The CBT Dive

E9 Awake and frustrated: all about insomnia

• Rahim Thawer, MSW • Episode 9

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What keeps you up at night? And how does a thought-restructuring tool help with sleep? In this special episode, I interview two sleep medicine specialists based in Australia. We discuss what drives sleep disturbance and insomnia and behavioural approaches to support people who struggle with getting good sleep. Have a look at the D-BAS 16 questionnaire below to see if you have dysfunctional beliefs that drive your insomnia.

-RESOURCES-

SCALE: Dysfunctional Beliefs and Attitudes About Sleep:
http://www.cets.ulaval.ca/sites/cets.ulaval.ca/files/dysfunctional_beliefs_and_attitudes_about_sleep_16_items.pdf

ARTICLE: Trauer JM, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med. 2015 Aug 4;163(3):191-204.
https://pubmed.ncbi.nlm.nih.gov/26054060/

PODCAST: https://sleephub.com.au/podcast/

-GUEST BIOs-
Dr. David Cunnington is a sleep physician and director of Melbourne Sleep Disorders Centre, and co-founder and contributor to the SleepHub podcast. David trained in sleep medicine both in Australia and in the United States, at Harvard Medical School, and is an International Sleep Medicine Specialist, Diplomate Behavioral Sleep Medicine and Registered Polysomnographic Technologist. David’s clinical practice covers all areas of sleep medicine and he is actively involved in training health professionals in sleep.

Twitter: @DavidCunnington
Instagram: @drdavidcunnington
More: https://drdavidcunnington.com.au/

Associate Professor James Trauer is a respiratory, sleep, general and public health physician, and head of Epidemiological Modelling at Monash University's School of Public Health and Preventive Medicine. He undertook regular practice in sleep medicine from 2013 to 2017 at Melbourne Sleep Disorders Centre with Dr. Cunnington, before focusing increasingly on research. His main research interests are the epidemiology and transmission of respiratory infections, which focused primarily on TB until 2019 when he shifted to predominantly COVID-19 research.

Twitter: @JamesTrauer
More: https://research.monash.edu/en/persons/james-trauer

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ABOUT THE CBT DIVE PODCAST
The CBT Dive is a video podcast that brings therapy skills to the real world. Each episode welcomes a new guest who wants to explore a challenging situation using the most common cognitive behavioural therapy tool: the thought record.

ABOUT HOST
Rahim Thawer is a queer, racialized social worker and psychotherapist based in Toronto. He's created The CBT Dive podcast to support folks who want to learn how to use a thought record and to demystify what therapy can look like.

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UNKNOWN:

Thank you.

SPEAKER_00:

Welcome to the CBT Dive, a vodcast that goes into the lives of real people with real struggles. Each episode welcomes a new guest who wants to explore a challenging situation using the most common cognitive behavioral therapy tool, the Thought Record. Your host, Raheem Thawar, is a social worker and psychotherapist based in Toronto and well-known for his work in LGBTQ communities. He's created the CBT Dive to diminish What therapy can look like and share intervention skills for wellness. We hope that each episode helps you along on your own journey for insight and self-compassion.

SPEAKER_01:

All right, folks, welcome to the CBT Dive. Today, I've got two special guests. The first is Dr. David Cunnington. He is a sleep physician and director of the Melbourne Sleep Disorder Center and a co-founder and contributor to Sleep Hub. David trained in sleep medicine, both in Australia and the United States at Harvard Medical School, and is an international sleep medicine specialist, diplomat in behavioral sleep medicine, and a registered polysomnographic technologist. David's clinical practice covers all areas of sleep medicine, and he's actively involved in training health professionals in sleep. Say hi, Dr. Cunningham. Cunnington Ham. Cunnington. Sorry. All right. And our next guest is Professor James Trower, who is a respiratory sleep general practitioner. and public health physician and head of epidemiological modeling at Monash University's School of Public Health and Preventive Medicine. He undertook regular practice in sleep medicine from 2013 to 2017 at the Melbourne Sleep Disorder Centre with Dr. Cunnington before focusing increasingly on research. His main research interests are the epidemiology and transmission of respiratory infections, which focused primarily on TB until 2019, when he shifted to predominantly focusing on COVID-19 research. So welcome to both of you. It's such an honor to have you both.

SPEAKER_04:

Thanks, Rahim. Thanks for having us.

SPEAKER_01:

You're very welcome. And just to be clear, you're both currently in Australia. Yep, absolutely. And I'm curious to know, So I understand that you're in sleep medicine, but what's the link between sleep medicine and CBT interventions? Or how did you come across the link between the two? David,

SPEAKER_04:

do you want to start it off, David? Sorry.

