Northern Colorado Sleep Consultants LLC

10 Mistakes People Make That Can Ruin Their Sleep

Talk to an insomniac about how miserable their life is. We hear it all the time. They struggle through the day fighting off fatigue. They have major problems thinking and concentrating. They are moody and irritable. Their nights are filled with frustration and anger as they seek sleep. They may spend hundreds of dollars a year on remedies that promise good sleep but often don’t work or soon stop working.

How did they get into such a state? Many times it was because they made mistakes – mistakes of ignoring their sleep, not knowing what they should do, or even doing the wrong things when their sleep started to go bad. You need not be one of these people if you avoid these pitfalls.

1. Not taking sleep seriously

Whether it is because of too many other “more important” things to do, too many entertainment temptations, or just plain thinking the sleep is a waste of time, many people simply don’t consider sleep as important. They may believe, falsely, that they can learn to get by with less sleep. It may seem that way for a while, but it catches up to them eventually. Or they may value and desire sleep but the need or want to do other things too so their sleep gets sacrificed. They get a short-term gain but often pay a severe long-term cost.

2. Have an uncomfortable sleeping environment

Whether it is an old, lumpy mattress, too much noise, a bedroom that is too warm or too cold, or too much light in the bedroom, a poor sleep environment can mean poor sleep. This can soon lead to poor sleep habits and unhelpful efforts to compensate.

3. Awake in bed too much

The bed and bedroom should help you sleep. This can break down if too much time is spent in bed awake. This can be from lying in bed awake too long when trying to get to sleep to staying in bed longer in the morning in the hopes of making up for lost sleep. Also from doing activities in bed other than sleeping such as watching TV, working with smart phones (or computers or smart phones), or, or even just reading. It is better to use the bed only for sleep (but pleasurable sex is also allowed), go to bed only when sleepy, and to get out of bed when upset about not sleeping. This last suggestion might mean a bit of sleep time is sacrificed now for more and better sleep in the future.

4. Don’t have a relaxing pre-bedtime ritual

Work right up to bedtime. Watch the news on TV. Do some emailing. Exercise. Whatever it might be, jumping into bed directly after doing these arousing things can mean difficulty falling asleep. And this difficulty can become a pattern. Your mind needs a buffer between the hectic waking activities and calming, refreshing sleep. Best it to have a relaxing routine – the same thing done every night before bed for 10 to 20 minutes. It might be listening to soft music, taking a warm bath, meditating or praying, light reading, and so forth. The same relaxing thing done every night before bed sends a strong message to the brain that it is time to turn off the day-shift and allow the night-shift to take over.

5. Don’t Eat and Exercise Regularly

Grab a bite of whatever, whenever. Don’t exercise or get it only occasionally. Such things throw your body off rhythm and can affect your ability to sleep. It is better to eat healthy meals on a regular schedule. And you should avoid large means too close to bedtime although a light snack then benefits sleep for some. Exercise daily, preferably in the mid-afternoon or early evening.

6. Drink too much caffeine and drink it close to bedtime

Caffeine is wonderful for keeping us alert and reducing fatigue. Caffeinated drinks, and food containing caffeine, are also enjoyable and sociable. However, caffeine can prevent and disturb sleep. The rule of thumb is to consume only a few cups of coffee or equivalent per day and to have nothing with caffeine in it 6 hours prior to bedtime. However, some people are so sensitive that they might have to curtail it even more.

7. Use alcohol to get to sleep

Yes, alcohol makes you sleepy and can speed sleep onset. Thus many people use it to help them fall asleep. However, this is another example of a short-term gain that is harmful in the long-run. First, it causes sleep to be fitful especially toward the end of the sleep time. Second, regular use of alcohol in this way can result in eventual problems with even sleep onset and other health issues. Alcohol as a sleep aid causes more problems than it solves.

8. Keep irregular sleep times

Going to bed and getting up at different times every day causes your body clock to be confused as to exactly when you should be sleeping. Late weekend nights followed by “sleeping in” the next morning is a typical example. The result is problems with consistently getting to sleep and staying asleep. Most important is aiming to keep the same wake up time every morning as much as possible. This is the major clue to keep your body clock properly set. Adding a regular bedtime to this helps ensure that you are getting the amount of sleep you require every night.

9. Nap too much

A mid-afternoon “power nap” of 20 to 30 minutes can be wonderful and work wonders for most people, even those with insomnia. More than one or one longer than half an hour can reduce your sleep need making it harder to fall asleep the following night.

