Insomnia Therapy
David N. Neubauer
The treatment of insomnia should be guided by a comprehensive patient evaluation and a review of the differential diagnosis. In some cases, sleep-related diagnoses require highly individualized treatment plans; however, basic management strategies for insomnia often are applicable for a broad range of patients. Important considerations in the development of a treatment plan include the characteristics and duration of the insomnia symptoms (e.g., onset vs. maintenance, acute vs. chronic), presence of daytime impairment, apparent factors precipitating and perpetuating the sleep disturbance, schedule issues, comorbid conditions, past response to insomnia therapies, and patient preferences.
The insomnia treatment plan should establish clear therapeutic goals that may relate both to daytime and nighttime patient complaints (1). The plan also should include strategies to identify and optimally manage any comorbid sleep, psychiatric, and medical disorders, and to assess the potential effects of any medications or other substances that may influence sleep and waking. Education regarding healthy sleep-related behaviors, often termed good sleep hygiene, is an important foundation in the management of insomnia. Although sleep hygiene recommendations alone typically do not cure chronic insomnia, they may help to create an environment conducive for sleep improvement. Other therapeutic approaches may be ineffective when a patient maintains a highly irregular schedule or imbibes excessive caffeinated or alcoholic beverages. The standard evidence-based treatment approaches for insomnia include psychological and behavioral strategies, typically represented as cognitive behavioral therapy for insomnia (CBT-I), and selected pharmacotherapeutic modalities (2). CBT-I and pharmacologic approaches may be employed alone or in combination with other therapies (3).
Patients treated for insomnia should be monitored and reassessed on a regular basis (1). Shifts in therapeutic strategies may be necessary over time. The safety and continued efficacy of any prescribed medications should be reviewed. Having patients complete sleep logs or diaries can be very helpful in evaluating the therapeutic outcomes and directing treatment plan adjustments.
SLEEP HYGIENE EDUCATION
The ability to fall asleep and remain asleep may be influenced by numerous factors related to a patient’s schedule, daytime and evening routines, bedroom environment, use of assorted substances, and other lifestyle choices (4). The reinforcement of current behaviors that should favor sleep and the modification of others may have significant beneficial effects. Further, education regarding sleep also will help provide to patients a rationale for the behavior and schedule changes that may be essential elements of CBT-I.
While there is no absolute list of sleep hygiene recommendations, common themes relate to maintaining regular bedtimes and morning wake-up times, the avoidance of napping, developing a relaxing evening routine, reserving the bed solely for sleep and sexual relations, creating a comfortable bedroom environment, and restricting caffeine and alcohol intake. A list of healthy sleep habits is listed in Table 9.1 (5). Consistent timing for nighttime sleep and avoiding daytime napping should maximize the functioning of the homeostatic and circadian systems in promoting sleep at the desired hours. A relaxing evening routine should minimize
bedtime stimulation that might interfere with sleep onset. Not watching television, writing checks to pay bills, or working with computers in bed also can limit arousing influences prior to bedtime. Evening bright light, perhaps even the illumination from computer screens, might promote a circadian phase delay that would inhibit an early sleep onset. A comfortable bedroom environment typically is a cool and relatively dark room without disturbing noises. Background white noise with a noise-generating device or a bedside fan may be soothing and block out extraneous house noises or noises from outside traffic or neighborhood animals. Insomnia patients generally should be advised to avoid caffeinated beverages past lunchtime due to the prolonged stimulating effects. Some individuals may need to discontinue the use of caffeine entirely. Although alcohol has initial sedating properties that might enhance sleep onset, the ultimate effect often is worse sleep due to arousing effects that disrupt sleep as the alcohol is metabolized and the serum level decreases. Additional advice may recommend against late heavy meals or spicy foods that could cause discomfort when one is recumbent or awakenings from sleep resulting from gastroesophageal reflux. Regular exercise also may be a valuable recommendation, as long as it is not scheduled so close to bedtime that the stimulating effects delay sleep onset.
