By Kathleen Yount

Cognitive behavioral therapy (CBT) addresses one of the most critical aspects of chronic insomnia: the patient’s own fear and anxiety about sleeplessness. It usually requires four one-hour sessions spaced every other week. The main thrust of the therapy, says Duke psychologist Jack Edinger, PhD -- one of the early founders of the technique -- is given in the first session, and following sessions troubleshoot and help patients problem-solve.

The therapy includes education on “sleep hygiene” -- a well-known list of environmental and behavioral recommendations to promote restful sleep. These tactics, such as avoiding alcohol, nicotine, and strenuous exercise near bedtime and keeping the bedroom a cool, quiet, TV-free place, are easy to teach, and, says Duke psychiatrist Andrew Krystal, MD, often already well-known to patients who struggle with chronic insomnia.

The core of CBT, though, is behavioral tactics and mental strategies that help patients rewire their poor sleeping tactics. Cognitive therapy helps patients understand their sleep needs and how the body’s sleep system works, and it defuses the dysfunctional thinking that generates anxiety and fuels insomnia.

“It’s thoughts like, ‘tomorrow is ruined,’ or the expectation that every time you get in bed, it will be a struggle to sleep,” says Krystal. These thought patterns can become so entrenched that, after a while, the mere idea of going to bed generates mental and physical anxiety in the patient.

“Once you do the cognitive and educational parts, the behavioral do’s and don’ts make more sense,” Edinger says, and they retrain the body into its natural sleep rhythms. These strategies include sleep restriction, which means limiting the time a patient spends in bed to the actual time he or she reports sleeping (measured as the average over several nights); keeping a consistent waking time seven days a week; protecting the sleep period from intrusions, be they external or internal; and cutting out daytime sleeping of any kind.

“I learned long ago that people with insomnia have as many words for naps as Eskimos have for snow,” Edinger says. “I’ll ask, ‘Do you nap?’ And they say no, but then they’ll admit to ‘resting their eyes.’”

CBT can also help patients who’ve become dependent on sleep medications. A recent NIH-funded study showed that these drugs, though perennially popular, hasten and lengthen sleep by only a handful of minutes. But for some patients, these effects are not only compelling -- they are also addictive.

Edinger says that these are the patients who have “lost faith in themselves as sleepers. They’re concerned about the long-term effects of medicine, but they’re frightened of coming off sleep meds.” Researchers are still sorting out how best to taper off medication, but Edinger says that CBT can help these people regain their confidence in one of their most basic and natural abilities: to rest.