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Cognitive Behavioural Therapy (CBT)

Definition:
Cognitive behavior therapy (CBT) is a type of psychotherapeutic treatment that helps patients understand the thoughts and feelings that influence behaviors. CBT is commonly used to treat a wide range of disorders including phobias, addictions, depression, and anxiety.

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Cognitive behavioral therapy (CBT) is a short-term psychotherapy originally designed to treat depression, but is now used for a number of mental illnesses. It works to solve current problems and change unhelpful thinking and behavior.  The name refers to behavior therapy, cognitive therapy, and therapy based upon a combination of basic behavioral and cognitive principles.  Most therapists working with patients dealing with anxiety and depression use a blend of cognitive and behavioral therapy. This technique acknowledges that there may be behaviors that cannot be controlled through rational thought, but rather emerge based on prior conditioning from the environment and other external and/or internal stimuli. CBT is “problem focused” (undertaken for specific problems) and “action oriented” (therapist tries to assist the client in selecting specific strategies to help address those problems),  or directive in its therapeutic approach.

CBT has been demonstrated to be effective for the treatment of a variety of conditions, including mood, anxiety, personality, eating, substance abuse, tic, and psychotic disorders. Many CBT treatment programs for specific disorders have been evaluated for efficacy; the health-care trend of evidence-based treatment, where specific treatments for symptom-based diagnoses are recommended, has favored CBT over other approaches such as psychodynamic treatments.  However, other researchers have questioned the validity of such claims to superiority over other treatments.

Description:
Mainstream cognitive behavioral therapy assumes that changing maladaptive thinking leads to change in affect and behavior,[8] but recent variants emphasize changes in one’s relationship to maladaptive thinking rather than changes in thinking itself.  Therapists or computer-based programs use CBT techniques to help individuals challenge their patterns and beliefs and replace “errors in thinking such as overgeneralizing, magnifying negatives, minimizing positives and catastrophizing” with “more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behavior.”  These errors in thinking are known as cognitive distortions. Cognitive distortions can be either a pseudo- discrimination belief or an over-generalization of something.  CBT techniques may also be used to help individuals take a more open, mindful, and aware posture toward them so as to diminish their impact. Mainstream CBT helps individuals replace “maladaptive… coping skills, cognitions, emotions and behaviors with more adaptive ones”,  by challenging an individual’s way of thinking and the way that they react to certain habits or behaviors,  but there is still controversy about the degree to which these traditional cognitive elements account for the effects seen with CBT over and above the earlier behavioral elements such as exposure and skills training.

Modern forms of CBT include a number of diverse but related techniques such as exposure therapy, stress inoculation training, cognitive processing therapy, cognitive therapy, relaxation training, dialectical behavior therapy, and acceptance and commitment therapy.  Some practitioners promote a form of mindful cognitive therapy which includes a greater emphasis on self-awareness as part of the therapeutic process.

CBT has six phases:
1.Assessment or psychological assessment;
2.Reconceptualization;
3.Skills acquisition;
4.Skills consolidation and application training;
5.Generalization and maintenance;
6.Post-treatment assessment follow-up.

The reconceptualization phase makes up much of the “cognitive” portion of CBT.   A summary of modern CBT approaches is given by Hofmann.

There are different protocols for delivering cognitive behavioral therapy, with important similarities among them.  Use of the term CBT may refer to different interventions, including “self-instructions (e.g. distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (e.g. minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting”. Treatment is sometimes manualized, with brief, direct, and time-limited treatments for individual psychological disorders that are specific technique-driven. CBT is used in both individual and group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are cognitively oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (e.g. in vivo exposure therapy). Interventions such as imaginal exposure therapy combine both approaches.

Types of Cognitive Behavior Therapy:
There are a number of different approaches to CBT that are regularly used by mental health professionals. These types include:
•Rational Emotive Behavior Therapy (REBT)
•Cognitive Therapy
•Multimodal Therapy

Medical uses of CBT:
In adults, CBT has been shown to have effectiveness and a role in the treatment plans for anxiety disorders,  depressioneating disorders chronic low back painpersonality disorderspsychosis,  schizophrenia,  substance use disorders,  in the adjustment, depression, and anxiety associated with fibromyalgia,  and with post-spinal cord injuries.  Evidence has shown CBT is effective in helping treat schizophrenia, and it is now offered in most treatment guidelines.

In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders,  body dysmorphic disorder,  depression and suicidality,  eating disorders and obesity,  obsessive–compulsive disorder,  and posttraumatic stress disorder,  as well as tic disorders, trichotillomania, and other repetitive behavior disorders.

