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Sleep Difficulties


Sleep impacts and is impacted by all aspects of our lives. If you are reading this page, chances are that you know the importance of sleep, but are struggling to get enough. You are not alone.

Studies show that 30-40% of adults report insomnia symptoms and more people than ever are seeking sleep medications. Millions of adults in the US are dealing with daytime sleepiness and negative health consequences from not using their PAP (Positive Airway Pressure) devices prescribed for sleep apnea. Countless others experience disrupted sleep and anxiety related to nightmares while others struggle with the timing of their sleep due to shift work or a delayed sleep phase. Individuals all over the world are trying to juggle demands related to family, caregiving, and work while feeling exhausted and dreading another nightly struggle.

The field of Behavioral Sleep Medicine (BSM) is a subspeciality that relies on empirically supported treatments to address behavioral, psychological, and physiological factors impacting sleep. The majority of nonpharmacological treatments for sleep problems fall under the umbrella of Cognitive-Behavioral Therapy (CBT). Behavioral interventions focus on reducing sleep-disruptive habits and forming positive associations while cognitive approaches address thoughts and beliefs that can interfere with sleep. We often incorporate mindfulness and values-based action to shift the way you relate to sleep and help reduce sleep effort so that you can live a full and meaningful life. Most treatments are time-limited (anywhere from three to 12 sessions depending on presenting issues and comorbidity). Daily sleep diaries are often used for assessment and to track progress. Please note that before beginning treatment, we conduct a comprehensive intake so that we are able to tailor treatment to meet individual needs. We can also collaborate with your medical providers when needed.

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  • Difficulty falling asleep or difficulty returning to sleep
  • Waking too early in the morning
  • Frequent awakenings
  • Difficulty tolerating PAP treatment for sleep apnea
  • Inability to fall asleep or wake at socially accepted times
  • Chronic nightmares
  • Panic attacks from sleep
  • Excessive daytime sleepiness

Insomnia is the most common sleep disorder we treat. Symptoms include difficulty falling asleep or returning to sleep (usually 30+ minutes) and early morning awakenings that occur three-plus times a week and are often accompanied by distress or other daytime impairment. Cognitive-behavioral therapy for insomnia (CBT-I) is the gold-standard treatment recommended by the American Academy of Sleep Medicine over any sleep medication. With CBT-I we go beyond basic sleep hygiene and tailor treatment to your unique sleep-wake patterns. CBT-I is a multi-component treatment, which means that it has several different parts, and not every person will require every part. Interventions may include sleep scheduling, stimulus control (changing how you use and relate to your bed), relaxation, worry management, and targeting unhelpful beliefs or expectations that can interfere with sleep. CBT-I takes work, but studies show it is just as effective as sleep medicine and benefits last long-term. CBT-I is also effective for individuals already taking sleep medications and if desired, we can work with you and your prescribing physician to help you taper off once your sleep has stabilized with initial treatment. A course of CBT-I typically ranges from four to seven sessions but may take longer when co-occurring disorders are present.

Sleep-disordered breathing

Obstructive Sleep Apnea (OSA) is the most common form of sleep-disordered breathing with estimates of 9-38% of adults having OSA. An overnight sleep study is needed to diagnose sleep apnea. Continuous Positive Airway Pressure (CPAP) is the gold-standard treatment for sleep apnea, but research shows that many individuals have difficulty using it consistently enough to benefit (30% of CPAP users have anxiety reactions, and over half of the patients started on CPAP are no longer using it one year later). Some of the most common barriers to PAP treatment are claustrophobia, low motivation, or co-occurring insomnia. Behavioral interventions (PAP desensitization, which is a type of graded exposure therapy) and motivational interviewing can help individuals tolerate CPAP better and increase utilization, and we combine CBT-I when appropriate.


Distressing dreams that lead to sudden awakenings and distress are nightmares. Although they tend to decrease with age (most common in children and adolescents), an estimated 50% to 85% of adults report having the occasional nightmare. Individuals with frequent upsetting dreams can benefit from CBT. The most researched treatment at this time that is recommended by the American Academy of Sleep Medicine is called Imagery Rehearsal Therapy (IRT). IRT involves the use of imagery to script and practice a new dream. This process can lead to a reduction in the frequency or intensity of nightmares as well as improve overall sleep.

Circadian Rhythm Sleep Disorders (CRSD)

Circadian rhythms regulate physiology and behavior on an approximately 24-hour schedule. CRSDs occur when one’s internal rhythms do not match up with the desired or required sleep-wake schedule. For example, the most common is Delayed Sleep Phase Disorder where an individual’s internal body clock is set several hours later than the average person so they have extreme difficulty falling asleep at the beginning of the night and difficulty waking in the morning in time to attend school or work. DSPD is much more common in adolescents and young adults. There is also research showing a high co-occurrence with OCD. Treatment may include scheduling and careful timing of light exposure and medication to help shift or anchor one’s sleep-wake system to improve their functioning. Shift work disorder is another CRSD we see in our clinic.

Excessive Sleepiness (Hypersomnia and Narcolepsy)

There are multiple causes of excessive daytime sleepiness (e.g., inadequate sleep, circadian misalignment, untreated OSA, medication side effects, illnesses), but sometimes it is due to Narcolepsy or Idiopathic Hypersomnia. These disorders require medical evaluation and treatment (often with stimulant medications). They frequently co-occur with anxiety and depression due to the unique struggles and significant psychosocial consequences of living with constant sleepiness. Our familiarity with these disorders puts us in a unique position to provide psychosocial support and CBT to help individuals pursue their values while managing their symptoms.

Other sleep symptoms we can help individuals manage include sleep paralysis, sleepwalking, and sleep terrors.

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