Insomnia treatment: Cognitive behavioral therapy instead of sleeping pills

Insomnia is a serious disorder and effective insomnia treatment can be crucial to getting the sleep you need. Until now, there were few safe, effective, non-drug insomnia treatments.
By Mayo Clinic staff

Insomnia is a widespread condition that's characterized by a difficulty in falling asleep, staying asleep or getting restful sleep. Like many people who experience insomnia, you may have turned to sleeping pills for relief.

However, new research and sleep studies show that your attitudes about sleep and certain behaviors are often the root cause of insomnia. Changing those attitudes and behaviors can lead to better sleep.

What's so good about a good night's sleep?

Sleep is essential for good physical and mental well-being. Natural sleep restores your body and mind and provides enough dreaming time (REM sleep) to sustain learning, memory and mood.

If you're sleep deprived, you're more likely to develop infections, and have high blood pressure, cardiovascular disease and diabetes. You may also be more prone to make mistakes on the job, take longer to recover from stress, have problems with learning and memory, and experience depression and irritability.

Problems with sleeping pills

There are times — such as during periods of pain or grief — when sleeping pills may help those who experience sleep deprivation. In addition, several hypnotics are now approved by the Food and Drug Administration for indefinite use.

However, many sleeping pills shouldn't be taken for more than a few days to a few weeks. Because they can be habit-forming, some people take these drugs far longer. Others may increase their dosage as the pills become less effective over time. Sleeping pills can also:

• Mask the real causes of poor sleep, such as depression, heart trouble, asthma and Parkinson's disease, and delay treatment of these disorders
• Interact with other medications or alcohol, often with serious, even deadly, results
• Cause next-day grogginess or rebound insomnia — an inability to sleep that's worse than the original problem
• Lead to high blood pressure, dizziness, weakness, nausea, confusion, short-term amnesia
• Cause bizarre behavior that goes beyond traditional sleepwalking to include "sleep binge eating," "sleep shoplifting" and "sleep driving" — none of which the person remembers

Cognitive behavioral therapy: A tool for treating insomnia

Cognitive behavioral therapy (CBT) has emerged as a treatment for insomnia that's an effective alternative to sleeping pills, even for people with severe or chronic sleep problems.

CBT is a relatively simple, short-term treatment that has long been used to treat a range of conditions, including depression, panic attacks, anxiety, eating disorders and substance abuse. Studies have shown that psychological and behavioral factors play an important role in insomnia and that CBT can be effective in treating insomnia. A 2006 review of insomnia treatment studies conducted by the American Academy of Sleep Medicine found that CBT can help improve sleep and that benefits can be sustained over a long period of time.

CBT can benefit nearly everyone, including older adults who have been taking sleep medications for years, people with physical problems such as restless legs syndrome, and those with primary insomnia, a lifelong inability to get enough rest.

What's more, the effects seem to last — a year after CBT, most people still show benefits from the therapy and sleep more soundly than before. And there is no evidence that CBT has adverse effects.


How does cognitive behavioral therapy work?

Cognitive behavioral therapy helps you change the thoughts and actions that interfere with your ability to get restful sleep. The approach is based on the idea that how you think (cognition) and act (behavior) affects the way you feel.

The cognitive portion of CBT teaches you to recognize and change false beliefs that affect your ability to sleep. For example, you may believe that you must get eight hours of sleep every night to function. In fact, seven hours of sleep may be adequate for you. Cognitive therapy also deals with misperceptions about the amount of time you actually spend sleeping. People with insomnia often sleep more than they realize.

The behavioral portion of CBT helps reprogram the part of your brain that governs the sleep-wake cycle. It targets specific behaviors — what sleep experts call "sleep hygiene" — that negatively affect your sleep. Such behaviors include failing to exercise or drinking beverages that contain caffeine just before bedtime.

When used as an insomnia treatment, cognitive behavioral therapy usually requires four to eight 30-minute sessions with a trained sleep therapist. The approach works on multiple levels and contains one or more of the following elements:

• Cognitive control and psychotherapy. This type of therapy helps you control or eliminate negative thoughts and worries that keep you awake. It may also involve eliminating false or worrisome beliefs about sleep, such as the idea that a single restless night will make you sick.
• Sleep restriction. This approach tries to match the time spent in bed with your actual sleep requirement. Reducing the amount of time you spend in bed without sleeping will actually increase your desire to sleep.
• Remain passively awake. Called paradoxical intention, this involves avoiding any effort to fall asleep, with the goal of eliminating any anxiety you may feel about falling asleep easily.
• Stimulus control. This method helps disassociate any negative cues you attach to the bedroom environment and condition a positive response with getting into bed. For example, you might be coached to use the bed only for sleep and sex.
• Sleep hygiene. This method of therapy involves correcting basic lifestyle habits that influence sleep, such as smoking or drinking too much coffee or alcohol late in the day and failing to exercise regularly. It also includes tips that help you sleep better, such as winding down an hour or two before bedtime with a warm bath.
• Relaxation training. This method helps you relax to reduce or eliminate the arousal that disturbs sleep. Approaches include meditation, hypnosis and muscle relaxation.
• Biofeedback. This method measures certain physiological signs, such as muscle tension and brain wave frequency, with the intent of helping you control them.