Cochrane reviews have found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition.   Other recent Cochrane Reviews found no convincing evidence that CBT training helps foster care providers manage difficult behaviors in the youth under their care,  nor was it helpful in treating men who abuse their intimate partners.

According to a 2004 review by INSERM of three methods, cognitive behavioral therapy was either “proven” or “presumed” to be an effective therapy on several specific mental disorders.  According to the study, CBT was effective at treating schizophrenia, depression, bipolar disorder, panic disorder, post-traumatic stress, anxiety disorders, bulimia, anorexia, personality disorders and alcohol dependency.

Some meta-analyses find CBT more effective than psychodynamic therapy and equal to other therapies in treating anxiety and depression.  However, psychodynamic therapy may provide better long-term outcomes.

Computerized CBT (CCBT) has been proven to be effective by randomized controlled and other trials in treating depression and anxiety disorders, including children,  as well as insomnia.  Some research has found similar effectiveness to an intervention of informational websites and weekly telephone calls.  CCBT was found to be equally effective as face-to-face CBT in adolescent anxiety  and insomnia.

Criticism of CBT sometimes focuses on implementations (such as the UK IAPT) which may result initially in low quality therapy being offered by poorly trained practitioners.  However evidence supports the effectiveness of CBT for anxiety and depression.

Mounting evidence suggests that the addition of hypnotherapy as an adjunct to CBT improves treatment efficacy for a variety of clinical issues.

CBT has been applied in both clinical and non-clinical environments to treat disorders such as personality conditions and behavioral problems.  A systematic review of CBT in depression and anxiety disorders concluded that “CBT delivered in primary care, especially including computer- or Internet-based self-help programs, is potentially more effective than usual care and could be delivered effectively by primary care therapists.”

Emerging evidence suggests a possible role for CBT in the treatment of attention deficit hyperactivity disorder (ADHD);  hypochondriasis;  coping with the impact of multiple sclerosis;  sleep disturbances related to aging; dysmenorrhea;  and bipolar disorder,  but more study is needed and results should be interpreted with caution. CBT has been studied as an aid in the treatment of anxiety associated with stuttering. Initial studies have shown CBT to be effective in reducing social anxiety in adults who stutter,  but not in reducing stuttering frequency.

Martinez-Devesa et al. (2010) found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition. Turner et al. (2007) found no convincing evidence that CBT training helps foster care providers manage difficult behaviors in the youth under their care,[39] and Smedslund et al. (2007) found that it was not helpful in treating men who abuse their intimate partners.

In the case of metastatic breast cancer, Edwards et al. (2008) maintained that the current body of evidence is not sufficient to rule out the possibility that psychological interventions may cause harm to women with this advanced neoplasm.

In adults, CBT has been shown to have a role in the treatment plans for anxiety disorders; depression;  eating disorders;  chronic low back pain;  personality disorders;  psychosis; schizophrenia;  substance use disorders;  in the adjustment, depression, and anxiety associated with fibromyalgia;  and with post-spinal cord injuries.  There is some evidence that CBT is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia.  CBT has been shown to be moderately effective for treating chronic fatigue syndrome.

In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders;  body dysmorphic disorder;  depression and suicidality;  eating disorders and obesity;  obsessive–compulsive disorder;  and posttraumatic stress disorder;  as well as tic disorders, trichotillomania, and other repetitive behavior disorders. CBT-SP, an adaptation of CBT for suicide prevention (SP), was specifically designed for treating youth who are severely depressed and who have recently attempted suicide within the past 90 days, and was found to be effective, feasible, and acceptable. Sparx is a video game to help young persons, using the CBT method to teach them how to resolve their own issues. That’s a new way of therapy, which is quite effective for child and teenager. CBT has also been shown to be effective for posttraumatic stress disorder in very young children (3 to 6 years of age).  Cognitive Behavior Therapy has also been applied to a variety of childhood disorders,  including depressive disorders and various anxiety disorders.

