Many individuals experience sleep disturbances after concussion, disturbances like: trouble falling asleep or staying asleep, irregular patterns of sleep, or sleeping too much. These difficulties with sleep interfere with day-time function resulting in increased feelings of fatigue, feeling mentally slower and feeling more down. CBT-i can correct unhealthy sleep habits through addressing and remedying factors that maintain insomnia.
The cornerstone of CBT-i is educating about sleep and the factors that affect it; highlighting beliefs/attitudes towards sleep that might be holding one back from ideal sleep; and then taking steps to correct any factor not helpful. Advice will vary from patient-to-patient but may involve advice regarding changing the sleep environment, aspects of one’s lifestyle, correcting faulty/taxing beliefs about sleep, relaxation techniques, restructuring sleep architecture, etc.
Formally, CBT-i contains the following components:
1. Stimulus Control – this refers to limiting/avoiding activities/habits that perpetuate sleep difficulties.
2. Sleep Hygiene – instituting certain habits that help promote healthy sleep.
3. Sleep Restriction – this is the more technical end of CBT-i. It involves keeping a sleep diary and following recommendations regarding when to go to sleep and when to wake up. Other data is also collected in the sleep diary which will help the team strategically restructure your sleep. Patients often find this the most tiring part of the program as sleep is initially restricted and fatigue usually ensues. However, this is a powerful method to restructure the physiology of your sleep. It also helps break psychological associations between your bed and insomnia; that is, it fosters an attitude of mindfulness which is an ideal context to any neurological training method.
4. Relaxation Training – many techniques are available to help foster relaxation. Relaxation is a skill that needs to be developed. Some patients find certain relaxation techniques more effective than others. Examples of relaxation techniques include different types of meditation (e.g., raisin meditation, body tension awareness, thoughts on leaves meditation, Metta, etc.), therapeutic activities, breathing training, journaling, etc. Energy management techniques, healthy lifestyle habits and regular cardiovascular exercise facilitates relaxation training. With the implementation of biofeedback technology in our program, we can be more objective about which relaxation technique is most congenial for a patient and how to measure improvements in many physiological measures that correlate to the state of one’s autonomic nervous system. It is an excellent, intuitive method for patients to get a handle on something that they likely always took for granted. Many of us do not know that we do have the ability to improve our nervous systems response to life’s incidents.
5. Cognitive Therapy – this involves educating patients about faulty/hindering beliefs they have developed with respect to sleep. The same cognitive behavioural therapy methodology that is used in other areas of psychological counselling is used here but with the focus on sleep. In practice, after educating the patient and pointing out cognitive fallacies, this may see the patient develop techniques to deal with worrying; it may also ask patients to ‘break-the-mould’ to challenge their (faulty) beliefs so that they can ‘discover’ better strategies to deal with fatigue or insomnia. CBT is also instrumental in preventing relapse of sleep difficulties. We all face incidents in life that can adversely affect our sleep. Awareness of facts and myths about sleep, awareness of our habituated tendencies/reactions that will affect sleep and in making healthy/informed choices that will not exacerbate sleep difficulties, we are well armed to avoid falling into the same sleep rut as before.
While medication may help with sleep disturbances acutely, it is not effective for ongoing sleep difficulties. CBT-i does not require medication. It is a natural remedy to sleep challenges. Its effect is not realized acutely; however its effect is more lasting, it is a “cure” rather than a “band-aid treatment”. CBT-i has helped resolve sleep difficulties in nearly every patient that comes in to our program, both patients in the early stages after a concussion and for those that have experienced a prolonged period of insomnia. At first, patients report feeling more tired but they are encouraged to stick to the plan and are reminded of the information provided in this post as it relates to their situation. Usually around the 2-6 week mark, patients report significantly better sleep quality that is backed up by their sleep journal.
As patients’ sleep improves, it serves as a positive reinforcement of all of the above as improving one’s sleep will have positive effects on every other aspect of the patients’ recovery.