Cognitive Behavioral Therapy for Insomnia

This is the 15th installment in the series Chronicle of Sleepless Nights.

Treatment 12

Finally, the day arrived for my first appointment with the sleep doctor. Dr. D was a clinical psychologist who specialized in Cognitive Behavioral Therapy for Insomnia (CBT-I).

In preparation for my first visit, Michael suggested I write a short history and lay out the problems I was dealing with and all I had tried so far. Here is what I wrote and brought to my first appointment:

Short Personal Statement and Sleep History

I have had a good life and have been happily married for 35 years. I have adult twins and three grandchildren, and get along well with them. I have had a very successful career as a professor at the U of M and am phasing out to retire in May.

I was very physically active, strong, healthy, and following a vegan diet for three years. I was hiking, climbing mountains, feeling happy and upbeat, and sleeping well (fell asleep quickly, woke up a few times during the night, went back to sleep easily) except maybe once a month, taking a Benadryl. I thought I was the luckiest person in the world, despite my low vision (loss of central vision in both eyes as of 2002). I have been independent, walking and taking buses and getting along well.

The only time I had sleep problems, other than during menopause, was when I traveled overseas and had jet lag. The worst was last June when hiking in Scotland, and I slept only every other night for two weeks. Then it cleared up.

My current sleep problems began on September 8 when I started sleeping every other night. It cleared up after a few weeks of acupuncture and Chinese herbs, but came back October 18.

Since then, I have tried many drugs and either they don’t work well or not at all or stop working after a while. It seems that my body does not want to let me sleep, even to nap. I don’t get drowsy. I can be yawning all afternoon and evening and when I lay down to go to sleep, I am wide awake.

I took Trazodone for several weeks but still got up every 2 hours and it started to not work after 4 or 5 AM. It made me very anxious and panicky. I was also taking a GABA supplement at the same time and all during the night.

I then began to take Ambien. The first time I took 5 mg, I was up all night. Then I went to 10, then 12.5 time-release pills. It gives me about four hours of sleep. For several weeks I then took Valium for another two hours. But then the Valium stopped working and I stopped taking it. Now I am on Ambien for a few hours and then Temazepam which I take at 3 or 4 AM. I have been on it for 10 days. I have been on Ambien for two months.

My main symptoms are feeling tired, yawning a lot, burning dry eyes, and anxiety about the sleep problems and my future plans. My already poor vision also feels blurrier from the drugs. I also get headaches from lack of sleep. I feel sleep deprived and had a breakdown in mid-December when nothing was working. That led to changes and increases in medication. I have changed my diet completely and am no longer vegan. I cut my exercise way back to mostly walking and yoga. I try to get outside every day and walk.

I am also taking Chinese herbs and having acupuncture, and have seen a therapist about five times since this began. I have given up caffeine, alcohol, sugar and gluten.

For the last two months I have followed a bedtime routine of taking a warm bath with Epsom salt and lavender oil at 9:30, then doing some restorative yoga poses, then listening to a good book, then taking my Ambien at 10:30. I have new bed clothes, use a sleep noise machine and a sleep mask, and put lavender oil on my bed linens at night. For the past week I have been listening to a sleep hypnosis app after I take Ambien to help me fall asleep, as sometimes I do not fall asleep until midnight or later.

My hypothesis of my sleep problems: I was getting too much exercise and depleting my body due to my low protein, low fat vegan diet. I seem to have caused adrenal fatigue and stopped producing enough cortisol and serotonin. These effects were masked by the endorphins I was getting from exercise so I felt great and had lots of energy, Until I crashed and stopped sleeping,

I have been trying to heal my body through less exercise, change in diet, vitamins, massage, acupuncture and herbs. But now I am dependent on drugs that don’t give me a lot of sleep and cause side effects.

We drove to the sleep center, which coincidentally was the same place my daughter-in-law, Laurel, had previously completed her overnight sleep study. In fact, on the day of my first appointment with Dr. D, Laurel saw a sleep psychologist as well, having had sleep apnea ruled out by her study.

