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With CBT, Learning to Sleep Again


One night, a few months ago, I couldn’t fall sleep. After lying wide awake for two hours in an uncomfortable hotel bed, I turned on Netflix and binge watched “Russian Doll” until the sun came up. I had just landed in a foreign country and was going through some big changes in my life, so I chalked up my sleep troubles to jet-lag and stress. But then the next night, same thing. And the next, and the next.

For weeks after I returned home, I moved through the motions of my days in a foggy, disoriented delirium. By the time night came, I felt completely exhausted, but I began to fear my bedroom and what I was sure would follow: hours of staring at the ceiling, heart and mind racing into the early hours of the morning.

“Am I going crazy?” I panicked. Why was sleep — a natural, effortless activity that I once loved — now something that I had seemingly forgotten how to do?

A Google search brought me some solace — I was apparently far from alone in my despair. A quarter of Americans experience acute insomnia every year, according to a 2018 study by Penn Medicine researchers. Seventy-five percent of those will recover without developing persistent poor sleep, but the rest will go on to experience chronic insomnia — defined as trouble falling or staying asleep at least three times per week for three months or more.

Still, my insomnia didn’t seem to make any sense. I had always slept fine, I thought. I could nap on trains and planes and library armchairs. Why was this happening to me?

The Spielman model of insomnia cites the “3 Ps” as the main contributors to chronic sleeplessness, Philip Gehrman, PhD, an associate professor of Psychology in the department of Psychiatry and a member of the Penn Center for Sleep and Circadian Neurobiology, tells me, weeks after my sleep problems have subsided.

The first are “predisposing factors” — some biological or psychological traits, such as our gender, age, or mental health state — that increase our vulnerability to sleep difficulties. Scientists still don’t fully understand the link between our genes and sleep habits, but Gehrman’s research suggests that there are dozens of genetic links with sleep duration and quality.

This made sense. I know at least a few of my family members who suffered from bouts of insomnia, and I had a few traits that put me at risk for the condition — being female, for one.

Some “at-risk” people will go their whole lives sleeping well, until the second “P,” a “precipitating factor,” comes along, which triggers their insomnia.

“Stress is the biggest factor, or worry, jet-lag, or pain. There are a million reasons,” Gehrman explains. “There are so many things that can cause insomnia, sometimes it’s a wonder that everyone doesn’t have it.”

For me, the combination of travel and stress seemed to set off my episode.

Once the precipitating event ends, your sleep will usually improve. However, some people fall into a cycle that perpetuates (the third “P”) the insomnia over time. One of the most common cycles to fall into is starting to obsessively worry that you can’t sleep, which can translate into behaviors that negatively — though inadvertently — impact your sleep cycle, says Ilene Rosen, MD, MSCE, an associate professor of Sleep Medicine. 

“People might start to have performance anxiety. They start thinking, ‘Oh my gosh, it’s getting closer to bedtime. I really need to sleep tonight. I have a big meeting at work.’ So, what do they do? They get into bed for 10 hours, and they lie there, and they only get their four hours of sleep,” Rosen says. “Now they’re reinforcing being in bed when they’re not sleeping.”

I could relate. To solve my own sleep woes, I tried everything — CBD oil, Benadryl, lavender pillows, Valerian root, exercising early in the day, exercising later in the day. But by the time I got into bed at night, I was thinking about sleep so intensely, that it was virtually impossible to relax enough to doze off.

“If you ask people who sleep great, ‘How do you fall asleep at night?’ They often will look at you funny and just say, ‘I just closed my eyes and it happens.’ It’s not something you usually have to put effort into,” Gehrman says. “And in fact, the moment you start putting effort into it, it becomes harder to do.”

It wasn’t until I started reading about and practicing some of the strategies of cognitive behavioral therapy that I finally cured my sleep troubles.

Cognitive behavioral therapy for insomnia (CBT-I) is the gold standard of care for treating the condition. It works because it gets to the heart of understanding — and reversing — those perpetuating factors, says Gehrman, who specializes in delivering CBT-I.

Rosen describes CBT-I as “re-training the brain to undo some of the subconscious, maladaptive behaviors” that are not conducive to sleep, by eliminating the factors that may be interfering with a body’s sleep-wake system.

“We’re not trying to work against your body,” Gehrman adds. “We’re trying to tap into your body’s natural sleep biology.”

That’s why Gehrman often prescribes a “restricted sleep schedule” as part of CBT-I for his patients, in which they are instructed to go to bed late and wake up early. It’s a way of training patients to sleep when their bodies feel tired, and ensuring that they don’t lie awake in their beds at night.

“They come to me and say, ‘I’m so tired.’ Well, we say, ‘A couple of weeks ago you couldn’t fall asleep. Now you can’t stay awake.’ We think part of the way it works is that it’s shifting people’s focus,” Gehrman says.

Luckily, my insomnia was new enough that I was able to overcome it on my own. I used some of the same training exercises that Gehrman and Rosen employ in their clinics — like getting out of bed when I couldn’t fall asleep right away and just flat out not worrying how much sleep I was going to get each night.

But many people who have suffered from insomnia for months or years either still don’t know about CBT-I, or they don’t have access to health care providers who are trained in the therapy.

Even some primary care doctors are unfamiliar with CBT-I, Gehrman says, and so they resort to prescribing sleep medications. Though these might work temporarily, they also can come with undesirable side effects, and are rarely a good long-term option, Gehrman says.

That’s why preliminary results from a new study led by Gehrman are so exciting for long-term sleep sufferers. For the past nine years, Gehrman, who has an appointment at the Department of Veterans Affairs, has been treating veterans experiencing insomnia — without them ever needing to take a trip to Philadelphia.

Instead of in-person counseling, Gehrman uses video conferencing to deliver CBT-I. A study investigating this method showed that telemedicine was just as effective as in-person therapy for treating insomnia. The results were presented at the Sleep conference in San Antonio, Texas in June 2019 and will be published later this year. Now, with funding from the American Sleep Medicine Foundation, Gehrman is in the midst of studying the effects of using telemedicine to treat a more general population of insomnia patients.

“The hope is that telemedicine would be one means for making CBT-I more readily accessible for anyone who wants it,” Gehrman says.

As someone who understands the psychological and physical toll that sleeplessness can take on a person, I hope that those experiencing insomnia know that they don’t have to suffer in silence.

“In the past, people might have thought, ‘All these people around me can fall asleep. What’s wrong with me?’ But the problem is not as hidden as it used to be,” Gehrman says. “You can reach out for help and learn to sleep well again.”

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