Is CBTi the best solution for Insomnia?

Updated: May 20

Psychological therapy for insomnia

Insomnia should not initially be treated with medication, except in exceptional situations. There are a series of non-pharmacological treatments that are recommended to be applied before giving medication to the person who is suffering from insomnia.

The non-pharmacological treatment of insomnia is based on cognitive-behavioral techniques. The application of these techniques and a series of recommendations that we will see below help to avoid the appearance and perpetuation of insomnia, thanks to the fact that they produce a change in the physiological, psychological, and behavioral factors that tend to make insomnia chronic.

What is the solution to this important health problem?

A third of those affected by insomnia bet on sleeping pills, despite the enormous controversy that surrounds them. Sleeping pills have been widely criticized for their dangerous side effects such as daytime sleepiness, lack of concentration, learning problems or the effect on short-term memory, which could be related to complex pathologies that many patients develop in the long term. term. Even so, doctors continue to prescribe them, as if there were no other more effective solution to combat insomnia. The paradox is that there is another way, and its effectiveness has been well proven in numerous studies.

Cognitive behavioral therapy is a widely studied technique that, unlike pills, works in the long term

The gold standard for treating insomnia, recommended by most medical associations, is Cognitive Behavioral Therapy for Insomnia (CBTI), which focuses on changing behaviors that contribute to the sleep disorder. It is a widely studied technique and, unlike pills, which begin to lose effectiveness after a few weeks, it works in the long term.

It is a very effective treatment that produces positive long-term effects. However, it requires active participation and high involvement of the patient, who will have to put into practice the recommendations made by the professional.

“The psychological therapy of insomnia requires the active participation of the patient.”

The three "P" model of insomnia

To understand how cognitive behavioral therapy works for insomnia, we need to understand the simple 3P model (predisposing, precipitating, and perpetuating).

1. The predisposing factors for insomnia are those individual characteristics of everyone (genetic, psychological, and physiological) that make them more vulnerable to insomnia.

2. Precipitators are usually adverse events that occur in a person's life. As many of these events are unavoidable, the development or not of insomnia will depend largely on the vulnerability of the person.

3. Finally, the perpetuating ones are usually the negative thoughts developed by a person who has suffered from insomnia during the last few days. That person, accustomed to not resting the last few nights, will be afraid to go to bed because they have the experience of having had a bad time and will therefore anticipate another sleepless night.

“Cognitive-behavioral therapy for insomnia is based on the 3 P model: predisposing, precipitating and perpetuating.”

I will give an example that encompasses all three concepts.

A person with an anxious character, emotionally sensitive and very involved in the problems of others (predisposing) presents three consecutive nights of insomnia when he receives the news that his sister is going to be evicted for not paying the mortgage (precipitating). As on other occasions when he has had problems, he has been weeks without being able to sleep well, now he begins to think that the same thing will happen to him again. He spends the night thinking that the next day he must go to work, but he won't perform well because he hasn't rested well. If she doesn't pay for it, they can fire her and, consequently, she will stop paying her mortgage and they can evict her too (perpetuating).

The 4 Components of Cognitive Behavioral Therapy for Insomnia

Once we have understood the predisposing, precipitating and perpetuating concepts, we are going to know what are the components that make up cognitive behavioral therapy for insomnia:

1. Sleep hygiene

2. Relaxation and mindfulness exercises

3. Cognitive therapy

4. Sleep restriction technique

1. Sleep hygiene

Sleep hygiene measures include behavioral habits that favor both initiation and maintenance of sleep. Although these measures alone have failed to prove capable of resolving chronic insomnia, they are considered a fundamental pillar in the treatment of insomnia when combined with other techniques.

“Good sleep hygiene is not just about changing habits and routines before bed; it is also important to notice and change what you do during the rest of the day.”

With a didactic purpose, we are going to divide the sleep hygiene measures into three groups

1. habits during the day

2. conditions that promote sleep

3. what to do if you can't fall asleep

A) Habits during the day to prevent insomnia

  • Avoid stimulants such as the caffeine contained in coffee, tea, cola, and energy drinks, especially after 4 p.m.

  • Avoid drinking alcohol.

  • Have routines: keep the same time every day to get up, go to bed, have breakfast, lunch, and dinner, including weekends.

  • Avoid long naps: they should be a maximum of 15-20 minutes once a day after eating.

  • Exercise daily, avoiding the last hours of the day so as not to go to bed with high heart rate.

  • Do not leave for the end of the day things that can produce anxiety, such as checking bank accounts, answering work emails, or watching violent or suspenseful movies.

B) Environmental conditions that favor sleep

  • Go to bed only when you are sleepy.

  • Optimal bedroom conditions: silence, darkness, pleasant temperature (20 °C), sufficiently ventilated, comfortable relative humidity.

  • Avoid using the mobile, tablet, computer, television, or radio in bed.

  • Stay in bed only if necessary to sleep do not prolong the time you spend lying in bed due to not having rested well, to avoid a new episode of insomnia the next night.

