Sleep: Experience with CBT-I for insomnia?
April 8, 2016 7:19 AM Subscribe
I’m looking to see if anybody has had success with CBT for insomnia, particularly one of those online programs that I can do from home. Particularly if it allows me to slowly taper off of my sleeping medication while doing the program.
Details: I’ve never been a good sleeper, but a combination of just getting older and calmer, and having pretty great sleep hygiene has kept my sleeping at a great level. It usually takes me around 30 minutes to fall asleep, and I wake several times in the night, but fall back asleep within 10 minutes or so, for a total of 7- 8 hours.
A few months ago, I came down with severe GI problems, and extreme insomnia (On the third day of no sleep, I can get about 4 broken hours, which set me up for another 2 days of little to no sleep). Eventually, I was diagnosed with and treated for a parasite, and I feel a lot better now, but I still cannot sleep.
My Doctor has tried various medications, and we’ve settled on a cocktail of 15 mg Remeron (Mirtazapine) and 0.5 mg of Klonopin (Clonazepam) an hour before bed. On this, I sleep like I used to, some night waking, but happy to be up at 6 to start my day.
I love the sleep, but ideally, I’d like to begin giving up the Klonopin, and after researching sleep, CBT seems the way to go. I’m happy to keep the Remeron for the time being, my doctor and I agree I don’t have major depression, but since I started it I’ve been able to deal with my health issues (and full time job, and freelance job, and small children, etc…) with a better sense of humour. One last thing, I’m a bit terrified of sleep restriction, so I’m hoping that combining CBT with medication will be more pain free.
Summary: Can’t sleep, can an online CBT-I (or in person) program help me gently wean of the benzos?
Details: I’ve never been a good sleeper, but a combination of just getting older and calmer, and having pretty great sleep hygiene has kept my sleeping at a great level. It usually takes me around 30 minutes to fall asleep, and I wake several times in the night, but fall back asleep within 10 minutes or so, for a total of 7- 8 hours.
A few months ago, I came down with severe GI problems, and extreme insomnia (On the third day of no sleep, I can get about 4 broken hours, which set me up for another 2 days of little to no sleep). Eventually, I was diagnosed with and treated for a parasite, and I feel a lot better now, but I still cannot sleep.
My Doctor has tried various medications, and we’ve settled on a cocktail of 15 mg Remeron (Mirtazapine) and 0.5 mg of Klonopin (Clonazepam) an hour before bed. On this, I sleep like I used to, some night waking, but happy to be up at 6 to start my day.
I love the sleep, but ideally, I’d like to begin giving up the Klonopin, and after researching sleep, CBT seems the way to go. I’m happy to keep the Remeron for the time being, my doctor and I agree I don’t have major depression, but since I started it I’ve been able to deal with my health issues (and full time job, and freelance job, and small children, etc…) with a better sense of humour. One last thing, I’m a bit terrified of sleep restriction, so I’m hoping that combining CBT with medication will be more pain free.
Summary: Can’t sleep, can an online CBT-I (or in person) program help me gently wean of the benzos?
Benzodiazepenes can actually interfere with normal sleep, so there's that.
Have you asked your doctor about Trazodone? Non-habit-forming, extremely well tolerated, mild antidepressant effect. Worked wonders for me. Take one about 45-60 minutes before you want to be asleep. Spend the next hour progressively winding down, in the last 10-15 minutes be comfortable in bed, in the dark, on your way to sleep. Trazodone will push you over the hump.
A sleep study may also be useful.
posted by feckless fecal fear mongering at 8:48 AM on April 8, 2016
Have you asked your doctor about Trazodone? Non-habit-forming, extremely well tolerated, mild antidepressant effect. Worked wonders for me. Take one about 45-60 minutes before you want to be asleep. Spend the next hour progressively winding down, in the last 10-15 minutes be comfortable in bed, in the dark, on your way to sleep. Trazodone will push you over the hump.
A sleep study may also be useful.
posted by feckless fecal fear mongering at 8:48 AM on April 8, 2016
I saw a sleep therapist monthly for about a year after being diagnosed with a sleep disorder. It wasn't CBT-I but it involved a lot of the same techniques and principles. I found it helpful but it quickly had diminishing returns.