In the United Kingdom, the National Institute for Health and Care Excellence (NICE) recommends CBT in the treatment plans for a number of mental health difficulties, including posttraumatic stress disorder, obsessive–compulsive disorder (OCD), bulimia nervosa, and clinical depression

Use of CBT  in other different ways:
With older adults:
CBT is used to help people of all ages, but the therapy should be adjusted based on the age of the patient with whom the therapist is dealing. Older individuals in particular have certain characteristics that need to be acknowledged and the therapy altered to account for these differences thanks to age.   Some of the challenges to CBT because of age include the following:
The Cohort effect The times that each generation lives through partially shape its thought processes as well as values, so a 70-year-old may react to the therapy very differently from a 30-year-old, because of the different culture in which they were brought up. A tie-in to this effect is that each generation has to interact with one another, and the differing values clashing with one another may make the therapy more difficult.  Established role By the time one reaches old age, the person has a definitive idea of her or his role in life and is invested in that role. This social role can dominate who the person thinks he or she is and may make it difficult to adapt to the changes required in CBT. Mentality toward aging If the older individual sees aging itself as a negative this can exacerbate whatever malady the therapy is trying to help (depression and anxiety for example).  Negative stereotypes and prejudice against the elderly cause depression as the stereotypes become self-relevant.[88]Processing speed decreasesAs we age, we take longer to learn new information, and as a result may take more time to learn and retain the cognitive therapy. Therefore, therapists should slow down the pacing of the therapy and use any tools both written and verbal that will improve the retention of the cognitive behavioral therapy.

Prevention of mental illness:
For anxiety disorders, use of CBT with people at risk has significantly reduced the number of episodes of generalized anxiety disorder and other anxiety symptoms, and also given significant improvements in explanatory style, hopelessness, and dysfunctional attitudes.  In another study, 3% of the group receiving the CBT intervention developed generalized anxiety disorder by 12 months post intervention compared with 14% in the control group.  Subthreshold panic disorder sufferers were found to significantly benefit from use of CBT.  Use of CBT was found to significantly reduce social anxiety prevalence.

For depressive disorders, a stepped-care intervention (watchful waiting, CBT and medication if appropriate) achieved a 50% lower incidence rate in a patient group aged 75 or older.  Another depression study found a neutral effect compared to personal, social, and health education, and usual school provision, and included a comment on potential for increased depression scores from people who have received CBT due to greater self recognition and acknowledgement of existing symptoms of depression and negative thinking styles.[99] A further study also saw a neutral result. A meta-study of the Coping with Depression course, a cognitive behavioural intervention delivered by a psychoeducational method, saw a 38% reduction in risk of major depression.

For schizophrenia, one study of preventative CBT showed a positive effect   and another showed neutral effect.

Criticisms of Cognitive Behavior Therapy:
The research conducted for CBT has been a topic of sustained controversy. While some researchers write that CBT is more effective than other treatments,[148] many other researchers  and practitioners  have questioned the validity of such claims. For example, one study  determined CBT to be superior to other treatments in treating anxiety and depression. However, researchers responding directly to that study conducted a re-analysis and found no evidence of CBT being superior to other bona fide treatments, and conducted an analysis of thirteen other CBT clinical trials and determined that they failed to provide evidence of CBT superiority.

Furthermore, other researchers  write that CBT studies have high drop-out rates compared to other treatments. At times, the CBT drop-out rates can be more than five times higher than other treatments groups. For example, the researchers provided statistics of 28 participants in a group receiving CBT therapy dropping out, compared to 5 participants in a group receiving problem-solving therapy dropping out, or 11 participants in a group receiving psychodynamic therapy dropping out.

Other researchers  conducting an analysis of treatments for youth who self-injure found similar drop-out rates in CBT and DBT groups. In this study, the researchers analyzed several clinical trials that measured the efficacy of CBT administered to youth who self-injure. The researchers concluded that none of them were found to be efficacious. These conclusions  were made using the APA Division 12 Task Force on the Promotion and Dissemination of Psychological Procedures to determine intervention potency.

However, the research methods employed in CBT research have not been the only criticisms identified. Others have called CBT theory and therapy into question. For example, Fancher  writes the CBT has failed to provide a framework for clear and correct thinking. He states that it is strange for CBT theorists to develop a framework for determining distorted thinking without ever developing a framework for “cognitive clarity” or what would count as “healthy, normal thinking.” Additionally, he writes that irrational thinking cannot be a source of mental and emotional distress when there is no evidence of rational thinking causing psychological well-being. Or, that social psychology has proven the normal cognitive processes of the average person to be irrational, even those who are psychologically well. Fancher also says that the theory of CBT is inconsistent with basic principles and research of rationality, and even ignores many rules of logic. He argues that CBT makes something of thinking that is far less exciting and true than thinking probably is. Among his other arguments are the maintaining of the status quo promoted in CBT, the self-deception encouraged within clients and patients engaged in CBT, how poorly the research is conducted, and some of its basic tenets and norms: “The basic norm of cognitive therapy is this: except for how the patient thinks, everything is ok”.

