The Mystery of Sleep: Why a Good Night's Rest Is Vital to a Better, Healthier Life

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Beating Insomnia Without Pills

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THE MYSTERY. If insomnia has many causes, can it also have many cures? Can it be treated without pills? Many patients can help cure their insomnia without using medications. Behavior modifications can often do more than hypnotics to give a patient a good night’s sleep.

The Case of the Woman Who Was Afraid to Make a Fool of Herself

After a referral from her doctor, a twenty-five-year-old woman came to my office and described her insomnia. She was very concerned about it—she even worried that her embarrassing sleep problem might break up her relationship with her boyfriend. When I asked her how insomnia could possibly be embarrassing, she explained that the insomnia was not really the problem. What was embarrassing was that when she did fall asleep, she apparently would get up and start screaming. She feared that her sleepwalking and screaming would drive her boyfriend away, and because she was so worried about this happening, she now had great difficulty falling asleep.

The patient had a lifelong history of sleepwalking and sleep terrors. While she was sleeping she would sometimes get up and walk around; at other times she would yell and scream. She never had any memory of these episodes, but other people would tell her about them, and she found this very embarrassing. She had developed a fear of falling asleep that was closely linked to her fear of embarrassment, and this had created a vicious cycle in which her fear caused sleep deprivation, which in turn exacerbated her episodes of sleepwalking and sleep terrors.

She was becoming desperate, but she made it clear that she did not want to take drugs to help her sleep. I thought there might be another solution.

An Alternative to Pills: Cognitive Behavioral Therapy

People with insomnia can often be effectively treated without pills. Before trying a medication-free approach, however, patients need to be evaluated by a doctor or sleep specialist. As we saw in Chapter 10, insomnia is a symptom and a disorder, and it can have many causes, including medical disorders, psychiatric disorders, and the effects of drugs (including caffeine). Most sleep specialists now recommend cognitive behavioral therapy as the first treatment of insomnia, especially for patients who want to avoid medications.

Cognitive behavioral therapy (CBT) is a psychological approach that includes techniques to treat people with insomnia as well as those with serious depression and anxiety problems. It is provided by many clinical psychologists and other types of health professionals who have had training in this area.

Because it seeks to resolve the problem with behavioral change, cognitive behavioral therapy can help to reduce sleeping pill use. With this approach, the patient receives information about how much sleep he or she needs, learns how to self-monitor sleep, and is encouraged to practice good sleep hygiene. Typically the patient learns to identify and alter behavioral cues that could be promoting sleeplessness and to develop new habits that promote better sleep. Once patients become more aware of their thoughts and expectations about sleep they might be able to modify them. They also learn different relaxation techniques that allow them to quiet their mind, fall asleep more easily, and have more restful sleep.

Cognitive behavioral therapy is provided by clinical psychologists and by other types of health professionals who have had specialized training in this area. Patients who want to try CBT should check to see if a clinical psychologist is available in their community and whether their health insurance covers such treatment; it often does. Psychologists treat people either individually or in a group setting. Although some people are initially skeptical about the effectiveness of CBT for insomnia, many become strong advocates of this approach once they have followed a course of such treatment (and even begin helping others with their sleep problems!). On average, 70 to 80 percent of individuals experience a significant improvement in their sleep after receiving cognitive behavioral therapy.

The degree of improvement usually depends on how much effort individuals have put forth, so I must stress the importance of being committed to practicing at home. It is important to keep in mind that to see an effect, patients must apply these strategies every night for at least three to four weeks. Practicing these techniques just once or twice, or every now and then, is unlikely to make sustained improvement in the patient’s sleep.

Recently, online or computerized cognitive behavioral therapy programs for insomnia have been developed, such as the restore program available through Cobalt Therapeutics (cobalttx.com) in the United States, and the Online Program for Insomnia available through the University of Manitoba (http://www.return2sleep.com/) in Canada, and Sleepio (sleepio.com) in the United Kingdom and the United States. These programs allow individuals to receive help for their insomnia in the comfort of their own homes. However, because individuals have different needs, some people require more sessions than others. Whereas many patients can learn CBT techniques on their own and are successful at improving their sleep, others might require help from a health care professional. Besides the online programs, mobile apps are available for both iOS and Android. These mobile apps are not designed to replace therapists but to supplement the therapy and as homework. Such smartphone apps are being developed continuously.

