To treat insomnia with CBT

One in five French people suffers from insomnia. While the use of sleeping pills remains the main resort for many insomniacs, behavioral and cognitive therapy is an unrecognized ally for restoring sleep. Explanations from Michel Billiard, neurologist and specialist in sleep disorders.

Interview by Lucien Fauvernier

How does behavioral and cognitive therapy treat insomnia?

Michel Billiard: Behavioral treatment consists of two things: bed time restriction and stimulus control therapy. The restriction of bedtime is aimed not at reducing sleep time but at bedtime. Indeed to compensate for his lack of sleep, an insomniac will tend to go to bed early and get up late. In the company of the therapist, the patient will hold a sleep log and agree on an hour of waking in the morning that will remain the same, while the bedtime will vary. The sleep log will allow, after one or two weeks, to see if the duration of sleep increases or remains low and to estimate an average of the "tested sleep". In parallel, we apply the stimulus control therapy, which consists of going to bed only when you really feel like sleeping. For example, if after 15-20 minutes in bed, you do not sleep, you have to get up again to practice a quiet activity like reading. Similarly, if you wake up in the night at 4am without getting to sleep, you have to get up. Of course it's not easy, but it's sure to better regulate your sleep.

The second part of the therapy, the cognitive angle, focuses on the harmful beliefs of chronic insomniacs: it takes a minimum of 8h of sleep to work well during the day, if I spend a bad night it will be worse at night next ... all these ideas are wrong. Indeed, it is only after several bad nights that the lack of sleep will be felt. With the help of a questionnaire, the therapist will give the insomniac a real definition of what sleep is and how it works. Relaxation comes in addition to different techniques such as autogenic training, mental imagery, not to directly improve sleep, but to reduce the anxiety of the insomniac induced by his daily fear of not sleeping.

Can it completely replace sleeping pills?

Michel Billiard: The studies are lacking in this regard, to know if the insomniacs having followed a TCC completely stopped sleeping pills or not, especially in the long term. What is certain, however, is that you must never suddenly stop sleeping pills.The reason is simple: brutal weaning, especially in a long-time consumer is harmful both psychologically and biologically, with real cardiac risks. If you start a CBT, it is only at the onset of the first that you can, under medical supervision, reduce sleeping pills. The underlying question is whether we should completely refrain from sleeping pills. Even in cases where the therapy works well, it does not prevent sometimes having a small sleep glitch: a snorer nearby, work at home ... In these cases, we can very well take a sleeping pill of punctual way.

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