The Well Worth It Series – DIY Sleep

Our Well Worth It feature (an article devoted to a proven treatment that doesn’t get enough mainstream

ssttt! little baby-mouse, sleeping on my hand
Image by e³°°° via Flickr

media attention – usually due to a lack of profit potential) for February is devoted to one item only: sleep. Why?

There are few things more tortuous than an inability to get to sleep. There are also few things that have such a profound long-term impact on your health than a lack of sleep (greater rates of obesity, diabetes, high blood pressure, behavior/learning disorders in kids, and even long-term increased rates of cancer). Sleep should be a cheap, readily-available health-promoting resource. But sometimes, knowing all that just makes night-time tossing and turning even more frustrating. So what’s a person to do? Especially if you are (justifiably) wary of expensive, potentially-addictive sleeping pills?

Cognitive behavioral therapy has been proven to be – brace yourself, folks – even BETTER than sleeping pills, and has absolutely NO side effects. It’s safe for people of ages, diseases and conditions. But I’m betting almost no one has ever seen an ad for it on prime-time TV.

So what is cognitive behavioral therapy (CBT)? Well, it’s hard to get a straight answer. Which is why this Well-Worth-It- Award winning summary (below) from Medscape is so great! CBT can vary, but the structure and key ingredients are pretty consistent – they all have to do with training your body to sleep. Most of us down-play (or perhaps don’t realize) that getting to sleep is mostly habit. Don’t believe me? Try messing with yours for just one night – nothing major, merely turn your pillow vertical instead of horizontal behind your head. Now check out how hard it can be for you to adapt to that one little habit disruption.

Getting yourself a good, solid sleep-habit is the cornerstone of CBT. It’s a two-month boot-camp for sleep, with weekly sessions chock full of tips. If you can afford to take a course, it’s best to get one. But even if you can’t afford professional sessions, CBT includes techniques that you can put to use right now at home. How do you Do It Yourself? First, set your date to start. For many of us, sleep is somewhat dependent on the activities and cooperation of the people you live with – so, ahead of time, rope them into the process too. The more, the rested-er (and, consequently, the merrier!). Read the summary of techniques below and plan how you’re going to implement the key ones (sleep time the same each night – as much as humanly possible, etc.).  Sticking to good sleep hygiene rules and using at least one relaxation technique are key components. Once you’ve got all your tools together, launch your start date, and every week hold your own CBT meeting to reinforce your habits. Discuss (even if you’re talking to yourself!) what didn’t work, and problem-solve how to change. Make a commitment to your health and be accountable – commit to from four to eight weekly CBT meetings. No matter what. For one or two months, promoting your health by getting better sleep will be a promise you keep to yourself. This is the kind of Wellth that’s free for the taking!

Print this summary (below) out, save it in your bedside table, and share the info frequently with friends. You never know who might be suffering in darkness:

Excerpt from Medscape authors:

“Cognitive behavior therapy (CBT) usually is given as 4 to 8 weekly sessions, each lasting 60 to 90 minutes. As initial therapy for chronic insomnia, however, CBT should be used more frequently. Studies of CBT, including studies in older adults, have shown sustained sleep improvements 12 and 24 months later, whereas patients treated with pharmacotherapy did not have sustained benefits. Compared with pharmacotherapy, CBT results in reports of greater patient satisfaction and in a greater number of normal sleepers.

The multiple components of CBT for insomnia include cognitive psychotherapy, sleep hygiene, stimulus control, sleep restriction, paradoxical intention, and relaxation therapy. Specifics of each of these therapies include the following:

  • Education regarding sleep hygiene instructs patients about good sleep habits and behaviors. These include the following:
    • Avoidance of caffeine and nicotine, especially late in the day.
    • Avoidance of exercise 4 hours before bedtime. Although daily exercise promotes good sleep, exercise shortly before bedtime can interfere with sleep.
    • Avoidance of heavy evening meals.
    • Avoidance of naps.
    • Maintaining regular bedtime and awakening hours each day.
    • Keeping the bedroom at a comfortable temperature.
    • Keeping the bedroom as dark as possible.
    • Regularly scheduled relaxation time before bed, with use of relaxation techniques.
    • Use earplugs if noise is a problem.
    • Exposure to daytime light for at least 30 minutes in the morning.
  • In stimulus control therapy, patients learn to associate the bedroom with sleep and sex only, rather than with other wakeful activities. It also involves going to bed only when a person is tired and leaving the room if not asleep within 15 to 20 minutes. Contraindications for this therapy include conditions of restricted mobility, frailty, and increased risk for falls.
  • To maximize sleep efficiency, sleep restriction therapy limits time spent in bed. It is calculated by dividing total sleep time by time spent in bed and multiplying by 100. If sleep efficiency exceeds 90%, the patient’s time in bed is increased by 15 to 20 minutes.  Sleep restriction therapy should be used with caution in patients with epilepsy, bipolar disorder, and parasomnias because of worsening of these disorders.
  • By advising the patient to remain awake, the aim of paradoxical intention is to remove the fear of sleep.
  • The goal of educating patients regarding relaxation therapy techniques is to decrease high levels of arousal that interfere with sleep. These techniques include the following:
    • Autogenic training: imagining a peaceful environment and comforting bodily sensations (warmth and heaviness in the limbs, warmth in the upper abdomen, and coolness on the forehead).
    • Visual or auditory biofeedback training to allow the patient to control specific physiologic parameters.
    • Hypnosis.
    • Imagery training with use of visualization techniques to focus on pleasant or neutral images.
    • Meditation, abdominal breathing.
    • Paced respirations: holding a deep breath for 5 seconds, repeating several times, and focusing on the sound of the breath.
    • Progressive muscle relaxation: tensing and relaxing large muscle groups from the feet all the way up to the facial muscles.
    • Repetitive focus on a word, sound, prayer, phrase, or muscle activity.

    Key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows [Doc Gurley note: A=best possible data evidence; B=worse data then A; C=even weaker than B]:

  • For chronic insomnia, CBT should be used as initial therapy (level of evidence, A).
  • Compared with pharmacotherapy, CBT for chronic insomnia is as effective, and the results are more sustainable (level of evidence, B).
  • When immediate symptom relief is desired, medications may be useful for acute insomnia (level of evidence, C).
  • For treatment of chronic insomnia, stimulus control and sleep restriction are effective (level of evidence, B).

“CBT is effective for treatment of primary insomnia,” the review authors conclude. “However, its use is impeded by several factors, including underdiagnosis of insomnia and lack of awareness among health care professionals. Cost can be a perceived barrier, but because of its sustained effects, nonpharmacologic therapy may be more cost-effective than pharmacotherapy.”

Got a question about what some of these phrases mean? Ask the Doc in the comments section below!

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