Cognitive Behavioural Therapy is more effective than drugs in overcoming insomnia.
Insomnia, or regularly not being able to get to sleep or stay asleep, is a problem that affects roughly 1 in 7 people in North America and can have serious consequences for daytime alertness and functional ability. Most insomniacs get less than 5 hours of sleep a night, and struggle with extreme fatigue during the day. It’s not any surprise that insomniacs are more accident prone due to daytime drowsiness. Although I seem to be doing much better than before, getting enough sleep is one of my own personal battles, and I feel like I have tried everything possible to improve my sleep, short of quitting my business and going on a vacation for an extended period of time. It feels like my body has forgotten how to fall asleep, which must seem absurd to those who have no trouble sleeping. I'm cozy in bed, feel dead tired, I feel like I'm dropping off and I think I'll be asleep in a few minutes, but I just don't seem to fall through the "sleep threshold", and instead hover in that la la land between sleep and wakefulness for most of the night, with my brain contemplating topics that would probably put most people to sleep, but I seem to find endlessly interesting, such as why trigger points in the platysma muscle would cause ringing in the ears. (Why is that?)
A couple of months ago I got an appointment at the Sleep Disorder Clinic at the University hospital. I was hoping they would hook up all kinds of electrodes to my head and analyze my brain waves etc. to determine why I wasn’t sleeping (wouldn’t that be cool?), but no, after an extensive interview, they opted for a low-tech solution. This was what they told me to do.
- Only use the bed for sleep and sex. Do not read in bed, watch TV in bed, do
homework in bed etc.
- Only go to bed when you feel sleepy, not tired. (Can anyone explain to me the difference?)
- Give yourself 20 minutes to fall asleep. If you are not asleep in 20 minutes, get up out of bed, and go back to bed when you are feeling sleepy
- If you wake up in the middle of the night, once again give yourself about 20 minutes to fall asleep, and if you are still awake, get up and only go back to bed when you feel sleepy.
- Get up at exactly the same time each morning, even if it is a day you are not working. So no sleeping in, even on weekends.
- No daytime naps or lying down to rest.
The idea is to use cognitive behavioural therapy to make you associate bed with sleep and nothing else. And I have to say it helped, although I found the rules pretty tough – particularly the getting up out of bed if you pass the 20 minute time allotment for getting to sleep. And I was scared about not being able to function adequately during the day if I spent the bulk of the night sitting in my living room. I suggest starting this when you have at least a couple of days off so that you won’t worry about your inability to function at work, as your worst days will probably be right at the start.
By recording your bed time, the time it took you to fall asleep, the number of awakenings, the total time awake in the middle of the night, the time you woke up and the time you got out of bed, you can figure out your sleep efficiency (SE), which is the total time asleep divided by the total time in bed. A sleep efficiency of 85% or higher is the goal. An Excel spreadsheet can work well for this. I jumped up to a sleep efficiency of 90% within three weeks, which is pretty good! I actually got to the point where I felt quite energetic during the day, but now I am backtracking again as I find myself slacking off on the rules. So, time to get strict again. Whenever my sleep efficiency gets below 60% I become a chronic tea drinker (which is counter-productive), and when it gets below 40% for 2 days in a row, I’m a dizzy zombie. Thankfully that’s a rare occurrence now!
Although the doctor at the sleep clinic did not suggest this, I thought it was important to keep the lights, TV and computer off when I was sitting in my living room in the middle of the night. No point shutting down melatonin, our night-time rest-and-repair hormone that can only function in the dark. So, I listen to relaxing music, or read a book using my red camping light. (Red light does not affect melatonin).
If you have a sleep disorder, sleep meds albeit tempting, are not a good permanent solution as they are addictive, don't give you the right kind of rest, and can have dangerous side effects such as increasing one’s risk of falls and car accidents. Try the suggestions here and in my other post entitled Getting to sleep and staying asleep, or find a sleep clinic in your community for personalized help.
If you want to subscribe or search for other posts by title or by topic, go to www.wellnesstips.ca.
Dr. Randhawa, personal consultation, Sleep Disorder Clinic, University of British Columbia Hospital, August 2009.
Morin CM et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA. 2009 May 20;301(19):2005-15.
Neubauer DN, Flaherty KN. Chronic Insomnia Semin Neurol. 2009 Sep;29(4):340-53. Epub 2009 Sep 9.
Sivertsen B et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006 Jun 28;295(24):2851-8.
Morin CM et al. Psychological and behavioral treatment of insomnia:update of the recent evidence (1998-2004). Sleep. 2006 Nov 1;29(11):1398-414.
Jacobs GD et al. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med. 2004 Sep 27;164(17):1888-96.
Sleep complaints: Whenever possible, avoid the use of sleeping pills. Prescrire Int. 2008 Oct;17(97):206-12.
Copyright 2009 Vreni Gurd
To subscribe go to www.wellnesstips.ca