But which came first, the chicken or the egg? It seems that infertility results in stress and stress results in infertility, thus creating a vicious cycle for women or couples trying to become pregnant, which often ultimately results in other forms of psychological distress such as anxiety or depression.  

 There are several ways in which infertility impacts functioning. When pregnancy is difficult or impossible to achieve, individuals find themselves having all kinds of negative thoughts such as, 

• “This is the worst thing that could ever happen to me!”
• “I’ll never have a baby!”
• “I’ll never be happy!”
• “It’s all my fault, I should never have drank so much in college!”
• “I have nothing going for me!”
• “My marriage is going to fall apart if I can’t have a baby!”

  Cognitive Behavioral Therapy (CBT) focuses directly on the cognitive distortions related to the current infertility. More specifically, cognitive behavioral therapists help individuals learn to identify their thoughts or cognitive distortions, examine ways they impact their behaviors and emotions, then change them in order to change emotions and/or behaviors. Practicing this over and over again in therapy sessions and in homework assignments eventually leads to a change in behaviors, thoughts, emotions, stress level, and sometimes your ability to conceive!

OBSESSIVE COMPULSIVE DISORDER(OCD)

What is OCD?

As the name suggests, Obsessive Compulsive Disorder is an anxiety disorder characterized by the presence of obsessions and compulsions.  Obsessions are intrusive, often disturbing thoughts or images that are difficult to get rid of and cause a lot of anxiety.  Compulsions are behaviors or rituals that a person performs to temporarily reduce the anxiety caused by the obsessions.

The exact content of obsessions and compulsions can vary by person, but there are some common clusters:

·         Contamination: Individuals with contamination fears have obsessive thoughts that germs or other contaminants may cause them to become sick or die.  They perform compulsions like hand-washing, showering, sterilizing their environment, or cleaning their house to an excessive degree.

·         Checking:  These individuals have obsessive thoughts that something important has not been done.  For instance, they may worry that they did not turn off the stove, turn off a light, or lock the door.  The compulsion is to check over and over that it has been done.

·         Symmetry/Order:  These individuals feel anxiety if something is not in its right place, or not the same on both sides.  For example, people with symmetry obsessions may tie and retie their shoes over and over until it “feels right” on both sides, or they may spend hours arranging things in their homes.

·         Hoarding:  Individuals with hoarding obsessions feel a great deal of anxiety about throwing anything away because they worry that they will need it again some day.  They may have homes that are overcrowded with papers or other items they collect and can not throw away.

·         Repeating/Counting:  These individuals have obsessive thoughts that they need to repeat something a certain number of times to prevent something bad from happening.  Repeating often includes mental rituals, such as repeating a word in one’s mind a certain number of times.  A person may also have counting compulsions, such as counting tiles on the floor out loud or in one’s head.

·         Religious:  Individuals with religious obsessions may have obsessive thoughts about or images of Satan, hell, or other religious figures and symbols. They may worry that they must pray or perform other compulsions to prevent something evil from happening.

·         Sexual/Aggressive:  These individuals have intrusive thoughts or images of a sexual nature or about harming themselves or someone else.  They may feel guilt and anxiety over the content of these thoughts and perform compulsions to alleviate the anxiety.

How is OCD treated?

A specific type of CBT called Exposure and Response Prevention (ERP) has been developed to treat OCD.  This treatment targets both obsessions and compulsions.  During exposure, the therapist helps the client to face feared situations head-on and to better tolerate and reduce the anxiety associated with obsessive thoughts.  In response prevention, the therapist and client identify and eliminate compulsions that are done to reduce anxiety. The goal is to replace the compulsions with more effective ways of coping with stress and anxiety. Cognitive Therapy is also helpful in addressing beliefs that exacerabte OCD such as thought/action fusion ("I thought about doing something terrible, that means I am going to do it") and overresponsibility ("I have to make sure there are no dangers in the road otherwise people will die because of me"). Also beliefs that interfere with engaging in ERP ("it will make things worse") can be addressed and evaluated.

Treatment involves confronting feared situations with the help of the therapist in session, and homework assignments in which clients develop and practice the skills needed to overcome OCD on their own.  ERP is typically done gradually, starting with situations that the client considers less stressful and working up to the most feared situations. Research has shown that ERP is a highly effective treatment for OCD.

