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Simple self-help for insomnia: an upgrade to counting sheep

this blog post is downloadable both as a Word doc and as a PDF file 

In a recent paper on cognitive behavioural treatment for insomnia - "Hyperarousal, sleep scheduling, and time awake in bed as mediators of outcome in computerized cognitive-behavioral therapy (cCBT) for insomnia"  - Vincent & Walsh particularly highlighted the importance of reducing pre-sleep arousal for effective results.  Gellis & Park explored similar territory in their publication - "Nighttime thought control strategies and insomnia severity" - reporting "Strategies used to control unwanted thoughts during the evening have been shown to be significantly associated with insomnia, a common problem associated with numerous negative consequences. This study examined whether nighttime thought control strategies would predict insomnia severity ... after accounting for well-established risk factors for the disorder such as anxiety, depression, sleep hygiene, and nighttime pain. ... Results ... showed that the strategy of cognitive distraction (attempts to withdraw from unwanted thoughts or think about more pleasant content) was negatively associated with insomnia severity and the strategy of aggressive suppression (the use of critical and punishing self thought) was positively associated with insomnia severity after accounting for other risk factors. These findings add to the growing literature highlighting arousing pre-sleep cognitions as a correlate of insomnia. These findings also add to emerging literature showing the ability to cognitively distract from the arousing thought as a correlate of good sleep."

In 2012, Gellis conducted a small exploratory study - "An investigation of a cognitive refocusing technique to improve sleep" - where he achieved encouraging results through "a technique that targets the refocusing of thoughts during the evening in order to improve sleep".  Gellis & colleagues then took their research a step further last year with a larger, controlled study - "Cognitive refocusing treatment for insomnia: A randomized controlled trial in university students".  They reported: "This investigation assessed the efficacy of a technique specifically designed to change the style and content of presleep thoughts in order to reduce nighttime cognitive arousal and decrease insomnia severity.  This investigation, termed "cognitive refocusing treatment for insomnia" (CRT-I), previously improved sleep in a small sample of veterans with primary insomnia.  In this investigation, university students with poor sleep were randomly assigned to attend either one session of CRT-I and sleep hygiene education (SH: n = 27) or one session of only SH (n = 24).  Insomnia severity (assessed by the Insomnia Severity Index) and nighttime arousal (assessed by the Pre-Sleep Arousal Scale) were measured at baseline and 1 month posttreatment. A significant Group × Time interaction for insomnia severity suggested more improved sleep over time for those receiving CRT-I + SH.  A trend for a Group × Time interaction showed decreased cognitive arousal over time among those receiving CRT-I."  (Click here for an example of typical sleep hygiene instructions, and click here for other more general sleep handouts & advice).  As is usually the case, we need more research on this encouraging cognitive refocusing approach, but it is such a simple method - an upgrade to counting sheep (!) - that it is already a technique for disrupted sleep that it's reasonable for any interested person to try.  

So what actually were participants taught to do?  The authors write: "Drawing on literature that highlights the usefulness of taking attention away from intrusive, negative thought content, a recently developed intervention termed cognitive refocusing treatment for insomnia (CRT-I) attempts to directly manipulate presleep thought content ... the participant and therapist collaborate to identify an engaging cognitive task that does not induce emotional or physiologic arousal.  This task involves focusing on any mental activity with enough scope and breadth to create multiple avenues of thought to maintain the interest and attention of the participant.  Reasoning that continual effort attending to an engaging yet nonarousing cognitive task (e.g., thinking about a recent line of clothing or mentally reciting lyrics from their favorite music album) would allow people with insomnia to shift attention from emotionally arousing cognitions to nonarousing cognitions, and sleep would be improved.  Allowing individuals to choose their own cognitive task is important in this intervention in order to maximize the likelihood that the individual will maintain interest and be able to focus on the task.  In this technique, participants are instructed to focus on this task upon initiating sleep and when waking up during the night." 

They go on to say:  "Discussion highlighted the importance of changing thought content from physiologically and emotionally arousing thoughts to nonarousing thoughts in order to improve sleep ... Next, the provider worked with the participant to identify three different categories of thought (topics of thought content) compelling enough to maintain his or her attention at bedtime.  For instance, an individual may think about new dinner recipes or plots from his or her favorite television programs.  These chosen thought categories were to have the following two qualities: (a) emotionally and physiologically nonarousing, and (b) compelling and engaging.  An emotionally and physiologically non-arousing category was indicated by thought content devoid of emotion-laden, negative, exciting, or worrisome content ... the participant was asked to become absorbed in or focus attention on one of the categories at bedtime and upon waking up during the evening. If thought content other than the specific categories came to mind during the evening, participants were instructed to let go of or take attention away from that content and focus their attention on their chosen topic.  Upon awakening during the evening, participants were instructed to avoid looking at the clock or any other activity that would take their attention from their targeted thought content.  Individuals chose the type of categories that would be focused on during the evening.  Three categories were identified by the participant.  They were instructed to pay attention to whether their thought processes elicited emotional or physiologic arousal, and they were encouraged to switch topics if the first-chosen thought content precipitated arousal or if it was not engaging enough to occupy their attention.  However, they were encouraged to focus on one thought category in order to develop learned associations between a specific category and sleep." 

Interesting stuff ... simple ... and makes good sense.  Cognitive refocusing treatment for insomnia (CRT-I) definitely looks an upgrade to counting sheep and well worth trying.  If you want to learn more about the cluster of well-validated techniques typically used in a full CBT approach to helping insomnia, Colin Espie's excellent & straightforward book "Overcoming insomnia and sleep problems" is a good place to start or you could treat yourself to the six week internet-delivered programme on his website www.sleepio.com.   

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