Meanwhile, Slife and Williams  write that one of the hidden assumptions in CBT is that of determinism, or the absence of free will. They argue that CBT invokes a type of cause-and-effect relationship with cognition. They state that CBT holds that external stimuli from the environment enter the mind, causing different thoughts that cause emotional states. Nowhere in CBT theory is agency, or free will, accounted for. At its most basic foundational assumptions, CBT holds that human beings have no free will and are just determined by the cognitive processes invoked by external stimuli.

Another criticism of CBT theory, especially as applied to Major Depressive Disorder (MDD), is that it confounds the symptoms of the disorder with its causes.

A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e., neither subjects nor therapists in psychotherapy studies are blind to the type of treatment). They may be single-blinded, i.e. the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in.

The importance of double-blinding was shown in a meta-analysis that examined the effectiveness of CBT when placebo control and blindedness were factored in.[156] Pooled data from published trials of CBT in schizophrenia, MDD, and bipolar disorder that used controls for non-specific effects of intervention were analyzed. This study concluded that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates, treatment effects are small in treatment studies of MDD, and it is not an effective treatment strategy for prevention of relapse in bipolar disorder. For MDD, the authors note that the pooled effect size was very low. Nevertheless, the methodological processes used to select the studies in the previously mentioned meta-analysis and the worth of its findings have been called into question.

Resources:
http://en.wikipedia.org/wiki/Cognitive_behavioral_therapy
http://psychology.about.com/od/psychotherapy/a/cbt.htm

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Few Tips to Improve Your Slumber Tonight

Sleep is important for your physical and emotional health. Sleep may help you stay healthy by keeping your immune system strong. Getting enough sleep can help your mood and make you feel less stressed.

But we all have trouble sleeping sometimes. This can be for many reasons. You may have trouble sleeping because of depression, insomnia, fatigue, or Sjögren’s syndrome. If you are depressed, feel anxious, or have post-traumatic stress disorder (PTSD), you may have trouble falling or staying asleep.

Whatever the cause, there are things you can do:

Your sleeping area :
•Use your bedroom only for sleeping
•Move the TV out of your bedroom
•Keep your bedroom quiet and dark
Your evening and bedtime routine

•Get regular exercise — but not within 3 to 4 hours before bedtime
•Create a relaxing bedtime routine
•Go to bed at the same time every night
•Consider using a sleep mask and earplugs
If you can’t sleep
•Imagine yourself in a peaceful, pleasant place
•Don’t drink any liquids after 6 PM if waking up during the night to go to the bathroom is a problem


Your activities during the day
Your habits and activities can affect how well you sleep. Here are some tips.
•Exercise during the day. Don’t exercise after 5 p.m. because it may be harder to fall asleep.
•Get outside during daylight hours. Spending time in sunlight helps to reset your body’s sleep and wake cycles.
•Don’t drink or eat anything that has caffeine in it, such as coffee, tea, cola, and chocolate.
•Don’t drink alcohol before bedtime. Alcohol can cause you to wake up more often during the night.
•Don’t smoke or use tobacco, especially in the evening. Nicotine can keep you awake.
•Don’t take naps during the day, especially close to bedtime.
•Don’t take medicine that may keep you awake, or make you feel hyper or energized, right before bed. Your doctor can tell you if your medicine may do this and if you can take it earlier in the day.

If you can’t sleep because you are in great pain or have an injury, you often feel anxious at night, or you often have bad dreams or nightmares, talk to your doctor.

Source: Health.com April 24, 2008

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Can Cold Temperatures Improve Sleep

Studies have found that in general, the optimal temperature for sleep is quite cool, around 60 to 68 degrees Fahrenheit. Temperatures that fall too far below or above this range can lead to restlessness.
….
Temperatures in this range help facilitate the decrease in core body temperature that in turn initiates sleepiness. A growing number of studies are finding that temperature regulation plays a role in many cases of chronic insomnia.

Researchers have shown, for example, that insomniacs tend to have a warmer core body temperature than normal sleepers just before bed, which leads to heightened arousal and a struggle to fall asleep.

For troubled sleepers, a cool room and a hot-water bottle placed at the feet, which rapidly dilates blood vessels and therefore actually helps lower core temperature, can push the internal thermostat to a better setting.

Source: New York Times August 3, 2009

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Practice Yoga & Sleep Well

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Nothing can make you more refreshed and energised for a long day than a night of sound sleep. Whether you are a corporate professional, a student or a housewife, all of us experience some form of stress in our day to day lives. There is no end to the number of worries and the anxiety that can plague one’s happiness; especially when we go to sleep. For some of us, depending on our lifestyle, this may be the only time that we get in the whole day, to relax our body and mind. This however, becomes difficult when you try too hard to relax. It only makes your body tenser.

