By Lynn Mollick

“CBT is superior to medication for long-term treatment of insomnia,” reported Rochelle Zozula at NJ-ACT’s January 8 workshop. Dr. Zozula described five components of CBT:

1) Improve “sleep hygiene.” Develop a calming pre-bedtime routine. Set consistent times to go to bed and to arise. No napping in chronic insomnia, napping only 20 minutes/day for occasional insomnia. No exercise within 2 hours of bedtime. Avoid nicotine, caffeine, stimulants (including Sudafed), and alcohol which causes drowsiness followed by premature awakening.

2) Teach relaxation skills. Teach progressive muscle relaxation, meditation, autogenic training, self-hypnosis, guided imagery, or any other relaxation technique. Practice regularly, regardless of amount of sleep.

3) Make the environment conducive to sleep. Minimize interruptions and interferences. Set the alarm and put the clock where it cannot be seen.

4) Make the bed a conditioned stimulus for sleep. Go to bed only when sleepy. If patients don’t fall asleep in 25 minutes, they should get up and do something relaxing until they become sleepy. Sleep only in bed and use the bed only for sleep (and sex if you must).

5) Create fatigue by limiting hours of sleep. Go to bed later but set the alarm for normal wake-up time. As patients begin to sleep better, they can gradually go to bed earlier.

6) Cognitive techniques. Address catastrophizing about not sleeping, particularly worry about the dangers of a bad night of sleep. Lack of sleep feels bad, but has no direct effects on health.

Assessment

Insomnia is often a symptom of another sleep disorder, psychological dysfunction such as anxiety or GAD, substance abuse, illness, or medication side effect.

Successful treatment addresses both the insomnia and its underlying cause. Careful interviews of patients and their bed partners, and a two week sleep record lead to choosing the applicable CBT techniques and appropriate pharmacological interventions. Other sleep disorders to evaluate include:

1) Restless legs – a need to move ones legs that develops in the evening and is only relieved by walking.

2) Periodic limb movement disorder – reflexive tensing of the limbs that occurs about every 30 seconds during sleep.

3) Sleep apnea – disordered breathing during sleep that is as mild as snoring and as serious as not breathing for as long as 10 seconds.

4) Circadian rhythm disorder – sleep/wake cycles are either ahead or behind the “normal” pattern. A delayed pattern is common in teenagers and Axis II disorders.

Medication

1) A short acting pill is best for difficulty falling asleep, while a longer acting one is helpful for interrupted sleep or early awakening.

2) Benzodiazepines should be used for no more than 7 – 14 days because patients quickly develop tolerance. If insomnia is chronic, use benzodiazepines intermittently.

3) Changing from a short- to a long-acting benzodiazepine and then tapering very slowly, and only after CBT has taken effect

4) All sleep medication can be psychologically addictive.

5) Non-benzodiazepines that cause drowsiness include: sedating antidepressants, antihistamines, melatonin, and chloral hydrate.

6) Always obtain a thorough list of patients’ drugs. Many commonly prescribed medications may cause insomnia or excessive somnolence.

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