VCU sleep medicine experts advance treatment of insomnia with a drug-free approach
All her life, she had slept like a baby. Her head would hit the pillow, and she would be out for the night. She would awaken the next morning feeling relaxed, energetic and ready to take on the day ahead.
But then one night, soon after her 40th birthday, something changed – she couldn’t fall asleep, or stay asleep. Night after night she would crawl into bed hoping, wishing and waiting anxiously for sleep. Instead, she would lie under her blankets, staring at the stark white ceiling from 9:30 p.m. until 5:30 a.m. Eyes wide open. Completely awake.
In the morning, she would be groggy, exhausted and irritable.
There were no major life stressors to occupy her mind during the sleeping hours; she had a happy marriage, a darling child and a job she adored. She underwent an extensive medical evaluation, but results revealed nothing out of the ordinary.
For nine years, on and off, she was prescribed a combination of sleep medications – some to get her to sleep, others to keep her asleep. They failed, as did the host of lavender products thought to aid sleep, sleep CDs, black-out window blinds and sleep goggles.
“It became horrific,” said the woman, a 49-year-old Richmond-area physician, who asked to remain anonymous. “And because every night I thought to myself, maybe this would be the night that I would find sleep. I became absolutely imprisoned by it.”
She said the mere thought of sleep made her anxious. Just walking to her bedroom made her chest feel heavy.
Exhausted, but determined to take her life back, she turned to Bruce Rybarczyk, Ph.D., clinical psychologist and leading sleep medicine expert at Virginia Commonwealth University.
Rybarczyk introduced her to a little-known, drug-free approach for the treatment called cognitive-behavioral therapy for insomnia, or CBT-I.
“I often refer to CBT-I as sleep boot camp,” Rybarczyk said. “Essentially, through CBT we want to retrain the sleep process and provide the patient with an owner’s manual for their sleep system by educating them about the science of sleep.”
Rybarczyk has been conducting research in the sleep medicine field for 16 years, and his research team has been steadily contributing to a mounting body of scientific work demonstrating the benefits of CBT for insomnia.
His team’s work has not only examined CBT-I for the general population, but also its practice for veterans with post-traumatic stress disorder (PTSD) and for individuals with comorbid psychiatric disorders such as depression.
According to Rybarczyk, CBT-I involves several treatment components, including an initial reduction in sleep to increase sleep drive and retrain normal sleep. It also serves as a method for eliminating time spent in bed while awake to weaken the association between being in bed and having anxiety about not falling asleep.
The problem with sleep
There are three different interrelated sleep problems that often get lumped together by the public as insomnia: sleep deprivation, acute insomnia and chronic insomnia. Sleep deprivation is a fairly commonplace sleep problem in which people shorten sleep by choice. In this age of technology, people have more choices for things to do late at night, and many experts believe that people are hyperstimulated and unable to settle their minds and focus on rest.
“We’re shorting ourselves on sleep,” Rybarczyk said. “Back in the day we used to wind down in the evening with relaxing or easygoing activities such as reading. But now, we are overstimulated – there’s television, mobile devices, computers – the list goes on.”
“Sleep deprivation is more of a social problem which has consequences to individual health and well-being,” Rybarczyk said.
But insomnia is a different animal. Insomnia is the inability to sleep even when you give yourself the opportunity for sleep.
Approximately, 60 million Americans suffer from insomnia, which is categorized as either acute/episodic or chronic. Acute or episodic insomnia affects 30 percent of the population at some point in their lives, while chronic insomnia, which was the case for the patient above, affects 5 percent of the population. Acute insomnia sufferers may be hit with a night here or there when they cannot fall asleep.
“Because these sleep problems are short in duration, these individuals are good candidates for sleep medication – it’s where sleep medications do their best work,” Rybarczyk said.
“But chronic insomnia is a life changer – it can have a deep impact on quality of life and health.”
“In chronic insomnia, the individual’s sleep system has gone awry – it’s in a state of disrepair and has stopped functioning the way it is supposed to.”
To compound the problem, individuals with chronic insomnia are often prescribed sleep medications by primary care doctors, to use on a regular basis. Unfortunately, in most cases, it makes the problem worse because the medications do not reset the sleep system that is at the center of the problem, and they also contribute to an erroneous belief that one needs medication to achieve adequate sleep, Rybarczyk said.
“People think they need medication to fix the problem, but the scientific community has now demonstrated through extensive research that the first line of treatment should be cognitive behavioral therapy.”
In 2005, an expert panel from the National Institutes of Health recommended that CBT-I should be the first line of treatment for chronic insomnia before medications are prescribed. However, according to Rybarczyk, a public and professional bias toward the use of medications and the lack of awareness of CBT-I as a newer treatment approach are key factors that have limited progress to disseminate the treatment. Additionally, sleep medicine is a new science and there are few health care professionals currently practicing who received specialized training in this field.
However, Rybarczyk and experts in the field hope that the research being conducted will fuel a change and raise awareness of the treatment so its benefits may be experienced by many more patients.
Rybarczyk’s patient who shared her story above was surprised she had never heard about CBT-I, especially because she’s a physician. Desperate to stop relying on sleep medications, she was unusually diligent in finding an alternative treatment and sticking with it. She ultimately is reaping the benefits of her efforts, but it was not an easy path.
Restoring the sleep system is at the core of CBT-I, but it’s not a fix that happens overnight. It takes time and commitment on the part of the patient.