A Healthy Night’s Sleep

A significant problem for many people who experience insomnia is a tendency to become worried and apprehensive about sleep loss. It might help these people to know that research shows that each person has different sleep needs. This is not surprising: people have different shoe sizes, blood pressure, weight—why should their sleep be any less variable and individual? Some people are by nature short sleepers and require only five to six hours per night to feel rested. Other people need nine to twelve hours. Most people fall in between these extremes.

Some of the people whom sleep specialists see feel certain that they need eight hours of sleep a night to function well and to be healthy. These people are often surprised (and relieved) to learn that they can sleep for six or seven hours and feel well the following day. Many people have pressured themselves to obtain an amount of sleep that their body resists. In short, a person who feels rested and alert after fewer than eight hours of sleep a night does not have a sleep problem—that person simply does not need eight hours of sleep a night. Furthermore, it is not a good idea for such people to try to sleep longer than they need. Oversleeping can cause morning headaches, grogginess, and (ironically) sleepiness the following day. Cognitive behavioral therapists suggest that patients conduct individual experiments to determine how much sleep they need to feel rested.

SELF-MONITORING OF SLEEP

A good way for patients to monitor how much sleep they are getting is to keep a sleep diary, such as the one shown in the figure below. Patients should take three to four minutes to complete these diaries before getting out of bed each morning. The diary helps patients collect information about their sleep schedule: how regular their bedtime is, how long it takes them to fall asleep, how many times they awaken in the night, and what time they wake up in the morning. Several devices based on smartphones and “wearables” are used to monitor sleep, but most have not been rigorously evaluated.

When working with a sleep diary, it’s important that the patient does not look at the bedroom clock during the night since this can lead to anxiety about not sleeping. Instead patients should guess or estimate how long it took them to fall asleep and how many times they awoke during the night. The sleep diary is an essential part of the therapy because it shows patients the associations between their behavior and their sleep patterns. Someone who is involved in a lot of pre-bedtime activity (for example, doing chores) and is also experiencing a delayed sleep onset might try to schedule a period of time before bed when he or she does nothing but relax. Some patients find that their bedtime varies widely from day to day; such patients could try to establish a more regular bedtime. By opening sleep sufferers’ eyes to their sleep behavior, self-monitoring might help those patients close them.

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Cognitive Behavioral Therapy Sleep Diary

SLEEP HYGIENE

Sleep hygiene refers to habits that promote or prevent sleep. Some of these habits relate to diet, exercise, alcohol and drug use, noise, light, and temperature. In cognitive behavioral therapy, patients will learn to assess their level of sleep hygiene and determine whether modifications are necessary. Some sleep hygiene areas were covered in the “Thirteen Commandments for Fighting Insomnia” (Chapter 10).

One area of sleep hygiene that people with insomnia often need to improve is sleeplessness caused by a snoring or restless bed partner. Cognitive behavioral therapists often encourage couples to consider sleeping in separate beds or even separate rooms to evaluate the impact of separation on their sleep. Though they might be concerned about the effect this will have on their relationship, couples usually find that their sleep improves, and they discover other ways to be intimate without sleeping in the same bed.

Another problematic area of sleep hygiene is sleeping in the same room as the family pet. Dogs and cats can disturb sleep by yawning, snorting, gasping, or moving around. Some patients feel guilty about shutting their pets out of the bedroom, but their sleep can dramatically improve if they do so. They can show their care for the pet by preparing a special place for it with a nice blanket and favorite toy outside of the bedroom.

