Discovering Healthy Sleep with Insomnia Therapy

**By Brandon Peters, MD**

What if it were possible to resolve insomnia without the perpetual use of a sleeping pill? This is the very promise of cognitive behavioral therapy for insomnia (CBTI), a drug-free treatment approach with multiple, long-lasting benefits. Insomnia therapy is so effective, in fact, that the American College of Physicians (the academy of internal medicine doctors) now recommends CBTI as the first choice for the treatment of chronic insomnia.

asleepCBTI can provide patients with the education and changes necessary to optimize sleep. In a few short months, the time it takes to fall asleep and the time spent awake at night is significantly reduced. The frequency of awakenings declines. Sleep quality improves. The symptoms associated with chronic sleep deprivation fade away. The risks and side effects associated with sleeping pills are avoided.

What Is Insomnia Therapy?

Formally known as cognitive behavioral therapy for insomnia (CBTI), the treatment is a 6-week program that can help people with chronic difficulty falling asleep, staying asleep, or who find that sleep is unrefreshing. If it takes more than 20 to 30 minutes to fall asleep, more than 3 nights per week, this is termed chronic insomnia. Insomnia therapy is a scientifically proven, highly effective way to end insomnia without relying on medications.

Some of the components of insomnia therapy include:

  • Education on normal sleep
  • Identifying triggers of insomnia
  • Emphasis on optimizing the circadian rhythm and building the sleep drive
  • Overview of sleeping pills and ways to taper them
  • Developing healthy sleep habits
  • Learning skills to calm a racing mind
  • Stress and anxiety management
  • Individualized sleep-wake schedule recommendations
  • Eliminating thoughts, behaviors, and feelings that compromise sleep
  • Coping strategies to respond to sleep loss and preserve daytime function
  • Identifying sleep disorders that contribute to poor sleep with testing

The benefits of insomnia therapy can last for years. This goal-directed treatment teaches a set of skills that can also be useful if insomnia recurs later in life. The interventions can always be re-applied to get sleep back on track. With improved sleep satisfaction, therapy participants find the support they need to avoid the use of sleeping pills.

Risks Associated with Sleeping Pills

Sleeping pills have their place in treating short-term insomnia, but there very good reasons to avoid long-term use of sleep medications. If insomnia persists for months requiring nightly medication, a new solution is needed. There are risks and side effects associated with dependence on sleep aids, including:

  • Confusion—Over-the-counter sleep aids that contain diphenhydramine (Benadryl, Tylenol PM, Advil PM, Aleve PM, ZzzQuil, etc.) may increase the risk of confusion in older people.
  • Sleepwalking—Medications like Ambien (sold as the generic zolpidem) are hypnotic medications that may affect memory and increase the risk of sleep-related behaviors without full awareness. This may provoke sleepwalking, sleep eating, sleep sex, and even sleep driving.
  • Dementia—Medications that contain diphenhydramine, benzodiazepines (used for anxiety and sleep), and others may increase the risk of long-term memory loss and dementia.
  • Increased falls—Sedatives may increase the risk of falls and hip fractures, especially among older people. This may be more likely if the person is prone to wake to urinate at night.
  • Death—Large population studies demonstrate an increased risk of dying from various causes—making death 2 to 3 times more likely—with sleeping pill use.

Accessing the Tools of Insomnia Therapy

How can insomnia therapy be pursued? While it’s true there is a general shortage of insomnia therapy providers – specially trained psychologists and sleep specialists available for one-on-one treatment – equally effective alternatives are available.

At Virginia Mason, we offer a shared medical appointment workshop. In these classes, 5 to 10 people are guided through the treatment program with one of our board-certified sleep physicians. Covered by insurance, the workshop requires a weekly visit lasting 90 minutes over 6 weeks. Each week your progress will be closely monitored with sleep logs. Feedback and specific guidance will be provided to advance you toward your goals.

Not everyone can make it to a weekly class. Fortunately, the same program basics and a collection of resources can be accessed via an online course called Insomnia Solved. Weekly lessons include self-assessment, education, sleep logs, and audiovisual materials.

Finally, the primary text of Insomnia Solved is also available in paperback for purchase from Amazon.

