As many of readers of this newsletter know, the last issue of Tinnitus Today focused on sleep. According to one systematic review (Gu, 2022), 54% of tinnitus patient reported sleep impairment. Marks (2019) noted sleep difficulties as the second most reported problem among those at tinnitus clinics. Cognitive behavioral therapy for insomnia (CBT-i) has proven to be a powerful treatment for primary insomnia, with medium to large effect sizes reported by high-quality systematic reviews (Okajima, Komada, and Inoue 2011). So if CBT-i is effective in treating insomnia, it should be effective in treating tinnitus-related insomnia, right?
This is not so clear. Generally, if the insomnia is the result of another condition, say a medical condition like an overactive thyroid, or a psychological condition like anxiety, the recommendation is to treat the primary condition first. Since tinnitus-related insomnia is the result of tinnitus, it would seem to imply we should treat the tinnitus before attempting to utilize CBT-i? Besides the fact that this distinction between primary and secondary insomnia is itself controversial, it is not clear exactly what a treatment for tinnitus would look like. As the National Center for Rehabilitative Auditory Research reminds us: “Many people with bothersome tinnitus spend a lot of time and energy searching for a way to quiet or eliminate the tinnitus. Unfortunately, there currently is no therapy that can safely and consistently reduce the loudness of tinnitus.”
Logic, then, would dictate we’ve nothing to lose by applying CBT-i to tinnitus-related insomnia, since there is not agree upon treatment for the primary condition. Yet surprisingly no study testing the effectiveness of this treatment on tinnitus related insomnia had been carried out until just a few years ago. Marks et al (2019) provided twenty-four tinnitus patients with six sessions of CBTi, supplementing it with some tinnitus-related elements such as a nighttime sound machine. The intervention achieved improvement across a range of well-established sleep outcomes, with 66.7% reporting reliable improvement on the ISI (insomnia severity index) post-treatment, sustained by 54.2% at follow-up. Patients in this evaluation also reported significantly lower tinnitus-related and psychological distress following treatment. This is pretty impressive.
I want to talk here in more detail about what exactly CBT-I since the Tinnitus Today articles did not describe the protocol in any detail. CBT-i is a qualitatively different intervention than CBT for tinnitus, as different, really, as physical therapy is from acupuncture, although that admittedly is not the best analogy. It is more accurate to say that CBT-I adds several processes that are not present in basic CBT. Indeed, the key component of CBT-i (the sleep diary) is not present at all in CBT for tinnitus. More importantly, CBT-i is an intervention that even more than CBT should be undertaken under the guidance of a therapist (and in consultation with one’s physician). With those caveats, I want to outline the intervention, explain some key concepts and provide some resources.
CBT-i is centered around the sleep diary. In the sleep diary, you record such information as when you go to bed, when you try to get to sleep, how often you wake up and how long it takes you to get back to sleep. The sleep diary will be used to set your sleep schedule for the course of treatment and will be used to adjust that schedule as well. You will keep a sleep diary for the entirety of your therapy.
Basically, you start off limiting your time in bed each night to the amount of time that you are actually sleeping according to your first week’s sleep diary. Hence this aspect of CBT-i is called, quite fittingly, SLEEP RESTRICTION. So, for example, if you determine that although you are in bed for eight hours between time spent trying to fall asleep and getting back to sleep you are only sleeping for six hours out of the eight, you would limit yourself to six hours of sleep for the first week. You are also expected to wake up at the same time every day of the week (including weekends) for the entirety of your therapy. Hence, if your baseline is six hours of sleep a night, and you regularly get up at six, you would not go to bed until midnight. One caveat here is that the minimum time in bed is five hours.