Cognitive behavioral therapists will also ask patients about their typical exercise pattern because it is related to their adherence to good sleep hygiene. Many people juggling multiple roles of caring for family and working outside the home find they have little or no time for exercise during the day. If they try to make up for this lack by exercising at night or within three hours of bedtime, they might find themselves experiencing sleep problems. Although exercise can leave them feeling tired and relaxed immediately afterward, many people experience an energy burst later that interferes with their sleep. People who work outside the home might want to consider joining a health club near the workplace where they can work out during the lunch hour.

No discussion of sleep hygiene can be complete without mention of the negative effects of caffeine (typically found in coffee, tea, colas, and chocolate), alcohol, and nicotine (see Chapter 20 for a fuller discussion). Although many people are aware of the impact of caffeine on sleep, some are surprised to learn that even one glass of whiskey or wine can interfere with their sleep. Similarly, although some people tolerate caffeine well, many notice an improvement in their sleep when they stop consuming caffeine, even if they have been in the habit of drinking only one or two cups of coffee, tea, or cola a day. Certain individuals appear to be very sensitive to the effect of caffeine. Additionally, nicotine can affect sleep. Smokers who cannot quit could reduce the impact of nicotine on their sleep if they were able to establish regular smoke breaks and smoked the last cigarette of the day several hours before bedtime.

How Cognitive Therapy Works

AUTOMATIC THOUGHTS AND COPING THOUGHTS

Cognitive therapy is based on the idea that our thoughts about various events, activities, and people can affect our feelings and our behavior. Some people are surprised to learn that their thoughts about sleep can affect their sleep behavior. In the context of insomnia treatment, cognitive therapy is used to help individuals become aware of what they are saying to themselves about sleep (their assumptions and beliefs) and to evaluate whether these are realistic and reassuring ways of viewing their insomnia. Therapists train patients to identify “automatic thoughts” (the catastrophizing that occurs when they are having trouble sleeping) and work to replace them with “coping thoughts” (realistic readjustments that recognize that things are never as bad as the insomniac imagines).

Here are some of the more common automatic thoughts connected with insomnia, followed by the coping thoughts that can be used to counteract it and promote better sleep.

Automatic thought: “If I don’t sleep well tonight, I won’t be able to function tomorrow.”

Coping thought: “If I don’t sleep well tonight, I’ll probably be grouchy tomorrow, but I’ll manage.”

Automatic thought: “My insomnia is never going to get better.”

Coping thought: “My insomnia is a problem now, but if I do the treatment techniques that worked for others, it will get better.”

Automatic thought: “I have no control over my sleep.”

Coping thought: “My body will tell me when it needs sleep.”

Automatic thought: “If I sleep poorly tonight, it will disturb my sleep for the next week.”

Coping thought: “If I sleep poorly tonight, I’ll sleep better another night.”

Automatic thought: “If I don’t fall asleep soon, I’m going to be up all night.”

Coping thought: “I may not fall asleep soon, but I’ll fall asleep eventually. The best thing for me to do is get up and relax until I become drowsy before returning to bed.”

Automatic thought: “If I don’t sleep well tonight, I’m not going to be able to go out after work, spend time with my family, or do my hobbies.”

Coping thought: “If I don’t sleep well tonight, I’ll probably be more tired tomorrow, but I can still do all the things I want to do even if I am tired.”

Automatic thought: “When I can’t sleep, resting in bed is better than nothing.”

Coping thought: “Resting in bed is likely to worsen or at least maintain my insomnia. Getting out of bed when I am not sleeping is likely to improve my insomnia.”

In cognitive behavioral therapy, patients are asked to develop their own list of automatic thoughts about their sleep habits and come up with reassuring but realistic ways of counteracting them.

STIMULUS CONTROL

Stimulus control is not a technique but a term that refers to situations when a particular behavior (for example, insomnia) is likely to occur in response to a particular stimulus. Certain activities, for example, can produce arousal or wakefulness when people are in the bedroom, whereas others can promote sleep.

Activities that can enhance wakefulness include watching television or reading in bed, or using the computer in the bedroom. Although many people find that these activities help them to relax, most people with insomnia are unaware that the activities could be perpetuating the problem. These activities require attention or alertness and stimulate the brain. The patient begins to associate the activities with insomnia, thus reinforcing the insomnia. In addition, many people become dependent on these activities, fearing that they will not be able to sleep if they do not follow their established routine.