 --Meghan McGinn, M.A.
UCLA Department of Psychology
back to top

DEPRESSION

What is depression?

SOCIAL PHOBIA 

What is Social Phobia?

Social phobia (Social Anxiety Disorder) is a fear of one or more social situations where there might be unfamiliar people or judgment by others.  Typically people with social phobia worry that they will embarrass themselves in such a situation, either by showing symptoms of anxiety (e.g., blushing, sweating) or by otherwise acting in a way that will be humiliating to them.  The lifetime prevalence of social phobia is 1 in 8, and it is twice as common for women than for men.  The typical onset of symptoms is in the early teenage years, though sometimes is diagnosed in childhood.  Severe cases of the disorder can be extremely debilitating (i.e., few friends, unable to attain goals).

What are the symptoms of Social Phobia?

In addition to the aforementioned fear of social situations, people with social phobia experience intense anxiety in these situations, and often avoid them when possible.  Although people with social phobia are aware that their fears are unreasonable, the anxiety experienced in social situations or worrying about social situations causes impairment in functioning (e.g., relationships, occupation). 

What causes Social Phobia?

There are a number of factors that are thought to contribute to social phobia, but the specific cause is unknown.  There is likely a genetic role, as many people with social phobia also have relatives with the diagnosis.  Often previous experience(s) with embarrassment or humiliation in social settings contributes to fear of future embarrassment.  It is also thought that negative automatic thoughts in situations (e.g., “I’m going to sound stupid when I try to talk about this topic”), as well as extremely high standards (e.g., “I should not be anxious”).  Although it has long been thought that people with social phobia lack social skills, recent theory has challenged this, posing that people with social phobia are actually more attentive to social cues, and thus more sensitive to unskillful behavior.

What treatments are available?

1.       Medication: There are a variety of anti-anxiety medications available for people with social phobia.  One problem with medication is that anxiety symptoms often recur when the medication is stopped; for this reason many think psychotherapy is the treatment of choice.

2.       Cognitive-Behavioral Therapy (CBT) is a widely used treatment for people with social phobia.  Based on the cognitive model, anxiety is reinforced and maintained by negative thoughts and avoidance of situations.  Thus, common interventions include changing thoughts and behavior. 

Given the propensity for negative automatic thoughts, CBT therapists help clients with social phobia test some of the assumptions that underlie these thoughts.  Clients might engage in observation of others’ behavior, behavioral experiments about others’ reactions to anxiety behavior (e.g., exercising before going to a part to test the impact of sweating in a social situation), and developing alternative explanations to others’ behavior (e.g., “John must not have seen me,” rather than “John must not like me” when friend does not make eye contact on the street). 

Another common CBT intervention used with clients with social phobia is exposure.  Using exposure techniques, the therapist introduces the client to the situations the client fears, first in the therapy room (i.e., imaginal or in-session role play exposure) and then in the uncomfortable social situation (i.e., in vivo exposure).  The therapist supplies the client with tools for these situations (with social skills training and relaxation training), and does not push the client to do anything the client is not ready and willing to do.  After repeatedly experiencing feared situations, clients realize that their fears rarely (if ever) come true, and anxiety related to these situations is reduced.  Clients that have gone through CBT for social phobia report that they feel less anxious, and are able to approach rather than avoid social situations.

3.   Acceptance and Commitment Therapy (ACT) is a new therapy that has been applied to clients with social phobia.  ACT focuses not on reducing symptoms, but on accepting symptoms and moving in the direction of things that the client values.  In an ACT model, the problem is not the symptoms, but the way in which individuals respond to those symptoms.  In treatment for social phobia, ACT focuses on avoidance (of both feelings of anxiety and external situations) that in turn keeps the client from obtaining goals and acting in line with his or her values.  Although individuals are often able to reduce anxiety through both internal and external processes, in the case of social phobia it is virtually impossible to move toward values when so focused on avoidance of unpleasant experiences. 

ACT interventions include discussion of control and the alternative of willingness and acceptance.  Through use of metaphors, therapists help clients to see what their true values are and how they can more effectively move in that direction with their lives, along with any negative emotions and experiences.  Many of the aforementioned CBT techniques can be used in the ACT intervention as well, but rather than helping client to approach avoided situations to reduce anxiety, the ACT therapist helps the client to approach only situations that are consistent with their desired values rather than all feared situations.