With your sleep and wake time determined, you would continue to keep your sleep diary to determine your sleep schedule, adjusting it slightly up or down depending on how you are responding using a formula we don’t need to go into here. SLEEP RESTRICTION lays the groundwork for the second component of CBT-i: STIMULUS CONTROL. Here, think Pavlov’s dog. Remember how Pavlov ultimately conditioned his dogs to salivate at the sound of a bell? Pavlov presented the stimulus of a bell each time he gave the dogs meat. Ultimately the dogs salivated at the very sound of the bell. This was the creation of a conditioned response. Essentially you are trying to do the same thing with your bed, only connecting your bed with sleep instead of a bell with salivation. Consider this. If Pavlov had rung a bell, blown a whistle, hummed a tune and tapped danced (I hear he was quite the hoofer) before giving the dog the meat, ringing the bell would not have elicited salivation. He had to specifically pair one stimulus with one response. Just so, if you read, watch TV, do work reports, worry, and engage in social media while in bed, sleep will not be the conditioned response when you go to bed. In short, you want your bed associated with one and only one (well, actually two, but this is a family friendly newsletter).
There are five components of stimulus control, which are all designed to strengthen the association between bed and sleep. They are: (1) The bed is to be used only for sleep and sex, (2) you are to unwind for one hour before bed, (3) no bed until sleepy, (4) avoid naps, and (5) If you cannot sleep after 15 minutes, get out of the bed and do something relaxing until you feel tire.
The final and most crucial part of CBT-I is the COGNITIVE THERAPY. Cognitive therapy is premised on the claim that is not a situation that causes our emotional reaction but our thoughts about the situation. Hence when it comes to insomnia, the assumption is that you are not worried, stressed and anxious because you can’t get to sleep. You are worried stressed and anxious because of your thoughts about not getting sleep, and most of these are unbalanced and extreme. In cognitive therapy as applied to insomnia, we examine the specific beliefs the person has about insomnia. We next look at how accurate or helpful a specific belief is. Finally, we attempt to come up with an alternate belief that can be more accurate/less harmful.
Someone who believes that their insomnia will destroy their health is asked to examine whether this assumption is in fact accurate or useful. The evidence certainly does not demonstrate a health link between periodic insomnia and negative health outcomes, while the belief is one that obviously not helpful. Someone who believes they cannot exercise if they did not sleep for eight hours likewise questioned about the validity of that claim. Is it that they cannot exercise, or that it is difficult to exercise? Have they ever had difficulty exercising when they had a good night’s sleep? Perhaps the bad night’s sleep is not the reason for difficulty exercising. And so on:
Some potentially unhelpful thoughts involve
- Unrealistic expectations about sleep
- Catastrophizing about the impact of a poor night’s sleep
- Erroneously blaming insomnia for all daytime problems
- Misattributions about causes of/control over insomnia
- Placing too much importance of sleep and intolerance for sleep loss
CBT-i is the most effective nonpharmacological treatment for chronic insomnia is cognitive-behavioral therapy for insomnia, producing results that are equivalent to sleep medication, with no side effects, fewer episodes of relapse, and a tendency for sleep to continue to improve long past the end of treatment. (Rossman). If this is something you might consider, you should find a therapist who is familiar not just with CBT but with this specific intervention.
References
Gu H, Kong W, Yin H, Zheng Y. Prevalence of sleep impairment in patients with tinnitus: a systematic review and single-arm meta-analysis. Eur Arch Otorhinolaryngol. 2022 May;279(5):2211-2221.
Marks E, McKenna L, Vogt F. Cognitive behavioural therapy for tinnitus-related insomnia: evaluating a new treatment approach. Int J Audiol. 2019 May;58(5):311-316
OKAJIMA, Isa, Yoko KOMADA, and Yuichi INOUE. "A Meta-analysis on the Treatment Effectiveness of Cognitive Behavioral Therapy for Primary Insomnia." Sleep and Biological Rhythms 9.1 (2011): 24-34. Web.
Rossman J. Cognitive-Behavioral Therapy for Insomnia: An Effective and Underutilized Treatment for Insomnia. Am J Lifestyle Med. 2019 Aug 12;13(6):544-547.