CBT for Insomnia with the Daily Mail
Libby Galvin for the Daily Mail:
Apparently, we spend one-third of our lives asleep. Not me. Ever since I was a child, most of the time everyone else has spent getting their beauty sleep, I've spent tossing and turning, exasperated at my inability to do what should be so natural. Once I do finally drift off, within what seems like minutes my alarm clock is ringing and it's time to start another day, exhausted and irritable. That is until I get home to bed when suddenly my brain comes to life and the cycle starts again.
I've tried everything: avoiding caffeine, practising good 'sleep hygiene' such as avoiding using my mobile phone before bed and blocking out light and sound with sleep masks and earplugs.
A couple of years ago I was prescribed the sleeping pill zopiclone, but there is a risk of addiction, and side-effects such as dizziness and headaches, and possibly confusion and anxiety, so my doctor recommended I use them only in emergencies and I've taken them only on the truly intolerable nights.
Up to 15 per cent of the population is afflicted by chronic insomnia (defined as a difficulty getting to or staying asleep most nights for a period longer than four weeks) and a third of us frequently suffer from poor sleep.
This has severe long-term implications for health, including lowered immunity, depression, type 2 diabetes, weight gain and high blood pressure - for me, at the age of 26, this is a pretty dismal prospect. But what if curing insomnia was as simple as talking to someone about it?
Recent research suggests that cognitive behavioural therapy (CBT), a psychological therapy more commonly used to treat depression and anxiety, could successfully treat sleep problems. CBT looks at how we think about situations, and how these thoughts affect the way we act and feel. The idea is to change thinking patterns and behaviour to achieve a more positive outcome - in my case, getting to sleep.
In a review published this year examining 20 studies into the use of drug-free methods to tackle sleeplessness, the Melbourne Sleep Disorders Centre in Australia found that CBT cut the time it took for patients to fall asleep by an average of 20 minutes. In another study conducted by Professor Jason Ellis, director of the Northumbria Centre for Sleep Research, 73 per cent of patients who had received CBT reported improvements in their sleep quality after three months compared to 15 per cent of those who had received no treatment.
Could it help me? To find out, I booked a course of CBT at Efficacy, a CBT clinic in London. Lee Grant, the clinical director and an accredited specialist in CBT, explains: 'For a lot of insomniacs, the thought, 'I won't be able to sleep' sets off feelings of anxiety - both mental and physical - and this itself results in an inability to sleep. CBT aims to break the cycle of worry that is causing the sleeplessness.'
I'm not convinced that it's a fear of being unable to sleep that's keeping me up at night - but as I've tried everything else to no avail, I head to my first session.
After establishing from a questionnaire that I don't have another underlying psychological problem which could be causing my insomnia (for instance, depression), Lee suggests a programme of six to eight one-hour sessions.
This is typical for CBT for sleep disorders, but there is a degree of trial and error involved because so much depends on an individual's particular thoughts and behaviours, so some people might need fewer sessions, others more. Lee starts by asking about my early experiences of sleep. I tell him I always felt I was missing out by being sent to bed.
As a toddler, I'd constantly come back downstairs and try to persuade my parents to let me sit up with them. As an older child, I'd read by a chink of light from the door or window until the early hours.
These days, the moment my head hits the pillow I start dissecting the day that's gone before and problem-solving for the ones to come.
Unsurprisingly, this is where I'm going wrong, Lee tells me. By the end of the first session, we've established I've developed a belief that sleeping is wasted time, that going to sleep means missing out on more important things, and that any concern I have must be dealt with before sleep is an option.
In the next session a week later, analysis of the sleep diary I've been told to keep (noting what time I go to bed, my estimate for when I fall asleep, when I wake up, whether I woke during the night, my mood during the day, and so on) shows that, left to my own devices, my ideal night's sleep is eight-and-a-half hours. This is how long I sleep on a 'good' night with no alarm to wake me.