Can people with Social Phobia have other illnesses?

Depression is common in people with social phobia.  Coping strategies (e.g., drug and alcohol use) can also become problematic.  Other anxiety disorders may also be found in people with social phobia.

Where can I get more information?

Websites

• The Anxiety Disorders Association of America (http://www.adaa.org/)
• The Association for Cognitive and Behavioral Therapies (http://www.abct.org/)
• Freedom from Fear (http://www.freedomfromfear.org/)
• Academy of Cognitive Therapy (http://www.academyofct.org/)

Books for Patients

• CBT:
  • Diagonally Parked in a Parallel Universe: Working Through Social Anxiety (Dayhoff, 2000)
• ACT:
  • Mindfulness and Acceptance Workbook for Anxiety (Forsyth & Eifert, 2007)
  • Get Out of Your Mind and Into Your Life: The New Acceptance and Commitment Therapy (Hayes, 2005)

Books for Clinicians

• CBT:
  • Cognitive Behavioral Therapy for Social Anxiety Disorder (Hofmann & Otto, 2008)
  • Contemporary Cognitie Therapy: Theory, Research and Practice (Leahy, 2004)
• ACT:
  • A Practical Guide to Acceptance and Commitment Therapy (Hayes & Strosahl, 2004)
  • Learning ACT (Luoma, Hayes, & Walser, 2007)
  • Acceptance and Commitment Therapy for Anxiety Disorders: A Practitioner’s Treatment Guide to Using Mindfulness, Acceptance, and Values-Based Behavior Change (Eifert, Forsyth, & Hayes, 2005)

Department of Psychology,
Univeristy of California at Los Angeles 

            A person who procrastinates will put off doing an activity until the last minute as a way of coping with the anxiety or negative feelings associated with that activity. Procrastination can occur in many areas of life including social activities (e.g., returning or making phone calls), work or school (e.g., finishing an assignment), health-related activities (e.g., making a doctors appointment or committing to a lifestyle change), and household or financial activities (e.g., filing taxes).  The anxiety or negative feelings associated with the activity can be avoided in the short-term by making the decision not to do it at that time.  However, putting it off can create more stress in the long term, since doing something at the last minute adds greater time pressure.  In addition, many other negative emotions are commonly associated with procrastinating, such as guilt, remorse, or depression.  Procrastinating also increases the likelihood that the activity will not get done in time, creating external consequences.  For instance, someone who puts off completing an assignment at work to the point that he or she turns it in late risks the disapproval of his or her boss.  Likewise, someone who files his or her taxes late must pay a penalty fee.  These consequences may, in turn, produce more worry and stress.  The long-term costs of procrastinating quite often outweigh the short-term benefit.

How is procrastination treated?

            Cognitive behavioral therapy (CBT) can be used to treat procrastination.  One way CBT can help is by challenging the thoughts and beliefs associated with completing an activity.  Some common thoughts include:

            “I have to do this perfectly.”

            “I don’t have enough time to do this right now.”

            “I need to be in the right mood to get this done.”

            “I’d rather do something else.”

            “I have to wait until _____ happens before I can do this.”

            “I don’t know how to do this.”

            “If I wait long enough, someone else might do this for me or help me with it.”

            “If I do this now, I’ll just be expected to do more.”

            “I can’t stand doing this.”

In CBT, the therapist will help you to examine the accuracy and utility of these thoughts.  The therapist will also help you to alter the behavioral contingencies (i.e., rewards and punishments) associated with procrastination.  When you procrastinate, the reward is that you avoid short-term anxiety.  The therapist can help you to create your own rewards system for completing each small step along the way so that your rewards system becomes more reinforcing than the avoidance.  The therapist may also help you to analyze the costs and benefits of procrastinating so that you are reminded of long-term punishments if you do not complete the activity on time and long-term rewards if you do complete the activity.  In addition, the therapist may teach you other skills in tolerating negative emotions, so that you can complete activities even if they are very unpleasant.