10. Watch the Clock

Looking at the time from your bed and calculating how much sleep you will be able to get (or have missed) only causes worry and tension. This makes it even harder to get to sleep. And what difference does it make, anyway, if you know how much or how little sleep you may get? If you have to, turn the clock so that it is hard to see from the bed; that way you will not be tempted.

Even if you have done every one of these things and are sleeping fine now, you, like others before you, can develop insomnia. Once the insomnia develops attending to these things may no longer be enough. Stronger cognitive-behavioral measures will be needed. Don’t let it happen to you. Attend to these things now and continue to sleep well.

 

New Hope for Sleeping Problems

“If only I could sleep better.”

Is getting the sleep you want and need a struggle for you? If it is you are not alone. Latest surveys show that up to 35% of adults share this complaint. Like many others, you want to sleep but you may have problems falling asleep. Or maybe your problem is being unable to stay asleep or waking too early. Then again you may be troubled by nightmares? Maybe it is not you but your child that is having a persistent, annoying problem with bedtime or sleep. Whichever it may be these problems are not just night problems; rather they negatively impact every area of your life.

“It seems like I have tried everything to improve my sleep.”

It’s true. Many people just like you have tried all sorts of things such as herbal teas, sleep tapes, magnets, and, of course, sleeping pills in their desperate quest for sleep. For example, people in the U.S. spend $1.6 billion annually for sleeping pills. But too often none of these worked  – or worked for very long.

“But I want to sleep better.”

Yes you do, because better, healthier sleep would give you a more productive and enjoyable life. Sleep should not be a problem. It should come easily – and without having to rely on sleeping pills or other external means – night after night.

The same is true for your child. When they sleep long and sound night after night they are brighter and happier when awake. And as a bonus, that allows you, the parent, to get more sleep and have better quality waking hours.

However you, like most people, do not know how to change things to allow you or your child to sleep more easily.

“So there is better way for me to get the sleep I need?”

Yes. The Behavioral Sleep Medicine Specialists at Northern Colorado Sleep Consults, LLC use treatment approaches backed by solid medical research. This research shows that chronic insomnia is caused by a combination of several different factors but mainly your negative thoughts and and emotions plus poor habits. Thankfully, these thoughts, emotions, and habits can, with the guidance they give, be changed so that you sleep better – usually within a few weeks.The specific changes are tailored to your exact needs that may be different from the needs of someone else. The end result is we help you get healthy sleep and have a more enjoyable and productive waking life.

“How can you help me make these changes?”

Just like a golf pro can help you correct a deteriorating swing, our Behavioral Sleep Medicine Specialists will diagnose the difficulty you or your child are having. Then using scientifically tested, proven, and effective methods, give you the coaching you need to help you rely on your body’s own natural ability to sleep. Our Behavioral Sleep Medicine Specialists offers you a cure that can last the rest of your life. There are some people also need the help of sleeping pills to assist their sleeping. If this is the case for you, our Behavioral Sleep Medicine Specialists will work with your primary care provider to see that you get the sleeping pill that is best for your particular sleep problem. But even if you are one of the few who really need sleeping pills our Behavioral Sleep Medicine Specialists can improve your sleep so that you may need less of the pills.

It has worked for many people. Even those who have suffered with insomnia for years and years have learned to sleep better in a matter of weeks. It can also work for you.

“What should I do?”

Go to the Contact page of this website or Call (970) 308-4495 today for an appointment. Northern Colorado Sleep Consultants, LLC has Colorado an office in Fort Collins but also can work with patients via the internet (TeleHealth) for whom travel to the office would be difficult or take too much time.

So if you or your child is having a problem sleeping please contact us now to get that little bit of help so that you or your child can sleep better.