If reading and watching television before bed are an important part of the patient’s wind-down period, therapists usually suggest doing them outside the bedroom. This will reduce the likelihood that these behaviors, and the concentration they demand, will become associated with being in bed.

After the lights are out, people should not lie in bed indefinitely trying to sleep; this is another cue that promotes wakefulness. By staying in bed, the person strengthens the association between lying in bed and struggling unsuccessfully to fall asleep, an association that makes it more difficult to restore a normal sleep pattern. Cognitive behavioral therapists encourage patients to get out of bed after they have been lying awake for more than twenty or thirty minutes. Once up, they should engage in a nonstimulating activity until they start to feel drowsy. At that time they should immediately return to bed; this exercise should be repeated as many times as necessary. Sometimes reading a book can work as a relaxant. But if it becomes too difficult to put a good book down before finishing a chapter, patients should consider less engrossing reading materials (for example, a boring history book).

People should not start doing activities that will take a lot of time or be difficult to stop doing, such as paying bills or doing household chores. It can be helpful to keep a notepad beside the bed to jot down any quick thoughts that need to be captured. On a personal note, I find it helpful to get up and write down what I need to do the next day or make a to-do list before going to sleep. All the thoughts keeping me awake are, in a sense, taken out of my head and put on paper. A less stimulating, duller activity will eventually have its effect, but patients should be sure that they do not to return to bed before they feel drowsy.

Therapists will help patients learn about the cues that promote sleep. Establishing a bedtime routine and a regular sleep schedule (or bedtime and wakeup time) are two important cues that help the body transition from wakefulness to sleep. Parents with young children might be used to preparing them for bed with a bath followed by a bedtime story. This is an excellent technique because it sets cues in the child’s environment to help signal that sleep is coming. But in the midst of getting children ready for bed and performing the other activities of their extremely busy lives, parents often forget or fail to realize the need to schedule a similar type of bedtime routine for themselves. Doing so is crucial.

In addition to following a routine, people experiencing insomnia need to set a regular bedtime and wake-up time for themselves. Many people fall into the habit of sleeping in on weekends to make up for lost sleep. Although this provides temporary relief, it sets the stage for insomnia.

Most people experience their worst night of sleep on Sunday night. This is partly due to apprehension about returning to work and responsibilities, but in addition, if they have slept longer over the weekend, they find themselves less ready to sleep at the end of it. People who like to stay up a little later on the weekend will not find their sleep overly disturbed, provided they continue to rise at their usual time. Therapists can help patients identify and review the types of cues that could be interfering with their sleep. They might suggest experiments that can help determine whether the patient’s sleep improves after removing or adding such cues. Typically, patients need to apply these strategies for several weeks before they start to see a sustained improvement in sleep.

SLEEP RESTRICTION

Another component of cognitive behavioral therapy for insomnia is sleep restriction, a strategy in which the amount of time spent in bed is limited to the time the person is asleep. For example, let’s say a person retires at 10:00 P.M. and gets out of bed at 7:00 A.M. but only sleeps from 2:00 A.M. to 7:00 A.M. This person has spent nine hours in bed for five hours of sleep—something sleep specialists would consider terribly inefficient. The patient is asleep for only 56 percent of the time he or she spent in bed.

There are two basic approaches a CBT therapist might suggest to improve this situation: to follow either a strict sleep restriction strategy or a lenient one. In a strict strategy patients calculate their current sleep efficiency and limit their time in bed to actual sleep time. The patient in the example above would go to bed no earlier than 2:00 A.M. for three consecutive nights and continue to get up at 7:00. After three consecutive nights of near perfect (100 percent) sleep efficiency, the patient can begin to go to bed progressively earlier (increasing by thirty-minute increments) until he or she reaches a sleep efficiency of 85 percent or until the sleep is satisfactory.

