Treating and Preventing Insomnia
Ivan Vargas: Happy to be here.
HY: So first off, how did you get into this field?
IV: It’s been a gradual process getting into the sleep field. I feel like – you know, I’ve always had an interest in doing research, especially research that has implications to health. But it really wasn’t until just before I started graduate school that I got interested in sleep. I didn’t realized that sleep was something that we could even study, you know? And I realized that, you know, this is something that we spend a third of our life doing, but we really didn’t know a whole lot about it. And so that was really interesting to me, and it was really interesting to me the idea of trying to understand for those people that can’t sleep, kind of the factors that go into that. So that’s kind of how it started. And then when I got into graduate school, it was kind of slowly getting myself integrated within trying to learn about sleep and how to measure sleep and, you know, asking different questions related to sleep and mental health in particular. And it really wasn’t until after I graduated from graduate school and started a postdoctoral fellowship at Penn in Philadelphia, that’s where I kind of doubled down on my interest in sleep and really integrated myself as a sleep researcher.
HY: So what are the dangers of either short term or prolonged insomnia?
IV: The short answer there is a lot. I think, until relatively recently, most people kind of considered insomnia a symptom of depression. So it wasn’t until really… in 1989 there was a paper that first introduced the idea that insomnia was more than just a symptom of depression. And a lot of research started coming out from there, really demonstrating that insomnia was really, it was a risk factor. And it predicted the onset of other disorders, particularly depression. And so from there, we’ve kind of, you know, the literature has really started to rise in terms of trying to understand all of the different long-term consequences of having insomnia. And so at this point, there’s now research really kind of confirming that insomnia is, in fact, a risk factor for developing future depression. But even more than that, I mean, at this point, we have research suggesting that insomnia is a risk factor for developing cardiometabolic disorders. It’s a risk factor for developing immune dysfunction, remission from cancer treatment. And so there are a lot of lines of research now showing that there are real long-term consequences to your health for those individuals that have untreated insomnia.
HY: This might be a gross simplification, but do you consider insomnia to be more of a psychological problem or is it more of a physiological problem? Or to what degree is it both?
IV: I think it’s a little bit of everything. So from the psychological perspective, you know, when you talk about how does one develop insomnia, stress is certainly an important piece, especially in the short term. So when we’re thinking about acute insomnia, stress and anxiety are big contributors to insomnia in the short term and certainly there are physiological processes that we’re still trying to understand. But there does seem to be a sense that there are several physiological processes that contribute to putting people at greater risk for developing insomnia. And then I’ll throw in a third one that is really important is thinking about insomnia as a behavioral thing, that there are a lot of behavioral factors, things that we do that also contribute to insomnia and how insomnia manifests.
HY: Well, I’m glad you brought that up because that goes into my next question. Can you tell us a little bit about cognitive behavioral therapy for insomnia? How does it work?
IV: Cognitive behavioral therapy for insomnia, or we commonly refer to it as CBT-I, is a form of cognitive behavioral therapy, which is a larger category of intervention, psychological interventions. But CBT-I, there’s a large emphasis on the behavioral pieces of the intervention. So it’s mostly a behavioral intervention for insomnia that tries to maximize people’s sleep habits and sleep behaviors to try to improve or try to alleviate their insomnia symptoms.
HY: So can you give me an example?
IV: Yeah. So cognitive behavioral therapy is a multi-component therapy. So there are two kinds of active interventions within CBT-I. I don’t love the names, but these are the names that we have, but they are sleep restriction therapy and stimulus control therapy. Sleep restriction therapy, the goal there in brief, is to kind of increase a person’s homeostatic sleep drive. So to put it differently, the goal is to maximize how much sleep pressure or increase the propensity that one has to sleep. And the way that we do that is by restricting your sleep. So I think most people, when they have a bad night of sleep, the natural response is to try to compensate, to try to get more, because usually the focus is on getting enough sleep, not necessarily getting efficient sleep. And so usually our reaction to not getting a good night’s sleep is “I’m going to take a nap the next day” or “I’m going to sleep in” or “I’m going to go to bed early.” Those are all forms of behavioral compensation. So we’re trying to make up for that lost sleep. The problem is, while that is good for maybe getting a little bit more sleep in terms of total number of minutes or hours in the long term, it’s not great for insomnia because what it’s doing is it’s decreasing that sleep pressure when it’s time to go to bed. And so the idea behind sleep restriction therapy is to try to maximize the amount of sleep pressure at night when we’re trying to go to bed with the goal of trying to make us more efficient sleepers.
Then stimulus control therapy, it’s another behavioral intervention that is trying to target the relationship that we have with our bed. And so individuals with insomnia, they have over time developed a maladaptive relationship with their bed. Their bed has become a place for wakefulness rather than sleep. And so what we’re trying to do is recondition their bed to be a place for sleep. And so it’s a relatively straightforward intervention where we’re asking individuals that when they’re laying in bed awake and they can’t fall asleep to get up and go do something else for a short bit of time and then come back and try again. But again, the idea is to try to recondition your bed to be a place for sleep rather than for wakefulness.
