It is estimated that as many as one in three people experience insomnia symptoms at some point in their lives (Ancoli-Israel & Roth, 1999), with 6-15% of the population meeting the full diagnostic criteria for insomnia (LeBlanc et al, 2009). This makes it the most common sleep disorder seen in sleep medicine clinics. Many people are unaware there is an evidence-based treatment for insomnia which doesn’t involve medication and which can give lasting improvement to long-term sleep problems.

 

What is insomnia?

Primary insomnia is characterised by complaints of sleep, including trouble getting to sleep, staying asleep or waking too early and being unable to return to sleep, despite adequate opportunity to sleep (DSM-V, American Psychiatric Association, 2013). The complaint occurs at least three times a week and has been present for at least three months (although some diagnostic manuals use the criteria of at least one month). This is accompanied by significant distress and daytime impairment to social life or work functioning. Finally, the sleep complaints cannot be better explained by other physical, mental or sleep disorders and cannot be due to substance use or medication.

 

How does insomnia develop?

It is important to distinguish between short-term sleep problems and insomnia. Short-term sleep problems can be triggered by stress or major life events such as bereavement and relationship break-up. One in three people experience these short-term sleep disturbances which are due to a combination of vulnerability factors (e.g. genetics, age, gender) and triggers (e.g. stress). For most people, the sleep problem will pass within a period of a few days to a few months. But for other people the sleep problem continues into the long-term, despite the stress being removed. This is because these individuals have changed their behaviours in order to adapt to the sleep problem and there is a change to the way these people think about their sleep. This can disrupt the biological systems that control sleep so that they are no longer performing as they should do. The unhelpful behaviours and thoughts coupled with repeated unsuccessful attempts at sleeping, lead to negative associations developing with the bed and sleep, so that the bedroom becomes linked with wakefulness rather than sleep. In addition, the negative thoughts associated with insomnia can lead to increased worrying about sleep which makes it harder for someone to sleep.

 

These changes are called maintenance factors and these are responsible for perpetuating the problem into the long-term (Spielman, 1987). People with insomnia often describe wanting to get to the “root cause,” but this is misleading as the triggers which set the sleep problem in motion are no longer relevant to what is maintaining the insomnia.

 

Here’s an example. After taking two hours to get to sleep one night, someone switches off their alarm when it wakes them in the morning and sleeps for an additional hour. During the day they worry that they will have another bad night’s sleep. Then they go to bed an hour earlier than their usual time to catch up on the lost sleep. However, they can’t get to sleep for an hour and a half because their internal body clock is not ready for sleep, despite being tired. So they toss and turn thinking “Why can’t I sleep? I need to get to sleep as I have an important meeting tomorrow and I won’t be able to function.” These thoughts set off the flight or fight response which is fuelled by adrenaline. In this state, it is very difficult to drop off to sleep.  This reinforces their belief that they cannot sleep and the cycle continues the next day.

 

 

How to treat insomnia

According to NICE guidelines (NICE, 2015) and recent European guidelines on insomnia (Riemann et al, 2017), the first line of treatment for insomnia should be cognitive behavioural therapy for insomnia (CBT-i). This has been shown in numerous clinical, randomised control trials to be the most effective treatment for insomnia, with effects lasting longer than sleep medication (Riemann et al, 2017). While hypnotics can provide short-term relief for sleeping problems, they are not recommended for long-term treatment due to tolerance and “rebound insomnia,” which is often experienced on withdrawal.

 

Studies show that, on average, 70% of people will show improvements to their sleep with CBT-i, making it the most effective treatment available (Morin et al., 2006). Despite this, CBT-i is not widely available on the NHS due to a lack of trained therapists and funding costs and individuals looking for this treatment often have to turn to private avenues.

 

 

So what does treatment with CBT-i involve?

CBT-i is a structured programme, focused on treating long-term sleep problems. This is different to general cognitive behavioural therapy as several of the techniques used are specific to insomnia and the treatment requires some knowledge of the processes that control and regulate our sleep.

 

CBT-i addresses the maintenance factors of insomnia, that is, the behaviours and thoughts (cognitions) that fuel the sleeping problem. The first step is a sleep assessment to understand the nature of the problem and to screen for other sleep disorders. There is an element of “psycho-education” about the biological processes that control sleep and how these go wrong with insomnia. Cognitive techniques address the mental factors that contribute to insomnia such as erroneous beliefs about sleep, a racing mind and worrying thoughts about sleep. Then behavioural techniques are used to help the natural, biological drivers of sleep to function properly. Behavioural therapy also aims to re-establish lost associations between the bed and good sleep and to help individuals to establish a healthy sleep routine.

 

So, if you have insomnia you don’t have to just live with it. There is an effective treatment available that doesn’t involve medication, but it will involve you changing your sleep habits and this can be a little anxiety provoking. You also need to be open-minded about your thinking and be prepared to challenge some of your thoughts. If this sounds like something you are prepared to try, then it’s worth trying CBT-i.

 

Christabel Majendie, is a sleep therapist and consultant, with expertise in sleep medicine and CBT for insomnia (CBTi). For more information visit www.christabelmajendie.co.uk

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)

Ancoli-Israel, S. & Roth, T. (1999). Characteristics of insomnia in the United States: results of the 1991 National Sleep Foundation Survey. I. Sleep; 22 (Suppl 2):S347–53.

LeBlanc, M., Merette, C., Savard, J., Ivers, H., Baillargeon, L. & Morin, C.M. (2009). Incidence and risk factors of insomnia in a population-based sample. Sleep; 32: 1027–37.

Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A. and Lichstein, K. L. (2006). ‘Psychological and behavioral treatment of insomnia:update of the recent evidence (1998-2004).’, Sleep, 29 (11), 1398–414.

National Institute for Health and Care Excellence. (2005). Clinical Knowledge Summaries: Insomnia. NICE, (https://cks.nice.org.uk/insomnia#!scenario:1)

Riemann, D., Baglioni, C., Bassetti, C., Bjorvatn, B., Dolenc Groselj, L., Ellis, J.G., et al. (2017). European guideline for the diagnosis and treatment of insomnia. J Sleep Res; 26: 675–700.

Spielman, A.J., Caruso, L.S., Glovinsky, P.B. (1987). A behavioral perspective on insomnia treatment. Psychiatr Clin North Am; 10(4):541-53.