bedtime stimulation that might interfere with sleep onset. Not watching television, writing checks to pay bills, or working with computers in bed also can limit arousing influences prior to bedtime. Evening bright light, perhaps even the illumination from computer screens, might promote a circadian phase delay that would inhibit an early sleep onset. A comfortable bedroom environment typically is a cool and relatively dark room without disturbing noises. Background white noise with a noise-generating device or a bedside fan may be soothing and block out extraneous house noises or noises from outside traffic or neighborhood animals. Insomnia patients generally should be advised to avoid caffeinated beverages past lunchtime due to the prolonged stimulating effects. Some individuals may need to discontinue the use of caffeine entirely. Although alcohol has initial sedating properties that might enhance sleep onset, the ultimate effect often is worse sleep due to arousing effects that disrupt sleep as the alcohol is metabolized and the serum level decreases. Additional advice may recommend against late heavy meals or spicy foods that could cause discomfort when one is recumbent or awakenings from sleep resulting from gastroesophageal reflux. Regular exercise also may be a valuable recommendation, as long as it is not scheduled so close to bedtime that the stimulating effects delay sleep onset.
TABLE 9.1 Healthy Sleep Habits (5) | ||
|---|---|---|
|
PSYCHOLOGICAL AND BEHAVIORAL STRATEGIES
Several different types of psychological and behavioral strategies are available to help insomnia patients by addressing aspects of the physiological regulation of the sleep-wake cycle, psychological processes that influence sleep, and cognitive distortions and bedtime mental arousal that can affect the ability to fall asleep and remain asleep (4). Combinations of behavioral and cognitive approaches with education regarding healthy sleep habits often are coordinated as CBT-I, which has been demonstrated to have very good efficacy for sleep outcomes in numerous controlled research studies and multiple meta-analyses (6). CBT-I is beneficial in short- and long-term treatment and has good durability, as shown by continued improvement in sleep parameters following the discontinuation of active treatment (3).
CBT-I generally is defined as a multimodal treatment that most commonly incorporates a cognitive approach with at least one behavioral strategy. CBT-I
typically is performed over a series of sessions with individuals or groups of patients. Among the different components that may be employed with CBT-I are cognitive therapy strategies, sleep restriction therapy, stimulus control therapy, relaxation therapy, sleep hygiene education, paradoxical intention, and biofeedback (6) (see Table 9.2). CBT-I sometimes is conducted following a highly structured format with specific content and instructions for each visit, but it also may be tailored for individual patients. There is no set number or frequency of sessions, although six to eight biweekly meetings is a common arrangement. Basic elements of the cognitive and behavioral approaches can be incorporated into the treatment of insomnia patients in a variety of settings, or patients may be referred to CBT-I specialists for more formalized therapy. The key features of the components that may be incorporated into CBT-I are described below.
typically is performed over a series of sessions with individuals or groups of patients. Among the different components that may be employed with CBT-I are cognitive therapy strategies, sleep restriction therapy, stimulus control therapy, relaxation therapy, sleep hygiene education, paradoxical intention, and biofeedback (6) (see Table 9.2). CBT-I sometimes is conducted following a highly structured format with specific content and instructions for each visit, but it also may be tailored for individual patients. There is no set number or frequency of sessions, although six to eight biweekly meetings is a common arrangement. Basic elements of the cognitive and behavioral approaches can be incorporated into the treatment of insomnia patients in a variety of settings, or patients may be referred to CBT-I specialists for more formalized therapy. The key features of the components that may be incorporated into CBT-I are described below.
TABLE 9.2 Cognitive-Behavioral Therapy for Insomnia Components (1) | |
|---|---|
|
Cognitive Therapy Strategies
Cognitive psychotherapy evolved from the work of Aaron Beck and over the past few decades has been applied to the treatment of insomnia. In general, cognitive therapy attempts to identify and change dysfunctional beliefs and how people respond to them. Charles Morin has elaborated common characteristics present among chronic insomnia patients in noting that they often assume that daytime problems result from poor sleep, view transient sleep problems as chronic, have unrealistic expectations about their sleep need, exhibit cognitive errors (e.g., overgeneralization, rumination, and magnification), and have high anxiety associated with attempts to fall asleep (7). Correcting and reframing these maladaptive thoughts and beliefs should limit the degree to which emotional responses perpetuate the symptoms of insomnia.