HY: Okay, so I’ve asked you this question before, and you said there’s a difference in that… so I’m going to bring this up again, which is the difference between CBT-I and what would be commonly described as sleep hygiene, because it kind of sounds like it’s sleep hygiene, but you’re saying there’s a little bit of a difference. Can you explain the difference?
IV: There’s an important difference, and I’m glad you asked, because I think most people, when they’re having trouble sleeping or experiencing insomnia, most of the recommendations you hear out there are more so related to sleep hygiene. And while sleep hygiene is a part of CBT-I, so in CBT-I we do cover sleep hygiene. It’s not necessarily an active ingredient of CBT-I. So what I mean by that is, I wouldn’t necessarily have any expectations that anyone’s insomnia would be corrected by just sleep hygiene alone. It’s really more a way to kind of augment some of the other interventions that I already mentioned. But sleep hygiene really is just more about lifestyle factors. It’s more about trying to put yourself in the best position for good sleep. So these are lifestyle factors related to the consistency in your diet and wake time, getting enough light, especially in the mornings, minimizing the amount of caffeine and alcohol that you’re drinking late into the night, those sorts of things. Making sure that the temperature and comfort is appropriate and a good setting for sleep. But it’s just that, it’s really just creating a good space and good setting for you to be able to sleep. But it’s not the actual intervention that’s going to help you become a more efficient sleeper.
HY: If somebody decides that they need to do CBT-I therapy, over what timeline would they expect to do that? How long would it take to correct prolonged insomnia?
IV: It kind of depends on the individual and their symptoms and how long they’ve been experiencing insomnia. But a traditional course of CBT-I is usually around six to 12 weeks. So it really kind of, some people really respond to the intervention. And so, you know, six weeks is kind of the low end of the range where somebody might begin to make changes, the recommended changes to their sleep schedule, they implement the restricted sleep schedule, and they really respond to it. And so after six weeks, they’re in a really good place. And from there it’s just kind of trying to get back to a place where they’re also getting enough sleep. But sometimes it takes longer, usually and the longer end it can take up to 12 weeks, sometimes even more, again, depending on the individual. But at this point, we’re also developing and testing other alternatives, short-term alternatives to CBT-I. These are probably more appropriate for individuals who have acute insomnia or maybe insomnia that is less severe. So these are shorter term alternatives. By shorter term, I’m talking about two to three sessions or even one-session interventions, one-session versions of CBT-I that might be useful alternatives for people that have less severe insomnia, or maybe they haven’t had it for as long. And it’s really more of a strategy to try to get ahead of the insomnia and correct you and put you on a better path for better sleep and maybe not necessarily appropriate for somebody who’s, you know, been dealing with chronic insomnia for, you know, the past decade. But that’s kind of like at this point, we have a somewhat of a menu of what CBT-I can look like depending on the individual.
HY: If you had one piece of advice to offer someone suffering from insomnia, what would it be?
IV: Yeah, I think the biggest piece of advice for someone with insomnia would be to do less. Earlier I referenced the idea that kind of the main thing that maintains or perpetuates our insomnia are those behavioral compensations. So I have a bad night of sleep, and so I decide I’m going to take a nap the next day or I’m going to sleep in or do something like that. And my recommendation would be to avoid those sorts of things, especially if you have a propensity for insomniac nights and having trouble falling asleep or staying asleep. And so try to ride it out and maintain that same sleep schedule, go to bed at the same time, wake up at the same time, but try not to compensate. I had… my mentor during my postdoctoral fellowship, who was a famous insomnia researcher, Michael Perlis, his expression would always say, “When in doubt, do nothing.” And so I think it kind of is along the same lines of not compensating for lost sleep. We are resilient individuals, humans. They’re resilient to the effects of lost sleep, especially in the short term. And so I think in the short term it’s probably best to not try to compensate.
HY: If somebody was suffering from insomnia and wanted to look into CBT-I, where would you direct them?
IV: I think if someone locally is experiencing insomnia, the resources for getting CBT-I are somewhat limited, but we are fortunate that we do have access to CBT-I here, at least in the university community. So the psychological clinic in our department here at the University of Arkansas, we have therapists that have been trained in CBT-I and you know, are available to provide services for CBT-I. We often will also run groups of CBT-I. So these are group therapy sessions where we do specifically CBT-I. So this is a particularly good fit for someone who’s kind of looking for CBT-I right now. And we have a group that should be starting up in the next couple of weeks. But yeah, I mean I think that’s kind of the best resource in the area right now is to give the psychological clinic a call.
HY: Ivan Vargas, thank you. Thanks for coming in.
IV: Yeah, thank you.
Matt McGowan: Short Talks from the Hill is now available wherever you get your podcasts. For more information and additional podcasts, visit arkansasresearch.uark.edu, the home of research and economic development news at the University of Arkansas. Music for Short Talks from the Hill was written and performed by local musician Ben Harris.
