Photo by Leohoho on Unsplash

Cognitive Behavioral Therapy Can Improve Sleep and Reduce Sleep Apnea Symptoms

By Admin   

A treatment known as Cognitive Behavioral Therapy for insomnia, or CBTi, has shown a high level of effectiveness as an integrated approach to treating sleep apnea, boosting PAP-therapy adherence rates while reducing symptoms such as daytime sleepiness or fatigue. The therapy, often used to treat insomnia, has been especially effective for those patients with both sleep apnea and insomnia. Patients engaged in CBTi use methods of self control, self conditioning, and relaxation techniques to improve their sleep experiences over time. Through the guidance of a trained therapist, patients gain important insights into how their thoughts and behaviors can lead to better sleep and better health overall. As an approach to insomnia, this therapy aims to reduce the time spent in bed to better match the patient’s total sleep time, making bedtime lead more quickly to sleep. For those with sleep apnea, this is also a helpful complement to PAP therapy, as it can lead to better therapy experiences all around. As the two most common sleep disorders, insomnia and sleep apnea often coincide, each potentially exacerbating the other and possibly leading to further health problems over time. By using methods such as CBTi, patients can not only benefit from the reduction in symptoms, but also learn how to incorporate those techniques into healthier habits that ultimately improve their quality of life.

What is CBTi and How Does it Work?

CBTi is a form of therapy that uses behavioral training and thought exercises to treat sleep disorders. By focusing on thoughts and behaviors associated with the disorder, CBTi attempts to reduce symptoms by replacing them with more positive alternatives. While approaches can vary from one therapist to another, these training exercises often include what is known as cognitive restructuring, a way of changing negative thinking habits, and stimulus control, which establishes rules for sleep behaviors, as well as a number of relaxation techniques to help patients ready themselves for the sleep hours to come. 

More specifically, CBTI focuses on how thoughts lead to behaviors in healthy or unhealthy ways. During treatment, a trained CBTi provider helps the patient identify thought and behavior patterns that relate specifically to sleep problems, and what techniques can be used to address them. One of the primary goals of CBTi is to educate the patient about the relationship between sleep health and psychology, and each of the techniques used is meant not only to improve sleep and health, but also to guide them to a better understanding of their own mental and behavioral processes. 

Cognitive Restructuring

Cognitive restructuring is a technique to help clients identify problem thinking and develop habits to replace them. In many cases, this type of problem thinking is error-prone and unrealistic. Some examples include all-or-nothing thinking, overgeneralizing, focusing on the negative or excessive worrying, or poor stress management. Often, a history of insomnia or other sleep disorders may cause a patient to worry about sleep or associate bedtime with negative events. Over time, this can become repetitive and come to define bedtime experience. Cognitive restructuring is a way of identifying and altering these seemingly automatic reactions to negative experiences. 

Stimulus Control and Sleep Restriction

Stimulus control and sleep restriction are important components of CBTi because they force the body to accept what the mind desires. During CBTi treatment, bed activities are restricted to sleep and intimacy with a partner. To reduce the amount of time spent in bed when the patient is not asleep or struggling to sleep, the time in bed itself is restricted. Ultimately, this will lead to less sleep, rather than more, but the resulting fatigue helps to condition the body to sleep at the correct time.

Initially, sleep restriction can lead to increases in daytime sleepiness, which is why sleep professionals recommend close monitoring by a professional during the early weeks of the treatment. This technique is intended to increase the physical need for sleep, but only long enough to ensure that the patient falls asleep when going to bed. This is not recommended for some patients, for example, those with epilepsy or those who may have a dangerous task or job to perform, but the results are effective enough to warrant consideration for those struggling with insomnia and/or daytime sleepiness due to sleep apnea. 

Sleep restriction does require patients to keep track of time in bed and sleep time, but there are a number of helpful apps that can do the same without much effort on the part of the user. Generally, the goal is to spend no more than 30 minutes more than your total sleep time in bed. 

Relaxation Techniques

A number of relaxation techniques exist for use in CBTi training, and some of the more common methods include breathing exercises, mindfulness and meditation, autogenic training (focusing on body parts and bodily systems for targeted relaxation), and progressive muscle relaxation (PMR), which involves the clenching and relaxing of muscles. Yoga is another popular exercise that can be done very easily before bedtime, as well as Tai Chi or Qigong, which are extremely good for the heart and lungs. 

Education 

During therapy sessions, a CBTi therapist will educate a patient about the various techniques of the therapy and often follow up with a homework assignment to complete before the next session. This strategy ensures that the patient is working on the techniques and getting better at identifying and addressing high-risk patterns. This is an essential component of the therapy, and requires the full cooperation of both the patient and the provider in overcoming the problem.

In addition to sleep-related health issues, CBTi is known to have lasting benefits for a range of mental health or mood problems, and is an effective alternative to sleeping pills, which can be addictive and often include unfortunate side effects. The skills learned are useful for a lifetime, and the habits established can lead to more positive thinking, higher self discipline, and a higher quality of life.

Sources

American Journal of Health Promotion - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3085832/

American Sleep Association - https://www.sleepassociation.org/about-sleep/sleep-statistics/

Brain Sciences - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6956217/

ERJ Open Research - https://openres.ersjournals.com/content/6/2/00161-2020

KaiserPermanaente.org - https://thrive.kaiserpermanente.org/care-near-you/northern-california/sanjose/wp-content/uploads/sites/7/2015/10/sleep-restriction-rev2_tcm28-557887.pdf

Sleep - Cognitive Behavioral Therapy for Insomnia enhances depression outcomes in patients with comorbid major depressive disorder and insomnia - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2279754/

Sleep - Cognitive Behavioral Therapy for insomnia increases the use of continuous positive airway pressure - https://pubmed.ncbi.nlm.nih.gov/31403168/

Sleep - The effect of Cognitive Behavioral Therapy for insomnia on week-to-week changes in sleepiness and sleep parameters in patients with comorbid insomnia and sleep apnea: a randomized controlled trial - https://academic.oup.com/sleep/article/43/7/zsaa002/5700798

Stanford Healthcare - https://stanfordhealthcare.org/medical-treatments/c/cognitive-behavioral-therapy-insomnia/procedures/stimulus-control.html