Meghan McGinn, M.A.
Department of Psychology
University of California at Los Angeles 
back to top

ANGER

Anger is an emotion everyone has felt at times. There will always be moments (and people) in life that push our buttons and try our patience. There is nothing wrong with feeling anger. It is how we react to it and express it that gets us into trouble. We hurt the people we love most with our words and behavior. We hurt ourselves, physically and emotionally, by holding on to these angry feelings. These feelings, if not appropriately managed and expressed, can lead to bitterness and resentment, which makes for an unhappy life.

The good news is that it is quite possible to learn how to manage your anger, and it begins with examining your thoughts. Examining the relationship between your thoughts, moods, and behaviors will help you understand your triggers, how you tend to respond to these triggers, and the repercussions of your typical response. By practicing new reactions, you can begin to incorporate more effective responses into your daily life.

How does Cognitive-Behavioral Therapy treat anger?

In cognitive-behavioral therapy, the therapist will help you identify “hot” and “cool” thoughts. Hot thoughts are the thoughts you have when your anger is at its peak. Therapy will offer a safe environment to challenge these hot thoughts and adapt them into more balanced and effective (“cool”) thoughts. CBT will also help you identify possible distortions in the way you are thinking about a situation, challenge you to determine the validity of these distortions or perceptions, and then reframe the thought into something more adaptive.

CBT will:

• Help you understand the situations and interpretations of those situations that have led to your feelings of anger
• Help you modify the interpretations and underlying beliefs that led to your feelings of anger
• Teach you how to identify prompting events that trigger your anger (for example: relationships, work situations, minor irritations, financial problems, high expectations that haven’t been met, etc.)
• Assist you in determining new behaviors and responses in situations that trigger your anger.

This will be done using several techniques:

• Thought Records
  • Using a written technique called a “thought record”, you will write down your hot thoughts and work with the therapist to modify them into cool thoughts. There are common distortions in thought that are connected with anger, including labeling (“He’s always such a jerk”), mind-reading (“She thinks I’m inadequate”), and magnification (“I can’t deal with this!”). You will learn which one(s) you tend to rely on and how to adjust them.
• Skills Training
  • Emotion Regulation Skills: It is important to understand the emotions you are experiencing – to understand what purpose they serve. Emotion regulation training will help you learn how to decrease the negative emotions and thoughts and increase the positive emotions and thoughts.
• Mindfulness
  • Mindfulness refers to what we pay attention to. Mindfulness techniques will help you harness your awareness rather than allowing it to wander around or get out of control, which often happens when we are upset. Mindfulness will teach you to focus on something other than your thoughts, which will then naturally calm your emotions.

CBT techniques for managing anger are extremely effective in helping clients understand and modify reactions and underlying beliefs that have caused their anger. The effects of this understanding have wide-ranging benefits, including better communication with others, healthier relationships, and higher self-esteem.

 
SUBSTANCE ABUSE

What is substance abuse/addiction? Based on the different theories surrounding the causes of addiction, the definition varies across schools.  

Addiction: A primary, chronic, and neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over medication use, compulsive use, continued use despite harm, and craving.

What is the difference between Substance Abuse and Addiction?

The Diagnostic and Statistical Manual of Mental Disorders IV-R describes abusers as those who abuse substances despite recurrent social, interpersonal, and legal problems as a result of using. Harmful use implies substance use that causes either physical or mental damage.

Abuse and addiction are not the same. Abuse always comes before addiction, which is  chronic and treatable. Abuse starts when there is a conscious decision to abuse substances. Used too often, the individual eventually craves the substance because physical changes in the brain haven taken place. Substances interfere with the brain’s natural processes by making both temporary and structural changes in brain cells. Mood, memory, thinking, and even motor skills such as walking may be affected. When this happens, drug abuse turns into addiction. People who are addicted have a compulsive craving and cannot quit by themselves.

What are the signs and symptoms?

Physical Signs

·         Loss of /increase in appetite, any changes in eating habits, unexplained weight loss or gain.

·          Poor physical coordination.

·         Inability to sleep, awake at unusual times, unusual laziness.

·         Red, watery eyes; pupils larger or smaller than usual; blank stare.

·         Cold, sweaty palms; shaking hands.

·         Puffy face, blushing or paleness.

·         Smell of substance on breath, body or clothes.

·         Extreme hyperactivity; excessive talkativeness.

·         Runny nose; hacking cough.

