jonquiljo wrote:robysue wrote:Or you do some hard work with CBT to literally re-teach your body how to sleep through the night.
CBT is hit and miss depending on who you go to see to work with.
Lots of things in life are hit or miss. Including how well sleeping pills will work for long-term management of insomnia. Some people will have no problems taking them---possibly for years. But for others, the pills seem to quit working after a while (due to increased tolerance) and they then find themselves on a merry-go-round of meds that never fully address why they can't sleep as well as they'd like: I have a friend at work who's been taking some kind of prescription sleeping pill for 10 years for her chronic insomnia. She tells me that while she can't fall asleep without it, she still wakes up numerous times at night and cannot get back to sleep, and sometimes lies in bed not sleeping for hours. And she has talked to her doctor about this. At this point, she's ready to give up on the sleeping pills since they don't seem to be helping her sleep anymore, but according to the doctor, she will have to carefully wean herself off of them carefully and slowly. And expect the insomnia to get worse before it gets better.
robysue wrote:Some links to refereed scholarly papers to consider:
Peer review is a tricky thing to consider - especially when it comes to anything medical. I used to do this kind of stuff for a living (pure science, though) so I am terribly wary of what people can publish. Statistics is an easy way of making most anything fit your model - it becomes more of a popularity contest (i.e. - your friends who like you get you published). Usually the best parts are the discussions at the end, if you take them in the light that they are the author's "opinion".
As an academic I know all about what you're talking about. Still, peer reviewed articles carry more weight that non-peer reviewed stuff in my humble opinion. As for the misuse of statistics, you are preaching to the choir---I am a mathematician.
Then it is best to lean CBT from someone who can teach it to you and adapt it to your life in whatever way you want. That takes years but can be worthwhile. But going to a shrink sometimes for 5, 10, 15, even 20 years can be a bigger habit than sleeping pills.
I really think you are misrepresenting CBT in its simplest forms---as in its use for managing insomnia. There's no reason to expect CBT (for insomnia) to last for 5 to 20 years and there's no need for it to require going to a shrink: I'm working with the PA in my sleep doctor's office as my "coach" for the CBT. We both expect that it will take a few more
months before the insomnia is really down to a level that I can comfortably manage long term.
At its most basic level, CBT is about identifying and changing behaviors that aggravate the problem, and replacing them with behaviors that tend to alleviate the problem. It's not about analyzing why the problem exists or why you are the way you are or why you developed the "bad" behavior patterns in the first place. It really is, at its most basic level, designed as problem solving: Here's a behavior pattern that's causing some trouble. Here's a way of learning how to substitute a better behavior pattern in its place.
If you are as screwed up as I am (and many tend to be) - you lean a technique and spend the rest of your life using it - kind of like using dental floss. It takes a long time to see results and is one in a bag of many things to work with.
Yes, CBT takes a long time to see results. And that is a major drawback for many, many people. And for anybody wanting a quick solution, CBT is NOT a good choice. But some people are willing to sacrifice a "quick" solution for one that will provide them with the tools to manage the problem for the rest of their lives. It's a highly personal decision to choose CBT for insomnia over sleeping pills. And it's not a decision to be made lightly: To really stand a chance of succeeding with CBT you have to have the patience and the commitment to do the hard work of changing your behavior. If you're not willing to do that, then CBT is NOT an appropriate way to treat the insomnia.
robysue wrote: However, I think you underestimate the ability of starting xPAP therapy to severely AGGRAVATE an existing insomnia problem.
No, not at all. Many people acclimate to XPAP readily, but some do not. Of those there are a percentage that are not adapting because the machine is not optimally set for them. Then, there are those who have true insomnia because they are hooked up to this foreign object blowing air into them. If it freaks you out - then CBT is a good candidate for this problem. Since most Dr's tend not to think about problems at any distance from their own discipline - many ignore the insomnia problem. It's the "not invented here" syndrome. I guess they need CBT to lean to open their minds a bit!
And how is insomnia "at a distance" from a
sleep doctor's specialty? My own sleep doctor's website talks at length about insomnia and when to seek professional help and so on ... But, yep, he ignored my history of stress induced insomnia at my one and only meeting with him. Fortunately his PA is much better at seeing the connections between my long and difficult adjustment to xPAP therapy, my pre-CPAP history of insomnia, and my current bout of insomnia. And in making useful suggestions on how to tackle both the current insomnia and the adjustment to xPAP issues.
And for new CPAPers who never fought with insomnia before, but develop the problems you are talking about: I think most of them will likely recover their ability to sleep soundly once they get through the learning curve. For some of them a short course of sleeping pills will likely even be a useful tool. For others paying a bit more attention to their sleep hygiene and working to solve the issues that freak them out about CPAP may be all they need.