The most effective treatment approach may combine a number of these methods. Realize that unlike sleep medications, CBT requires steady practice and that some approaches may cause you to lose sleep at first. Stick with it, and you should see results.

Insomnia as a symptom of another disorder

Because insomnia can be associated with many underlying disorders, such as depression, substance abuse or another sleep disorder, a thorough sleep evaluation is key in determining the appropriate treatment. In these cases, the root cause should be addressed simultaneously.

Finding help

The American Academy of Sleep Medicine has developed a standardized process and certification for behavioral sleep therapists, and you can locate a practitioner through its Web site.

However, there is currently a shortage of certified sleep therapists, and you may not live near a practitioner who can help. Further, the type of treatment — such as group versus individual — and frequency of sessions, may vary depending on the provider.

You may have to do some searching to find a trained practitioner and a treatment schedule and type that fits your needs. Start by obtaining a list of sleep centers from the National Sleep Foundation Web site. Many are associated with major hospitals. If you can't find one close to you, try locating a therapist who offers phone consultations. CBT books and CDs may be a good option until you find someone to help.

Read More...

Sunday, July 5, 2009

Antisocial Personality Disorder Treatment

Introduction

Antisocial personality disorder is often misunderstood by both professionals and laypeople. Confused with the popular terms, "sociopath" or "psychopath," someone who suffers from this disorder can be discriminated against within the mental health system, because of the symptoms of their disorder. Because there is usually a pervasive lack of remorse, and many time any feelings at all, they are assumed not to have any real feelings by many professionals. This can lead to difficulties within treatment.

Psychotherapy is nearly always the treatment of choice for this disorder; medications may be used to help stabilize mood swings or specific and acute Axis I concurrent diagnoses. There is no research that supports the use of medications for direct treatment of antisocial personality disorder, though.

Psychotherapy

As with most personality disorders, individuals with this disorder rarely seek treatment on their own, without being mandated to therapy by a court or significant other. Court referrals for assessment and treatment for this disorder are likely the most common referral source. A careful and thorough assessment will ensure that the person that the person has antisocial personality disorder. This can often be confused with simple criminal activity (all criminals do not have this disorder), adult antisocial behavior, and other activities which do not justify the personality disorder diagnosis. As with a thorough assessment of any suspected personality disorder, formal psychological testing should be considered invaluable.

Because many people who suffer from this disorder will be mandated to therapy, sometimes in a forensic or jail setting, motivation on the patient's part may be difficult to find. In a confined setting, it may be nearly impossible and therapy should then focus on alternative life issues, such as goals for when they are released from custody, improvement in social or family relationships, learning new coping skills, etc. In an outpatient setting, the focus of therapy can also be on these types of issues, but a part of the therapy should be devoted to discussing the antisocial behavior and feelings (or lack thereof). Common in the population who suffer from antisocial personality disorder is the lack of connections between feelings and behaviors. Helping the client draw those lines between the two may be beneficial.

Threats are never an appropriate motivating factor in any sort of treatment, and least of all with this disorder. If the only way to motivate the patient is to threaten to report their noncompliance with therapy to the courts or warden, it is highly unlikely the clinician will make any type of gains within therapy anyway. It is appropriate, however, to try and help the individual with this disorder find good reasons that they may want to work on this problem further. For instance, ensuring that they not come into contact with the court system again, be incarcerated, have to submit themselves to additional psychological examinations, etc.

Effective psychotherapy treatment for this disorder is limited. It is likely, though, that intensive, psychoanalytic approaches are inappropriate for this population. Approaches the reinforce appropriate behaviors and attempting to make connections between the person's actions and their feelings may be more beneficial. Emotions are usually a key aspect of treatment of this disorder. Patients often have had little or no significant emotionally-rewarding relationships in their lives. The therapeutic relationship, therefore, can be one of the first ones. This can be very scary for the client, initially, and it may become intolerable. A close therapeutic relationship can only occur when a good and solid rapport has been established with the client and he or she can trust the therapist implicitly.