Many patients find that it is easier to begin this strategy on a weekend, when they have fewer work commitments or other daytime demands. People trying the strategy should expect to feel tired during the day, but after about two weeks the strategy generally has the desired effect.

The lenient approach to sleep restriction involves restricting time in bed more gradually, over a number of weeks, rather than immediately limiting it to match the time spent sleeping. Using the example above, the patient might postpone bedtime until midnight in the first week while continuing to arise at 7:00. In the second week, the person would start going to bed at 1:00 A.M., again, continuing to get up at 7:00. The patient should continue the lenient sleep restriction process until near-perfect sleep efficiency is reached. At that point, he or she would schedule the bedtime progressively earlier, as long as he or she could maintain sleep efficiency. As with the strict strategy, most people will find that the strategy becomes effective fairly quickly, but it will take longer than the strict regimen.

Strategies of using sleep restriction alone have been found to be highly effective even in the primary care setting by a group in New Zealand in 2013.

Relaxation Training

Relaxation training encompasses a variety of relaxation strategies intended to enhance the quality of sleep. When a person is relaxed bodily tension is reduced; additionally, a relaxed person is less likely to focus on his or her sleeplessness. Although self-help books abound with relaxation techniques, here are strategies that have been extensively researched and found to be effective. These relaxation techniques include progressive or deep muscle relaxation, paced breathing, imagery-induced relaxation, and hypnosis or self-hypnosis. Each requires several weeks of daily practice before it can produce results. Patients should practice relaxation and meditation techniques during the day until they have mastered them; only when the techniques have become almost automatic should patients try them at night.

DEEP MUSCLE RELAXATION

Deep muscle relaxation is based on the idea that when their muscles are tensed, people feel unsettled and anxious, and when they are relaxed, people feel calm and peaceful. As developed in Clinical Behavior Therapy, by Marvin R. Goldfried and Gerald C. Davison (1976, expanded edition 1994), deep muscle relaxation trains patients to identify when their muscles are tense and to relax them when this happens.

Begin by tensing each of the muscle groups in the list below for about five seconds, and then relax that same muscle group for about ten seconds. When you are tensing, tense the muscles firmly but not hard enough so that you feel pain, cramping, or trembling. You can do this exercise sitting up or lying down, whichever is more comfortable for you. You can do this in bed.

1. Clench your right fist.

2. Clench your left fist.

3. Tighten the biceps muscles in your right arm.

4. Tighten the biceps muscles in your left arm.

5. Bring your right shoulder up toward your ear.

6. Bring your left shoulder up toward your ear.

7. Tighten the muscles of your forehead.

8. Tighten your jaw and grit your teeth.

9. Tighten the muscles in your stomach.

10. Stretch both legs out in front of you, pointing your toes toward the ceiling or sky.

As you release the tension in each muscle group, say the word relax slowly to yourself. Focus on the word and on the feeling of relaxation that comes as the tension flows out of your muscles. Tense and relax each group of muscles twice before moving on to the next group.

When you are first learning progressive muscle relaxation, following the instructions on an electronic device might be useful to help you focus. You can record your own instructions by reading into a recording device such as a smartphone. You can even program your smartphone to remind you when you should do the exercise.

PACED BREATHING

Shallow, rapid breathing causes a reduction in blood carbon dioxide levels. It can result in an unsettled, nervous, or even light-headed feeling, caused by mild hyperventilation. The paced breathing technique teaches patients how to breathe slowly and deeply so that they can achieve a deeper state of relaxation. This slow, deep breathing also helps lessen stress, a major culprit in insomnia.

Place one hand on your chest and the other on your abdomen. Inhale slowly through your nose, and as you do so, use the breath to push your abdomen out about one inch. As you exhale, let your abdomen fall back in. Inhale slowly and exhale slowly. Imagine your stomach inflating like a balloon. Allow the hand on your abdomen to rise higher than the hand on your chest (which should move only slightly). Repeat this cycle as many times as needed; make sure you breathe slowly. If you begin to feel dizzy or light-headed, simply breathe through your nose and close your mouth.