But there are lots of people who just have insomnia. Many whom I have talked to are simply afraid of not sleeping - and so the cycle continues. Its one big anxiety disorder - or a part of a bigger anxiety problem. That's where people get tricky. You cant take a Type-A person and easily convert then into a Type-B. Sometimes you have to deal with a deck that is not full. I certainly do and have limped by with the best of all worlds. I guess what I am saying is that anxiety problems are complex and sometimes you can take 20 years and just get yourself so far. It's part of the human condition. Sounds like you are not a stress case of anxiety - so it's is probably easier for you.
I'm much more a Type-A than Type-B when it comes to stress and how I handle it (or rather how I fail to handle it).
Now, it's true that stress and anxiety are not the same beast. My brother deals with both severe stress and severe anxiety at times. While I'm a rather anxious person in my own right, I will admit that the level of my anxiety seldom gets high enough to be a real problem. It sounds like your anxiety is as bad or worse than my brother's. And my heart goes out to you: Severe anxiety is a beast that is very resistant to effective medical treatment in many folks.
But not all chronic insomniacs are anxious in the sense of severe anxiety. Many of them are world class worriers (as I am) and many of them do spend too much time worrying about not sleeping (or being afraid of not sleeping). And you are right, that many of them worry/fear about their lack of sleep and that feeds the insmonia night after night. And appropriate CBT work can be critical in breaking that cycle---regardless of whether they decide to take sleeping pills or not. Giving up the clock is critical: As long as you can lie in bed and quantify exactly how long you've not been sleeping each night, it's hard to not worry about how much time you know you are awake. Though many insomniacs have a hard time believing it, simply putting the clock out of sight goes a long way in giving you the freedom to NOT worry about how little time you've been asleep. And the underlying reason for all the sleep hygiene rules is to make it
easier to NOT worry about how little sleep you are getting while lying in bed.
robysue wrote:This is exactly why I so strongly feel that if a person decides that sleeping pills are the right choice for them, that it is critical that they have a long chat with the prescribing doctor: About which medicine will be prescribed and why. About potential side affects. About the potential for addiction or even more run of the mill "dependence" that falls short of true addiction.
If you can find a Dr that knows what he or she is talking about - just don't totally take their word for it. I have seen so many people rely on Dr's for this kind of information just to end up on some suboptimal medicine (or worse) to end up on something that is severely addictive. That is what I meant about Klonopin being prescribed commonly. Lots of Dr.'s think that this is a relatively "un-abusable" benzodiazepine - and therefore won't be a problem. Well, it may not be easily abused - but gets you to sleep with the side effects of being tired all day long - mainly because it's half life is way too long. And it is a benzodiazepine nevertheless, which means that getting off it is a pain in the butt. It is just as hard to get off of as an addictive one. So, if you're going to get addicted at all - then best take something that works well. Now Ambien, etc are much less addictive (but still addictive regardless). But they really work. When behavioral training isn't enough - you sometimes need a helper. This is the "bag of many tricks" approach I alluded to before.
I agree you need to not just take the doctor's word for it---research of your own is critical. And I also agree that sometimes you need a "helper' when the behavior training is not enough. But I'd also suggest it goes the other way too: Without at least a bit of the behavior training, the sleeping pills are less likely to be effective in the long run.
As far as Ambien working: It only worked "so-so" for me on the three nights I actually took it. (The nights were not in a row.) Yeah, it put me to sleep right away; but I still woke up for three or four long wakes in a six hour in-bed time frame. And I was groggy all day. And I had a scare with Ambien-induced taking my mask off and putting it back on (badly) without remembering a thing.
Sonata? Well the one time I took it, it still took me about 30 minutes to actually get to sleep. And again, I still woke up in the night for several long periods of time. Of course I was stressed out big time that night from having not slept much the night before.
I think we differ only in that insomnia is more of a treatable problem when it is someone with relatively few anxiety problems. In someone like me, with a plethora of neuroses, it takes a more varied approach, as no single thing will work. And if I am correct, severely neurotic and anxious people like me are in the majority too!
I'd say that none of the insomniacs that I personally know are "severely neurotic and anxious", and I know a fair number of insomniacs---most of my relatives on my mother's side of the family have intermittent problems with moderate to severe insomnia.
But I don't think we're as far apart as you think we are on treating insomnia. I think that the particular approach to treating insomnia must be based on the particular patient: His/her own opinion of what's the best way to proceed is critical. Will some folks want or need sleeping pills? Yes. Will other folks not want them at all? Yes. Will some folks want or need or embrace CBT? Yes. Will other folks find CBT more trouble than its worth? Yes. Neither approach is inherently "right" for everybody. And for many, many folks a more varied approach will be critical: They will likely need some medicine to help them sleep---either in the short run or on an intermittent basis for a long time. And they will likely need some changes in behavior to really be able to manage the insomnia in the long run. One without the other will simply not properly address all the issues. And so a combined approach is called for.