 

Things that Interfere with Sleep:
The Model for the Integrative Management of Insomnia

There a number of possible factors contributing to insomnia, but they are not well understood by most people. The Model for the Integrative Management of Insomnia (MIMI)1 provides a framework for elucidating these factors in a way that is easy to comprehend. MIMI posits three general sources of things that interfere with sleep. These include situational (environmental) factors, sources from within the body (biomedical factors), and contents of the mind  (psychological sources). Examples from each of these realms include:

SITUATION

1) Sleep Surface: poor quality mattress

2) Sleep Environment: disturbing levels of light, temperature, and noise

3) Psychological Factors: using the bed and bedroom for other than sleep (and sex)

BODY

4) Lifestyle: poor nutrition, lack of exercise, use of “substances”

5) Medical Conditions and Symptoms: pain and discomfort

6) Medications: side effects of drugs that disrupt sleep

MIND

7) Cognitive: uncontrollable thoughts that keep the mind active

8) Meta-Cognitive: misbeliefs about the nature and purpose of sleep

9) Hyper Arousal: high nervous system alertness

The quantity and quality of our sleep depends on what might be called the “sleepiness to interference” ratio. At bedtime, sleepiness is naturally high and, under desirable circumstances, interferences are low allowing good sleep to ensue.

However, when interference levels become too great they will hamper initial sleep onset and/or sleep continuance. Essentially, MIMI suggests that insomnia results when the cumulative level of interferences surpasses the level of sleepiness. In fact, too much interference may cause a person not to even feel sleepy.

It follows then that there are two basic approaches for managing insomnia. The first and most common is “taking something to sleep” — the idea that we can swallow something to help us become more sleepy or to force sleep. It might be a sleeping pill, some warm milk, a soporific herb, or tea. Virtually anything we take to help us sleep, however, will not decrease the level of things that interfere with our sleep.

The second approach for managing insomnia focuses on reducing the things that interfere with sleep. This approach stresses reducing the interferences to a level lower than sleepiness thus allowing normal, healthy, beneficial sleep to occur. Cognitive Behavioral Treatment of Insomnia (CBT-I) does this by teaching patients skills that they can use to control body, mind, and situational interferences, thus allowing natural sleepiness to dominate. And these skills, once learned over several weeks, last a lifetime without negative side effects.

Another way of looking at the problems of managing insomnia stems from a common misunderstanding of sleep, that we tend to view sleep simply as the absence of waking — a kind of unconsciousness or a knockout or being “dead to the world” with little benefit other than to alleviate sleepiness. Such a perspective clearly encourages “taking something to sleep,” that is to force sleep to occur, to knock us out. Thus the growing dependence on sleeping pills. In contrast, it is much healthier and more natural to focus on reducing the level of things that interfere with sleep, allowing natural sleepiness to dominate.

This is not to suggest that we should never take something to sleep in the short run, only that we do so judiciously and that we always complement such strategies with a plan to control the underlying interferences in order to improve sleep in the long run. Habitually forcing sleep with alcohol, sleeping pills, analgesics, or even botanicals too often results in dependence, habituation, and tolerance not to mention too frequent negative side effects. Additionally, and most importantly, forced sleep is usually far from ideal sleep because of the disruption of its normal patterns and the important functions of sleep.

1 Adapted from an unpublished paper “Sleep Disturbance and Chronic Pain: An Integrative Approach” by Rubin Naiman, PhD, (Clinical Assistant Professor of Medicine at the University of Arizona Center for Integrative Medicine in Tucson, Arizona).

 

Solutions for Problems Children have with Sleep

“My child has a problem with sleep and I’m frustrated because I can’t seem to help.”

If your child has a problem with sleep, you are not alone. Surveys show that 76% of parents would like to change something about their child’s sleep habits. The problems vary but often include one of the following: not wanting to go to bed, not being able to fall asleep, waking during the night, wetting the bed, having nightmares, or a host of other things. And you, like most parents, may have gotten all sorts of advice and tried all sorts of remedies but nothing seems to help. You’re frustrated and worried about your child, and, because of your child’s sleep problem, your own sleep may be suffering.

“At times I think my child just can’t or won’t get enough sound sleep.”

Most children have the ability inside of them to get good, solid sleep. Also they can learn that it is important to get the sleep they need. They will go to bed without a fuss and sleep well. The wonderful result is that with great sleep children are happier, healthier, and learn better. They are not tired and cranky when awake. All this is pleasing to parents. With good information and coaching, parents can help their children get this wonderful sleep. And the good sleep habits children learn stay with them the rest of their lives.

“This sounds great, but how can MY child become a good sleeper?”

Each child is different, so there is no one solution that fits all. However, there are a number of principles and practices that have been shown to be effective. The ones that are best for your child can be selected and you can learn to apply them effectively. When implemented correctly, they usually work within a matter of days or weeks and result in a cure that can last the rest of your child’s life. The end result is that your child gets healthy sleep and has a more enjoyable and productive waking life.

“Who can help me make these changes?”

