Treatment Approaches

Cognitive-Behavior Therapy for insomnia (CBT-I):

The National Institutes of Health (NIH) and the American College of Physicians (ACP) recommend Cognitive Behavioral Therapy for Insomnia (CBT-I) as the first line treatment for chronic insomnia. CBT-I is a very effective, short-term, and scientifically proven treatment.  CBT-I does not involve long-term treatment and is commonly completed in 6 treatment visits.   CBT-I is tailored to each patient and has been shown effective for those individuals ranging from adolescence to later adulthood. Participating in CBT-I is like going to sleep school.  You will learn how the sleep system works and how to apply the science of sleep to allow your sleep system to function optimally.  Through this process you will learn about what makes you vulnerable to insomnia and how to manage these vulnerabilities.  You will meet with your provider every 2-weeks to review your sleep logs, discuss contributing factors, and then apply what you learn to improve your sleep. 

CBT-I is not to be confused with “sleep hygiene” recommendations which are often not effective for chronic insomnia. Sleep hygiene recommendations are the list of things to avoid (i.e. caffeine) and strategies (i.e. go to bed at the same time).  Many of our patients have already seen providers who have introduced them to sleep hygiene recommendations.  Unfortunately, practicing good sleep hygiene often doesn’t resolve the sleep problem.  Many providers are familiar with the basic concepts of CBT, however competently providing CBT-I can be complicated by a number of factors.  If seeking CBT-I it is best to find a provider who is trained in both CBT-I and treatment for other commonly co-occurring sleep disorders.  Finding such an expert can be challenging as there are only a few hundred of these experts nationwide.  To find a behavioral sleep expert, look for a provider who is certified in behavioral sleep medicine and/or a diplomate of behavioral sleep medicine.

Note on Sleep Medications -  Although sleep medications are often recommended for management of insomnia, these medications are only recommended for short-term use (4-6 weeks).  The reason medications are only for short-term use is because they carry significant consequences.  Consequences of sleep medication include impaired cognitive functioning (learning and memory problems) and dependence (believe you have to take it in order to sleep). In addition, sleeping pills have been associated with risk for developing other serious health complications including cancer.

Chronotherapeutics for Circadian Rhythm Sleep Disorders:

Chronotherapy involves making changes to your sleep and wake times to reset your biological sleep clock in order to maximize health benefits and minimize adverse effects.  Commonly used chronotherpeutic approaches include scheduled light exposure, activity/inactivity, and meal times to facilitate movement of the circadian rhythm in the desired direction.  It may also involve short-term use of a low dose of melatonin taken at a specified time to promote circadian movement or adjustment to schedule changes.

Imagery Rehearsal Therapy (IRT) for Nightmares:

Imagery rehearsal therapy (IRT) is a cognitive-behavioral treatment for reducing the number and intensity of nightmares.  Nightmares are particularly common in those with posttraumatic stress disorder (PTSD).  In IRT treatment, you're helped to reimagine your nightmares with different, less frightening outcomes. The goal is to "reprogram" your nightmares to be less terrifying if and when they occur again.

Relaxation Training and Mindfulness Based Cognitive Therapy for Cardiac Conditions:

Relaxation Training involves development of an understanding of how your sympathetic nervous system works, identifying triggers, and learning relaxation techniques.  Mindfulness is defined as the capacity to intentionally be in the present moment without judgement. Two of the main mindfulness based approaches, which aim to cultivate mindfulness therapeutically include Mindfulness Based Stress Reduction (MBSR), and Mindfulness Based Cognitive Therapy (MBCT). MBSR is a structured, manualized treatment program originally developed for the management of chronic pain and now used widely to reduce psychological morbidity associated with chronic illnesses. MBCT, derived from MBSR, was designed for people with a history of recurrent depression to help prevent future recurrences and is now being applied to help manage many chronic health conditions.  The goal of treatment is to reduce your reactivity to stressors, better control anger, and improve recognition/management of anxiety.

Cognitive-Behavior Therapy for Pain (CBT-P):

CBT for pain management (CBT-P) has three basic components. The first is a treatment rationale that helps patients understand that cognitions and behavior can affect the pain experience and emphasizes the role that patients can play in controlling their own pain.

The second component of CBT is coping skills training. Training is provided in a wide variety of cognitive and behavioral pain coping strategies. Progressive relaxation and cue-controlled brief relaxation exercises are used to decrease muscle tension, reduce emotional distress, and divert attention from pain. Activity pacing and pleasant activity scheduling are used to help patients increase the level and range of their activities. Training in distraction techniques such as pleasant imagery, counting methods, and use of a focal point helps patients learn to divert attention away from severe pain episodes. Cognitive restructuring is used to help patients identify and challenge overly negative pain-related thoughts and to replace these thoughts with more adaptive, coping thoughts.

The third component of CBT involves the application and maintenance of learned coping skills. During this phase of treatment, patients are encouraged to apply their coping skills to a progressively wider range of daily situations. Patients are taught problem solving methods that enable them to analyze and develop plans for dealing with pain flares and other challenging situations. Self-monitoring and behavioral contracting methods also are used to prompt and reinforce frequent coping skills practice.

PAP Desensitization for Claustrophobia:

PAP desensitization involves learning how your anxiety response system works, developing relaxation techniques, and systematically applying these techniques to enable you to overcome your PAP related anxiety. 

Biofeedback:

Biofeedback is the process of gaining greater awareness of many physical functions primarily using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will.  Some of the processes that can be controlled include heart rate, skin conductance, skin temperature, and muscle tension.  In biofeedback, you are connected to electrical sensors that help you receive information (feedback) about your body (bio). Biofeedback may be used to improve health, performance, and the physiological changes that often occur in conjunction with changes to thoughts, emotions, and behavior. Eventually, these changes may be maintained without the use of biofeedback equipment.  Biofeedback has been found to be helpful with anxiety, pain, headache, bruxism, and other stress related health conditions.