After you have finished your breathing exercise, sit quietly for several minutes with your eyes closed. Enjoy the relaxation.

A device that tracks breathing with a smartphone app (2breathe.com) has been approved to treat insomnia.

IMAGERY-INDUCED RELAXATION

Imagery-induced relaxation is based on the idea that imagining a relaxing scene can help people feel more relaxed, breathe more slowly, and feel calmer. Patients are directed to think of a time or place during or in which they felt truly relaxed. Perhaps they were sitting on the edge of a dock at the lake, on the beach, or in their backyard on a hammock, or were out walking on a mild winter day. They might have been at a vacation spot.

Find a comfortable place, close your eyes, and imagine yourself in your relaxing scene. If a particular memory doesn’t come to mind, develop a new image that you find relaxing. Try to focus on the smells, sights, and sounds of your image. Let yourself become involved in the image as you get in touch with your senses. Feel free to change any aspect of the image at any time should it cease to be relaxing. After approximately ten to fifteen minutes, open your eyes. Sit quietly and enjoy the relaxation.

HYPNOSIS AND SELF-HYPNOSIS

The principle behind self-hypnosis is that people respond to information that comes from both their conscious and their unconscious minds. Consciously, they can learn to become more relaxed through a number of the exercises already discussed. They can also use their unconscious minds (thoughts and feelings that are outside waking awareness) to learn to identify personal stress-ors and become more relaxed. Using self-hypnosis, patients can enter a trance-like state of heightened relaxation through any of several techniques.

Therapists who teach self-hypnosis will initially guide the patient through a series of suggestions, including intense focus on some bodily function (such as breathing). Under hypnosis, patients will be guided through various relaxing scenes and be asked to generate others. The therapist might offer some suggestions about possible ways to approach personal problems. As the patient considers these suggestions, he or she will continue to hear the therapist talking, but will pay attention to the therapist only sporadically. The feeling they experience during hypnosis might be similar to feelings they have had when watching a very engrossing movie or listening to a favorite song. When the hypnosis session concludes, patients might feel that they have been on a journey of some kind. After hypnosis, many people spontaneously have new insights about what has been upsetting them in their lives. Sometimes these insights are not new; the patient had simply not appreciated their value. The hypnosis experience helps patients relax both by the change in their tension level while in a trancelike state and by the insights gained regarding what they must do to feel emotionally better.

Patients should not be concerned that they will lose the ability to control themselves during hypnosis. They will be in full control and can stop the hypnosis at any time. Typically, the therapist will guide a patient through hypnosis the first time and then the patient practices it alone at home. It is suggested that he or she find a comfortable chair or bed for self-hypnosis.

MINDFUL MEDITATION

Mindful meditation (also called mindfulness) is the practice of paying attention in a particular way, in the present moment, nonjudgmentally. The practice of mindful meditation has received a lot of attention in the popular press and in academic circles in the past decade. Even some police departments have integrated this technique into their training. Mindful meditation has been associated with improved sleep in individuals with a variety of health conditions, and some recent studies have shown an association between regular meditation and lower levels of fatigue among those with insomnia. Medical science does not yet understand precisely how mindfulness helps with sleep. A number of recent studies have linked mindful meditation to changes in blood flow to the brain. While this research is very preliminary, it does support the idea that meditation might lead to changes in the way our brains process information. Other studies have proposed that mindful meditation increases our ability to alter thoughts, feelings, and behaviors; clarify values; deal with situations flexibly; and tolerate unpleasant thoughts and emotions. Many people also report that practicing mindfulness helps them feel more calm and relaxed.

At its core, mindfulness practice involves non-doing and observing without judgment. It follows a number of principles that, as in relaxation training, are intended to guide the patient’s meditation practice but are not hard-and-fast rules. These principles include non-judging, patience, using a beginner’s mind, trusting, non-striving, acceptance, and letting go. The principles are described in detail in Jon Kabat-Zinn’s Full Catastrophe Living. While all these principles are important, many people with health concerns struggle the most with the principles of acceptance and letting go. It is important to realize that acceptance refers to seeing things as they are right at that time, in the present moment. It does not mean accepting that things will always remain this way.

