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How Does The Non-Drug Treatment Of Insomnia Work?

Insomnia is the most frequent sleep disorder. It is estimated that, on average, 1 Italian out of 4 suffers from it, with a higher prevalence in the female population. Approximately 36% of the general population experiences at least one episode of acute insomnia in a year. Many think that drug therapy is the only possible solution, but it is not. It is possible to avoid the many contraindications of drugs by undergoing cognitive behavioral therapy.

What Is Insomnia?

Insomnia can be characterized by difficulty initiating or maintaining sleep and waking up early. One of these characteristics can represent the disturbance or, in more serious cases, all three. Furthermore, patients with insomnia also have problems during the day, such as daytime sleepiness, irritability, mood disturbances, irritability, behavioral disturbances, greater propensity to make mistakes at work or in life, almost obsessive thoughts concerning sleep, and dissatisfaction with night rest.

How Is Insomnia Diagnosed?

The diagnosis of insomnia is, above all, clinical. Only in some exceptions do we proceed with the execution of instrumental tests, with prolonged monitoring of the sleep-wake rhythm or actigraphy, in the case, for example, of a circadian rhythm disorder or a motor disorder, or by performing a polysomnogram if a lower extremity disorder, respiratory problem, or other disorder not reported by the patient is suspected.

When Is It Necessary To Consult A Specialist?

To diagnose chronic insomnia, the patient must show difficulty sleeping for at least 3 nights a week and for at least 3 months. Otherwise, we speak of acute insomnia, which is generally associated with particularly stressful periods: change of job, final exam, mourning.

What Can Be The Causes Of Insomnia?

Insomnia can be associated with other pathologies, often psychiatric/psychological, such as depression, somatoform disorders, and anxiety disorders, and medical disorders, such as chronic pain, neurological pathologies, and autoimmune diseases. This is the main reason the multidisciplinary approach is indicated for the diagnosis and treatment of the same.

How Can Insomnia Be Treated?

Treatment for insomnia can be pharmacological, but only in specific cases and for short periods, or psychological-psychotherapeutic. The pharmacological one is indicated above all for cases of acute insomnia as the treatment involves using drugs such as benzodiazepines or specific Z-drugs for sleep, which tend to be habit-forming, and which, in any case, should not be taken for more than 4 weeks. These drugs must be used under specialist medical supervision as they have numerous side effects, among which the most worrying is rebound insomnia caused by the sudden withdrawal of the drug.

Cognitive-behavioral psychological-psychotherapeutic treatment (CBT-i, Cognitive-Behavioral Therapy-Insomnia) is currently considered the treatment of chronic insomnia, and national and international guidelines recognize it as the first choice therapy. This treatment involves the use of different techniques, both on a behavioral and cognitive level. The main objective is to teach the patient to recognize his sleep, understand what happens during the night, the mechanisms underlying insomnia, and “prevent” relapses.

How Does Insomnia Therapy Work?

Therapy begins with sleep-wake rhythm monitoring by compiling a simple sleep diary for about 10 days, including at least 2 weekends, to verify the variability between weekdays and holidays; subsequently, we move on to the sleep psychoeducation phase, which is the basis of the treatment. During the interview, the mechanisms that regulate sleep and the mechanisms of insomnia are discussed together with the patient.

The behavioral techniques are different. We can remember the Stimulus Restriction Technique, whose objective is to restrict the time the patient spends in bed while awake, reaching the final goal of equaling the hours spent in bed with the hours of sleep totals. A technique, however, is difficult for patients who feel that they are required to sleep less, which is why the therapeutic alliance is fundamental: the patient must feel he can rely on the specialist.

Another part of the treatment is certainly sleep hygiene, i.e., the advice to follow that helps the patient sleep better. These are indications that many insomnia patients already follow but without benefit. This happens because the patient needs more education on sleep and its functioning. Here are some:

  1. Avoid eating heavy or too light foods in the evening. In the first case, my sleep will be disturbed by the longer and more difficult digestion; in the second, from hunger and more intense gastric juices. 
  2. Follow the times of falling asleep and waking up as regularly as possible to avoid having trouble falling asleep and waking up.
  3. Limit devices (mobile phone, tablet, computer, etc.) in the evening because they prevent melatonin production and cognitive activation.
  4. Limit exposure to light in the evening because it prevents the production of melatonin, a hormone essential for sleep.
  5. Stop doing any demanding and activating activity for at least 2 hours before bed and engage in relaxing activities.
  6. Better to drink a cup of milk with honey rather than herbal tea or chamomile, as we risk waking up at night to go to the bathroom. Additionally, milk contains tryptophan, which helps in the production of melatonin.

On a cognitive level, it is certainly necessary to identify patients’ wrong thoughts or beliefs (such as having to spend more time in bed than expected to make up for lost sleep hours), discuss them together, and improve the approach to sleep. Patients with insomnia often report racing minds and being unable to stop the flow of thoughts. In these cases, you can use visual imagery, relaxation, deep breathing, and real progressive muscle relaxation training.


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