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Treating Sleep Disorders with Cognitive Behavioral Therapy and Taking Another Look at Anxiety Disorders and Depression Through Sleep

Isa Okajima
Assistant Professor, Faculty of Human Sciences, Waseda University

Becoming Interested in Clinical Psychology

My interest in clinical psychology began when I was in high school. My health and physical education teacher was attending graduate school to become certified clinical psychologist, and he introduced the use of persona (theatrical mask) in his lesson. During his lesson, he pointed out to me that I was focusing too much on acting and that there was no feeling in it. I too had been thinking about it and was impressed at how people’s minds can be read. This led me to study psychology in college.

However, the psychology program at college focused on fundamental theory consisting of social psychology, cognitive psychology, perceptual psychology and so on, instead of the clinical psychology that I wanted to study. At first, I was disappointed. But as I delved deeper into to the subject, I became more and more interested. Learning fundamental theories was important and useful when moving into the field of clinical psychology.

Meanwhile, my wish to study clinical psychology grew. I read books on psychological therapy and learned about a new field called cognitive behavioral therapy. It is a method that goes beyond psychological counseling to listen actively to the patient into providing treatment through the patient's behaviors and cognitions based on their own statements and actions. For example, the therapist works with patients who becomes anxious or distress when performing a certain action, known as exposure. For a person who is afraid of making telephone calls, the therapist has the patient actually make a call, and then follow-up by asking how they felt and what was it that made them afraid. The therapist tries different methods with the ultimate purpose of leading the patients into thinking that what they used to feel anxious about doing was not as bad as they thought after all. The goal of cognitive behavioral therapy is to change behaviors and cognitions to help patients face distress situations, which in turn enables them to live a more fulfilling life.

At that time, Professor Yuji Sakano at Waseda University (currently professor at the Health Sciences University of Hokkaido) was a pioneer in this field in Japan, and I visited him hoping that he would be my mentor. He was about to be relocated to Hokkaido, so I decided to apply to the Health Sciences University of Hokkaido. The topic of my research was social anxiety disorder, which is known to be treated effectively through cognitive behavioral therapy. I studied a series of social anxiety disorders such as nervousness in front of others, the inability to talk to others and other types of fear of people, and anxieties such as agoraphobia and claustrophobia. My research focused on safety behaviors, which is a typical symptom of the disorder. For example, when your nerves hit their peak during presentations, you tend to look down at notes and manuscripts instead of looking at the audience. All people have experienced such safety behaviors (or safety-seeking behaviors), in one way or another. A comparative investigation was conducted on this topic between individuals with social anxiety disorder and individuals who do not suffer from it, and although levels of safety behaviors do not differ significantly, the effect on anxiety did. It was found that for individuals suffering from social anxiety disorder, the safety behavior itself became the factor in negative belief, and that for such individuals it can be used as a target for exposure therapy, which proved to be very effective.

Clinical psychology is an accumulation of daily trial-and-error

Although I majored in clinical psychology, I focused mainly on research in the graduate school. As I feel that the study of clinical psychology was meaningless without on-site training, as soon as I completed the doctoral program, I began to work at the Institute of Neuropsychiatry and the Yoyogi Sleep Disorders Center annexed to the institute, a facility with both clinical and research functions. Here, for the first time, I specialized in sleep-related disorders such as insomnia.

Dr. Yuichi Inoue, a prominent researcher on sleep, told me right from the beginning: "I'll give you one month to study about insomnia and cognitive behavioral therapy for insomnia (CBT-I). Create your own treatment program." I read everything I could about the subject in literature and documents from overseas, created programs and tested them on patients, but I felt that they did not lead to good results. I realized the difficulty involved with clinical treatment and that proven theories do not necessarily have a place in actual practice. How could I link knowledge and theories to treatment? It was an entirely trial-and-error treatment process. I received feedback from patients and learned from each piece of evidence, a process that I have continued to this date; and I feel my clinical skills have become more sophisticated.

