Sleep Education
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Cognitive Behavioral Therapy (CBT)
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What is it?

Cognitive behavioral therapy (CBT) helps you change actions or thoughts that hurt your ability to sleep well. It helps you develop habits that promote a healthy pattern of sleep. Talk to your doctor or to a sleep specialist to see if one of these methods might improve your sleep. Following are the most common forms of CBT:

Stimulus Control
A stimulus is anything that causes a response. The goal of this method is for you to have a positive response when you get into bed at night. It is used for people who toss and turn in bed, unable to fall asleep. When this happens for many nights, you begin to get frustrated. You may even dread bedtime, expecting to toss and turn for hours. Bedtime and even your bed itself are causing you to have a negative response.

This method teaches you to use the bed only for sleep and for sex. You are not to read, watch TV, or do anything else in bed. You are also taught to go to bed only when you feel very sleepy. If you are not asleep after about 20 minutes, then you are to get out of bed to do something else relaxing. When you feel sleepy again, then you return to bed.

Over time, this method helps you to fall asleep more quickly after you get into bed. You begin to have a positive response toward going to bed at night. Instead of being frustrating, it becomes relaxing and restful.

Sleep Restriction
This method sets strict limits on the time you spend in bed each night. The initial limit used is the same as the amount of sleep you tend to get on a nightly basis. For example, you may only get five hours of sleep even though you spend seven hours in bed at night. Two hours in bed are spent trying to fall asleep or go back to sleep after waking up. In this case, your initial limit would be to spend only five hours in bed at night. This means that you would be likely to get less than five hours of sleep.

This sleep loss will make you even more tired at first. But it will also help you fall asleep faster and wake up fewer times in the night. This gives you a solid period of sleep and a more stable sleep pattern. As your sleep improves, the limit on your time in bed is slowly increased. The goal is to reach the point where you get the amount of sleep you need without reducing the quality of your sleep.

Relaxation Training and Biofeedback
Relaxation training teaches you how to relax both your mind and your body. This helps you to reduce any anxiety or tension that keeps you awake in bed. This method can be used both during the day and at bedtime. It involves training you how to better control the following functions:

  • Muscle relaxation
  • Breathing
  • Mental focusing

Biofeedback may be used along with relaxation training. The process of sleep is more complex than it may seem. It involves such things as your brain, your breathing, your heart and your muscles. Biofeedback teaches you how to raise or lower various signs of how your body is working. You are given the details of certain indicators in your body. Biofeedback can provide details on such things as the following:

  • Muscle tension
  • Brain waves
  • Blood pressure
  • Heart rate
  • Body temperature

In order to sleep better, you are taught how to change either your muscle tension or your brain waves. You wear a device that signals to you the level of your muscle tension or brain wave frequency. You then try to change that level in a way that will help you sleep. The device uses a gauge, visual images or sounds to tell you how your level is changing.

These methods require you to focus and concentrate in order to see results. Some people may quickly learn the methods in just a few sessions. Others may need many sessions to master the techniques.

Cognitive Control and Psychotherapy
These methods are used to help you identify attitudes and beliefs that hinder your sleep. These negative thoughts involve worries and stress that keep you awake. A therapist helps you process your thoughts and feelings about sleep.

You learn ways to overcome negative thoughts and promote positive attitudes and beliefs. This might involve setting a “worry time” in the afternoon or early evening. This is a time when you review the day and plan for tomorrow. You focus on getting all of your worries out of your system. At the end of this time you feel “free” to relax. This helps your mind to be at rest when you go to bed.

Another method is to use guided imagery. You imagine that you are in a story. In your mind you try to picture what things look, feel, and sound like. You try to make it as real as possible. This keeps your mind from thinking about other concerns. You stop “trying” to go to sleep. As a result, your mind settles down and stops racing. This allows your body to relax and go to sleep.

A therapist will often see you weekly on an individual basis. Sessions may vary in length from 30 to 90 minutes. Other options are to do group therapy or to consult with a therapist by phone. These options may cost less than individual sessions.

Sleep Hygiene Training
This method of therapy is used to correct things you do on a regular basis that disturb your sleep. Sleep hygiene consists of basic habits and tips that help you develop a pattern of healthy sleep. Disturbed sleep will often be caused by more than one thing that you do. To improve your sleep, you will need to improve all of these habits.

For example, a man begins a regular exercise routine. He hopes that it will help him sleep better. After a while he becomes frustrated. He is still having a hard time falling asleep at night. This is because he continues to drink caffeine in the evening. He also takes long naps in the afternoon. Even though he corrected one habit, the other actions keep him from sleeping well.

You need to learn how to practice good sleep hygiene on a regular basis. This will greatly improve your chance of sleeping well at night.

Who gets it?

Cognitive behavioral therapy is most often used for people who suffer from insomnia. Sometimes insomnia is caused by one of the following:

  • Another sleep disorder
  • A mental health disorder
  • A medical condition

In one of these cases, the root cause needs to be treated first. This should help solve the problem with insomnia. In other cases, the cause of insomnia is very complex. The best treatment for it may involve more than one method. More than one form of CBT may be used. Drugs may also be used along with cognitive behavioral therapy.

People who complain of sleeping better away from home may benefit from Stimulus Control Instructions. This method should also help someone who spends a lot of time in bed doing things other than sleeping. This includes such things as reading, writing, and studying.

Sleep Restriction Therapy is useful in many different cases of insomnia. It can help someone who is trying to stop using sleeping pills. It may not be the best option for someone who is severely sleepy. This person may not be able to handle the initial sleep loss that is involved. It is also not intended for the person who sleeps well but does not get enough sleep.

Relaxation training and biofeedback are useful for people who are very tense and anxious when going to bed.

Cognitive Control and Psychotherapy are useful in many different cases of insomnia. This includes cases where depression or stress is seen as a cause of the insomnia.

Anyone whose habits are disturbing their sleep will benefit from sleep hygiene training.

Possible side effects?

Cognitive behavioral therapy is not a quick fix for a sleep problem. It requires steady practice over time. Frustration may arise if you expect dramatic results right away. The time, effort, and money required may turn some people away.

Sleep Restriction Therapy will make you sleepier at first. This is due to mild sleep loss in the early stages of the therapy.

To find a specialist near you who is trained in behavioral sleep medicine, visit the Web site of the American Academy of Sleep Medicine.

Reviewed by David A. Kristo, MD
Updated November 28, 2005

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