  • Use a firm mattress and comfortable pillows.

C) What to do if you can't sleep?

  • It is better not to look at the clock so as not to worry as the minutes go by.

  • If after approximately 15-20 minutes you have not been able to fall asleep, it is preferable to get out of bed and do a relaxing and unstimulating activity, such as reading.

  • Currently, avoid eating, drinking plenty of fluids and, of course, not smoking or drinking alcohol or coffee.

  • Do not go back to bed until you feel sleepy again.

  • It may happen that, when you go back to bed, the same thing happens again. In that case, it is recommended to get up again to continue reading.

2. Relaxation and mindfulness exercises

Relaxation exercises decrease our state of activation, distance us from our worries and bring us closer to ourselves: this is precisely the same thing that happens when we go to sleep. Therefore, these exercises suppose a facilitation of the transition from wakefulness to sleep.

“People with insomnia and anxiety problems should do these exercises several times a day, not just at bedtime.”

Mindfulness is a meditation technique from Eastern philosophy that has been incorporated into the psychology of the Western world.

3. Cognitive therapy

Cognitive techniques in insomnia try to show the patient the erroneous thoughts and beliefs that arise around insomnia, which increase their worry and anxiety.

The minutes and hours of insomnia are often "used" to turn problems over and over in the head and arrive at catastrophic predictions, which do not usually help much in the attempt to fall asleep. The days get longer and heavier when we don't sleep well, which leads us to think that the consequences of insomnia are even greater than they really have been. All these pessimistic conclusions that we reach when we have had a sleepless night is what is known in psychology as a mistaken belief. The professional helps the patient with insomnia to identify their erroneous beliefs that generate anxiety and, later, help them to restructure those beliefs with alternative interpretations that reduce the anxiety generated. All this leads to reassuring the patient for the day, that he believed that he was not going to improve or sleep well again and, therefore, makes it easier for him to sleep the following nights.

Cognitive therapy acts on pessimistic thoughts and beliefs that appear after days without sleep.”

For example, it is common to find people who are very overwhelmed thinking that they only sleep 6 hours a night and that they are not going to be productive at work. When I ask them, it turns out that they also take two hours of naps a day. By explaining to them that they could sleep more hours in a row at night if they reduced the nap from two hours to 20 minutes, they manage to calm down and understand that they were resting enough but badly divided.

4. Sleep restriction technique

The sleep restriction technique consists of limiting the time the person with insomnia spends in bed each night. Its objective is to increase what we call sleep pressure, which consists of the time a person has been awake and the fatigue that has accumulated throughout the day. The therapist advises the patient to keep the number of hours spent in bed relatively constant whether he slept well or poorly.

This technique arises because people who have insomnia tend to do one of two things: they either get up later or go to bed earlier. These two strategies that are done intuitively worsen insomnia. First, they mean that the person spends more hours in bed each day and less time awake. If you spend less time awake, the pressure to sleep will be lower the next night, possibly making your insomnia worse. Second, the person will have the belief that they sleep very little because they spend so many hours in bed that it is impossible to sleep all of them.

For example, a person who normally goes to bed at twelve at night and gets up at eight in the morning, begins to sleep poorly and gets up later each morning until getting up at twelve at noon. If he could get six hours of sleep one day, although it may be enough for her, she would feel that she has slept less than half the time she has been in bed, which would cause her discomfort and frustration due to a mistaken belief, which would have been avoided if she had not been getting up later and later. This usually happens a lot in unemployed people or in students who go to class in the afternoons.

This technique requires active collaboration on the part of the patient, since his instinct will ask him to continue more hours in bed than his therapist recommends. He may be sleep deprived for a few days, but afterward he will be able to return to his normal pattern of restful sleep.

Emerging CBTi with Technology

Pendulum is plug and play, based on science, and makes improving sleep engaging by augmenting data insights into pragmatic actions. The science behind it is inspired by a heritage of research, called operant conditioning, and further developed in-house, based on real user data and analytics.

Drowzee has optimized its algorithm for providing NFT and by improving the NFT protocol by refining the duration and frequency of the NFT sessions. The algorithm is the core of the Drowzee SW and its functioning is key to deliver effective NFT. Drowzee has developed this algorithm using a system known as Live Z-score training, which is applied by clinicians in NFT clinics.

Pendulum is not only helping patients of insomnia by providing them with a at-home solution but is also helping clinicians and sleep clinics by equipping them with an innovative solution that helps managing patients and providing CBTi therapy efficiently in less time.

By using Pendulum, doctors will not have to conduct individual CBTi sessions with patients as users, can train their brain through the guided sessions using Pendulum to spend less time in phase I and II of their sleep and more in phase III and IV to attain optimal level of rest.

Thus, Drowzee works on the idea that sleeping 8 hours might not always be the answer. Achieving phase III and IV of your sleep cycle and ensuring that a higher percentage of your sleeping time is spent in these two phases is the key to getting a good night sleep.

If you wish to use Pendulum or know someone who is suffering from difficulty falling or staying asleep, you can buy our product here.

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