Dr. Moorcroft at Northern Colorado Sleep Consultants, LLC will help. In the same way that a golf pro helps correct a deteriorating swing, Dr. Moorcroft will start by diagnosing the difficulty your child is having. With this information, he will help you select from the scientifically tested, proven, and effective methods that can help your child sleep better. Dr. Moorcroft will give you the coaching you need in these methods so that you can help your child improve their sleep. Dr. Moorcroft will follow your child’s progress and give you further advice and encouragement along the way.

It has worked for many parents and their children. Even those who “tried everything.” It can also work for you.

“What should I do?”

Go to the Contact Us portion of this website or Call (970) 308-4495 today for an appointment. Northern Colorado Sleep Consultants, LLC has offices in Fort Collins  as well as working with clients via Telehealth for people who are unable to travel to the Fort Collins office.

So if your child is having a problem sleeping please contact us now to get that little bit of help so that your child can sleep better.

 

Cognitive Behavioral Treatment of Insomnia (CBT-I) is more than Sleep Hygiene

Sleep hygiene (SH) is a good component for the treatment of many sleep disorders, especially insomnia. However, contrary to the widespread belief, it is not the only behavioral treatment for sleep problems. While it is true that practicing good sleep hygiene may relieve insomnia for some people, for most it is just the start of what is needed to consistently obtain good sleep.

In 2007 Dr Moorcroft wrote a chapter on SH (Sleep Hygiene. In Burkov N., Lee-Chiong T (Eds). Fundamentals of Sleep Technology. Lippincott Williams & Wilkins). In the course of researching SH for the chapter, he discovered the following:

The Origin of Sleep Hygiene Sleep Hygiene can be traced back to Peter Hauri in 1977. Dr. Hauri, a psychologist at Dartmouth College and later at the Mayo Clinic, has had a long and illustrious career treating insomnia. He observed commonalities among his patients with insomnia – things they were not doing that would help their sleep and things they were doing that were actually making their sleep worse. From these observations he created the sleep hygiene list.

Problems with SH Since its origins, SH has gained a life of its own. Today a list of SH rules may be handed to patients by health care providers, included in written articles on sleep, and on websites. However, SH has never been officially standardized by any professional body such as the American Academy of Sleep Medicine. As a consequence, there are now many versions of sleep hygiene available. Usually the core of each of these lists is pretty much the same – “pretty much” because in some handouts the descriptions are better than in others.

There are other problems and misunderstandings of SH. All too frequently in many SH lists there is the addition of “original” or unique items that are rarely found in other SH lists. An example is a magazine article with a SH list that touted the benefits of soft pillows. Apparently the author of the article had a personal fondness for soft pillows and felt they could improve sleep, so he included this in his list without any scientific research support or consensus of those in the sleep field.

It is my opinion, and that of many of my sleep treatment professionals, that treatment options for insomnia ought to be evidence based. When such evidence is unavailable, there should at least be well reasoned consensus among sleep experts based on their clinical experience. Components that do not meet these criteria should not be included in SH lists.

Value of SH Too often SH is thought to be the total extent of cognitive behavioral treatment of insomnia (CBT-I). While following SH rules may be enough for some people to improve their sleep, usually it is just the start (Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults,  Journal of Clinical Sleep Medicine, Vol. 4, No. 5, 2008, 487- 504). I view treating insomnia like putting a jigsaw puzzle together. Just like jigsaw puzzle pieces interlock and work with one another to complete the picture, it takes several CBT-I components working with one another to yield good sleep improvement. SH is like the border of the jigsaw puzzle into which other puzzle pieces fit like how to turn off a running mind, body and mind relaxation, reducing worries that interfere with sleep, increasing confidence in the ability to sleep, and scheduling sleep an appropriate amount of time in bed. SH is the start, but just the start, of improving insomnia with CBT-I.

 

Typical Patients

A Typical Case of Insomnia

Patient: S.A., 51 year-old healthy female.

Problem: Primarily difficulty of returning to sleep after waking during the night but also sometimes a problem of initially getting to sleep when anxious. Some nights have been OK, but more often sleep was a problem. Problems started about 15 years ago. S.A. has tried nutrition, herbals, acupuncture, over-the-counter and prescription sleeping pills, meditation, and a sleep facilitating CD – all to no avail. Ongoing psychotherapy for her PTSD was helpful in many ways, but not for her sleep.

