Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Every Tuesday, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the author.
When I was finishing up my clinical training on internship, I was co-leading a therapy group for WWII Veterans who had all been POWs while in theater. Here it was over 50 years since their military service and they all had the same complaint; they had not been able to get a good night of sleep since that time. This is unfortunately a common problem for Veterans and active duty Service members. There have now been several studies reporting high rates of sleep problems, in particular insomnia and nightmares. While nightmares are most common in those with PTSD, insomnia is more widespread. Poor sleep impacts many aspects of daily life and can lead to irritability, tiredness, affect interpersonal functioning, and impair attention and concentration. I often refer to insomnia as a ‘gateway’ problem because patients often show up in the sleep clinic saying that they can tolerate their pain, anxiety, or other problems, but they just can’t deal with not getting a good night of sleep so that is what brings them in for treatment.
For many years, sleep problems were considered to be symptoms of other, more serious, conditions. Insomnia was thought to occur as part of depression, PTSD, chronic pain, or other disorders, but with the assumption being that sleep would improve if the ‘primary’ problem was addressed. This viewpoint is changing in the face of several lines of evidence. First, there are now over two dozen studies showing that sleep problems often precede the development of mental illness. The presence of insomnia even increases the risk of new onset disorders such as depression and PTSD. So rather than being a consequence of these conditions the insomnia may have increased vulnerability to illness in the first place. Second, even with successful treatment of ‘primary’ disorders, sleep often does not improve. Sleep problems are often the most treatment-resistant symptoms, and when persistent they interfere with treatment progress and increase the risk for relapse. Third, and perhaps most interesting, is the growing evidence that treating sleep problems not only helps with sleep, but can also lead to improvements in co-morbid disorders. In a patient with insomnia and depression, treating the insomnia can lead to improved mood and augment antidepressant treatment. Clearly, sleep problems warrant focused attention and treatment even in the presence of co-morbidities.
Most frequently, treatment of sleep problems has consisted of pharmacotherapy. There are several sleep medications available (e.g. zolpidem, temazepam) and many other medications are used off-label because of their sedating properties (e.g. trazodone, diphenhydramine). For some, sleep medication works very well and leads to a good night of restful sleep. Oftentimes, the improvements are modest and outweighed by side effects. Ironically, one of the most common complaints with sleep medication is sleepiness! The problem is that the sleepiness occurs in the morning when the person wants to be awake and alert. Even when sleep medications are effective, they usually do not fix the underlying problem and need to be taken long-term to maintain clinical improvements.
An alternative approach is to use cognitive behavioral treatments for sleep problems. Cognitive behavioral treatment of insomnia, or CBT-I as it is commonly known, is the best example of a non-pharmacologic treatment approach with strong evidence of efficacy. CBT-I is based on the idea that insomnia becomes a chronic problem because of perpetuating factors that develop over time and maintain the pattern. A nice example of a perpetuating factor is conditioned arousal. For good sleepers, repeated pairing of the bed and sleep leads to sleepiness as a natural response to getting into bed. Individuals who suffer from insomnia night after night end up pairing the bed with wakefulness and arousal rather than sleep. As a result, when they get into bed they have a response of becoming more awake rather than feeling sleepy. I’ve had some patients say that they feel as if a light switch is turned on in their mind whenever they get into bed. This conditioned arousal, along with other factors, then keeps the cycle of insomnia going. CBT-I consists of a collection of strategies designed to break these cycles and re-establish a health sleep pattern. It’s sort of like boot camp for sleep.
There are several components of CBT-I, but the core strategies are stimulus control therapy and sleep restriction therapy. Stimulus control is designed specifically to address conditioned arousal. The goal is to pair the bed with sleep and sleepiness rather than with wakefulness. Some of the guidelines in stimulus control include getting out of bed if you’re unable to sleep, and not using the bed as a place to read, watch TV, or engage in other waking activities. Any tossing and turning in bed is eliminated so that they are only in bed if they’re sleepy or asleep. Sleep restriction therapy, awful as it sounds, is another core component of CBT-I. It involves intentionally reducing the amount of time spent in bed by going to bed later at night while maintaining a fixed wakeup time. By waiting until later to go to bed, there is a higher level of sleepiness built up to help facilitate falling and staying asleep. Once they are able to get good quality sleep during the restricted time in bed, the time is gradually expanded until the quantity of sleep is sufficient to feel rested during the day. Sleep restriction therapy can be a difficult process to go through, but it is highly effective.