No matter why you have insomnia, or for how long you have had it, insomnia therapy can effectively help to end it. For some this may mean falling asleep more easily, sleeping through the night, sleeping without the use of sleeping pills, or improving daytime fatigue. If sleep is a struggle, do not hesitate to get the help that you need and discover ways to enjoy healthy sleep again.

Peters-Mathews_BrandonBrandon Peters, M.D., is board-certified in both neurology and sleep medicine and currently practices at Virginia Mason Medical Center in Seattle and Federal Way. He is also a clinical faculty affiliate at Stanford University‘s School of Medicine in the Department of Psychiatry and Behavioral Sciences. 

Belleville G. “Mortality hazard associated with anxiolytic and hypnotic use in the National Population Health Survey.” Can J Psychiatry 2010; 55:558-567.

Glass J et al. “Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits.” BMJ 2005; 331:1169.

Hausken AM et al. “Use of anxiolytic or hypnotic drugs and total mortality in a general middle-aged population.” Pharmacoepidemiol Drug Saf 2007; 16:913-918.

Qaseem A et al. “Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians.” Ann Intern Med 2016; 165(2):125-133.

Siebern AT and Manber R. “New developments in cognitive behavioral therapy as the first-line treatment of insomnia.Psychol Res Behav Manag 2011; 4:21-28.



Breathing Easier: Noninvasive Therapy Helps Treat Sleep Apnea

Most of us are familiar with a condition known as obstructive sleep apnea, when soft tissue near the throat obstructs air flow during sleep. But there are two things you may not know – that obstructive sleep apnea or sleep-disordered breathing can occur in children, and there’s a noninvasive option that offers hope to treat the condition in both children and adults.

The treatment is orofacial myofunctional therapy (OMT), an individualized regimen of exercises designed to re-pattern oral and facial muscles. Conditions treated involve a variety of disorders including muscle dysfunction of the tongue, lips, jaw and face. A common disorder is “tongue thrust,” where the tongue is incorrectly placed during swallowing and resting, leading to the improper growth and shaping of the palate. Orthodontists have referred patients to this therapy for decades as additional treatment for muscle issues that orthodontic appliances can’t fix.

Recent research has elevated the role of OMT as an effective treatment to help correct sleep-disordered breathing in children. Mouth breathing during sleep, whether caused by tonsils, allergies or other problems, directly affects tongue position and strength of the oral muscles, leading to abnormal airway development in a growing child. OMT can eliminate mouth breathing during sleep, which can stop a child’s progression to obstructive sleep apnea.


Christian Guilleminault, MD, and Roberta Kelley

“There’s always been a focus on the importance of nasal breathing in kids, but now there’s increased focus with studies showing OMT plays a critical role in clearing and maintaining the airway,” says Roberta Kelley, a speech-language pathologist and certified orofacial myofunctional therapist at Virginia Mason.

The impact of OMT in the prevention and treatment of sleep-disordered breathing was identified by renowned expert Christian Guilleminault, MD, professor of psychiatry and behavioral science, Stanford Center of Sleep Sciences and Medicine. Virginia Mason sleep medicine physicians Matthias Lee, MD, and Oneil Bains, MD, both completed sleep medicine fellowships at Stanford University under the directorship of Dr. Guilleminault.

As evidence accumulated showing OMT’s positive effects on pediatric sleep-disordered breathing, Drs. Lee and Bains began referring select sleep study patients to Roberta. “I’ve gone from treating one myofunctional patient a week to sometimes treating five patients a day,” says Roberta, one of only three providers certified in OMT in the Seattle area. “This is a noninvasive treatment. The patient commits to daily exercises to correct the tongue position, tongue-resting posture and nasal breathing.”

Currently Roberta sees more adults than children, benefiting from OMT when other sleep apnea treatments, such as CPAP, aren’t tolerated by the patient. A 2015 analysis of multiple study results showed OMT reduced the severity of obstructive sleep apnea by 50 percent in adults and 62 percent in children.

While OMT has yet to be recognized as a mainstream therapy for sleep-disordered breathing and obstructive sleep apnea, Virginia Mason’s Sleep Medicine team, with Roberta’s support, offers patients access to a leading-edge treatment.