SPEAKER_03:

So as clinicians working with people who've got sleep problems, so even though we're both physicians, so we come to this as medical practitioners, as medical practitioners, we have to work on people's behaviour and change their behaviour, change their beliefs, get them on board, get them engaged with the treatment program we want them to follow. work with us on and so part of doing cbt although we don't have formal cbt training if you like as medical practitioners we get a lot of exposure to it and then in sleep medicine in particular it's got such an overlap with the behavioral sciences with psychological sciences with sociology with cultural factors that you can't really practice as a doctor in sleep medicine without being pretty broad and having that interest outside of the strict medical sort of construct. Right. And so that's sort of partly that sleep medicine sort of lends itself to a much broader sort of practice outside just that straight medical construct. And so to the area that we were working in and we still work in is a lot of insomnia. And really, the first line therapy for insomnia should be psychologically based strategies. And the only way I can... deliver therapy to my patients is having to outsource it to yet another provider. That's not really providing a great service for my patients. So I'd much prefer to be able to go, right, okay, at a medical level, this is what I think the overarching framework is in terms of a diagnostic approach. But let's just kick it off and let's be able to deliver some CBT. And that's sort of where we come from clinically. And then when we were looking, you know, part of the research that James led is we were trying to look at, well, how do we sort of try and bring cognitive behavior therapy to the forefront and sort of highlight its role in a research sense as the sort of starting point or sort of the key sort of first-line therapy when you're looking at insomnia treatment.

SPEAKER_01:

Okay. So, Dr. Trauer, maybe you could enlighten us. Take us back a step. What is insomnia? Yeah. Like how do people experience it? How is it? What are the criteria for diagnosis? What is insomnia?

SPEAKER_04:

Yeah. Well, I mean, I think in terms of the formal criteria, I mean, I guess looking them up in a textbook or probably David will know them a lot better than me, but I suppose usually the reason for patients to present for care for insomnia and perhaps to see medical care given by medical practitioners, people don't generally have to have like quite a high level of dissatisfaction for what they're getting from sleep. And, I mean, it's more about that really. I mean, certainly like if you ask lay people, of course, what they perceive as being insomnia, it's just like not sleeping. And so you could obviously just like have a threshold and say, well, if somebody gets less than X number of hours per night, then that's insomnia. But that's really... not what insomnia is, of course, because some people are able to function on a much shorter period of time asleep or a much shorter period of time in bed each night, or they might have different sleep patterns. And if they're getting what they need out of sleep and they're able to function, then, of course, that's not necessarily a problem. But, yeah, the people who present to us for advice and for care are people who are who I suppose there's a disconnect between what they're getting out of sleep and what they feel they should be getting out of sleep.

SPEAKER_01:

I see. Thank you for that. David, do you want to add anything?

SPEAKER_03:

I agree with James. It's got to have those two pieces. It's got to have the sort of the criteria that, you know, really you could think about as sleep disturbance, which is an income

SPEAKER_02:

there.

SPEAKER_03:

And then it's got to have the criteria of impact on daytime functioning.

SPEAKER_02:

An

SPEAKER_03:

impact can be pretty broad. It can be distress, dissatisfaction, tiredness, poor ability to concentrate, a whole range of different things. And for insomnia, you've got to have each of those pieces. And so you've both got to have some disturbed sleep and it's got to have some consequences. That's really what takes it out of sleep disturbance. It's interesting. So when I'm peer reviewing for journals, often non-sleep sort of james public health specialists sometimes who are non-sleep people will send a paper and say it says you know this about insomnia and it's been some population-based survey and what they've really surveyed on is sleep disturbance so people who have disturbed sleep which again is just a different beast it's not it's not insomnia insomnia is going to have that daytime dysfunction and distress and that's really important when we start to get into thinking about some of the treatment Because a lot of the treatment is actually relieving distress, again, which sort of comes back to the CBT. Whereas often people are coming to us going, well, what I want is more minutes of sleep. And really they're like, what we need to do is reduce distress. And the minutes of sleep, you know, that's not really the thing. It's actually about distress. And so a lot of the sort of research tools now we're using to look at outcomes in insomnia research are measure distress or have a distress as one of the sort of key measures, much more so how many more minutes of sleep did you get?

SPEAKER_01:

Okay. Look, I'm very curious to know if there's a particular type of client or patient that you see that's affected by insomnia. For example, people sometimes will comment on somebody who works night shifts or somebody who's a chronic cigarette smoker or somebody who smokes weed. There are stereotypes or ideas that there's a particular kind of person who's more vulnerable to insomnia. Do you see that in your work?

SPEAKER_03:

So yes, except we all get insomnia. All of

SPEAKER_01:

us. Oh, okay.

SPEAKER_03:

So all of us get short-term acute insomnia. So at any point in a given year, all of us will get sleep disturbance that impacts on our daytime function. You know, when we used to travel, change in time zones or we have intercurrent stress or any of those things. So we're all prone to it. It's the human condition. But then if we think of subgroups that are more prone to it, so who gets more incidental sleep disruption? Shift workers. Absolutely. Because they're making non-biological shifts. Who gets more sort of biological sleep disruption? So people who are taking substances that might impact on sleep. So that's your cigarette smoking, some other illicit substances. substances, prescribed medications that can impact on sleep, people with comorbid physical or mental health issues. And then there are thinking or behavior patterns that make people more predisposed to getting insomnia. So we're doing some work at the minute on perfectionism and insomnia because there's a clear relationship there. And so that perfectionism trait runs pretty strongly in working professionals. So I see an over-representation of working professionals, particularly healthcare providers often. And it's almost, because insomnia as well, it's not insomnia, sleep's one of those domains in life. You can't make it better by trying harder. In fact, you make it worse by trying harder. And if we're sort of task-oriented and attention to detail people, that internal commentary. Well, I'm doing the nine out of 10 things. The reason I'm not sleeping is I haven't got to the 10th thing. I really need to get that on track. Then you're going to set yourself up for having increasing trouble about sleep.

