Now we talked about pharmacological or medication treatments for insomnia. Let's turn our attention to non-pharmacological or non-medication treatments for insomnia. Before talking about the specific non-pharmacological treatments, I think it's important to understand how we in the Sleep World view the development of insomnia over time. There's a prevailing model that's often discussed that indicates how insomnia gets going and started in the first place, and then what keeps it going over time. We sometimes refer to this model as the 3P model or the behavioral model of insomnia. In this particular model, it suggests that there are three factors that all begin with P that are important in the initial development of insomnia and then keeping it going over the long term. If you consider the black line in the picture to be a threshold of insomnia, the first P in yellow is called predisposing factors. Consider these to be risk factors that may put people at risk for developing insomnia but don't necessarily cause it. Common risk factors we think about in our study in the literature include having a family member who had insomnia, having a personal history of mental health disorder. These things might put you at risk and lower the threshold for developing insomnia. But they don't necessarily cause it. When insomnia becomes an acute problem, it's often precipitated by what's called a precipitating factor or a trigger. In upwards of 70 percent of cases, individuals can identify some specific trigger that initiated the onset of an insomnia episode. In the early stages of insomnia, perhaps when that precipitating factor or trigger remains active, people start to engage in a variety of behaviors and thought processes that make sense in the short term, but actually serve to disregulate the regulatory systems that help us sleep at night time. Those are indicated in red and called perpetuating factors. These perpetuating factors include behaviors such as sleeping in late on the weekends, going to bed early, napping during the daytime, using extra caffeine to ward off the consequences of sleep deprivation, perhaps using alcohol at nighttime. For many individuals, these behavioral strategies make sense and they can be beneficial for some people, but for many people who are at increased risk for developing insomnia, these factors further disregulate the system and keep insomnia going over time. So when insomnia becomes a chronic difficulty, the precipitating factor or the original trigger that started the insomnia episode maybe gone or maybe at least under control and it pushed them under that threshold for insomnia. But now, these perpetuating factors, these behavioral factors, and thought processes, worrying about sleep, thinking about how you're going to function when you're not able to sleep, these things become central, and they can keep insomnia going over time. Once insomnia becomes a chronic problem, these perpetuating factors need to be targeted. And that's what cognitive behavioral therapy for insomnia primarily does. Cognitive behavioral therapy for insomnia is a relatively short term treatment that can be delivered individually or in groups. It's a multi component treatment that's made up of really three broad treatment components. The first is an educational treatment component. Here we educate people about normal sleep versus insomnia sleep. We tell them about things they do during the daytime that can help or hurt sleep at night time. The targets of the educational portion of cognitive behavioral therapy for insomnia, are really to identify and fix what we call inadequate sleep hygiene, substances, environmental conditions, certain situations that can put people at risk for having a bad night of sleep. Treatment components that we spend most of our time in follow across to other domains, behavioral and cognitive. In the behavioral domain, we teach people behavioral strategies to help improve sleep quality. And here, what we're doing is targeting behaviors that people engage and that we think keep insomnia going over time. Common targets include excessive time in bed, highly irregular sleep schedules, sleeping compatible activities, that is doing things other than sleep in the bedroom environment, or what's called hyper arousal or excessive arousal that people experience sometimes in the presence of sleep cues. Behavioral strategies include things like sleep restriction, which is a technique where we temporarily reduce the amount of time spent in bed to improve sleep quality, stimulus control, where we control stimuli that help sleep and get rid of stimuli that interfere with sleep, and relaxation or meditation kinds of exercises to really target arousal level and reduce arousal so that sleep can happen. In the cognitive domain, we're really trying to identify thoughts and attitudes that can interfere with sleep or put people at risk for developing insomnia. Some common cognitive targets that we identify are unrealistic expectations about sleep: an individual who says he or she needs eight hours of sleep every night to function well, misconceptions about sleep and the causes of insomnia, anticipatory anxiety around sleep. At nighttime, people may sometimes get worried about the upcoming night of sleep and that can interfere with their ability to sleep. And finally, poor cognitive coping skills. When people don't sleep well, not having the cognitive reserve to deal with these issues and to manage them accordingly. So cognitive behavioral therapy for insomnia is a multi component treatment package, and it's considered the first line treatment for addressing perpetuating factors that can keep insomnia going over the long term.