Trust brings up the issue of confidentiality, since often the patient with antisocial personality disorder is mandated to therapy. This means that the clinician may have to occasionally report on the patient's progress in therapy. While this can usually be done in a very general way which reveals no significant details of the content of therapy, it is still an important issue for the client. He or she may be suspicious and distrustful of the clinician at first, since it will be unclear as to who has the highest priority -- the patient or the court. This fear can only be alleviated with an honest disclosure as to what the therapist will reveal to the courts, and with time, as the client learns that what he says in the therapy session does not become common knowledge. The limitations of therapy should be discussed with the patient up-front, in a clear and matter-of-fact manner, so there are no misunderstandings later.

The content of therapy should focus on the patient's emotions (or lack thereof). As the individual learns to experience various emotional states, one of the first may be depression. The client will likely be unfamiliar with the feelings associated with depression, and so it is beneficial for the clinician to be supportive and empathetic to the individual during this time. Reinforcing any emotions, outside of anger or frustration, is usually beneficial. Experiencing intense affect is usually a sign of progress in therapy. Staying on "safe issues," and discussing more real-life concerns, while one way of treating this disorder, is not likely to be as effective in long term behavioral change as an approach emphasizing the discovery and labeling of appropriate emotional states.

People who have antisocial personality disorder often experience difficulties with authority figures. The therapist should usually take a neutral stance in this matter, since it is a firmly held belief by the client. The clinician should avoid arguments and taking sides on authority issues and those who hold authority over the client. Their moral and ethical makeup may leave a lot to be desired as well. While this may be an appropriate topic for discussion in therapy, it will also likely be one of little progress. Usually one of the more effective ways for a person with this disorder to learn to change their ineffective behaviors is to have to face up to the consequences of their behavior. This sometimes means dealing with courts and jails, but it can also eventually be a motivating factor in the client's treatment.

Other modalities of psychotherapy, such as group and family therapy, can be helpful. Often people with this disorder find themselves in a group setting, because they aren't given any treatment choices. This is usually not conducive to their treatment, since in most groups, the individual can remain emotionally-closed and has little reason to share with others. It also doesn't help that these groups are often made up of people suffering from a wide range of mental disorders. Groups which are devoted exclusively to this disorder, though rare, are the best choice. In such a group, the patient is given a greater reason to contribute and share with others. Care must be utilized by group leaders to ensure the group doesn't become a "How-to" course in criminal behavior. Family therapy can be helpful to increase education and understanding among family members. Families often misunderstand and are confused about the cause of the antisocial behaviors and the idea that it is a mental disorder. Phillip W. Long, M.D. adds, "This confusion, guilt, the temptation to make restitution for the patient's criminal acts, and the frustrations of working with someone who is seen to be quite ill but who will not be treated should all be discussed openly with family members."

While there are many theories, as with all personality disorders, research has found little significant causative factors.

Hospitalization

Rarely is inpatient care appropriate or necessary for this personality disorder. Like most personality disorders, most people will go through their lives with little realization of the difficulty they have. In this case, though, the person is more likely to be seen as a criminal and have a history of difficulties with the law. Loss of freedom may be more of a motivating factor than in other personality disorders, so some specialized treatment facilities have started to treat people with this disorder.

One such program we've read about is the Patuxent Institute, located in Jessup, Maryland in the U.S. This hospital utilizes a strict behavioral approach of placing patients on a token economy based upon their treatment progress. This is a relatively new and radical approach to this sort of disorder and little research has been conducted to confirm its long-term effectiveness.

As with any treatment, the focus on feelings and connecting antisocial behavior to appropriate feeling states is appropriate. Since inpatient programs tend to be more intensive and expensive, they are rarely sought out by the patient themselves. Community followup and support, either by the hospital or professionals, or with the use of self-help support groups, is imperative to maintaining treatment gains.

Medications

Medications should only be utilized to treat clear, acute and serious Axis I concurrent diagnoses. No research has suggested that any medication is effective in the treatment of this disorder.

Self-Help Strategies

Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Groups can be especially helpful for people with this disorder, if they are tailored specifically for antisocial personality disorder. Individuals with this disorder typically feel more at ease in discussing their feelings and behaviors in front of their peers in this type of supportive modality. Leaders of such self-help support groups, though, must be wary of individuals who come to group just to brag about their exploits and who may seek to use the group inappropriately. Usually a group can be very helpful and beneficial to most people with this disorder, once they overcome their initial fears and hesitation to join such a group. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.

Read More...

Friday, June 19, 2009