Generally, CBT-I begin with listening to medical history and symptoms (assessment), explaining psychological education (general sleep improvement techniques) and points of caution; and asking on what is not working in the patient's life. Patients are then asked to compensate for what they are not working on by the next session. In the next session, patients are taught muscle relaxation techniques to be performed before going to bed or in bed to relieve the tension in their bodies. Patients are also instructed to decide on the length of time to stay in bed, e.g. five hours, and to restrict the time in bed to that amount of actual sleep time. If the hours in bed awake and hours in bed sleeping are too diverse, the quality of sleep is degraded. Putting a restriction on the hours in bed allows patients to feel that they had a good night's sleep.

The best part of clinical therapy is seeing that the same treatment given to different patients leads to different results. A therapy that may be effective for some may not be effective for others. Such a clinical question is always present, and data collected from the clinical treatment are then used for research. When research brings results, empirical data are presented to patients to inform them that "the treatment was effective for this many patients." My research results have been presented at international meetings and published in journals, and their assessment overseas led to my receiving thesis awards. After working at an institution with ideal cycles in clinical practice and research for seven years, I was appointed to a post at Waseda University; and I still continue clinical research at the Sleep Disorder Center.

The best possible treatment for each patient

In Japan, there are really a few clinical psychologists who specifically research on insomnia and other sleep issues. Insomnia is considered a secondary symptom to other psychiatric or physical diseases and is not a main topic of research; but thinking very carefully, sleep is transversely related to wide ranging these diseases (Fig. 1). Maybe the core problem is sleep and the other problems are the secondary symptoms; as such, active treatment for sleep problems would allow patients to be physically and psychologically healthy without the need for medication. I began to think that researching this is my mission as a clinical psychologist. I think that engaging in enlightenment activities to spread knowledge related to sleep is an important role. I have published a book for the general public entitled Treatment of Insomnia with Cognitive Behavioral Therapy (joint authorship) and How to Sleep Soundly in Four Weeks: Sleep Diary for Treating Insomnia, a workbook style publication designed to improve sleep by recording daily sleep habits (photo).

Fig. 1 Sleep is related to all daily physical and psychological conditions

Joint authorship: Isa Okajima, Yuichi Inoue, Treatment of Insomnia with Cognitive Behavioral Therapy, (Subarusya, 2012)

Isa Okajima, How to Sleep Soundly in Four Weeks: Sleep Diary for Treating Insomnia, (Sakurasha, 2015)

Poster presentation at the World Congress of Behavioral and Cognitive Therapies (Melbourne) (He is carrying his baby on his stomach)

At the university, I preside over the Sleep Journal Club, an extracurricular activity offered to graduate students in the Graduate School of Human Sciences. I meet some students once a month and students present summaries of literatures that interest us in a round table seminar style. The objective of the activity is for students with various research topics to gather together and discuss topics of interest linked to sleep.

Delving into the world of sleep is very interesting and profound. Cognitive behavioral therapy is known to be effective in treating insomnia and social anxiety disorder, and I would like to completely look into it to find reasons (intermediary factors). I am thinking that ultimately an algorithm for cognitive behavioral therapy can be derived from the wisdom accumulated through psychotherapy and research. It will not be easy, but my biggest goal is to establish a method to propose suitable treatment for each patient.

Isa Okajima
Assistant Professor, Faculty of Human Sciences, Waseda University

Isa Okajima graduated from the Department of Psychology, College of Humanities and Sciences, Nihon University in 2003, and then completed his Ph.D. at the Graduate School of Psychological Science, Health Sciences University of Hokkaido in 2008. He holds a Ph.D. in clinical psychology. He has been a Research Fellowship for Young Scientists for the Japan Society for the Promotion of Science, Researcher at Institute of Neuropsychiatry, a visiting lecturer for Department of Somnology at Tokyo Medical University, and has worked as a senior clinical psychologist at the Yoyogi Sleep Disorder Center. Professor Okajima has held his current position since 2015. Professor Okajima's awards include the Uchiyama Memorial Award from the Japanese Association of Behavioral and Cognitive therapies (2007), the 2011 Poster Prize from The Worldsleep, the 17th Sleep Research Award from the Japanese Society of Sleep Research (2012), the Insomnia Research Okuma Award (2013), the Young Researcher Award for the Milk Product Health Science Conference (2016) and the 2017 Waseda Research Award (High-Impact Publication).