What is Cognitive-Behavioral Therapy for Insomnia (CBT-I)? 

CBT-I addresses behaviors and thinking patterns that interfere with sleep (Manber et al., 2014). In treatment, you can expect a thorough examination of your sleep patterns and habits followed by a structured and brief treatment (typically 6-8 sessions) that assists in creating new patterns.  

Does it really work? 
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According to many studies, CBT-I is as effective as medication in the short term and more effective than medication in the long term (as cited in Muench et al., 2022). Why? Because we may become tolerant of medications but behavioral and cognitive changes can be maintained over time. 

What does good sleep even look like? 

‘Good’ or ‘healthy sleepers’ take on average 30 minutes to fall asleep (as cited in Manber et al., 2014). They also wake up two times or less in the night and are awake for 30 minutes or less once awake. If your sleep difficulties extend beyond this range, you may benefit from treatment. 

What does CBT-I entail? 
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You can expect the first few weeks to entail data collection (as cited in Manber et al., 2014). We will ask you many questions about your sleep habits and routine. In CBT-I, we generally will collect 2 weeks of sleep data, in what is often called a sleep diary, to identify averages. We will then calculate what is called your sleep efficiency. Sleep efficiency is defined as follows: 

Total Sleep Time/ Time in bed x 100. 

This number should be more than 85% for a healthy sleeper. 

What is the goal of treatment?

In short, the goal is to sleep in your bed and to stop wasting time tossing and turning! How will we help you do that? We will recommend, if indicated, what is called sleep restriction or a structured way to restrict time in bed. This may not make sense at first. Why would we recommend you sleep less to sleep more? Because this will help you reset and create new sleep rhythms and habits. Essentially, we will calculate, on average, how long you are actually sleeping in your bed. We will encourage you to only be in your bed for that amount of time for a short period of time (days or weeks, at most) by setting a consistent rise time and changing your bedtime over the duration of treatment (as cited in Manber et al., 2014). Once sleep efficiency improves, we will assist with expanding more time in bed slowly so that your body can adjust to sleeping more when you are supposed to when in bed. For example, if on average you are only sleeping 5/ 8 hours in bed, we will encourage a bed time and rise time that only allows for 5 hours in bed. Once you start sleeping during the majority of that time in bed, we will assist with slowly expanding time in bed. We will do so by recommending an earlier and earlier bed time while maintaining the same wake time and ensuring you are still sleeping the majority of that time in bed.  

Can I do anything before I get started to help improve sleep? 

Yes! Follow some general sleep guidelines as follows (as cited in Manber et al., 2014): 

• Create a calming routine before bed. 
• If you are awake for more than 15 minutes, get out of bed and go relax elsewhere. Return to bed when you are tired! 
• Reserve bed for sleeping! No computers or TV time. 
• Eat regular meals.
• Do not consume more than 8-10 oz of liquids after dinner.
• Eliminate caffeine 8 hours before bed.
• All substance use worsens sleep so avoid alcohol use 3 hours before bed.
• Avoid exercise and warm baths before bed (about 1.5 hours before bed time).
• Allow for bright light in the morning but create a dark, cool environment at night. 
• Try eliminating naps. Naps reduce the sleep drive!
• Don’t watch the clock! It creates anxiety. 

How will my sleep anxiety be addressed in treatment? 

Many people have anxiety-provoking thoughts about sleep. For instance, some people think, if they wake up, they won’t be able to go back to sleep, or they may think they will not fall asleep and oversleep and miss work and and and! Unfortunately, sometimes these anxiety-provoking thoughts end up creating a self-fulfilling prophecy… if you wake up and have the thought “it’s 2am, now I’m never going to get enough sleep and my day will be horrible,” that thought will trigger anxiety which will then make falling back asleep even more difficult.

We will help you challenge your thoughts about sleep by helping you become a scientist. We will encourage you to ask yourself “is this really accurate?” We can also assist by helping you learn how to tolerate anxiety and uncertainty, in general. Most of our thoughts are not really accurate. Also, I bet you have gone to work exhausted many days and somehow got through it. That is the goal: To learn that you will get through the next day even if sleep deprivation occurs! 

References: 

Manber, R., Friedman, L., Siebern, A.T., Carney, C., Edinger, J., Epstein, D., Haynes, P., Pigeon, W., & Karlin, B. E., (2014). Cognitive behavioral therapy for insomnia in veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs.

​An intense, disproportionate fear of vomiting might not sound all that debilitating for those who don’t suffer from emetophobia or for those without a loved one with emetophobia. However, having an intense fear of vomit can wreak havoc on one’s life and interfere in one’s ability to engage in activities that they might otherwise love to do, such as travel, eat at restaurants, try new foods, attend school, watch certain movies or tv shows, have children or care for sick children, spend time around children, visit a loved one in a hospital, etc. 

Essentially any activity that might create a situation perceived as being conducive to nausea or vomiting might be completely avoided or only engaged in with significant safety behaviors or compulsions such as bringing medications, water, safety people, excessive checking, washing, reassurance seeking, etc. 

Emetophobia is sometimes considered a Specific Phobia and is sometimes considered to be a form of Obsessive-Compulsive Disorder. Either way, the recommended treatment is Exposure and Response Prevention (ERP). ERP is a type of Cognitive-Behavioral Therapy (CBT). This treatment includes having individuals confront the things that cause them anxiety and distress and then having the client "response prevent," or in other words stop engaging in, or significantly modify, the avoidance/safety behaviors/compulsions that are normally used in response to external (e.g., certain foods, public transportation) or internal (e.g., feeling dizzy, the thought “I might puke”) triggers. This is done in a safe, gradual, systematic way to ensure that individuals are as successful as they can be. 

There are typically three exposure types: in-vivo, imaginal, and interoceptive. 

An in-vivo exposure is an exposure where a client is asked to directly face their feared situation or physical trigger in real life. In the case of emetophobia, this may encompass traveling via various modalities (e.g., flying, taking a bus, train, driving, etc.), eating foods outside of what the client may usually deem “safe” (e.g., foods with certain textures that are normally avoided, eating foods that have not been excessively checked for their expiration), listening to the sound of someone else vomiting in a movie or tv show, looking at or holding a substance that resembles the texture or smell of vomit, mimicking the motion or experinece of vomiting, reading a book about vomit (yes those exist), etc.

An imaginal exposure refers to an exposure where a script or informal image is used to confront a feared situation and/or image specific to the client’s fear. These might be used as a build-up to in-vivos, or may be used when exposure to the in-vivo might not be feasible. For example, the client might be asked to imagine sitting with the possibility of vomiting, imagine eating at a certain restaurant and incorporate their senses such as what they would hear, smell, and taste, etc.

An interoceptive exposure involves asking a client to face their “interoceptive symptoms” that are associated with their fear of vomiting. Interoceptive specifically means physical/somatic symptoms/symptoms associated with the internal state of the body. For someone with emetophobia, this might include intentionally inducing symptoms such as dizziness, nausea, hot flashes, etc. Usually, a mental health provider will clear their client’s for light to moderate activity with their client’s physician and ensure that interoceptive exposures are indicated.

The goal of all of these exposures and treatment is not necessarily to induce vomiting. The goal is to encourage the client to approach the situations, people, places, things, physical symptoms, and thoughts that they might normally avoid because of their fear, and teach them that they are safe and can handle the distress associated with facing their fears, and that they can do so without the use of avoidance, safety behaviors and/or compulsions. And IF they do vomit, they can handle that too. This all, with the goal of getting the individual back to their life, doing things that they love to do and value, with the power and freedom that comes with not being bossed around by anxiety.