SPEAKER_01:

Okay. I just have to let you know that I'm an overachiever perfectionist and I sleep fantastically. So study me, please. I treat sleep like a task. I just say it's bedtime. And this is a thing you have to do and you have to wake up by this time. And then I do. And it's very

SPEAKER_03:

lucky. You've got the benefit of youth on your side because the natural history of this is we don't see many people in their 20s and 30s with this because essentially we all get these little nudges that push our sleep out. And we, in a task oriented way, get it back on track. But then as health is a little less robust and we get a little bit more, our list of sort of contingent thinking around sleep gets a bit longer and our baggage around sleep and life gets a bit more complex, it doesn't come back on track as readily. So we're often seeing people in their sort of mid-30s into their 40s who said, you know, 20s, I could sleep okay. 30s, not quite so great. Now it's just not working.

UNKNOWN:

Yeah.

SPEAKER_01:

Okay, well, I'm almost 37. So I'm, I guess I'll get a referral. Look, before I get I have a couple more questions about CBT for insomnia. But before I get there, I think there's a misinformation or stereotypes or, you know, multiple truths out there about the impact on alcohol and sleep. In my therapy practice, I see some people who sometimes rely on alcohol to fall asleep and others who have very disturbed sleep when they drink too much. I don't know. James, do you want to comment on that?

SPEAKER_04:

Sure. Well, I mean, of course, alcohol is a central nervous system depressant. So it will be effective for people to get off to sleep. But then we also know that it causes dehydration and various other issues. And I mean, my clinical practice, I found it really is actually something that disturbs sleep quite a lot and really fragments sleep. And so and so is is a significant problem. And I mean, we'll probably come to sleep hygiene at some point. And I guess it's something I guess I think David and I are maybe not the greatest believers in sleep hygiene. But the one bit of sleep hygiene that I think really is worth focusing on is if you're sleeping poorly, cut out alcohol. It's really also my personal experience. I find it's really particularly bad for sleep. And yeah, so it causes it causes fragmentation. But then it also sort of like. because it helps people to get off to sleep. If somebody has insomnia and has disturbed sleep, they might then start drinking more alcohol to sort of compensate for that and get themselves off to sleep, but not realize that under the surface, they've got highly fragmented sleep that they're perpetuating by drinking alcohol.

SPEAKER_01:

Ah, I see. David, did you want to add anything?

SPEAKER_03:

James has summarized that really well.

SPEAKER_01:

All right. So, you know what, since we're on it, What are some of your critiques of sleep hygiene? And I ask this because I've had physicians refer people to my therapy practice to say this person is struggling with insomnia. But usually for me, it's also comorbid with substance use disorders. And the physician will say, I think they need some CBT and some sleep hygiene coaching. So, and I, you know, for us as doing like the one-on-one therapeutic work, like there's all kinds of worksheets in sleep hygiene. The things that are recommended in that are not always things that I do myself. So I don't have a strong belief in it, but it's a resource I give to people. So I'm curious to hear your thoughts on it. Whomever wants to share.

SPEAKER_03:

So maybe I'll start. So in terms of, if you think of, we talked a little bit about who's coming with insomnia and who gets insomnia. So sort of think of it as there are some people who get it because they're disrespectful of sleep. So think of that as using illicit substances that might keep you awake, for example,

SPEAKER_02:

or

SPEAKER_03:

using socially acceptable substances that keep you awake, like caffeine, right? for example, and drinking too much or, you know, watching TV too late at night, right? Or, you know, I love this term that's, you know, it's a recent term people talk about called revenge bedtime procrastination. And, you know, it's just really summarizes a lot of people's behavior around sleep as well. And so there's some people that are doing it all wrong. They're disrespectful of sleep and they're not sleeping. And in fact, all I got to do is just cut that out. Be respectful of sleep and sleep will sort itself out. So for them, sleep hygiene can be a really good strategy, can be a really helpful strategy. But often as healthcare providers, people have sorted that out themselves. You know, there's enough barriers, particularly, you know, for James and I as medical specialists, the way it works in Australia, you've got to get through your primary care practitioner and get a referral and wait and then come and see us. So by the time people have sort of gone through those steps, they've usually sorted out, yeah, maybe I could sort this out myself. Maybe there's some things I could tidy up. And they've sort of worked through that. So we've, by the time someone's getting to us as the healthcare providers, I'm giving them, yeah, here's the tear off sheet of some rules you could have accessed on the internet, you know, day one. It's not a high value ad. And it's not, it doesn't sort of, they don't respect me then as a therapist or as a healthcare provider because they're like, yeah, I know that. I've already got that covered. And so that's one group. And then there's the group who I talked about, you know, perfectionistic sort of traits. So really the reason they've gotten into insomnia is they're trying too hard. That's, and they almost need to sort of back away from it and back away from sleep. And for them, sleep hygiene is particularly problematic because because they're the sort of diligent, responsible, sort of pay attention to detail type of individuals. And they're already scoring, they're acing their sleep hygiene exams. You know, their sleep hygiene is perfect. You know, it's squeaky clean already, but they're looking to tweak it to the nth degree and to find just the extra thing. If only I could find that extra thing, that would... sort of solved my problem. So they're the group where sleep hygiene can actually be really bad. And by the time someone's coming to me as sort of a specialist provider in sleep, I'm actually deconstructing their rules and getting them back to a more fluid way of thinking about sleep. That's sort of that. And then, James, you know, talk about the research side of it and where we think the sort of hygiene sort of fits in that side.