I do think you should start with a sleep study to determine whether there are any underlying issues that need to be treated first.
posted by fox problems at 9:19 AM on April 8, 2016 [1 favorite]
I do think you should start with a sleep study to determine whether there are any underlying issues that need to be treated first.
posted by fox problems at 9:19 AM on April 8, 2016 [1 favorite]
Nthing getting a sleep study - I had terrible, terrible insomnia and it turned out I had severe sleep apnea. My sleep isn't perfect, but it's MUCH better now that I have a CPAP machine. Sleep apnea is seriously underdiagnosed in women, especially young, thin women.
By all means try the CBT-I - I know it works wonders for many people, and it can't hurt, but get a sleep study first, to rule out any physical issues behind your insomnia.
posted by Rosie M. Banks at 10:44 AM on April 8, 2016
By all means try the CBT-I - I know it works wonders for many people, and it can't hurt, but get a sleep study first, to rule out any physical issues behind your insomnia.
posted by Rosie M. Banks at 10:44 AM on April 8, 2016
Best answer: I think it's worth trying. Try everything.
I started with a DIY version of sleep restriction - waking up at the same time, regardless of hours slept. It was scary. There were a couple of months during which I only got 4-5 hours of sleep. I wasn't really functional in that time (although, honestly, it was comparable to how I felt in the past on prescription sleep meds [zopiclone] with 8 hours). But I may have screwed it up; I think it could be less hairy with pro guidance. I'm up to 6-8 hours now, with 1) light/dark therapy - litera scripta manet has talked about it several times (e.g. here); this is how I did/do it, 2) valerian root most nights, with OTC sleep meds in reserve for a crisis, 3) exercise (cardio + lifting, usually done evenings), and 4) doing sleep hygiene in a not half-assed way (as I had all my life).
RE CBT-related stuff, I resolved to only let myself be anxious about life stuff during daylight hours - whatever is bugging has to wait. I was so fed up with the sleep issue that it overcame anxiety about other stuff, I wanted to fix this more than anything. It's not "fixed", perfectly - I do have just 6 hours sometimes (like now), but it's 8 hours more often when I'm consistent with light/dark exposure and the rest of sleep prep (regular wind-down time, showers at night, etc). DIY CBT re sleep-related cognitions - I resolved to not stress about not sleeping, and just be grateful for any time I get. Sometimes I do things right and still don't fall sleep at a great time. That's ok, I have to tell myself. It's ok to do the steps and let sleep come when it does. Lack of sleep is uncomfortable but not world-ending. Overall, much more functional sleepwise, 8/10 vs 1/10. Key thing, I think - high motivation to go through all this junk. I was desperate, it just had to change, and I felt strongly that prescription drugs were not an option for me.
posted by cotton dress sock at 5:44 AM on April 9, 2016 [2 favorites]
I started with a DIY version of sleep restriction - waking up at the same time, regardless of hours slept. It was scary. There were a couple of months during which I only got 4-5 hours of sleep. I wasn't really functional in that time (although, honestly, it was comparable to how I felt in the past on prescription sleep meds [zopiclone] with 8 hours). But I may have screwed it up; I think it could be less hairy with pro guidance. I'm up to 6-8 hours now, with 1) light/dark therapy - litera scripta manet has talked about it several times (e.g. here); this is how I did/do it, 2) valerian root most nights, with OTC sleep meds in reserve for a crisis, 3) exercise (cardio + lifting, usually done evenings), and 4) doing sleep hygiene in a not half-assed way (as I had all my life).
RE CBT-related stuff, I resolved to only let myself be anxious about life stuff during daylight hours - whatever is bugging has to wait. I was so fed up with the sleep issue that it overcame anxiety about other stuff, I wanted to fix this more than anything. It's not "fixed", perfectly - I do have just 6 hours sometimes (like now), but it's 8 hours more often when I'm consistent with light/dark exposure and the rest of sleep prep (regular wind-down time, showers at night, etc). DIY CBT re sleep-related cognitions - I resolved to not stress about not sleeping, and just be grateful for any time I get. Sometimes I do things right and still don't fall sleep at a great time. That's ok, I have to tell myself. It's ok to do the steps and let sleep come when it does. Lack of sleep is uncomfortable but not world-ending. Overall, much more functional sleepwise, 8/10 vs 1/10. Key thing, I think - high motivation to go through all this junk. I was desperate, it just had to change, and I felt strongly that prescription drugs were not an option for me.
posted by cotton dress sock at 5:44 AM on April 9, 2016 [2 favorites]
Best answer: Hi, I've had a lot of success with CBT-I as a provider (I'm a Behavioral Sleep Medicine trained Counselor who works in research for the University of Illinois, at Chicago). I've also worked with folks who wanted to taper off sleep mediciation including BZs.