Sleep Restriction Therapy
Sleep restriction therapy targets the length of time insomnia patients spend in bed. People with chronic insomnia frequently are in bed for excessive periods of time. They hope to maximize their opportunity for sleep but ultimately exacerbate the problem due to the reinforcement of the mental association of being in bed with the experience of frustration and wakefulness. While awake in bed the insomnia patients worry about their inability to sleep and how they will suffer the following day, and perhaps even for the rest of their lives. Their sleep tends to become fragmented. The goals of sleep restriction therapy are promoting a rapid sleep onset, sustained and deeper sleep, and reinforcement of the circadian regulation of the sleep-wake cycle. While there likely is a direct psychological benefit in reducing the wakeful time in bed, sleep restriction probably also enhances sleep onset and consolidation through temporary sleep deprivation. Accordingly, patients should be warned about possible daytime impairment related to excessive sleepiness when undergoing sleep restriction therapy.
TABLE 9.3 Sleep Restriction Therapy Instructions (4) | ||
|---|---|---|
|
The therapeutic sleep restriction approach for insomnia initially was developed in the early 1980s by Arthur Spielman (Table 9.3) (4). The basic plan calls for limiting patients’ time in bed to the duration that they believe they are actually sleeping. Patients are instructed to complete a 2-week sleep log. An average nightly total sleep time is calculated and a schedule is devised that maintains a regular everyday morning wake-up time but delays the bedtime to restrict the time in bed to the estimated sleep duration. Generally the time in bed restriction is no shorter than 5 hours. Daytime napping is not allowed. Patients continue to complete the sleep log so that their average sleep efficiency (total sleep duration divided by time in bed) can be calculated. Adjustments may be made on a weekly basis. When patients sleep at least 90% of their allotted time in bed their bedtime may be advanced earlier by 15 to 30 minutes. If their sleep efficiency falls below 85%, the bedtime is delayed by 15 minutes. The restriction guidelines may be liberalized for elderly patients, such as allowing earlier bedtimes with 85% sleep efficiency. Generally this formalized sleep restriction continues for 6 to 8 weeks. Abundant evidence from controlled clinical trials with insomnia subjects supports the efficacy of this therapeutic modality.
Stimulus Control Therapy
A fundamental tenet of the psychological understanding of chronic insomnia is the conditioning process where the bedtime location and timing, as well as the intention to fall asleep become associated with mental arousal, frustration, and an inability to fall asleep rapidly. Over time, evening routines, bedtime behaviors, and the bedroom environment come to represent stimuli for the perpetuation of insomnia. The goal of employing stimulus control therapy for insomnia is helping patients re-associate going to bed with successfully falling asleep. The therapy essentially involves a deconditioning process supplemented by transient sleep deprivation.
The stimulus control therapy approach for insomnia was developed in the 1970s by Richard Bootzin (Table 9.4) (8). The guidelines instruct patients to go to bed only when they are sleepy and feel that they will be able to fall asleep. If they are unable to fall asleep within 10 minutes, they are to get out of bed and go to another room. They should not engage in especially stimulating or strenuous activities, or anything else that might limit their ability to return to bed. The process is repeated as necessary every night during the course of the therapy. Patients additionally are instructed to maintain a regular morning wake-up time, not to nap during the
daytime, and to avoid using their beds for any activities other than sleep and sexual relations.
daytime, and to avoid using their beds for any activities other than sleep and sexual relations.
TABLE 9.4 Stimulus Control Therapy Instructions (29) | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Relaxation Therapy
People with chronic insomnia are viewed as having difficulty sleeping due to their experience of excessive arousal and tension at bedtime. Therefore, any strategies that promote relaxation should have the potential to enhance their sleep. General relaxation techniques include progressive muscle relaxation, biofeedback (see below), abdominal breathing, guided imagery, and various forms of yoga and meditation. When employed for the treatment of insomnia, the goal is to decrease the somatic and cognitive arousal that may interfere with sleep. Patients may find these relaxation strategies most successful when they practice them other times of the day before initiating bedtime use.
Sleep Hygiene Education
Sleep hygiene education promotes healthy lifestyle practices that should optimize the ability of an individual to sleep well at nighttime and remain awake and alert throughout the day and evening. While sleep hygiene recommendations may offer benefits to all insomnia patients, offering basic education and guidelines regarding healthy sleep practices routinely is incorporated into CBT-I treatment. However, sleep hygiene education alone is not viewed as an effective treatment for chronic insomnia.
Paradoxical Intention
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