Diagnosis: Psychophysiological Insomnia (ICD-10 F51.04). Over the years S. A. has developed strong associations and habits that interfere with her sleep and cause her performance anxiety and body tension. Her poor sleep results in decreased functioning during wakefulness.

Treatment: We started by taking steps to retrain her body to sleep when in bed. S.A. was also educated about how the brain produces sleep, informed about good sleep hygiene, taught how to relax her body, and instructed on how to focus her mind to prevent random thoughts and worries from interfering with her sleep.

Outcome: Within a week sleep quality began improving and after several weeks S.A. was getting close to eight hours of sleep per night. She reports, “The quality of my sleep is improved 100% [and] I am feeling better the next day.”

Comment: This case is typical and common. Events happened in S.A.’s life that disrupted her sleep and in turn caused her to become anxious about it. A cycle developed of maladaptive thoughts and bad habits that caused her poor sleep to become habitual. In such cases, education and relearning tailored to the individual almost always restore adequate, natural sleep in a matter of weeks.

 

Dependency on Trazodone to Sleep

Patient: DC, a 50 y/o male litigation attorney.

Presenting Problem: DC desired to reduce or eliminate the need to take Trazodone in order to sleep. Even with the 100 mg Trazodone that he had been taking nightly for 10 years, he still had many nights of difficulty returning to sleep when he woke during the middle of the night. In addition, sometimes he awakened too early in the morning. He rated his overall sleep quality as mediocre.

Sleep History: DC’s sleep problems started about 10 years earlier, soon after his son was born. He stated that he was also “pushing at both ends” at that time in his life.  Primarily his active mind was keeping him awake with uncontrollable replays of thoughts from the day, especially things he was upset about. Additionally he described himself as a light sleeper – noise (such as his wife’s snoring), lights, and room temperature could easily disrupt his sleep. His wife got up earlier than he did in the morning, which often disrupted his sleep.

DC uses a dental appliance to reduce his snoring. He reported occasional bad dreams/nightmares that could disturb his sleep. Hip pain would occasionally awaken him. Generally his sleep hygiene was good.

He believed that exercise (he is a marathon runner) sometimes helped his sleep. He generally slept better on vacations.

Diagnosis:  Primary Insomnia (ICD-10 F51.01).

Treatment Dr. Moorcroft saw CD five times for a total of 5.75 hrs. during which he used a variety of cognitive behavioral treatment for insomnia (CBT-I) techniques to give him the resources he needed to functionally replace the Trazodone. This included how to gain control of his thoughts at night so that they did not keep him awake; how to relax his body and mind to allow sleep to happen; and how to ignore bedroom noise, light, and temperature. Gradually these gave him the ability and the confidence that he could sleep without Trazodone. At this point Dr. Moorcroft gave him a taper schedule specifically designed for dependency on sleep medications.

Outcome: DC reports that he can now relax more and not worry about his sleep. As a result his sleep has improved to a satisfactory level, allowing him to gradually taper off Trazodone. He occasionally has not-so-good nights, but these do not bother him like they did before. He is also confident that he will sleep well the next night. As long as he continues to use the CBT-I components, he learned he should continue to sleep well without Trazodone for the rest of his life.

Comment: This case is not unusual. Most patients who have taken a sleep medication for years lose their confident in their ability to sleep without it. Simply stopping the medication is unsuccessful because if they have a night or two of poor sleep they give up and return to using the medication. They are then at a loss for how to sleep without medication. Yet even with the medication, their sleep is often still not entirely satisfactory. They can be successful at eliminating the need for medication to sleep when they have the CBT-I components that can functionally replace what the medication was doing for them.

Most people like DC are generally hyperaroused and  hypersensitive to their environment. Once they learn how to use CBT-I components to help them relax, pay less attention to their environment, and quiet their mind at night their confidence in their ability to sleep builds and the need for medication lessens. At this point, they can gradually reduce or totally eliminate the medication and sleep even better.

 

Infant Not Sleeping Through the Night

Patient: L.S., 10-month-old healthy male

Problem: His parents described a persistent pattern of L.S. awakening every three hours during the night followed by crying until his mother nursed him back to sleep. At bedtime L.S. was nursed until he fell asleep, then put in his crib. Sometimes if L.S. was real fussy during the night, his parents would bring him into their bed to sleep. As a result, they were very sleep deprived themselves, which was affecting their waking lives.

