What are the best treatments for a person who is struggling with chronic insomnia? According to the American Academy of Sleep Medicine there are several alternatives that have been shown to be effective, including (among others):
- Stimulus Control Therapy: This form of treatment is designed to form a strong link between bed and sleep, and includes things like getting out of bed if not falling asleep, limiting in-bed activities to sleeping and having sex, and avoiding daytime napping.
- Relaxation Training: As the name implies, learning effective ways to relax can help a person fall asleep and also reduce the bedtime anxiety that often goes along with difficulty sleeping.
- Sleep Restriction: In this somewhat counterintuitive treatment approach, a person’s time in bed is limited to the actual time the person spends sleeping (based on sleep logs) plus a little extra time to fall asleep. It can help with sleep quality, and also fits well with stimulus control therapy in that it reinforces an association between bed and sleep.
A recent study in The Behavior Therapist asked an important question: What do treatment providers recommend for their patients who have insomnia, in light of the treatments that are known to be effective?
Based on the authors’ survey results, the vast majority (88%) of health practitioners (including physicians, psychologists, nurses, and others) recommended sleep hygiene as a stand-alone treatment for insomnia, even though there is little evidence for its effectiveness by itself. In contrast, only about 30% recommended stimulus control and around 25% recommended sleep restriction. These numbers were in line with what the health practitioners believed about the effectiveness of these treatments.
The study’s authors conclude that it is troubling that treatment providers most often recommend sleep hygiene when there is limited evidence that it works as a stand-alone treatment (sleep hygiene is often included in multi-component treatments like cognitive behavioral therapy for insomina, or CBT-I). In light of existing research studies and practice guidelines, it is important to make the public and health providers aware that sleep hygiene alone is not backed by solid research evidence, and that much more powerful and well-tested treatments are available.
A list of tips for good sleep can be found here
Moss TG, Lachowski AM, Carney CE: What all treatment providers should know about sleep hygiene. The Behavior Therapist 36:76-82
This week my colleagues and I had a paper published in Psychological Science in the Public Interest that calls for more evidence-based treatment of posttraumatic stress disorder (PTSD). Even though there are really effective treatments for PTSD–for example, prolonged exposure, cognitive processing therapy, EMDR–it can be pretty hard for a person with PTSD to find a therapist who provides these treatment programs. We talk about reasons therapists give for choosing not to use evidence-based treatments, and discuss examples of successes in getting effective treatments to the people who need them. The article is available for free on the journal website: http://www.psychologicalscience.org/index.php/publications/journals/pspi/ptsd.html
Last month the New York Times had a related piece that nicely summarizes the issues: http://well.blogs.nytimes.com/2013/03/25/looking-for-evidence-that-therapy-works/?ref=policy. The article includes questions to consider asking a potential therapist, for example, “How do you know that what you do in treatment works?” The therapist should be able to point to studies that have shown the effectiveness of the specific treatment that he or she uses for specific psychological conditions.
Our local NPR station summarized the article here.
On a snowy night in South Brunswick, NJ, I recently had the opportunity to speak with members of the community about cognitive-behavioral therapy for anxiety and depression. The talk was organized through South Asian Mental Health Awareness in Jersey (SAMHAJ) which is affiliated with NAMI NJ. (The slides from the talk are available on their website here.) It was a terrific group and they posed some great questions. One of the questions had to do with the length of treatment in CBT, which I had described as generally being about 12 to 20 sessions. Someone in attendance asked why the treatment tended to be short and whether a person could be seen for longer than that if they wanted to continue treatment–that is, are people “kicked out” of CBT after 12-20 sessions?
CBT generally is brief because it tends to be highly effective at treating well-defined problems that a person is dealing with. For example, CBT for OCD consists of exposure and response prevention (ERP), which provides significant relief to the majority of treatment seekers in about 15 sessions. Similarly, CBT for posttraumatic stress disorder (PTSD) helps most people in about 8-12 sessions. The advantage of these short treatments is that people usually feel better pretty quickly; the fewer number of sessions also reduces the cost of treatment.
Depending on a person’s goals, it’s possible to continue in treatment beyond the acute phase. While the initial phase of treatment is usually about relieving suffering, later phases can address areas of growth and creating the kind of life that the person values. For example, a person with severe OCD likely comes to treatment to stop the powerful cycle of obsessions and compulsions. Once these symptoms are no longer controlling one’s life, the person is in a position to begin thinking about broader issues that perhaps couldn’t be addressed while the OCD was so overwhelming.
Similarly, a second phase of treatment may begin to address the many ways that a person has structured his or her life around debilitating levels of anxiety or depression; for example, a man might realize that he has allowed his anxiety to dictate his job choices, and as a result has passed up many opportunities for career advancement. Once the anxiety symptoms are no longer “front and center” the person can focus on building a life that is based on deeply held values and goals.
Even if the person decides not to continue with “phase 2″ of treatment, he or she is generally in a good position to build on the progress that was made. Whenever treatment ends, it’s important to take stock of what one has learned and to identify ways to continue to apply that learning.
An article that my colleagues and I wrote (led by Dr. Idan Aderka) was recently published in the Journal of Consulting and Clinical Psychology. The main thrust of the paper deals with the sequence of symptom improvement among people who receive an evidence-based treatment for PTSD. This treatment tends to improve not only the symptoms of posttraumatic stress disorder but also depression–good news for the approximately 50% of PTSD sufferers who also have depression. We asked a relatively simple question: Which improves first, depression or PTSD symptoms? It could be that the PTSD symptoms get better first, which then causes the depression symptoms to lift; the reverse could also be true (depression improvements drive PTSD improvements). Or, it could be that both sets of symptoms improve at the same time. I want to focus on what we found among people who received traditional prolonged exposure (our study also looked at a group of people who got a similar treatment that was supplemented with a heavier dose of cognitive work). Our analyses showed that PTSD improvements led to improvements in depression, whereas the reverse was not the case. That is, improvements in depression did not seem to account for improvements in PTSD symptoms.