There are numerous benefits of a night of good, sound sleep. It is when you sleep that your body repairs the damaged cells in it. It also helps increase your concentration and retention power because your mind is relaxed. When you do not get this dose of sleep, you feel tired, drained out and unable to concentrate on work at hand. Worse, if this continues, it leads to disorders like insomnia and sometimes people even start hallucinating.

While there are drugs and chemicals to superficially cure you of such disorders and make you sleep, nothing can replace the benefits of a natural remedy. Yoga is such an experimental science. Through yoga, you learn to experiment and understand your own body. It automatically tells you what is good for your body and what is not, what relaxes your body and what does not. The external environment around you will then no longer matter, because you know that you can calm your body down no matter where you are and give it the relaxation it needs. You will not need to depend on anything else to get that night’s sleep.

Shavasana is a relatively common relaxation yogasana but its benefits are innumerous. It relaxes your entire being. This asana should be practiced before sleep as it will take away all your physical and mental fatigue and make you aware of your own body. Ujjayi Pranayama when done in Shavasana helps in inducing sleep. It is a tranquilising  pranayama and a perfect cure for insomnia. It has an enormous soothing effect on the nervous system and calms down your nerves. Matsya Kridasana is another relaxation asana that can be practiced before going to sleep. It is especially helpful in calming down. Source

Source: Yoga.am Dec 13.’09

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Cold Air Blast May Cure Isomnia

A cap that cools the brain could mean a better night’s sleep for insomniacs.

The cap pumps a liquid coolant round the front of the scalp and the forehead.
This chills the prefrontal cortex, a part of the brain thought to play a role in prompting deep sleep.
Tests show insomniacs have higher levels of activity in this part of the brain at night than those who have no trouble nodding off.
But cooling the brain seems to dampen this activity and allows it to switch off properly for a good night’s sleep.
Eight volunteers wore the cap for an hour before bedtime and the first hour of sleep, after which researchers removed it.
Scans taken during the night showed wearing the cap caused a marked decline in brain metabolism, the rate at which cells in the frontal cortex process sugars and chemicals in the blood.
Six of the volunteers reported more refreshing sleep, fewer distracting thoughts at bedtime and waking up less in the night.
One in four people is affected by insomnia – most have ‘primary’ insomnia, an inability to fall asleep because of worries or stress.
Secondary insomnia, which is due to existing illness or a side-effect of prescription drugs, is less common.
Lots of money are being spent every year towards sleeping pills. Many sufferers rely on drugs such as benzodiazepines, which act as tranquillisers, to help them.

In England alone, there are ten million prescriptions for sleeping pills every year.
Yet the drugs can have side effects, such as memory and concentration problems, and make you more likely to have an accident.
In the search for drug-free alternatives, scientists at the University of Pittsburgh have spent the past few years studying the brain’s metabolism at night.

They found insomnia patients have increased activity, especially in the frontal cortex. Essentially, their brain cells continue to work at full capacity at night when they should be resting.
Professor Eric Nofzinger, who led the research, said they then searched for ways to slow the brain’s metabolic rate. ‘That’s when we came across cerebral hypothermia or brain cooling,’ he says.
This technique is already used in medicine. Researchers first discovered its benefits ten years ago, when they found babies starved of oxygen at birth had a better chance of survival if their brains were quickly cooled from the normal temperature of 37c to 32c.

This stops brain cells from committing suicide when deprived of oxygen.
Scalp cooling is also used as a way to minimise hair loss in cancer patients undergoing chemotherapy.
Professor Nofzinger and his team recruited eight patients with primary insomnia and scanned their brains to measure activity levels in the frontal cortex at night.
They then used the cooling cap to see if it made a difference.
The results, presented at a recent conference in Seattle, showed a significant drop in activity levels once the brain was chilled.
‘There was an increase in deeper, restorative sleep, feelings of relaxation and a reduction in distracting thoughts before sleep,’ says Professor Nofzinger.
But British sleep specialists say there are simpler ways to cool the body to aid sleep.
Professor Jim Horne, from Loughborough University, says that a bedside fan that blows cool air over the face can help.
As cooled blood from the cheeks flows back to the heart, it runs alongside an artery transporting warmer blood in the other direction to the brain.
‘It’s like having a hot water pipe next to the cold pipe,’ Professor Horne says.
‘Cooler blood enters the brain and leads to better sleep. A gentle breeze over the face is all that’s needed.’

Source: Mail Online. 14th. July.2009

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