It's longer than I expected and explains why I so often feel tired despite having had perhaps seven hours' sleep on 'good' nights, which I felt should have been sufficient, particularly compared with the 'bad' nights (two to five hours' sleep, which is what I had for about half of the time). 'Some people do thrive on seven hours or less, but many more need perhaps nine hours,' says Lee. 'You need to make sure you're allowing enough time at night to get the amount you need, with a little room either side to drift off.' We discuss solutions. I need to challenge my assumptions surrounding sleep to create new, positive ones, and acknowledge the triggers that set off the spiral of sleeplessness. Lee suggests that whatever thought pops into my mind at night, I'm to put it into one of three categories - 'do it', 'plan it' or 'forget it' - then go to sleep.
So if the thought is an issue that must be dealt with right now, such as 'I've left the front door unlocked', then I get up and lock it (do it). If it's something I need to do in the future, for instance, book a holiday, I can plan it - perhaps by writing a note reminding me to search for flights tomorrow. Or if the thought is theoretical and out of my control - such as 'what if I get gazumped on the flat I'm buying' - I'm to forget it. After the thought has been categorised, my mind can relax.
Between sessions, I dutifully put Lee's 'do it, plan it, forget it' rule into practice and by the third or fourth appointment, I realise not only does it help me get to sleep - but in the morning I often feel better about whatever I was concerned about the night before.
This idea that sleep itself could help fix a problem is a real shift in perspective from before when I saw sleep as a waste of time - and this is what Lee meant by replacing my old assumptions about it.
For someone whose insomnia is driven by the common fear that they will be unable to sleep, getting one good night's sleep could be enough to challenge their old attitudes.
To help them get that one good night, a CBT specialist will suggest different behavioural 'interventions'. So for me it's Lee's 'do it, plan it, forget it' rule, but someone who fears sleep might be told to get out of bed and do something else if they don't fall asleep straight away (so you learn to associate bed with sleeping rather than worrying).
After three sessions (and sleeping better already) I'm curious to see how accurate my sleep diary - and my perception of my sleep quality - is. Could I be imagining the difference CBT is making?
To find out, I sleep wearing a specialist device known as an Actiwatch, a wristwatch from Philips which uses sophisticated technology to detect movement and how well you're sleeping.
The data confirms I'm now sleeping for between seven and eight hours and nodding off after 15 minutes or so. I also rarely wake during the night. And all this after just three sessions - although Lee tells me that I am particularly responsive to the treatment.
1 in 20, the Number of people who get fewer than five hours' sleep a night.
Throughout my course of CBT, I experience a host of worrisome things - changing job, a new shift pattern, a break-in.
But using the 'do it, plan it, forget it' rule and reminding myself that 'sleep is the solution', I'm settling down every night, bar the odd irritating hour of wakefulness.
Of course, there are causes that CBT can't help with, such as insomnia that's a side-effect of medicine or the menopause, but for cases such as mine where there's no underlying physical cause, it seems a sensible solution.
The problem is getting it. Although the National Institute for Health and Care Excellence (NICE) recommends CBT as an option for insomnia that's lasted more than four weeks, it's 'virtually impossible' to get CBT for insomnia on the NHS, says Dr Paul Reading, a consultant neurologist at South Tees Hospitals: 'Or at least it's a bit of a postcode lottery.'
Cost is clearly a factor. Delivering a course of CBT costs on average £850 per treatment cycle, compared with a few pounds for a prescription for sleeping pills.
'But we have to consider the wider implications,' adds Lee. 'When it comes to sustainable treatments that work in the long-term, cognitive behavioural therapy is the treatment of choice.'
Where else can insomniacs turn? There are online CBT packages, such as Sleepio, which can be prescribed on the NHS or purchased for a small fee, as well as private clinics offering CBT where treatment typically costs from around £50 up to £150 per session. I had my doubts about seeing a 'sleep therapist' - but it really has helped. Who knew you could talk yourself to sleep?