Michael and I parked in the little lot, went inside, checked in, and waited expectantly. Eventually, a pleasant looking man in his forties came out to greet me and take us back to his office. He had read my prepared remarks and asked me some questions. I had also completed a survey about my sleep, as well as my physical and mental health. I had rated the quality of my sleep on a scale from 1 to 10 as a -3.

After we talked about my responses to the questionnaire and my prepared summary, I asked Dr. D if he thought he could help me. He said he could, and had helped many others with a success rate close to 100 percent. He believed he could help me eventually stop taking sleeping pills as he had helped other patients before. Dr. D was positive and encouraging. He told me about the treatment he used.

Cognitive behavioral therapy for insomnia (CBT-I) is a technique for treating insomnia without (or alongside) medications. CBT-I aims to improve sleep habits and behaviors by identifying and changing the thoughts and behaviors that are affecting a person’s ability to sleep. First, there are sleep hygiene guidelines to follow, such as:

• Limit activities in bed to sleep and sex.
• Get out of bed at the same time every morning.
• Get up and move to another room when sleep-onset does not occur within ten minutes.

The major component of the therapy is sleep restriction. Insomniacs typically spend a long time in bed not sleeping, which CBT-I sees as creating a mental association between the bed and insomnia. The bed therefore becomes a site of nightly frustration where it is difficult to relax. Sleep restriction is an effective component of CBT-I. It involves controlling time in bed (TIB) based upon the person’s sleep efficiency in order to restore the drive to sleep and reinforce the bed-sleep connection. Sleep Efficiency (SE) is the measure of reported Total Sleep Time (TST), the actual amount of time the patient was able to sleep, compared with her TIB. Sleep Efficiency = (Total Sleep Time / Time In Bed). For a good description of CBT-I, check out Mayo Clinic’s webpage Insomnia treatment: Cognitive behavioral therapy instead of sleeping pills.

Dr. D gave me a form to fill out for a week. Each morning and night I was to record my data. This included number of times awake and out of bed, what time I got into bed, and what time I got out of bed in the morning. Also I was to include any naps and alcohol consumed. Miraculously, Dr. D found four slots in his busy schedule for me to return to see him. He said it usually took five to six visits to complete the treatment. After a week of data collection, we returned to meet with Dr. D and start the CBT-I with restricted sleep. I was to stay up until 11:30 at night, and then go to bed. If I did not fall asleep within 20 minutes, I was to get out of bed and then return after 20 minutes and try again. I was to get out of bed for good at 6:30 AM. I was still taking Ambien when I went to bed and then Temazepam when I woke up during the night. But even with Ambien, I sometimes had trouble falling asleep and my sleep never lasted more than four hours. Michael was concerned that following this protocol of getting out of bed would disturb his sleep, so he decided to sleep in the basement for a while.

I was to keep my room dark, use eye shades and a sleep noise machine, and not read in bed. I decided to set up my office as the place to go during the night. I made up my futon/chaise longue with comfy pillows, afghans and quilts. I dimmed the bright floor lamp with a heavy orange shawl wrapped around the lamp shade. I bought a timer so I could set it for 20-minute increments in my office. I also started knitting a scarf to occupy my fingers while I was sitting in my office listening to a book. The book I started with was Maisie Dobbs.

My new routine at night began with my usual warm bath. I took my Ambien at 11 PM. Then I got into bed at 11:30. If I did not fall asleep within 20 minutes, I would get up, go into my office, and sit on the couch and listen to Maisie Dobbs while I knit, waiting until the magic 20 minutes had passed and I could go back to bed. I will never forget how this wonderful book helped me get through the nights. And then I followed the first book with the rest of the books in the series. If I woke again during the night and could not go back to sleep, I was back in my office again. I was to set an alarm at 6:30 AM and get out of bed. But I was always awake before the alarm, so I would shut it off early.

At night, before my bath and Ambien, Michael and I started another routine: watching an episode of Downton Abbey. We had never watched this series so we began with the first episode and continued on through the entire series. I looked forward to this each night, and would review the stories as I lay in bed later. We made it through all the seasons and they helped to keep me going. I realized that while watching this show, I forgot about my tiredness and sleep problems. They offered me a wonderful, nightly escape.