Another component of CBT-I is sleep hygiene, which consists of a diverse set of guidelines related to behaviors that impact sleep. While each provider’s sleep hygiene list is slightly different, they typically include minimizing caffeine and other stimulants, avoiding alcohol or heavy meals close to bedtime, and ensuring that the bedroom environment is conducive to sleep. Of all the components of CBT-I, sleep hygiene has received the most attention and is most commonly used. Oftentimes patients will already be aware of sleep hygiene because they have read about the guidelines on the Internet or in a magazine. The problem with sleep hygiene is that, by itself, it is rarely an effective treatment for insomnia, so correcting poor sleep hygiene alone is not likely to lead to significant improvement. It is a necessary, but not sufficient, component of CBT-I.
Many individuals say that the reason they cannot sleep at night is because their mind is too active, highlighting the important role that cognitive factors play in perpetuating insomnia. As a result, CBT-I takes advantage of cognitive therapy techniques to address sleep-related cognitions and excessive mental arousal. Rather than being a single technique, the ‘C’ in CBT-I consists of a variety of approaches ranging from basic psychoeducation about sleep to formal cognitive restructuring, depending on the importance of cognitive factors for a particular patient and the therapists’ degree of cognitive orientation.
CBT-I has demonstrated efficacy in many randomized trials in a wide range of patient populations. It is a relatively brief therapy with 4-8 sessions being a typical duration. Approximately 80% of patients achieve clinically significant improvements, with about half of these having complete remission of insomnia and the other half improved but continuing to have some sleep problems. There are few forms of therapy that work so well in so few sessions! CBT-I is also flexible in the way that it can be delivered. While individual therapy is associated with the best outcomes, it can be delivered in groups of 6-8 patients at a time. There are increasing options to use technology to facilitate delivery including telemedicine, web-based programs that do not involve a ‘live’ therapist, and mobile applications. Each delivery approach has advantages and disadvantages to consider.
Cognitive behavioral treatment for insomnia is a well-established intervention, but it is also important to consider treatments for nightmares because they also tend to be persistent over time and negatively impact daily functioning. Some individuals fear going to sleep or try to avoid sleeping as much as possible in order to reduce the likelihood of having a nightmare. While nightmares are most prevalent in the context of PTSD, they can occur in non-traumatized individuals as well. The primary cognitive behavioral treatment for nightmares has several variations including Imagery Rehearsal (IR), Imagery Rehearsal Therapy (IRT), and Exposure, Relaxation, and Rescripting Therapy (ERRT), which are collectively also referred to as dream rescripting. While the techniques for each approach differ slightly, they all involve selecting a recurrent nightmare and coming up with a way to change to content of the nightmare to make it less distressing and more controllable. This changed version of the dream is written out as a detailed dream script, which is then mentally rehearsed at night before going to bed. The pre-bed rehearsal is attempting to take advantage of the fact that our pre-sleep cognitions are more likely to be integrated into dream content.
There is a growing evidence base for dream rescripting approaches, but the results are very mixed. Clinical improvements are strongest for samples that do not include Veterans or service members, such as civilian populations that are victims of assault or who witnessed a natural disaster. The largest randomized trial to date was conducted in Veterans with PTSD and reported modest effects at best. The jury is still out regarding the efficacy of nightmare rescripting, but there definitely seems to be a subgroup of individuals who derive significant benefit. Future studies are needed that identify this subgroup for more targeted treatment.
While sleep problems are highly prevalent in Veterans and Service members, there are treatment options available. There is a growing push to increase routine screening for sleep problems in order to identify those would might benefit from sleep-focused treatment in order to improve their sleep and, potentially, get secondary benefits in comorbid conditions. The challenge will be having enough providers trained in CBT-I and other sleep interventions to meet the demand.
Phillip Gehrman, Ph.D., is an assistant professor of psychology in the Department of Psychiatry of the University of Pennsylvania School of Medicine, and a clinical psychologist at the Philadelphia VA Medical Center. He directs the Sleep and Traumatic Stress program at Penn. He completed his graduate training in clinical psychology at the University of California, San Diego including a predoctoral internship at the Durham VA Medical Center and a post-doctoral fellowship in sleep medicine at Penn. He has an active research program exploring the mechanisms and treatment of insomnia in the context of mental illness. His work includes studies on the genetics of insomnia for which he leads an international consortium of genetics researches. Dr. Gehrman also has an active research program on sleep problems in veterans with Posttraumatic Stress Disorder (PTSD). Dr. Gehrman’s clinical work is in the area of Behavioral Sleep Medicine and he provides cognitive behavioral interventions for sleep disorders. His clinical work includes a national telehealth insomnia program in the VA.