SPEAKER_04:

Yeah, I mean, I guess the other thing to mention is, as you said in my bio, Rahim, that I haven't been working in this field for a little while, but at the point that we reviewed the evidence, which was sort of five or six years ago now, I guess we reviewed CBT as a multimodal therapy for sleep. And some of the components are probably more effective than others. There is not as strong evidence around sleep hygiene as a single therapy for sleep, as far as I'm aware, unless the field's moved on.

SPEAKER_01:

And you did review 91 articles, right?

UNKNOWN:

Yeah.

SPEAKER_04:

Right, but we excluded ones that only included one modality. But even so, you know, I guess we developed some familiarity with the evidence base, which David will still have. And I mean, you know, like sleep, there is not like a glut of randomised controlled trials showing that sleep hygiene alone will cure somebody's insomnia. So to begin with, I think the evidence base is relatively weak. But for me... I guess for me, the biggest thing, which I can talk to you more if you want, is that it doesn't really get to the nub of what most people's problem is. It doesn't address the problem, which is frustration with time spent awake in bed. It's sort of like, it's almost totally, I guess, oblique to that fundamental problem.

SPEAKER_01:

Okay. Look, so when you talk about frustration of... time spent awake in bed, it makes me think about just what it is that keeps people up. And I've often conceptualized difficulty with sleeping is rooted in anxiety and depression at times. Would you agree that a lot of people with insomnia do have concurrent anxiety or depression?

SPEAKER_04:

there's an association. I'm not sure how strong it is. I mean, specifically in relation to the one study that we're mentioning, we excluded studies that just focused only on anxiety and depression. I mean, I think there is an association. There's an interesting relationship between anxiety and depression. And there's all sorts of really interesting studies like studies of sleep restriction for depression as a treatment. So reducing sleep time can actually help in some states have a positive, like in some delivery modes, I guess, can have a positive effect on depression and the relationship with anxiety is probably there. And there is a lot of interplay there, but there's also like a large proportion of people who just have, who have insomnia as the primary condition. And I guess the other thing is that insomnia is sometimes like, almost like a pre-diagnostic feature of depression. Like people would develop some When people have that real sort of biological or organic depression, they'll have like a period of a lead in period where they have some insomnia features before they develop mood disturbance. So it's a really fascinating and complex interaction that I don't fully understand. But there's also a lot of like non-depression and anxiety related insomnia out there, I think.

SPEAKER_03:

And it's interesting that it comes in, in a clinical sense, it comes in a couple of flavors. So, you know, you will recognize the fire. I'm getting a lot of these referrals at the minute because with pandemic, our mental health services are overwhelmed, you know, where the referral is, you know, this person has got a background of anxiety and depression and that's decompensated and they're not sleeping well. Can you fix their sleep? Like seriously, you know, you need to up the ante on the anxiety and depression treatment because that's, the thing that's gone off. And as a consequence of that, they're not sleeping well. But then there's also the other, the other sort of way of coming at it, like James was talking about. So no background anxiety and depression, you know, maybe that tendency of a ruminative type of thinking style or a tendency to worry and just in a sort of personality or thinking style characteristic start to not sleep well. start to get some sleep-related anxiety and some sort of negative cognitions and self-doubt and that sort of stuff around sleep. And then you sort of just, it's a little spark that starts the sleep anxiety. And once the sleep anxiety ramps up, then that anxiety spreads to another domain and you start to get a little bit of health-related anxiety and then that starts to ramp up and then you get a little bit of work or relationship-related anxiety. And it's like the sleep stuff, the spark and the kindling that then sort of grows and it goes into a bigger fire and a bigger fire and a bigger fire. But it's the sort of anxiety about sleep that's what turns it from just a tendency to worry and ruminate into not sleeping and anxiety.

SPEAKER_01:

Okay. James, did you want to add anything? I saw you on mute. Oh,

SPEAKER_04:

no, no. Yeah. I think I've covered that. Yeah. Okay. Yep.

SPEAKER_01:

Okay. Well, look, you, you, uh, David, you've taken us to the next thing that I really want to ask about. So when we think about CBT, cognitive behavioral therapy and its specific techniques and tools, you know, there's all kinds of things. There's like, um, uh, behavioral exposures, there's behavioral experiments, there's thought records, there's activity scheduling and activity diaries. So there's a number of tools embedded in CBT. Primarily, I think the most popular for a lot of people is the thought record. And when I do work around the thought record, it is identifying unhelpful thinking styles or negative automatic thoughts and trying to restructure some of them. So my question is, what CBT tools are helpful for insomnia? And are there thoughts and beliefs that are connected to poor sleep?