During the first treatment session, Rybarczyk sits down with patients to provide them with an extensive lesson in the science of sleep. By understanding what is happening to their bodies they can understand why their sleep system no longer works.
“The trigger of the insomnia may be something different for each person, but it boils down to the fact that people who suffer chronic insomnia have disabled their sleep systems. We need to go in and reboot this system – basically hit the reset button to get it operating correctly again,” he said.
With that groundwork in place, patients begin the cornerstone of CBT-I, a process called sleep restriction, akin to putting someone on a highly restrictive sleep diet. During this period, which typically lasts a couple of weeks, patients have a firm wake-up time and can only have five to five-and-a-half hours of sleep each night.
It may seem counter-intuitive, and most patients ask Rybarczyk why it would help to starve their bodies of sleep, fearing it will make their problem even worse.
Rybarczyk’s response: “It’s true that they have lots of nights when they starve themselves of sleep already, but what happens with insomnia is that people get recovery sleep every third or fourth night and they also get snippets of sleep because they stay in bed for long periods of time. So they do not experience a super high and consistent sleep drive that we want to create for a short stretch of time in order to reset their sleep system.”
The first two or three nights of the sleep restriction phase usually do not come as a shock to patients because they have stayed up late at night before. But by the fourth, fifth or sixth night in a row with a 2 a.m. bedtime, their need for sleep has reached a new level.
“At this point, patients are so tired and their usual anxiety about going to bed has declined and is replaced with high levels of drowsiness,” Rybarczyk said. “They then get their first experience in years of crashing to sleep. Now we’ve reactivated a neural circuit that was there for years before, but has been dormant – we’re on our way to retraining the sleep process.”
According to Rybarczyk, after that first experience – a patient’s first five-hour block of sleep in a long time – their confidence returns, too.
“They feel like they can continue with CBT and commit to it,” Rybarczyk said. “Once it begins happening the next night and the next night, they become hooked and motivated to continue on. They may not be getting enough sleep, but they are able to fall asleep and stay asleep naturally, which they thought they were no longer capable of doing.”
After a week of this routine, patients return to Rybarczyk’s office to discuss their progress. At that time, they are instructed to do another few days of the five to five-and-a-half hour sleep schedule. Then, during the following few weeks, they are asked to move their bedtime up by half-hour increments – so instead of 2 a.m., bedtime becomes 1:30 a.m., then 1 a.m., then 12:30 am.
“Now it’s at five to six weeks since the start of treatment,” Rybarczyk said. “Along the way, they’ve really retrained the brain to have that automatic sleep response and have a consistent sleep pattern. That reactivates the circadian system which serves a vital role by creating an infusion of drowsiness in the second half of the sleep period.”
“With the circadian system restarted, they are able to sustain sleep throughout the night,” he said.
The patient who shared her story above was instructed by Rybarczyk to stay awake until 12:30 a.m.and wake up at 4:30 a.m., which was her preferred wake-up time due to her work schedule. He also instructed her not to lie down, nap or rest before her designated bedtime. To help her stick to this, she would sit on a hard, wooden chair in front of the television to keep her awake until her bedtime target. She said that if she sat on her couch and got all cozied up, she would risk falling asleep for a brief period. According to Rybarczyk, even these “microsleeps” can diminish the sleep drive that she worked so hard to build up.
By the fourth and fifth day, she was exhausted – but there was no reconnecting with a restful sleep. Yet.
“At about the two-week mark, I made my turn,” she said.
“On that 10th day, there was an odd ‘lightness’ that came over my body. It was the first time that I got to bed at 12:30 a.m. and slept for two hours. I could not believe it – I slept, really slept,” she said.
After that, she experienced a few setbacks, but she would discuss all difficulties and her progress with Rybarczyk, which helped keep her on course.
Creating sleep believers
It’s that reconnection with a patient’s own confidence and in his or her sleep system that drives the second part of CBT-I. Patients take part in counseling sessions with Rybarczyk to reinforce their progress and accomplishments.
According to Rybarczyk, self-doubt generated by a patient can set them up for negative consequences and the progress they made can gradually unravel. If a patient’s prior beliefs that they are not capable of falling asleep, or that they can only do it with medications, begin to return it can undermine their success.
“People overthink sleep, but it is really a lower brain process that is not meant to be activated by problem solving or thinking in a certain way,” Rybarczyk said. “To keep the progress moving forward we have counseling sessions to help them overcome their thoughts of anxiety, worry and insecurity, which undermine the natural process of sleep. Counseling and talking through the experience helps to deprogram those interfering thoughts.”
“We want to keep the conditioning as rock solid as can be. Patients who have had insomnia are vulnerable to having it reoccur. Insomnia sufferers need a little extra discipline around their sleep and routines once good sleep is reestablished,” he said.
During the counseling sessions, he discusses how to help keep the patient’s environment conducive to sleep – to create a sacred sleep space that is reserved for sleep alone. This means a bedroom with no televisions, no office space or phones, and no activities that might pair stimulation with the bed. He also instructs his patients to have a wind-down routine and to keep it consistent.
Rybarczyk has observed how CBT-I has changed the lives of his patients for the better.
And his patients are thankful for the progress they’ve made.
“Since doing CBT things are unbelievably different,” said his patient, the physician. “The medications make you unconscious, but they don’t make you sleep. I was miserable before.”
“To make this treatment work, you have to stick to the program … Will I have a perfect night of sleep ever again? Probably not. But I have functional sleep now.”