From your description of wanting to taper off Clonazepam I think your likely a poor candidate for online CBT-I as most software / web based solutions don't have a medication titration program built in and because any time Bz's are involved, the insomnia rebound effect that typically follows titration is better managed by an experienced Behavioral Sleep Medicine provider in person. The software just isn't there yet.
Telemedicine (therapy over a skype like program) is an option. You'd have to find someone local as there are laws that require licensing specific to the state your in and there are no directories of providers of Telemedicine CBT-I that I am aware of).
On the benzo's, there are typically two approaches, stopping cold turkey before the CBT-I sessions then doing CBT-I after you've experienced withdrawal or titrating down the BZs as the CBT-I sessions progress. A good provider will work with you to find the option that better fits you.
A good CBT-I provider will also work with you on any anxiety your feeling about sleep restriction. The goal is to help you feel comfortable enough with the schedule to succeed while creating enough sleep pressure actually get you to sleep.
Here is a list of Behavioral Sleep Medicine trained CBT-I providers sorted by state.
Also, Dean_deen, its far from ideal but if you subtract the time spent napping from the time allotted by your sleep prescription, Sleepio still works.
If you have any more questions, your welcome to contact me as an information resource.
posted by Jernau at 6:09 AM on April 9, 2016 [1 favorite]
From your description of wanting to taper off Clonazepam I think your likely a poor candidate for online CBT-I as most software / web based solutions don't have a medication titration program built in and because any time Bz's are involved, the insomnia rebound effect that typically follows titration is better managed by an experienced Behavioral Sleep Medicine provider in person. The software just isn't there yet.
Telemedicine (therapy over a skype like program) is an option. You'd have to find someone local as there are laws that require licensing specific to the state your in and there are no directories of providers of Telemedicine CBT-I that I am aware of).
On the benzo's, there are typically two approaches, stopping cold turkey before the CBT-I sessions then doing CBT-I after you've experienced withdrawal or titrating down the BZs as the CBT-I sessions progress. A good provider will work with you to find the option that better fits you.
A good CBT-I provider will also work with you on any anxiety your feeling about sleep restriction. The goal is to help you feel comfortable enough with the schedule to succeed while creating enough sleep pressure actually get you to sleep.
Here is a list of Behavioral Sleep Medicine trained CBT-I providers sorted by state.
Also, Dean_deen, its far from ideal but if you subtract the time spent napping from the time allotted by your sleep prescription, Sleepio still works.
If you have any more questions, your welcome to contact me as an information resource.
posted by Jernau at 6:09 AM on April 9, 2016 [1 favorite]
As a note on the above information, when I say "stopping cold turkey" on the Benzo's, what I actually mean is titrating down under your doctors supervision prior to starting treatment. Depending on your dose, just stopping BZs without medical supervision is a very bad idea that can get you hospitalized or worse.
posted by Jernau at 6:19 AM on April 9, 2016
posted by Jernau at 6:19 AM on April 9, 2016
Response by poster: Thanks everyone! My doctor and I are fairly sure I don't have apnea (though I am as guessed, a younger thin woman) and I never snore. Since my sleep was adequate before I got sick, I thought that CBT might work. I may try to get a sleep study, but waiting times in Canada are.... a lot. I think I might try to find a therapist who can work with me in person, while I do a slow taper. My benzo use is not extreme, I took Zopiclone for a few weeks, then switched to Ativan, then Klonopin as the Ativan wears off pretty quickly as I'm a fairly fast metabolizer. I should be able to taper ok, as long as the rebound insomnia isn't too terrible...
posted by Valancy Rachel at 8:01 AM on April 9, 2016
posted by Valancy Rachel at 8:01 AM on April 9, 2016
This thread is closed to new comments.
I can't really say how much it helped me. I finally ended up getting a sleep study out of desperation, and I found out I have moderate sleep apnea. So you may want to consider that, if you find the CBT-I doesn't work (but I hope it does!) Good luck!
posted by dean_deen at 8:11 AM on April 8, 2016