SPEAKER_03:

Yeah, so let me pick on that thoughts bit and then maybe... I think James would probably be best to talk about the different components of CBT and how it all comes together. So the thoughts, so a really helpful tool for clinicians. If you're thinking about working clinically with people, I love a questionnaire called the DBAS or DBAS 16. So dysfunctional beliefs and attitudes around sleep, the 16 item questionnaire. And it's really 16 statements with like at scale responses of how strongly do you agree or disagree with these responses. And it's things like, I can't control my sleep. If I don't sleep eight hours, there will be these dire consequences, you know, statements like

SPEAKER_02:

that.

SPEAKER_03:

Once you're familiar with the items on the questionnaire, as a clinician, you just listen. You can almost sort of just listen to the narrative and you're like, yep, There's that one, there's that one, there's that one. The reason I quite like the questionnaire is that if I'm going to fill it out, I'll just fill it out and then we'll go, you score pretty high on these ones. And they can then become targets for your thought restructuring because they've already outed what's their sort of strong core beliefs that might be some of the drivers behind their insomnia. So that's what I really like as a clinical tool. And then how I sort of now use that as an experienced clinician is giving someone the space. to have a narrative and it's really telling them what does sleep mean to them i want to hear from them what does sleep mean what's the language they use around sleep do they use a motive language is it got a history has it got a story has it got emotion because that's the stuff i need to unpack to be able to help them manage their sleep in the longer term like sure i could give them a very didactic sort of structured sort of program but if I don't know the story around their sleep and what sleep means to them and what it means in an emotional sense. People with insomnia, sleep has emotional currency. Another way of thinking about it is it's a luxury good. I really want to sleep and I just can't have it. It's this aspirational thing. Whereas people who are good sleepers, sleep's a commodity. It's like, oh, yeah, take it or leave it. I'll have the white one. you know, whatever, I don't care. People who are insomniac, it's the, you know, it's the handbag, it's the Birkin bag, you know, it's the unachievable sort of aspirational thing.

SPEAKER_01:

I love it. You cited a Birkin bag. Okay, great. James, do you want to tell us a little bit more about the CBT tools or maybe the key components of CBT for insomnia?

SPEAKER_04:

Yeah. Yeah. Well, so, I mean, there are five, at least in the way that we defined the study five years ago. And we've discussed two of them to some extent. I think there's like heaps more we could say, of course, about those two, but we've discussed sleep hygiene and cognitive therapies to some extent. And then there's relaxation therapies, stimulus control and sleep restriction. Those other three, I find are, that we haven't talked about yet are really, really useful because they really get to the nub of the problem and particularly stimulus control and sleep restriction, I suppose. I mean, yeah, I'm not a great believer in sleep hygiene, as you've heard, but the other four, I think, as a package are really, really helpful. And all of them do actually really, all of the four other ones do get to the root of the problem for me, which is time awake in bed. And also, I guess, like, maybe the reason why I haven't mentioned cognitive therapy so much is just because I'm a physician and just the way, I guess, a consultation is set up with a physician, I've never felt like I have the time to work through that. So I usually outsource that and I usually refer that off to a psychologist. And I mean, and because of that, you know, they're better at it than I am. So I just sort of let them do it really. But I think like within the scope of anybody's consultation, like a general practitioner, a family physician or a sleep physician, I think there's plenty of scope to do really helpful work with sleep restriction and stimulus control. Actually, relaxation therapy. Sorry. Sorry, go on.

SPEAKER_01:

Okay. When you say stimulus control, sleep restriction, can you define some of these? What is this? I have no idea what these mean.

SPEAKER_04:

Sorry. Yeah. Let's talk about them a bit. I mean, so I guess what I was saying earlier is that the, sorry, I was, I promise I was going to come to that. What I was saying earlier is that the, is that the root, for most of these people who are frustrated with their sleep and would admit that they have insomnia is that they go to bed for however many hours and they spend a significant period of that time awake in bed. And the fact that they're awake in bed means that they're not achieving what they want to achieve from that time in their life. And so they may be perfectionistic, they may not be that perfectionist, but they're intensely frustrated about the fact that they really want to sleep and they're unable to do it. And so these are two techniques that just cut that out or are designed to it anyway. And they're very, very simple. So we can just describe them now, essentially. I mean, what I'd say to a patient for sleep restriction is think about how many hours of sleep you feel like you're getting per night and just spend that period of time in bed. And people are often doing the opposite, of course, with insomnia. So sleep restriction is just, you know, I guess you often get people come in that I'm spending eight hours in bed because that's ingrained culturally and people have told me to do it and I'm getting five hours of sleep. And so I guess sleep restriction, you spend five hours in bed. And if you do that, if you spend five hours in bed, you'll probably still get five hours of sleep, maybe four, five, something like that. You'll have three hours less time each night to lie in bed and get frustrated about the fact that you're not doing the thing that you want to be doing. So that's sleep restriction and why it works. And

SPEAKER_01:

then does the stimulus

SPEAKER_04:

control,

SPEAKER_01:

does the duration of sleep grow over time? Cause patients I've worked with, like they'll say, here's a common narrative is that, okay, I'm in bed. I'm in bed for six or eight hours and I'm only getting three or four hours of sleep. And so they're thinking if I, if I input this, my output is this. So maybe I need to make my input bigger. so that the number of hours of sleep I actually get grows a little bit. So with sleep restriction, so if I'm getting four hours and I just go down for four over time, can I expect that to grow? Because people's chief complaint is also that they're like exhausted the next day, they're grumpy, their partners are not happy with them, that kind of thing.