“There are multiple benefits of OMT, including the improvement of symptoms related to sleep-disordered breathing, snoring and obstructive sleep apnea,” says Roberta. “It is truly a quality-of-life enhancing therapy.”

Top Ten Tips for a Better Night’s Sleep

**By Oneil Bains, MD** 

young woman in a white sheet bed on white backgroundAlmost everyone has experienced a bad night’s sleep – tossing and turning, being unable to fall asleep or even waking in the middle of the night. For some of us (approximately 40 million Americans according to the National Sleep Foundation), trouble sleeping has become a chronic issue.

While I work with patients to tailor a plan to meet their individual needs, I have found a few tried and true tips that can help almost anyone achieve a better night’s sleep.

Make mornings consistent
Waking up at the same time every day helps your body find a consistent sleep rhythm. Try to have a set wake-up time regardless of when you fall asleep the night before. It might be difficult at first, but after about a week your body clock will adapt and make you feel sleepy earlier.

Go to bed sleepy
Listen to your body and go bed when it tells you. Going to bed before you are actually sleepy can lead to anxiety and frustration, making sleep even more elusive. Conversely, don’t stay up past the point of sleepiness just to finish a show or a book.

Treat Sunday like Monday
Trying to catch up on rest by sleeping in on weekends might be tempting, but it will shift your body clock away from its established rhythm and make it that much tougher to get up on Monday morning. Rather than sleep in, make morning plans on the weekend – such as breakfast with family or friends – that will motivate you to get up at a consistent time.

Relaxation is key
The most common cause of insomnia is anxiety. Worrying about the future and ruminating about the past can become endless circles of thought that keep you awake. Turning off your brain isn’t easy. Yoga, stretching and breathing exercises can help clear your mind and prepare you for sleep. A quiet and relaxing activity such as writing a journal entry, reading a book or enjoying a hot bath can also be helpful.

Stow the phone
When sleep won’t come, reaching for a phone or tablet is a natural response. But studies have found that the light produced by these devices actually stimulates the brain and pushes sleep further away. Also, the emotions and thought patterns generated by browsing social media and the news can promote anxiety. If you want to read before bed, it is better to read a real book with a soft light.

Eat early to sleep early
For your body, digestion is an activity. Letting it run its course before you lie down to sleep puts you in a much better position to fall asleep easily. An earlier dinner will naturally help bring an earlier bedtime while avoiding heartburn, weight gain and other potential health issues.

Sweat it out in the morning
If you think exercise is good for your sleep, you’re right. It fatigues your muscles in a positive way and releases endorphins that ease anxiety and promote mental well-being. However, the benefits of exercise can also produce a stimulating effect that can last for hours afterward and make it difficult to fall asleep. Because a relaxed body is more likely to fall asleep, try to get your exercise in the morning or early afternoon.

Put away the pills
There is a common misconception that sleep medication should be taken to induce sleepiness.  While they can be effective for certain types of sleep problems, sedating medicines are most appropriate for enhancing sleepiness.  When sleeping medication is taken to induce rather than enhance sleepiness, the likelihood of having adverse side effects is significantly increased.  This is particularly true for night owls and shift workers that are frequently in the situation of trying to sleep at a time when actually alert. Getting sleepy at bedtime is better accomplished by establishing a consistent sleep cycle and going to bed relaxed.

Collect data while you dream
Understanding your sleep patterns can give you helpful insights into your own habits and lead to strategies for possible solutions. Devices such as a Fitbit or Microsoft Band can be helpful in tracking sleep patterns, especially when they’re erratic. This data can be helpful for pinpointing specific problems and observing progress for you and your doctor.

 Talk to your doctor
Contact your physician if you continue to experience trouble sleeping. He or she can help you find the right treatment course and help you get back on track.

bains_oneilOneil Bains, MD is Section Head of the Sleep Disorders Center at Virginia Mason. He is board-certified in Sleep Medicine and Internal Medicine, with expertise in the treatment of insomnia, pediatric sleep disorders, narcolepsy and sleep disordered breathing. Dr. Bains’ innovative five-week insomnia program has helped hundreds of patients sleep better without the use of medication.