Many people with sleep difficulties have insomnia.
Insomnia is a difficulty falling asleep or staying asleep. People with insomnia take time, even hours, to fall asleep at the start of the night or cant fall back asleep after awakening over night. Insomnia can affect around a third of the population at some time.
The importance of recognising insomnia is that it is a medical condition with many causes that can be effectively treated. At Sydney Sleep Centre, our Insomnia Clinic has experts in the field of insomnia, offering both a diagnostic and treatment service. Patients with possible insomnia should initally be referred to one of the Centre's Sleep Physicians who will confirm the diagnosis and order any testing necessary (e.g a sleep study if needed). The Sleep Physician will then initiate treatment for insomnia and will likely involve the Centre's Sleep Psychologist. Sydney Sleep Centre's focus is on the management of insomnia through non-drug strategies. Although much harder than simply writing a script for a sleeping tablet, they are evidence based strategies that achieve the best long term results (superior to drug therapy in the long term).
The Sleep Centre's Sleep Psychologist is an expert in Cognitive-Behavioural Therapy (CBT), th main non-drug approach used.
CBT targets unhelpful coping behaviours and cognitions which are meant to reduce, but inadvertently maintain, insomnia, and introduces sleep-conducive behaviours whilst raising the individual’s awareness of more realistic expectations about sleep and daytime functioning.
In meta-analytic studies CBT has shown evidence for improved total sleep time and general sleep quality, reduced sleep latency times and improved expectations and thinking about sleep.
(Re)learning more adaptive, sleep-promoting behaviours
CBT incorporates effective behavioural methods such stimulus control therapy (teaching the client to associate bed environment with sleep rather than wakefulness); and sleep or bed restriction (ie restricting time spent in bed to be roughly equivalent to actual sleep time, and challenging clients’ perception that more time in bed will of itself make up for poor sleep, when in fact the outcome is less consolidated sleep, more time in bed awake and worrying about not sleeping). The treatment focus is on increasing a client’s homeostatic drive for sleep by restricting time in bed to the existing sleep time.
CBT can effectively treat circadian rhythm sleep-wake phase disorders causally associated with insomnia, like advanced or delayed sleep phase disorders (where clients’ physiological sleep time set by their ‘circadian’ internal 24-hour clock is at odds with their desired/required social or occupational sleep time, and this causes worry and distress).
In CBT setting a constant waking time regardless of sleep quality or quantity is a crucial component of behavioural sleep management. This is more important than a regular bedtime which will not of itself guarantee sleep onset. Morning light acts as a “handbrake” on the natural human tendency to phase delay, and is critical for resetting the circadian clock.
CBT incorporates education about sleep hygiene, or good sleep habits, dispelling myths and clarifying factors known to interfere with sleep (eg caffeine, alcohol, nicotine, daytime napping, and late-evening exercise). The behavioural treatment focus highlights the role of exercise in improving mood, reducing muscle tension and autonomic arousal, thus promoting better sleep. It promotes psychologically healthy behaviours and social connectedness, compared with the depressogenic behaviours of lying awake in bed monitoring fatigue and perceived sleep loss.
CBT promotes use of daily relaxation strategies to dampen down chronically heightened physical and mental arousal. These include progressive muscle relaxation, controlled breathing exercises, imagery training, and mindfulness practice.
Changing negative beliefs and expectations about Sleep
CBT also focuses on the link between thoughts and maladaptive behaviours, clarifying client appraisals of daytime functioning, to improve quality of life and reduce worry. Clients with primary insomnia tend to be “tired and wired” rather than involuntarily sleepy during the day, but disproportionately worried about quantity and quality of sleep experienced. Common maladaptive beliefs include “If I don’t have 8 hours of sleep I won’t function the next day” and “(sleep)quantity= quality”. Using behavioural experiments to challenge unhelpful beliefs and associated safety behaviours, CBT helps individuals challenge catastrophic expectations about feared consequences for health & functioning, leading to more realistic appraisals:
“The more I strive for “ideal” sleep the worse my anxiety, and sleep, will be”;
“ Good sleep sure isn’t as simple as fixating on X number of hours.” This reframing of unhelpful thoughts is a key factor in improving self-efficacy and restoring sleep confidence.
Simultaneously using a daily “worry session” can help reduce ongoing worries about sleep (ie giving full attention to the concern in a circumscribed worry period, and using problem-solving techniques, to reduce vulnerability to worry-driven sleep disruption at night).
The CBT strategies outlined above give some illustration of how psychological treatments work to change client beliefs, expectations and behaviours, and create longer term improvement in sleep habits.
Obtain a GP referral to see one of the Sleep Centre Sleep Physicians who will assess your condition, order any tests and start treatment.
If your GP is confident of the diagnosis and treatment need, your GP can refer you direct to the Sleep Centre Sleep Psychologist for her assessment and management.