SPEAKER_04:

Yeah, I think that's... Well, yeah, but then they also will probably be getting better quality sleep. I think that's certainly the goal of it. Well, it's not certainly the goal. It's part of the goal. The main goal actually is to cut out time awake in bed. But part of the treatment does aim to increase sleep. total sleep time and it also will hopefully increase the quality of sleep so in the initial phase when you're first recommending somebody restrict their time in bed when you're recommending sleep restriction which is actually a bad term of course it's actually time in bed restriction you're trying to ultimately get more sleep so you initially restrict the time in bed And sleep hopefully fills up that time in bed. And once you've done that, you know, they're not an insomniac anymore. Like the problem in a sense is solved. And then you can just gradually, gradually increase the amount of time that they spend in bed and expect to get more sleep. And usually that works pretty well. They might, you know, they're probably not going to suddenly go to somebody who, become somebody who sleeps eight and a half hours every night and runs around the block, but it's going to be a pretty nice improvement.

UNKNOWN:

Okay.

SPEAKER_04:

Yeah.

SPEAKER_03:

Okay. Okay. So thank you for that. Another language around that that I'll use clinically is, you know, people, it's their aspirational sleep time. That sort of input approach is, you know, it's I'll choose to go to bed when I wish to sleep. And sleep is, like I talked about earlier, sleep is one of the few things in life we can't actively control. And it's frustrating because most other things we can actively control.

SPEAKER_01:

Yes.

SPEAKER_03:

And My wife loves Dr. Phil and people tell me, yeah, but I've been spending eight hours in bed and I'm only getting three hours sleep and you want me to spend less time in bed. It's going to be even worse. And I go, well, how's it working for you? Because that's the Dr. Phil line. How's it working for you? And it ain't working. So you do have to get people to be open to trying something different. And that's often the tricky part because people are highly distressed. When you're highly distressed, it's hard to change your thinking, change your behavior, which is what we need when someone's doing CBT. So that's a really tricky part of what we've got to do is get people to understand the rationale behind it, which James has explained nicely, so that then they're willing to take a risk, make some changes to their behavior, to try something new, try things in a new way.

SPEAKER_01:

Okay. Thank you for that. James, I'm going to go back to you. So we talked about sleep restriction and it's actually a misnomer because it's restriction of time awake in bed. Right. And the other thing you mentioned was stimulus control. Can you tell us a bit more about, like, what does that mean? So that is, it's, it's an intervention or a suggestion you would have for a patient, right? What does that involve?

SPEAKER_04:

Yeah. And that's, again, I mean, I mean, probably I'm just simplifying things because I'm just a doctor. And if you asked a proper psychologist, they would have a much better description of this, but, but stimulus control for me and the way I describe it to patients is just, if you're, if you're awake in bed and you, particularly if you're getting progressively frustrated with the time that you're spending in bed, just get out of bed, do something else, get outside of the bedroom environment so that you're not spending those large periods of time in the bedroom doing something other than sleep. And the classic one is just sort of lying in bed, trying to sleep, lying in bed, trying to sleep. I think a lot of people with insomnia do that for hours on end every day. And if you just stop doing that and if you're sort of, If you know after maybe 15 minutes or something that you're not getting off to sleep, you go into another room and do something else. And part of stimulus control is also removing any other activities from the bedroom. So the bedroom environment, I think it's, sorry, I'm probably speaking to psychologists now, but I think it's almost a Pavlovian sort of trigger that if you go into the bedroom and the bedroom is somewhere where you just sleep, that you will just sleep. Whereas if you go into the bedroom and the bedroom is somewhere where you watch television, Oh, there's one other thing you can do in the bedroom, of course, but we won't talk about that. But if you're frustrated and lying in bed, then just get out of bed and do something else in another room.

SPEAKER_01:

So here's the thing. We are going to talk about that thing. Is sex or masturbation helpful for sleep? Lots of people talk about it that way. Is there any research? Do we actually know if it's helpful? Yes.

SPEAKER_02:

Okay,

SPEAKER_01:

because is that a thing you would recommend to people?

SPEAKER_03:

No.

SPEAKER_01:

Oh, why not?

SPEAKER_03:

But most people aren't coming to us as medical practitioners going, do you think I should be doing this to help with my sleep? Because, again, by self-experimentation, they've usually tried that before they've come. Ah, okay. But absolutely there's a thing. And there's a couple of small papers that have put a sort of, not a research framework about it, but a sort of case description, case series around it. So not just for insomnia and helping with sleep, there's a paper on restless legs. So people with restless leg symptoms that can be settled after sex. So, yeah. Okay. Okay. It's a thing.