Diagnosis: Behavioral Insomnia of Childhood, Sleep Onset Association Type (ICD-10 Z73.810). L. S. had not learned to “self sooth” in order to get to sleep because falling asleep had always been assisted by a parent (in this case by nursing).

Treatment: Dr. Moorcroft worked with his parents on the best way to help L. S.  get to sleep at the beginning of the night-time sleep period. He needed to learn to fall asleep on his own. Once this was learned, he would fall back to sleep on his own whenever he awakened in the middle of the night. I also instructed them to continue responding to the night awakenings as they have been, but they would soon find that they would not have to respond when L. S. learned to fall asleep on his own.

Outcome: “Within three nights, he was sleeping through the night,” said L.S.’s mother. “It was incredible.” This new pattern has continued so his parents are now also sleeping through the night and they no longer feel sleep deprived.

Comment: This is a common problem. All babies wake up during the night; that is not the problem. The problem occurs when a baby is unable to return to sleep by themselves. Many parents need to know that it is best to allow their child to learn to fall asleep on their own rather than depend on an adult to nurse or rock them to sleep. In this way children learn to easily fall asleep without help whenever they need to, which sets the pattern for good sleep for the rest of their lives.

Bouts of Insomnia

Patient: AJ 49 Y/O healthy, female educator.

Presenting Problem: AJ said she was currently experiencing a bout of insomnia characterized by having trouble falling asleep and staying asleep. She started having recurring bouts of insomnia alternating with periods of good sleep when she had her first child 21 years ago. Additionally, she said that she has to nap a lot because she is often very sleep deprived.

Sleep History: AJ said that she “fought sleep” as a child because she enjoyed waking activities. She felt that stress was now a major contributor to her bouts of insomnia because stress kept her mind going when she wanted to fall asleep or return to sleep. When she is awake but wants to be sleeping she gets anxious and tries to force sleep. Her teeth clench and hands ball. She snores but otherwise shows no signs of sleep disordered breathing. She does not use any sleeping medications or any other prescription medications.

Diagnosis: ICD-10 F51.01 Primary Insomnia.

Treatment: Dr. Moorcroft saw AJ four times for a total of 5.25 hrs. during which he taught her a variety of cognitive behavioral treatment for insomnia (CBT-I) components to give her the resources she needed to more consistently fall asleep and return to sleep after awakening during the night. He started her with sleep hygiene, then gradually added instructions on how to relax her body and mind to allow sleep to happen rather than trying to force it to occur; how to put closure on the day so that she could enter sleep calmly and peacefully; how to maintain a relaxing image in her mind that encouraged sleep; and how to change her negative thoughts about her sleep into more positive ones.

Outcome: AJ reports that she can now fall asleep more easily and return to sleep more quickly when she awakens during the night. She also reports that she needs much less napping. She is confident that she now has the ability to sleep more consistently by using CBT-I techniques to quickly stop new bouts of insomnia before they become prolonged.

Comment: Although unrelenting insomnia is more common, some people like AJ have bouts of insomnia alternating with times of good sleep. Often they will  report that a night or two of poor sleep leads to a chain of poor sleep nights. Once they have mastered the components of CBT-I they have confidence in their ability to prevent the occasional poor night of sleep from becoming a sequence of poor nights.

 

Treatment Failure to Treatment Success

Patient: A Married couple, WL and WR. WL is a 52 Y/O female employed at a state university. WR is a 53 Y/O self employed male.

Presenting Problem: Both complained of being unable to return quickly to sleep after waking up during the middle of the night. In addition WL had problems initially falling asleep. This had been a problem for both of them for a number of years. Both were taking Seroquel for their sleep but both desired to stop using it.

Diagnosis: ICD-10 F51.01 Primary Insomnia.

Treatment: Dr. Moorcroft initially treated WL and WR simultaneously using CBT-I. During the five sessions totaling over 10 hours plus several email messages he presented them with the typical components of CBT-I.

Outcome: WR responded well and reported that his sleep has greatly improved to the point that he has been successfully tapering off of the Seroquel. At last report he has almost completed the process.

Although she made a concerted effort, WL did not respond well to the CBT-I treatment. She reported that the more she focused her efforts on improving her sleep the more anxious she became about it. The result was that her sleep problems became worse.

