Therapy to change sleep beliefs may help insomniacs

Thursday, October 31, 2002

Psychologists have been thinking about how someone with insomnia thinks about sleep. Their efforts suggest that an insomniac's thinking is part of the problem. And, research indicates, changing that thinking may be part of the solution.

"We're addressing the dysfunctional attitudes -- common misconceptions people have about sleep that serve as the basis of aberrant sleep habits," says Dr. Jack Edinger, an insomnia expert at Duke University Medical Center. The approach targets chronic sleeplessness not caused by other ailments.

Known as cognitive therapy, the method aims to correct sleep myths and misconceptions (such as the belief that a poor night's sleep will result in disaster the next day). It can be used along with behavioral changes (such as getting out of bed if sleep doesn't come quickly). And combining the two types of therapy could be more effective and long-lasting than sleeping pills, studies suggest.

'A crapshoot'

Insomnia afflicts 5 to 10 percent of the population, according to various estimates. Yet it's not the average amount of sleep that discriminates normal people from insomniacs.

"It's the variability," says Edinger, a professor of psychiatry and behavioral sciences. "That's what drives people nuts ... what's it going to be like tonight? It's a crapshoot."

By using an approach that has been successful in other areas, such as in treating depression, cognitive therapy shows promise, says Richard Bootzin, director of the insomnia clinic at the University of Arizona Sleep Disorders Center.

"But there's actually been very few evaluations of cognitive therapy approaches as single interventions for insomnia," he notes. Instead, its effectiveness typically is tested along with behavioral approaches.

Normal sleepers tend to spend about 85 percent of their time in bed sleeping, Edinger says. Insomniacs may sleep only 60 to 70 percent of that time, and the worst ones only about 50 percent.

In research published last year in The Journal of the American Medical Association, Edinger and colleagues noted that sleep medications address only symptoms of insomnia, not some of the processes that sustain it. And while behavioral therapies, designed to correct poor sleep habits, clearly bring on sleep faster, their ability to help people sleep through the night is unproven, the researchers wrote.

Combining cognitive and behavioral therapies into a "cognitive behavioral" approach may help fill some gaps.

The Duke study involved 75 adults who had endured problems staying asleep for an average of more than 13 years. Those who underwent cognitive behavioral therapy cut the amount of time they spent awake in the middle of the night by 54 percent.

That compared with a 16 percent reduction for those given only a behavioral treatment -- in this case, a muscle relaxation technique. Behavioral measures in cognitive therapy included urging patients to wake at the same time each day and eliminate naps.

Not one-size-fits-all

The cognitive part of the therapy featured an audiotape designed to dispel false ideas about sleep. Patients often believe, for instance, that everyone needs eight hours of sleep a night. And they become preoccupied with sleep if they don't get that amount. "It's not one-size-fits-all," Edinger says. "So to try to shoot for that every night ... would only lead to frustration."

Some people do fine on just three or four hours of sleep, some need nine or 10.

Other sleep misconceptions relate to aging. "As we get older we don't sleep quite as deeply and as solidly as we did when we were younger," Edinger says.

But that doesn't translate into insomnia any more than typical age-related loss of jumping and running skill poses a problem "unless we're an NBA player," he says.

A perceived need to catch up on lost sleep by napping or sleeping late can also be problematic -- it throws off people's internal clocks, making it harder for them to be alert during the day. "The problem with insomnia sufferers is that they vary their sleep-wake cycle so much they put themselves through jet lag, so to speak, without the travel," Edinger says.

Common misconceptions

Other scientists have directly studied the impact of such false beliefs on sleep. Psychologist Charles Morin and colleagues, of Universite Laval in Quebec, questioned some 70 subjects to determine the extent of their misconceptions.

The misconceptions fit into five areas: the causes of insomnia, a person's perceived loss of control over sleep, unrealistic expectations about sleep, overstating the consequences of insomnia, and false ideas about what will help someone sleep.

Then the Quebec scientists put cognitive behavioral therapy to the test. They divided their subjects -- older adults who had suffered from insomnia for an average of 17 years -- into four groups. One group received cognitive behavioral therapy, one was given sleep drugs, one received both, and one was given a drug placebo. Besides behavioral and educational measures, the therapy addressed the various areas of false beliefs, challenging them and offering alternatives.

Afterward, those who received cognitive behavioral therapy either alone or with a medication held fewer false beliefs about sleeping, compared with the other two groups. And a drop in false beliefs was related to an increase in the proportion of time in bed actually spent sleeping, the scientists reported in July in the journal Behaviour Research and Therapy.

"These findings highlight the importance of targeting sleep-related beliefs and attitudes in the treatment of insomnia," the researchers wrote.

Moreover, the link between attitude changes and sleep improvements appeared to strengthen over time. The improvements, however, were reflected more in people's own perceptions of the time they slept, as noted in diaries, than in actual sleep-time differences measured in a laboratory.

Perhaps the "attitude adjustment" helped the insomniacs overcome a known tendency to magnify their sleep problems, the scientists suggested, in turn allowing those changes in thinking to gain even a better foothold against insomnia.

The study offers solid evidence of how changes in attitudes can predict later outcome, says Bootzin. But it doesn't say what methods can best treat insomnia.

For instance, behavioral therapy alone could work, and when someone's sleep improves, his attitudes could, too, says Bootzin, developer of stimulus control, a behavioral treatment that urges patients to, among other things, restrict bedroom use for sleeping. Cognitive approaches may work better in maintaining improvements than in initiating them, he says.

Mentally magnifying sleep problems may be what distinguishes someone with occasional sleep trouble from a chronic insomniac, notes Allison Harvey, a psychologist at the University of Oxford in England.

In the August issue of Behaviour Research and Therapy, Harvey proposes a framework to explain not why insomnia arises, but why it can become so unrelenting.

In essence, a tendency of insomniacs to be preoccupied with their sleep -- and with the daytime consequences of not getting enough -- causes physical agitation and emotional distress at bedtime, she writes. These, in turn, prompt insomniacs to selectively focus on any little thing that might keep them from sleeping -- from noises in the environment to the pounding of their own hearts.

Together, the anxiety and hyperattentiveness prompt people to overestimate how poorly they are sleeping and how much that affects their daytime abilities, Harvey suggests. (Various studies have reported that people with insomnia may not differ markedly from others in measures of alertness, daytime sleepiness and cognitive functioning.) In desperate bids to improve their sleep, insomniacs may add to the problem with counterproductive measures, such as drinking alcohol, Harvey notes.

People will also try to stop thinking about their day -- which can prompt them to ruminate over it even more. Or they will try to have an easy day after a sleepless night -- creating more time to be bored, to feel sleepy, and to focus on their insomnia.

Eventually this escalating anguish can create substantial, ongoing sleep loss and problems with daytime functioning. "The important point here is that these deficits are the direct result of cognitive processes rather than a central deficit in the sleep/wake cycle," Harvey writes.

The theory is novel because it looks comprehensively at specifics of thinking that may affect many aspects of behavior, says Bootzin, so more chances for intervention may be available.

But, he adds, "it's primarily a theory. It hasn't really been translated into treatments. That's the next step."

Harvey contends that her model suggests sleep doctors shouldn't focus on increasing a patient's total sleep time and speed of falling asleep. Rather, they should try to reduce patient attention to the small events that threaten sleep, correct distorted perceptions of sleep and of insomnia's effects, and prevent people from taking actions that don't work.

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