When people think of meditation, many imagine that the goal is to make the mind still or “blank.” This is not the goal of mindful meditation. Mindful meditation is a practice in which practitioners focus their attention on their experiences in the present moment in a particular way.

Mindful meditation can be performed while you are eating, brushing your teeth, washing the dishes, or looking after children. When you are practicing with mindfulness, you can let your senses guide your attention. You may notice random or worrisome thoughts pass through your mind, but you don’t engage with them. Simply observe them and let them continue passing by. In these moments, you might focus on your breathing. To get the most benefit from these exercises, you should practice them every day for at least two to four weeks. It is very common to feel that nothing is happening at first or to find the meditation boring or frustrating. This is normal; however, most people find that if they persevere and continue to practice regularly these feelings pass. You might wish to try practicing mindful meditation at different times of the day to see what time is best for you. Many people find that starting the day by taking ten to twenty minutes to meditate leaves them feeling calm and refreshed—it’s worth getting up early for! Others prefer to include time for meditation as part of their winding-down routine at the end of the day. Some people even use these exercises to calm their bodies and minds when they wake up during the night. There is no wrong way to practice mindful meditation, and the more you can include it in your day, the more quickly you will notice changes.

Tapering Off of Sleeping Pills

As we have seen, one of the main advantages of cognitive behavioral therapy is that it enables the patient to stop using sleeping pills. Many people prefer to sleep without medication, but some feel they cannot do so. Whether a patient takes medication or not is a matter of personal preference. But for those who worry that they are developing a psychological dependence on sleeping medications (and sometimes a physical dependence as well), CBT can offer an alternative therapy for insomnia. Some patients wean themselves gradually: one woman going through behavioral treatment for a sleep problem said that she liked to have her sleeping medication on hand just in case she needed it. She felt apprehensive and anxious unless it was available. But as noted above, taking a pill for sleep reinforces the idea that the patient will not be able to sleep without it. (Sleep medication can also be expensive.) Therapists work with patients to help them taper off the sleeping medication once they have learned other skills to manage their insomnia. If a patient has been taking a sleeping pill regularly for several years, it could be dangerous to stop cold turkey. This is why the patient needs to taper off the medication.

To taper off a sleep medication, start by reducing your medication to its lowest dose and taking it as often as you did the full dose. If you have been on sleeping pills for many years, it is safest to do the tapering under the supervision of a doctor; the tapering process might last several months. After you have adjusted to taking only a small dose, you should begin scheduling times when you will not take a sleeping pill, no matter how hard it is to sleep. It is best to set aside at least two nights for this. Many people choose to begin on a weekend or at a time when they have fewer responsibilities to deal with during the day. Most find that they feel anxious and have difficulty sleeping the first night without sleeping pills, but by the second night they are usually tired enough to sleep well unassisted. It typically takes several weeks to stop using sleeping pills altogether, and people often have lapses or difficult times during this period. Many people report feeling a sense of intense pride and accomplishment once they have managed to get off their sleeping medication.

A study published in 2003 reported that the combination of cognitive behavioral therapy and tapering off medications was much more effective than tapering off alone in helping people stop using sleeping pills. After one year, 70 percent of those who received the combined treatment had stopped using sleeping pills, compared to 24 percent of those who tapered off without CBT.

Back to the Woman Who Was Afraid to Make a Fool of Herself

Since the patient’s insomnia stemmed from her embarrassment about her sleepwalking and screaming, I referred her to a psychologist for cognitive behavioral therapy. Several months later, I received a letter from the psychologist reporting that the patient had significantly improved. She was no longer afraid of what would happen after she fell asleep, and this had contributed to her getting a better night’s sleep with fewer episodes of sleepwalking and sleep terrors.

Many patients with insomnia want to avoid medications, fearing that these could become addictive or dangerous. They begin to think of their insomnia as an untreatable condition. But therapies and therapists are available to give people a good night’s sleep without medication.