·         Needle marks on lower arm, leg, or bottom of feet.

·         Nausea, vomiting or excessive sweating.

·         Tremors or shakes of hands, feet, or head.

·         Irregular heartbeat.

 Behavioral Signs

·         Change in overall attitude/personality.

·         Changes in friends or social circles.

·         Change in activities or hobbies.

·         Drop in performance at work or school.

·         Change in habits at home; loss of interest in family.

·         Difficulty in paying attention; forgetfulness.

·         General lack of motivation, energy, self-esteem.

·         Sudden oversensitivity, temper tantrums, or resentful behavior.

·         Moodiness, irritability, or nervousness/giddiness.

·         Paranoia.

·         Excessive need for privacy; unreachable/secretive or suspicious behavior.

·         Problems with the law.

·         Chronic dishonesty/stealing.

·         Change in personal grooming habits.

·         Possession of drug paraphernalia.

What causes substance abuse/addiction?

While some researchers would say that there are a specific number of personality traits that precede the development of substance abuse one can not predict with certainty that any personality traits predispose a person to abusing substances. Therefore, we can not determine with confidence that, based on someone’s personality alone, they will become a substance abuser.

The medical model claims that addictions are a disease. This model states that addiction is an inherited disease, and an addicted individual is permanently ill, at a genetic level. The medical model also believes that like other medical diseases the person will remain ill even after years of sobriety.

The Dual Diagnosis philosophy dictates that addiction is a dual problem consisting of both physical and mental dependency on chemicals, combined with a pre-existing mental disorder and that the mental disorder needs to be treated first as the primary cause of the addiction. This philosophy supports the idea that chemical dependency leads to chemical imbalances in the neurological system, which would be then a substance induced imbalance. 

What treatments are available?

1. Cognitive Model of Addiction (CT)- this theory is based on Aaron T. Beck’s work that examined thoughts as the originating factor of any behavior. An individual’s behavior and affect are determined by his or her view of the world and the way they structure their world. Beck’s work also explored what he called a “schemata”- a stable, mental representation of experiences that are involved in the evaluation of information. Basically, thoughts are interpreted based on experiences and activating emotions when new situations and events arise.

Abnormal or dysfunctional thinking occurs when systematic distortions are applied to the new incoming situations or events affecting motivations, actions, and feelings. CT is utilized to change these cognitive distortions by assisting the client to change one’s actions, motivations, and feelings by assisting the client in challenging their own dysfunctional cognitive processes. 

There are many reasons people use and abuse substances; they range from pleasure, creativity, experimentation, relief from sadness, anxiety or even boredom. It is the underlying belief in any reason for substance use that shape the physiological sensations linked to the cravings and usage, and eventually addiction.

These addicted behaviors are shaped from core beliefs that have to do with personal survival, autonomy, and freedom. An addict’s beliefs, in all three of these areas are dysfunctional. The dysfunctional thought patterns seem to take over and as the person becomes addicted, the drug appears to take control of the individual. The obstacle in addiction is eliminating the person’s dysfunctional beliefs that they hold about the substance. These dysfunctional beliefs can range from fear of side affects to the belief that they cannot function without the substance. Changing the maladaptive beliefs, thought patterns, and schemas are at the core of the CT approach for substance abuse and addiction. These beliefs must be changed in order for long-term behavioral change and sobriety.

In CT patients are taught to face the source that is leading to their emotional distress and to change the beliefs that substances can assist in the mending of these or any other problems. This is done by reducing the intensity and frequency of the urges by exploring the underlying beliefs and to teach the patient techniques for managing and controlling their urges. In all areas the individual’s faulty beliefs about people, events, and their views on drug and alcohol use need to be fully examined.  

2. Acceptance and Commitment Therapy (ACT)

ACT, a form of CBT, uses a wide range of experiential exercises to examine the power of destructive cognitive, emotive, and behavioral processes that have contributed to and maintain substance abuse problems. It helps clients to fundamentally change their relationship with painful thoughts and feelings, to develop a clearer sense of self, to live in the present, and to take action, guided by personal values, and to create a rich and meaningful life without the use of substances.