Second Treatment: During a subsequent course of treatment, D. Moorcroft used a different approach with WL – a combination of Mindfulness with Acceptance and Commitment Therapy that he calls gMATI (guided Mindfulness and Acceptance Treatment for Insomnia). The focus of gMATI is to accept sleep as it is rather than making efforts to change it. gMATI uses the practice of guided mindfulness with acceptance of the way things are followed by “letting go.” This reduces the anxiety about sleep and the energy used trying unsuccessfully to improve it. He did four weekly sessions of gMATI with WL for a total of about 3.5 hours.

Second Outcome: WL responded well to the gMATI approach and her sleep soon improved. She reports that she is now able to fall asleep quickly and sleep through the night. She is now confident enough that she has begun to taper off of her sleep medications.

She also reports that her waking hours are much better. This is because of her improved sleep at night but also because learning to accept the way things are and then let go through her practice of gMATI has reduced the level of her waking anxiety. Overall she reports less fatigue, more energy, and a clearer mind.

Comment: CBT-I works for most people with primary insomnia. However, for some people trying to change sleep increases their negative emotional reaction to not sleeping because they are increasingly focusing on their poor sleep. The result is no improvement or even a worsening of their insomnia. The same thing can also occur in people with insomnia that is secondary to a general anxiety disorder. Interestingly those people for whom CBT-I does not work also frequently report that other new treatments they had tried, including prescription hypnotics and CAMs, briefly worked but then stopped working.

For such people gMATI is a more recent, cutting edge behavioral treatment that takes the totally different approach of not trying to directly change sleep. The result is paradoxically more and better quality sleep. gMATI then is another tool that can help improve upon the already high rate of success of behavioral treatment of insomnia.

This reinforces the fact that the causes of insomnia are multifaceted and treatment needs to be tailored to the unique situation of the individual.

American Academy of Sleep Medicine Guideline for Drug Treatment of Chronic Insomnia in Adults

Excerpts from: Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307–349. And Sateia MJ, Sherrill Jr WC, Winter-Rosenberg C, Heald JL. Payer perspective of the American Academy of Sleep Medicine clinical practice guideline for the pharmacologic treatment of chronic insomnia. J Clin Sleep Med. 2017;13(2):155–157.

A previous AASM clinical guideline2 recommended cognitive-behavioral therapy for insomnia as an initial intervention for chronic insomnia. It also advised that, when medication is used, it should, whenever possible, be supplemented with cognitive-behavioral therapy for insomnia. Most investigations that are included in the current analysis address relatively short-term use (e.g., 1 day to 5 w). Some studies3,4 have shown that long-term treatment with newer-generation benzodiazepene receptor agonist hypnotics can be safe and effective under properly controlled conditions.

A “WEAK” recommendation requires that clinicians use their clinical knowledge and experience and assess the individual patient’s values and preferences in determining the best course of action. Importantly a “WEAK” recommendation against a hypnotic agent is not a recommendation that the hypnotic agent should never be used; it too requires clinicians to use their knowledge and experience and evaluate the needs of the individual patient. A “WEAK” recommendation primarily indicates that either the available evidence is insufficient and fails to provide convincing support in favor of (or against) this patient care strategy (hypnotic medication), or that the balance of benefits versus harms and patient values and preferences are such that the use of the hypnotic agent cannot be confidently recommended for use in all patients. It is noteworthy that clinical guidelines from a variety of specialties are replete with weak recommendations for commonly employed therapies, for many of the same reasons. A recommendation “against” use is often more reflective of a lack of quality data, as opposed to high-quality data demonstrating a true absence of effect.

  1. We suggest that clinicians use suvorexant as a treatment for sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
  2. We suggest that clinicians use eszopiclone as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
  3. We suggest that clinicians use zaleplon as a treatment for sleep onset insomnia (versus no treatment) in adults. (WEAK)
  4. We suggest that clinicians use zolpidem as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
  5. We suggest that clinicians use triazolam as a treatment for sleep onset insomnia (versus no treatment) in adults. (WEAK)
  6. We suggest that clinicians use temazepam as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
  7. We suggest that clinicians use ramelteon as a treatment for sleep onset insomnia (versus no treatment) in adults. (WEAK)
  8. We suggest that clinicians use doxepin as a treatment for sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
  9. We suggest that clinicians not use trazodone as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
  10. We suggest that clinicians not use tiagabine as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
  11. We suggest that clinicians not use diphenhydramine as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
  12. We suggest that clinicians not use melatonin as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
  13. We suggest that clinicians not use tryptophan as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
  14. We suggest that clinicians not use valerian as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
  • This field is for validation purposes and should be left unchanged.
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