SPEAKER_01:

Okay. It's a thing. Are there any other intervention strategies that are part of CBT therapy? for insomnia that we haven't discussed or that you would want to highlight for some of our listeners?

SPEAKER_04:

I guess just because we've covered four of the five, we might as well cover the fifth briefly, which is because I do think it's really useful, which is relaxation. I mean, I guess in my practice with David, we were recommending a lot of mindfulness meditation type therapies, but it's not so much about which therapy it is. It's just about reducing levels of anxiety through the day and not necessarily immediately before bed because it's Because then it can become about like some sort of, again, it's sort of like perfectionistic. I'm like I'm desperately going to try to relax for one hour before I sleep. It's not so much about that. It's about just doing something that works for you and just, you know, like just getting your regular daily bubbling anxiety levels that everybody has to some extent, just get them down sort of 10%, 20%. We'll just make it easier to sleep at night when you come to trying to do that exercise. So it's a really helpful part of the package as well.

SPEAKER_01:

Okay. You know, of the five components, can we name them all again in just a list now that we've described them? So there's relaxation. What are the other ones again?

SPEAKER_04:

Sleep hygiene. In our paper, it's called cognitive therapies, which we were discussing earlier. I guess that's the thought restructuring we were talking about. Stimulus control and sleep restriction.

SPEAKER_01:

Okay, stimulus control, sleep restriction, cognitive behavioral techniques or thought records or whatever, like cognitive restructuring, relaxation, and sleep hygiene. Okay, I've got it covered.

SPEAKER_03:

That's a pretty standard package, and still is, in the insomnia research world. Over about the last 20 years, it's been that sort of five-component package. And what we've been doing in recent years is thinking, okay, that's got a certain efficacy, but there's a certain proportion of people who don't respond or don't completely respond to that. So we're looking at add-ons, you know, what's going to give you more than that. And so that's where in recent years, metacognitive techniques, be it mindfulness, be it acceptance commitment therapy, but largely sort of thinking about how you think in some respects and being a bit more okay with just thinking around sleep it is you know acceptance letting go those sort of concepts have been used in some randomized um control trial evidence we published a study um looking at mindfulness um based therapy for insomnia and then another add-on is light and looking at the impact of light on sleep Because there's data in not just thinking about circadian rhythm disorders, but also in insomnia, that a certain proportion of people with insomnia have a circadian rhythm disturbance as part of their insomnia. So managing either too much light exposure once the sun's gone down or insufficient light exposure once the sun comes up is contributing factors to sleep problems.

SPEAKER_01:

Oh, okay.

UNKNOWN:

Yeah.

SPEAKER_01:

My last question for both of you is about sleeping pills and other medications. I've known a number of patients that I've tried to support around sleep issues, sometimes concurrent substance use issues, and their doctors are often prescribing them medication. And then there's, it's, almost always there seems to be a kind of dependency that's developed, a request for more, a denial of an increase in prescription. I feel like I see a pattern and it makes me as a therapist feel a bit helpless. And I wonder if you could shed some light on when medication is helpful and when it's not, or what the challenges are around sleeping pills.

SPEAKER_03:

Yeah, so I think there are a couple of situations. So one situation where I find medication helpful is someone who, let's just say coming in, doesn't have prior mental or physical health issues but has had difficulty with insomnia and have really become highly distressed with it. So in that situation, short-term use of a medication is helpful to give them the stability and the wiggle room to be able to feel like they can take a risk and make the behavioural changes and think about sleep in a different way. Because if they're highly distressed and just hanging on by their fingertips, they're not going to be able to make those changes in behaviour that you've got to do with sleep restriction and stimulus control, you know, do things differently. They're not going to be able to look at sleep a different way, which is what you need with the thought restructuring and the cognitive therapy to be able to go, yeah, could I approach this differently? If you're just hanging in there and you're highly distressed, you're not in the headspace to participate in that. So that's one sort of wrong interpretation. A good research base showing in that group, if you initiate medication and CBT concurrently, then you can fade out the medication and then continue on the CBT and drugs sort of strategy. Another group I see, which your description reminds me a lot more, is people whose really the underlying problem is impulse control and inability to self-soothe. That's the underlying sort of personality characteristic that I've got to fix it now. I can't sit with something that's not the way I want it to be.

SPEAKER_02:

And

SPEAKER_03:

I'll try a CBT for two nights and dismiss it and then be on the phone going, this psychology-based strategy doesn't work. Or they'll drop the medication and one night in going, that didn't work. What else you got for me? And you find in a week, churned through four meds or gone from one tablet to three in four days. And that becomes messy. Right. That is the red flag going, you know, that is the group. I don't have to start down that road of medication because once you start down that road, it never ends. You know, it's a road that doesn't have an end. Unless they wouldn't sign up for two years of DVT and some pretty serious type of therapy. Sure. Okay. And so there's a group where early on in my sense is it's that impulsivity and just inability to tolerate things not being the way I wish they were. That's a group I'm really cautious about. And often, like you said, they're the group that come to us as healthcare providers from the illicit substance use because it's those same characteristics that have gotten into that illicit sort of substance use sort of area. So I'm much more taking the slow road, trying to do some longer term, maybe not CBT, but some of the longer term psychotherapies for that growth. Okay.