ACT takes the view that most psychological suffering is caused by 'experiential avoidance', i.e. by attempting to avoid unwanted private experiences, such as unpleasant thoughts, feelings, urges & memories. The individuals efforts at experiential avoidance might work in the short term, but in the long term they often fail, and in the process, they often create significant psychological suffering. In individuals with substance abuse disorders or any serious addiction: in the short term the substance of choice makes a person feel good and helps rid of unpleasant thoughts and feelings - but in the long term, it destroys their health and vitality.

In ACT, clients develop “mindfulness skills” which enable them to fundamentally change their relationship with painful thoughts and feelings and the connection these thoughts and feelings have with substances. When clients practice these skills in everyday life, painful feelings and unhelpful thoughts have much less impact and influence over them. Therefore, instead of wasting their time in a battle with their inner experiences, they can invest their energy on taking action to change their life for the better - guided by their deepest values and absent of drugs and alcohol.

3. Emotion Regulation and Mindfulness

Growing literature is supporting the importance of emotional regulation in the treatment of substance abuse. Research has mainly been done on nicotine cessation however, since nicotine and other psychoactive substances, such as cocaine, activate similar psychopharmacological pathways, an emotion regulation application may be applicable. This model focuses on negative reinforcement as the primary driving force for addiction and patients are encouraged to identify and recognize their negative and emotional states and prevent the maladaptive, impulsive, and compulsive responses that they developed to deal with them.  In the cases of addiction, these responses would be abusing substances. Like CBT this approach involves the thoughts involved in maladaptive and dysfunctional emotional states but the focus here is the reaction to those states. Therefore, this could be used in conjunction with CBT if found affective.

4. Motivational Enhancement Therapy (MET)   

MET is based on the principles of motivational psychology and is designed to produce rapid internally motivated change. This treatment employs techniques that mobilize the individual’s own change resources. CBT and MET share a focus in the beginning of exploration early in treatment of what the patient stands to lose and gain through continued substance use as a strategy to build on the patient’s own motivation to change the substance abuse. However, unlike CBT, it does not maintain that learning and practice of specific substance related coping skills promote abstinences, but instead believes that motivation to use available resources is the patient’s responsibility and therefore no training is needed. For this reason MET would work most efficiently when combined with CBT because of the focus on the different aspects of the change process.

Can Patients with Substance Abuse and Addiction have other illnesses?

As mentioned in “What causes substance abuse and addiction”, many individuals with a substance abuse problem also suffer from a psychological/mental disorder. The combination of the two tends to complicate the diagnosis and treatment. When other disorders are present the need to have multiple aspects of treatment increases significantly. Often times psychotropic medication is needed to treat a mental disorder before you can begin to work on the substance abuse problems because many individuals chose to self medicate their mental disorders with drugs and alcohol. CBT can be combined with pharmacological treatment and has been found to be affective in the reduction of substance abuse.

Where can I get more Information?

Websites:

1. National Institute of Drug Abuse (NIDA) (www.drugabuse.gov)
2. Substance Abuse (www.drugfree.org)
3. Substance Abuse and Mental Health Service Organization (SAMHSA) (www.sanhsa.gov)
4. Alcohol and Substance Abuse (www.mentalhealth.net)

Books for Patients and Families:

1.Anonymous (2002). Alcoholics Anonymous: The Story of How Many Men and Women Have Recovered from Alcoholism. Fourth Edition New York: Alcoholic Anonymous World Servives, Inc.

2.Black,C. (2002). It will never happen to me: Growing up with addiction as a youngster, adolescents, adults. Bainbridge Island: MAC Publishing.      

3.Johnson, Vernon(1973). I’ll quit tomorrow. New York: Harper & Row

4.O’Neil, John T. & Pat O’Neil (1989). When Your Loved One Wont Quit Alcohol or Drugs. Oakland, California: New Harbinger Publications.

Books for Clinicians:

1. Beck, A.T., Wright, F.D, Newman, B.L (2001). Cognitive Therapy for Substance Abuse. New York: Guilford Press.

2.Nace, E & Tinsley, J. (2007). Patients with substance abuse disorders: Effective identification, diagnosis and treatment. New York: Norton and Company.

