Psy.D.

What is a Sleep Disorder?

Many, many people have difficulty falling asleep or staying asleep.  Research generally suggests that around a third of Americans have insomnia at any given time, and about 1 in 10 have chronic insomnia, lasting three months or longer.  While many people have brief periods of difficulty sleeping (for example, a few days after starting a new job), if you regularly experience sleep problems that interfere with your daily life, you may be suffering from a sleep disorder. A sleep disorder is a condition that frequently impacts your ability fall asleep, stay asleep and  get enough quality sleep, leaving you feeling exhausted or sleepy during the day.  The most common sleep disorders include insomnia, sleep apnea, narcolepsy, restless legs syndrome (RLS), and circadian rhythm sleep disorders often triggered by shift work or jet lag.Insomnia is a sleep disorder in which people have difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least one month.  People with insomnia have one or more of the following symptoms:

​

• Difficulty falling asleep

• Waking up often during the night and having trouble going back to sleep

• Waking up too early in the morning

• Having unrefreshing sleep

• Having at least one daytime problem such as fatigue; sleepiness; problems with mood, concentration; accidents at work or while driving, etc, due to not sleeping well. 

 

There are two types of insomnia: primary insomnia and secondary insomnia.

​

• Primary insomnia: Primary insomnia means that a person is having sleep problems that are not directly associated with any other health condition or problem.

• Secondary insomnia: Secondary insomnia means that a person is having sleep problems because of something else, such as a health condition (like asthma, depression, arthritis, cancer, or heartburn); pain; medication they are taking; or a substance they are using (like alcohol).

 

Insomnia varies in how long it lasts and how often it occurs.  About 50 percent of adults experience occasional bouts of insomnia and 1 in 10 suffers from chronic insomnia.  Insomnia can occur by itself or can be associated with medical or psychiatric conditions.  Insomnia can be short-term (acute or adjustment insomnia) or can last a long time (chronic insomnia).  It can also come and go, with periods of time when a person has no sleep problems.  Acute or adjustment insomnia can last from one night to a few weeks.  Insomnia is called chronic when a person has insomnia at least three nights a week for a month or longer.

​

Evidence for CBT-I

You don’t have to suffer the vicious cycle of sleepless nights and daytime fatigue that takes such a toll on your mood, energy, and overall health. For many sleep problems, Cognitive Behavioral Therapy for insomnia (CBT-I) can be more effective than sleeping pills—but without the unpleasant side effects or long-term health concerns. CBT-I can help relax your mind, change your outlook, improve your daytime habits, and set you up for a good night’s sleep. CBT-I is an 'evidence-based therapy', meaning that it has been shown to be effective in controlled scientific clinical studies.  The earliest research, in fact, goes back more than 30 years, so several decades of evidence has accumulated to show that CBT-I can teach people how to fall asleep faster, stay asleep longer and feel more awake and refreshed during the day.   CBT for insomnia has been assessed in over 100 randomized controlled trials (RCT), the gold standard method for evaluating the effectiveness of a treatment, and the results show that on average 70% of people with even very long-term poor sleep obtain lasting benefit from the treatment.  The fact that CBT-I produces “durable results” – generally continuing after a person stops the therapy – makes it an optimal approach. 

​​

• In 2016 The American College of Physicians published guidelines for the treatment of sleep disorders and recommended that all adult patients receive Cognitive Behavioral Therapy for Insomnia (CBT-I) as the initial, first-line treatment for chronic insomnia disorder.  

​

CBT-I in Action

The length of CBT-I therapy depends on the type and severity of your sleep disorder but is typically delivered in just six to eight sessions. While CBT-I is rarely an immediate or easy cure, it is relatively short-term.  Many CBT-I treatment programs for insomnia, for example, report significant improvement in sleep patterns following a course of just 5 to 8 weekly sessions.

​

CBT-I consists of four basic components: sleep restriction, stimulus control, sleep hygiene and cognitive therapy.  Sleep restriction may sound counterintuitive.  One might think that if you can’t sleep you should stay in bed for longer.  But actually experts say it’s important to match your 'sleep opportunity', or how long you’re in bed, with how long you’re able to sleep, and then gradually work on increasing sleep time. CBT-I doesn't aim to restrict actual sleep time but rather to initially restrict the time spent in bed.  Subsequent steps consist of gradually increasing the time spent in bed while identifying and changing sleep habits, improving your sleep environment, observing sleep hygiene, and practicing relaxation training, and cognitive control. 

​

While some people may feel they're familiar with certain concepts and components of CBT-I, like sleep hygiene (being mindful of how factors like caffeine and alcohol consumption, bedroom environment,and  limiting daytime naps can affect sleep), implementing CBT-I correctly is much more complex and involved. Experts say that's why it’s key to see a professional experienced in CBT-I for effective treatment.

​

• According to behavioral sleep expert Michael Perlis, PhD, those that try to do CBT-I on their own are likely to not be successful. But worse is that they will believe that they’ve been there, done that, and so the likelihood of seeking out professionally administered CBT-I diminished significantly.  

​

Use of Sleeping Pills 

If you have trouble sleeping, you may be thinking about getting a prescription for sleeping pills. While a sleeping pill may be effective at ending your sleep problems short-term, it's important to make sure you understand the risks and benefits associated with their use.  That includes knowing about sleeping pill side effects and both short- and long-term effectiveness.  Here are some important considerations:

​

• Sleeping pills are one of the most-prescribed drugs in the U.S. and are frequently over-used.  This is partly because many patients demand them and sleeping pills seem like a fast and easy solution.  Also, many doctors prescribe sleeping pills instead of trying other treatments first.  Some of this is due to the pervasive influence of drug companies, who sponsor scientific conferences, advertise in medical journals, send sales personnel to doctors’ offices, supply free samples of sleep medications, and fund research studies. Therefore, doctors may be subtly influenced to prescribe the sleeping pills that the drug companies manufacture.

• Sleeping pills may not help as much as you think. Sleep studies show that common sleep aids only help people fall asleep about 8 to 20 minutes faster. Moreover, they add less than 35 minutes to nightly sleep.

• Sleeping pills have risks and side effects. If you take sleeping pills for many days in a row, one risk is that you may start to depend on them and may not be able to fall asleep without them.  If you stop taking them, you may sleep worse than you did before you tried the pills.  This is why most doctors recommend you only take them on a short-term basis - but this doesn't get to the root of the problem.  Other risks and side effects may include: prolonged daytime drowsiness, dizziness, lightheadedness, headaches,  nausea, diarrhea, daytime memory and performance problems, and sleepwalking/sleep-eating.

• Over-the-counter sleep aids can be effective for an occasional sleepless night.  There are a few caveats, however.  Most over-the-counter sleep aids contain antihistamines. Tolerance to the sedative effects of antihistamines can develop quickly — so the longer you take them, the less likely they are to make you sleepy.  In addition, some over-the-counter sleep aids can leave you feeling groggy and unwell the next day.  This is the so-called 'hangover effect'.  Medication interactions are possible as well, and much remains unknown about the long-term safety and effectiveness of over-the-counter sleep aids.

​

Insurance Coverage

Insurance coverage of CBT-I varies so it is important to check with your insurance company ahead of time to see whether they will cover the type of treatment you need.  As CBT-I is more widely used, and given the support for its effectiveness, clinicians are hopeful insurance coverage of CBT-I will improve, but it’s not universal today.