Going off Temazepam

I was starting to experience some side effects from the Temazepam. In particular, I was feeling dry eyes, a dry nose making breathing uncomfortable, a drugged feeling, and blurry vision. This last symptom was the most worrisome for me, given my low vision disability. Most people take Temazepam at bedtime, but I took it at 4 AM. Perhaps that is why I was more aware of the side effects. I decided to try to get off Temazepam and go back to taking GABA after I woke up from Ambien.

The first night of my CBT-I treatment, I went to bed at 11:30 PM with a sense of happiness and relief that I could now go to my comfy bed. I did not fall asleep until 12. I woke up at 4, and did not go back to sleep again.

I broke down and tried JK’s Pineapple Kush, but nothing happened. I did not take Temazepam, because by now it was 5 AM and it seemed too late to take it.

I thought that if Temazepam was not working, that meant I was not dependent on it. But what a surprise: stopping was terrible. First of all, GABA also soon stopped working, so I would be up from 3 or 4 AM each day, after the Ambien wore off. I then started having some awful withdrawal symptoms — dizziness, woozy feeling, and a dry mouth — but I managed to survive each day. After six days my withdrawal symptoms became even worse. More dizziness and now a new symptom: trouble swallowing. I thought I would tough it out, and would inform my doctor about the withdrawal the next time I saw him.

February 27 I woke up at 3:30 AM and could not go back to sleep, despite taking seven GABA over two hours. The next day I felt awful — nauseated, dizzy, and depressed. I felt as if drugs were coursing through my body. I cancelled my regular time with my grandson Davis.

I lay on the living room couch for four hours and dozed a tiny bit. I had no appetite. I began to feel scared. I realized that I would probably have even more discomfort when I eventually withdrew from Ambien. On February 28, 2016, I wrote to my sister:

I had the weekend from hell. Very very hard. Trying to keep a stiff upper lip. Feel like I went back to square one. Gave up Temazepam last week and thought I was over it, but withdrawal hit me big time on Thursday. I should have tapered off rather than going cold turkey.

What a lesson this has been. Three days of awful drug withdrawal, 4 hours of sleep at night, constant diarrhea, more weight loss, shaking, dry eyes, dry mouth, dry nose, waves of hot and cold flashes, UGH. I am trying to keep my spirits up as I cancel events right and left. Sorry to be so negative.

My sister wrote a loving and encouraging message back, which I clung to. She was the closest thing to a parent, and I felt I needed some parenting to get me through this time.

As I practiced the new routine and recorded my data each day, I also checked in with Laurel. While I was told to go to bed at 11:30, her treatment started with a 2:30 AM bedtime. She was miserable. Each morning we texted each other about how we were doing and offered encouragement and support. She went off of the Ambien she had been taking and soon began to improve. I was happy for her and also envious, as my progress seemed much slower.

I still felt hopeful that Dr. D could help me sleep better and get off drugs. But I was increasingly worried about my physical state. At our next appointment, I told him about my drug withdrawal symptoms. Because he was a psychologist and not a medical doctor, he suggested I talk with my doctor when I was ready to stop Ambien, for a planned tapered withdrawal. He suggested I first start sleeping better and then deal with stopping the Ambien.

At that appointment Dr. D. told us that his patients were usually angry at him after their first week of sleep restriction because they had slept even worse than before the treatment, but he assured me things would get better. He entered my sleep data into his computer and shared with me my dismal statistics on sleep efficiency. There was much room for improvement.

Michael and I actually enjoyed our visits with Dr. D. Because he knew we both had degrees in psychology and expertise in statistics and research methods, he shared information on both his dissertation research on CBT-I and other current research. One day he told us with excitement that the American Medical Association had issued a statement that CBT-I was a more effective treatment for insomnia than sleeping pills.

However, I would soon have to take a short detour from therapy, before returning again.

Next post: A Plea for Help