3. Smith, D & Seymour, R. (2001). A clinicians guide to substance abuse: New York: McGraw-Hill Press.

Referrals to Cognitive Therapy in Your Area

                 www.academyofct.org

Amanda Gutierrez, MA,
Psychology Intern:
Hutchings Psychiatric Center 
back to top 

Eating Disorders and Cognitive Therapy

back to top 

INSOMNIA 

What is Insomnia?

People with insomnia experience inadequate or poor quality sleep, including one or more of the following sleep problems:

1.      Difficulty falling asleep

2.      Difficulty staying asleep

3.      Waking up too early

4.      Poor quality of sleep

Estimates from the National Institutes of Health suggest that insomnia affects more than 70 million Americans.  Research conducted in 2002 by the National Sleep Foundation showed that 58% of adults in the U.S. experience symptoms of insomnia a few nights a week or more.  Insomnia can be either acute, lasting one to several nights, or chronic, lasting months or years.  Research suggests that about 10-15% percent of adults have chronic insomnia.

What causes Insomnia?

Insomnia can be a disorder in its own right, but in many cases it is a symptom of another disease or condition.  Insomnia can have many causes, including:

·         Stress

·         Anxiety and worry

·         Depression

·         Long-term use of sleep medications

·         Stimulant medications (examples: high blood pressure medications, decongestants, weight-loss products, & some pain medication combinations)

·         Change in your environment or work schedule

·         Eating or drinking too much too late in the evening

·         Medical conditions that cause pain (examples: arthritis, fibromyalgia, neuropathies)

·         Common sleep disorders, such as restless legs syndrome & sleep apnea

What treatments are available for Insomnia?

1.      Medications (i.e., sleeping pills).  Medications can be helpful for temporary or occasional insomnia lasting one or two days.  However, physicians generally don't recommend relying on prescription or over-the-counter sleeping pills for more than a few days because they may cause side effects, be habit-forming, and become less effective after a while.

2.      Cognitive Behavior Therapy (CBT).  CBT is an approved method for treating insomnia without the use of sleeping pills.  CBT has repeatedly been proven to be the most effective treatment for chronic insomnia.  Research has shown that CBT improves sleep in 75-80% of insomnia patients and eliminates sleeping pill use in almost half of patients. Several major studies which directly compared CBT to sleeping pills demonstrated that CBT was more effective than sleeping pills. CBT also has no side effects and results in long-term improvements in sleep.

CBT for insomnia focuses on changing behavior patterns and thinking patterns.  It includes regular, often weekly, visits to a clinician, who will assess your sleep and work with you in sessions to help you change the way you sleep.  In addition, CBT for insomnia involves completing daily sleep worksheets to measure your sleep throughout treatment.  CBT can be challenging and requires a lot of effort, but it has great potential benefits.

Several specific techniques used in CBT include sleep hygiene education, stimulus control, cognitive therapy, and relaxation training.  Sleep hygiene education includes a discussion of things a person should and should not do, in order to sleep.  Some common suggestions include sleeping in a cool, dark room and avoiding caffeine, alcohol, and tobacco before bedtime.  Stimulus control involves training a person to use their bed and bedroom for sleep and sex only, and not for other activities such as reading or watching TV.  Stimulus control procedures encourage the person who is struggling to fall asleep to go another room and engage in a relaxing activity until they are sleepy, and then return to bed.  Cognitive therapy is a process of examining one’s attitudes and thoughts that may contribute to poor sleep.  Thoughts can influence how we feel, and strong negative feelings, such as anxiety or frustration, can interfere with sleep.  Examples of negative thoughts include: “Why does sleep come so easily to everyone but me?” or “I’m never going to get back to sleep!”  Cognitive therapy helps you recognize the negative thoughts you may be having, and to replace those thoughts with more accurate, positive thoughts.  Finally, relaxation training provides instruction in ways to reduce tension, including deep breathing and muscular relaxation techniques.

Where can I get more information about Insomnia?

Websites

1.      National Sleep Foundation (www.sleepfoundation.org)

2.      CBT for Insomnia (www.cbtforinsomnia.com)

Books for Patients

1.      “Say Goodnight to Insomnia” by Gregg Jacobs (Henry Holt & Company, 1998)

2.      “Overcoming Insomnia: A Cognitive Behavioral Approach Workbook” by Jack Edinger & Colleen Carney (Oxford University Press, 2008)

 --Jennifer Robles, Ph.D.
back to top