So how does a decrease in PTSD symptoms lead to improvements in depression? One possibility has to do with facing one’s fears. People with PTSD often avoid situations and memories related to their traumatic experience, and can start to feel bad about themselves as a result. For example, a person might tell himself, “I’m too weak to face these situations”–a kind of thought that can contribute to depression. As a person starts to approach avoided situations and memories as part of the treatment, the person recognizes personal strengths that he or she might not have realized were there: “Hey, I’m strong enough to handle this.” These more hopeful thoughts can directly contribute to an improved mood.
The full paper is available here.
I recently came across an excellent article on OCD recovery written by Dr. Michael Tompkins, a cognitive-behavioral therapist in the Bay Area. The article originally appeared in Cognitive Therapy Today, published by the Beck Institute. Dr. Tompkins highlights several attitudes that are essential both during active OCD treatment and in supporting ongoing wellness. What I was most struck by in the article was the emphasis on acceptance–of uncertainty, of discomfort, of imperfect knowledge. Accepting what is can help us to stop fighting against things we can’t change and to focus our energy on things that we value. The full article is available here.
The article is copyrighted by the Beck Institute for Cognitive Behavior Therapy, 2012. Reprinted from “CBT for OCD: The Importance of an Effective Recovery Attitude,” by Michael A. Tompkins, Ph.D., in Cognitive Therapy Today, www.beckinstitute.org. Used with permission.
Michael A. Tompkins, PhD, is author of OCD: A Guide for the Newly Diagnosed and is a founding partner of the San Francisco Bay Area Center for Cognitive Therapy.
Is it possible to tell if someone has a psychological disorder based on looking at that person’s brain? Does neuroimaging help us to distinguish between similar diagnoses? In a recently published article in the American Journal of Bioethics – Neuroscience, Dr. Martha Farah and Dr. Gillihan address these and similar questions. They review some of the applications of current technology to assist with diagnosis and ask whether these applications are justified. They also address aspects of our diagnostic system (currently the DSM-IV-TR) that might make brain-based diagnosis difficult. The full article is here.
Two studies that were published over the summer provide further evidence for the power of mindfulness meditation. Mindfulness is the practice of being present, in the moment, in an open and non-judgmental way. It’s contrasted with how we live our lives most of the time: focused on anything other than what’s actually happening, judging everything as either “for us” or “against us,” ruminating about the past and worrying about the future…. We can practice being more mindfully aware in our daily lives, and one effective way to cultivate greater mindfulness is to meditate.
Hundred of studies over recent decades have shown that mindfulness practices are linked to all kinds of good things: creativity, happiness, stress reduction, mental health, physical health, to name just a few. These two recent studies added to the existing knowledge base about the benefits of mindfulness. The first study by Zindel Segal and colleagues in Canada–who developed a mindfulness-based cognitive therapy (MBCT) for depression–shed light on how it is that mindfulness helps to prevent relapse into depression. They found that MBCT helped people to treat their thoughts as nothing more than thoughts, rather than viewing them as objective truths about the world. For example, a person could learn to recognize the thought “I’m such a loser” as mental activity rather than actually meaning that the person is a loser. Additionally, MBCT led to increases in a measure of curiosity which was defined as “approaching and investigating one’s experience without judgment.” People who became more curious about their experiences and who got better at treating their thoughts as just thoughts were less likely to relapse into depression down the road. The study was published in the Journal of Consulting and Clinical Psychology.
The other recent study showed that mindfulness meditation helps not only the mind but also the body. Bruce Barrett and his collaborators at the University of Wisconsin in Madison randomly assigned participants to 8 weeks of mindfulness meditation training, 8 weeks of exercise, or to no active treatment (the control group). Mindfulness training resulted in shorter and less severe acute respiratory infections compared to no treatment. The meditation group also missed significantly fewer days of work because of respiratory infections (16) compared to the control group (67); similar benefits were found for the exercise group. These results, which were reported in the Annals of Family Medicine, provide additional support for the powerful effects of mindfulness meditation.
These studies and countless others demonstrate scientifically what thousands of mindfulness practitioners have known from direct experience–that the practice of mindfulness is life changing and can touch all important aspects of a person’s life.
Dr. Gillihan and colleagues recently wrote an article in which they discuss how ERP works, common therapist mistakes that can weaken the treatment, and how therapists can avoid these pitfalls. For example, when is it harmful to use distraction during exposures? When is the right time to use imaginal exposure versus in vivo exposure? What if a person has mostly mental compulsions? How can family members help a person with OCD to get the most out of ERP treatment?
The article may be of interest both to therapists and to individuals with OCD who are considering their treatment options.
Here is a related blog entry on ocdtalk that expands on the issue of mental compulsions in OCD.
Scientists are starting to figure out how the brain is involved in mental disorders like depression, bipolar disorder, obsessive-compulsive disorder, and schizophrenia. Some clinics are now offering brain scans to identify which specific condition a person might have. Are these scans worth their significant cost? Probably not. In an interview published in Medical Ethics Advisor, Dr. Gillihan discusses reasons to beware. Read more (article entitled “Diagnostic neuroimaging for psych patients — ethical?” begins at bottom of first column): MEA August 2012 issue_SPECT scans