The development and treatment of insomnia

Insomnia is defined as insufficient, inadequate, or poor-quality sleep due to one or more of the following reasons:
• difficulty falling asleep
• difficulty staying asleep during the night
• waking up too early in the morning
• feeling overtired and unrefreshed in the morning

How did you get insomnia? It starts as short-term insomnia. Not being able to sleep for a few days or weeks is normal, especially in response to stressful life events and usually resolves within a few days or weeks. Insomnia that persists for a month or longer is termed chronic insomnia, which can affect you a few nights per week or most nights, and can occur weekly or in a cyclical fashion.

Short-term insomnia develops into chronic insomnia as a result of worrying about sleep loss, associating the bed with wakefulness, spending excessive time in bed, trying to “force” sleep, engaging in other disruptive or negative sleep behaviors such as arising at irregular times, and experiencing stress. As a result, the insomnia becomes a "learned" habit due to these behaviors.

The treatment for chronic insomnia can include the careful use of a sleep medication such as Ambien, Lunesta, or Sonata to break the insomnia cycle. These sleeping pills may temporarily improve sleep for a brief or occasional episode of insomnia. However, the use of sleep medicines is not recommended for the treatment of chronic insomnia for the following reasons:
• They are only moderately effective and lose their effectiveness with long-term use
• They have multiple side effects that can outweigh their benefits
• People can become dependent on the medication
• They do not treat the causes of insomnia
• The insomnia returns when the medications are discontinued

The recommended first line treatment for chronic insomnia is Cognitive behavioral Therapy, or CBT. CBT is based on the idea that chronic insomnia is due to the learned thoughts and behaviors described above that can be unlearned. CBT teaches poor sleepers how to:
• Modify stressful, inaccurate thoughts about sleep
• Modify disruptive or negative sleep behaviors
• Improve relaxation skills
• Improve lifestyle practices that affect sleep

A significant amount of research now suggests that CBT is more effective than sleeping pills for insomnia. Because of these findings, CBT is now recommended as the preferred first line treatment for chronic insomnia by the National Institutes of Health; in reviews in major scientific journals such as the New England Journal of Medicine and the Lancet; and, by Consumer Reports.

If you have a sleep center in your area, they may offer CBT. However, many sleep clinics don't offer CBT because they are directed by physicians who specialize in sleep apnea (see Dr. Park’s forum on sleep-related breathing disorders for a description of sleep apnea). For that reason, CBT is becoming increasingly available online in interactive format. You can visit my website for more information on online, interactive CBT if you cannot find a sleep clinic in your area that offers CBT.

Dr. Gregg D. Jacobs
www.cbtforinsomnia.com/mh