CBT (Cognitive Behavioral Therapy) for insomnia is used to address the thoughts and beliefs that contribute to the problem initiating or maintaining sleep.
Common beliefs about sleep that are not helpful.
– A bad sleep always equals a bad day.
– Belief that sleep becomes unpredictable, random. This becomes anxiety provoking.
– The belief that insomnia will always be outside of their control.
– The belief that there is something inherently wrong with them.
– I need 8 hours of sleep to function.
– Medication is the only solution.
– Can’t function without adequate sleep.
– Poor night’s sleep affect whole week.
– Can’t manage negative sleep consequences.
– Insomnia prevents enjoying life.
– Insomnia is due to a chemical imbalance.
Once a person’s insomnia is started, all they think about is sleep. Those who are highly focused on negative body sensations take longer to fall asleep.
Have you ever felt like you got a poor night sleep but still got through the day? Have you ever slept great but still felt fatigue at the end of the day? So there are multiple factors that go into how you are going to feel the next day. There are other determinant factors of daytime fatigue.
Common Belief: After a poor night sleep I will feel terrible the next day and there is nothing I can do to help that. — There are things that can be done that generate energy regardless of sleep. You want to challenge the thoughts that will keep you up at night. Energy generating thoughts can be a breath of fresh air, lunch with a friend, taking a walk on a crisp day.
Fear of poor sleep!
This is a very powerful fear. Tackles the belief that poor sleep is inevitably dangerous and must be avoided at all costs. This fear paradoxically increases anxiety and therefore increases the chance of night of poor sleep.
Clock Monitoring is Not Helpful!
Joe-Sleep wakes up at 3a.m. If he focus on fact that he is awake, he is more likely to stay awake. Then he starts to calculate how much longer he has to sleep, or even how long he has been awake. What do you need to do to calculate time? Stay awake!
Upon wake up in morning he has option to say (1) I feel sleepy most mornings, I’m sure it will be fine or (2) I am never going to be able to get my work done today. With the mindset of I am never going to be able to get my work done today, dysfunctional thoughts and negative arousal rule the day. Also, it causes an urgency next evening to sleep, which causes further arousals.
Negative experiences can lead to “helplessness-related” experiences. This contributes to Automatic Thoughts (ANTs). Such as I can’t cope. Negative experiences, such as a poor night sleep before a big day, are stored in our memories, called “schemas”. When the schemas are activated, instead of feeling a broad range of experiences, one feels focused negative thoughts. Almost like having blinders on where all you see is confirmatory information about your thoughts.
Morin noticed a difference between people with insomnia and good sleepers. Fear of losing control (hopelessness) and that there is nothing that can be done to address it (helplessness) are key in differentiating those with insomnia from good sleepers.
When one feels helpless, they have a “there is nothing I can do about it” mindset that develops. Subsequently one gets anxiety about failed attempts to address a problem. – In contrast, if one feels there is something wrong with them, they will feel that they need to exert effort to fix a situation.
Sometimes we can develop negative thoughts about sleep. Leads to distress. Selective monitoring includes noticing every symptom of tiredness or anxiety. Subsequent coping behaviors, to get your mind off the fact you are not sleeping, sometimes can be wake promoting. Smoking a cigarette or drinking alcohol. Doing something to get there mind off it, but it perpetuates to the fact that they are not sleeping. Then in the 24 hour model, they feel bad, they feel un-rested, this causes further distress next evening about getting to sleep. Feelings like “its so hard to concentrate” leads to thoughts of hopelessness. Coping behavior may include over-caffinating or napping, both of which lead to poor sleep next attempt. Increased attention to selective monitoring that would confirm the thoughts that a poor night sleep leads to poor next day.
Pre-sleep thoughts can be overwhelming with intrusive and worry related thoughts. When people think of sleeplessness, it leads to distress and emotional arousal. People with insomnia report more emotional stressors, and they report it takes longer to recover from such stressors.
Studies have shown that when people were asked to monitor a clock as opposed to not monitor a clock that the group of clock monitoring took longer to fall asleep. (Tan, Schmidt & Harvey, 2008).
Therapy of any type in reality is less than 1% of the person’s life. What is 50 minutes of a session in the context of all the life you have lived and still plan to live. The challenge is getting that 1% of time to impact the other 99% of your life. That is why explanation is more important than instruction.
2. Thought Records and in-session Socratic questioning: Targeting the thought-distress connection and belief modification. à Interrupt automaticity.
3. Behavior Experiments.
Psychoeducation: Providing verbal information with the hopes that they will change their beliefs about sleep.
– We don’t need 8 hours – variability
– Norms: Number of wakeups, and wake time in bed.
– Increased sleep effort interferes with homeostatic regulation of sleep
– Sleep need decreases with age and decreased activity
– Fatigue can be caused by boredom, circadian factors, diet, caffeine crash, virus, dehydration, so there are multiple causes of fatigue beyond just a poor night sleep.
Thought Records – Means by which we try to modify Thoughts, Mood, and Beliefs.
If I don’t sleep well, I will perform bad. Perform bad, get fired. Get fired, I will become homeless or institutionalized. Then you get evidence for thoughts, but facts only. Not exercising, don’t feel like doing things. Feels like something bad will happen (emotional reasoning, not a fact).