SPEAKER_01:

James, did you want to add anything?

SPEAKER_04:

Oh, well, not too much. I mean, that covers a lot of it. I guess just the only, maybe the only other thing that I'd add is just that it's not just the dependence. I mean, I think we do see, of course, dependence for people who use these things long term. For me, the reason not to use it for chronic insomnia or insomnia disorder or like, you know, you can use it for acute insomnia, like it has a place for those sorts of things. I mean, you take a sleeping tablet three nights because you've just had a distressing experience event in your life or something you're not going to suddenly get addicted to it so we don't

SPEAKER_02:

need

SPEAKER_04:

to overstress that either but for people with chronic insomnia for me the main issue is that it again is not treating the problem the problem is that people are frustrated with time time awake in bed and they're getting anxious during the day. And what you will often see is that you start people on these tablets and they're sort of like a bit spaced out over and you say, were you awake for three hours? And they're like, well, sort of, I was a bit like dazed. And then you ask them how they felt the next day and they actually feel the same during the day. So they're still sort of dissatisfied with sleep and they still have the same daytime symptoms, which is sort of what it's all about anyway. But they're just, it's just sort of like altered their perception of sleep. And if you do a sleep study, it's all about their sleep architecture as well. So I guess it's like... And it's also to acknowledge that insomnia is essentially a behavioral condition. And so a behavioral treatment is probably the most appropriate for that and gets to the root of the problem.

SPEAKER_01:

So... I don't know what the status of cannabis use is like in Australia, but in Canada, since it's become legalized and regulated and sold and all kinds, there's dispensaries popping up on every block and CBD in particular is being promoted to help people with better sleep. And I don't know if that, does that enter your practice? Is that something that people should be looking more at or would you caution against that?

SPEAKER_03:

So part of the interesting area, I suppose, with CBD and medicinal cannabinoids, absolutely, I'm sure they will have a role, but the hype and the promise is well ahead of the research at the moment. Okay. So if we look at randomized controlled trials of medicinal cannabinoids, for example, for insomnia, it's actually very little. There's just been a study completed in Australia that had a total of 33 participants, showed some positive results. but that's for a particular mix of CBD with some THC. Now, can you generalise that to the CBD you're going to buy from the dispensary around the corner to the one that's from the next corner that had a different mix of plants that they've made their CBD oil from? No. And it's only one small study. So there's lots of promise, but the research is lagging. And so that makes it really hard. So I don't prescribe medicinal cannabinoids, not because I don't believe in them, but my analogy is it's a bit like cooking. And I want to see the very experienced chef who knows the pinch of this and a pinch of that, and I just need a little bit more to get the recipe right. And that takes quite a lot of expertise. Yes. Because medicinal cannabinoids isn't sort of one drug. It's many, many, many drugs and just a tincture of this, a tincture of that. Right. And it's a bit more of a craft at the moment than a science.

SPEAKER_01:

Okay. All right. James, anything you want to add to this conversation? I see you smiling about it.

SPEAKER_04:

Oh, no, no, no. Yeah, I don't have anything else to add. Sorry.

SPEAKER_01:

All right. Look,

SPEAKER_04:

I'm just enjoying the chat.

SPEAKER_01:

Oh, you are? Okay, good, good. Dr. Cunnington and Dr. Trauer, thank you so much for joining me today on the CBT Dive-In for shedding light on both the issue of insomnia and how CBT is one of the multi-pronged approaches that can support people who are struggling with sleep. And for people who want to read CBT, And like more of your work that you've published, how could they, what can they look out for? Where can they find it? Or how can they follow your work in any way?

SPEAKER_03:

The meta-analysis that James was the lead author on that we published, that was in Annals of Internal Medicine. So that's in the medical literature in 2015. So that's sort of a meta-analysis of cognitive behavior therapy for insomnia. It talks about all the different sub-components and the effectiveness and In terms of then some more general information about sleep, I run an online website about sleep at sleephub.com.au. I've got a sleep-related podcast about sleep that's Sleep Talk that's in all the podcast streaming apps as well. So there's lots of information about sleep on those two resources as well.

SPEAKER_01:

Okay, lovely.

SPEAKER_04:

If you follow me on Twitter, sorry, if you follow me on Twitter, you'll just get a whole lot of stuff about COVID. So I'll probably stay clear of that.

SPEAKER_01:

Okay, but who doesn't want a few more Twitter followers? So Dr. Trauer, what is your Twitter handle?

SPEAKER_04:

Oh, I think it's at James Trauer. Oh, easy peasy. Yeah, it's pretty easy.

SPEAKER_01:

All right. Thank you both for being on this show. And yeah, I look forward I look forward to maybe meeting you when I come down to Australia sometime.

SPEAKER_04:

Great. Take care. Thanks

SPEAKER_00:

for tuning in to the CBT dive. Don't miss an episode. Subscribe to our YouTube channel at the CBT dive.ca. You can also listen on the go wherever you get your podcasts to follow Rahim on social media, check out lady at Ivan.com. See you soon.

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Rahim Thawer, MSW

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