts interfering with the ability to function at work or kind of cognitive effects like concentration and memory issues or even just in social interactions with loved ones or coworkers. Most of the time that’s kind of initiating factor for a lot of people to say, okay this is not just the problem with my sleep, its now kind of spreading over into these other spheres of life and may be I need to get this evaluated more thoroughly.

Melanie: When you do the evaluation, you know, people have heard of sleep studies, Dr. Deoras. Is that always what’s involved?

Dr. Deoras: Usually, no in fact for just curing insomnia, so one of the main things that we do in a sleep evaluation is we are also looking for other medical issues or other sleep disorders that could be causing the insomnia or exacerbating them. If we come on to that initial kind of reevaluation or assessment and feel that its just an insomnia on its own, there is not much utility in doing that sleep study for that by itself because most of the time, people just kind of stay up for most of the night and all the sleep study shows that the person had difficulty sleeping which we already kind of knew because that’s what they came in to begin with, so we are really looking if there is something more kind of comorbid along with the insomnia to prompt that sleep study.

Melanie: Dr. Deoras, once you have determined that someone has chronic insomnia, what do you do for them and what are the treatments for insomnia?

Dr. Deoras: Following an evaluation where we talk about the risk factors and we’ve determined that you have chronic insomnia, I usually will talk with the patients about kind of two types of treatment that we use for it. One, we sometimes refer to the medication and the other will talk about being the meditation route. Medications consist of over-the-counter sleep aids as well as prescription medications including what we call sedative hypnotics and things like antidepressant or other medications that will sometimes use the sedating effects more to try to treat the insomnia. For the cognitive behavioral therapies, we talk about different modalities within the same framework to try to deal with insomnia, so for example, we will focus on relaxation methods and that can be anything from deep breathing exercises to yoga to just exercising earlier in the day. We advise patients not to exercise at least two to three hours before their desired bedtime and then we also focus on their thought pattern about sleep and that’s really where the cognitive behavioral therapy comes in. We talk about what is causing the anxiety regarding falling asleep or staying sleep and try to see how some of those thought patterns might be able to be corrected and then lastly also we look at things like sleep restriction. We will actually try to taper the sleep hours to what patients describe that they are actually sleeping throughout the night. We find insomnia that patients will spend a lot of time in bed, awake and that’s actually detrimental in the long run.

Melanie: With patients that tell you about their symptoms Dr. Deoras, what do you recommend that they do at home if they are suffering from a bout of insomnia and you know do you recommend you just said that they lie in bed awake, do you recommend that people lie there for 20 minutes and then get up walking around that they make sure its dark. Give us some sort of complementary treatments that people can do at home to help them get a good night’s sleep.

Dr. Deoras: Yeah, so you just put up a great point, it was they are lying in bed for about 20 minutes and then they can fall asleep, getting up and doing something else, that’s what we call stimulus control and that’s also a part of cognitive behavioral therapy for insomnia. The reason we recommend that is the longer the patients lay awake in bed, the more their brains are making this association that its not a place that they quickly fall asleep, so we don’t want patients looking at the clock because that just tends to foster anxiety, but we tell them when it feels like it has been 20 minutes or half hour, to get up out of bed and go do something somewhere else so that your brain isn’t developing this association. We also tell patients not to watch TV in bed, not to use electronics in bed. They can do all those things, but just not while they are in bed. Again it goes back to trying not to have association with the bed as with all these other activities. We really just want to confine it as much as possible to sleep, so that it kind of gets ingrained in.

Melanie: So what about melatonin and some of the things that people are seeing on the market, you know and they are over-the-counter and they are not sure if they should be taking these to relax us, what about those kinds of things.

Dr. Deoras: Yeah, so often by the time patients have come to me, they have already tried things like melatonin, valerian, kava-kava, all these kind of natural supplements and so my perspective, I feel little biased because by the time they are coming to see me, it is typically one thing did not work for them. In the studies, melatonin has not been shown to be particularly effective or ineffective because there is not a whole lot of supporting data for it, but that being said, I talk with my patients all the time about if they feel like they are gaining some benefit to go ahead and continue taking things like melatonin. The nice thing about medications or melatonin, over-the-counter supplements is that they are really complemented well by these cognitive behavioral therapies, so that they don’t have to be mutually exclusive and they can use both things together, kind of medications or supplements as well as the behavioral techniques that are taught in cognitive behavioral therapy.

Melanie: Dr. Deoras in the last minute or so, please wrap up for us, getting a good night’s sleep, the treatments for insomnia, really your best advice for insomniacs out there.

Dr. Deoras: I think the best advice is to like I said, I work on sleep hygiene as much as possible, so that entails trying to set regular sleep and wake times, not using the electronics in bed, not lying in bed awake for too long and then if it has come to a point where you have tried relaxation methods such as yoga or deep breathing and supplements as well and you are not really noticing any benefit then its really the opportunity to go and discuss this further with a sleep specialist to see may be is there some other medical or sleep disorder that might be contributing that’s being overlooked or to just get kind of more guided individual treatment to help.

Melanie: Thank you so much Dr. Ketan Deoras. You are listening to Talking About Your Health with Cleveland Clinic. For more information, you can go to clevelandclinic.org/sleep. That's clevelandclinic.org/sleep. This is Melanie Cole. Thanks so much for listening.