A Concise Review Of Behavioral Approaches To Insomnia

From the American Academy of Sleep Medicine. Below is the current recommendations for behavioral treatment of insomnia.


Common Cognitive and Behavioral Therapies for Chronic Insomnia

Stimulus control (Standard) is designed to extinguish the negative association between the bed and undesirable outcomes such as wakefulness, frustration, and worry. These negative states are frequently conditioned in response to efforts to sleep as a result of prolonged periods of time in bed awake. The objectives of stimulus control therapy are for the patient to form a positive and clear association between the bed and sleep and to establish a stable sleep-wake schedule.

Instructions: Go to bed only when sleepy; maintain a regular schedule; avoid naps; use the bed only for sleep; if unable to fall asleep (or back to sleep) within 20 minutes, remove yourself from bed—engage in relaxing activity until drowsy then return to bed—repeat this as necessary. Patients should be advised to leave the bed after they have perceived not to sleep within approximately 20 minutes, rather than actual clock-watching which should be avoided.

Relaxation training (Standard) such as progressive muscle relaxation, guided imagery, or abdominal breathing, is designed to lower somatic and cognitive arousal states which interfere with sleep. Relaxation training can be useful in patients displaying elevated levels of arousal and is often utilized with CBT.

Instructions: Progressive muscle relaxation training involves methodical tensing and relaxing different muscle groups throughout the body. Specific techniques are widely available in written and audio form.

Cognitive Behavioral Therapy for Insomnia or CBT-I (Standard) is a combination of cognitive therapy coupled with behavioral treatments (e.g., stimulus control, sleep restriction) with or without relaxation therapy. Cognitive therapy seeks to change the patient’s overvalued beliefs and unrealistic expectations about sleep. Cognitive therapy uses a psychotherapeutic method to reconstruct cognitive pathways with positive and appropriate concepts about sleep and its effects. Common cognitive distortions that are identified and addressed in the course of treatment include: “I can’t sleep without medication,” “I have a chemical imbalance,” “If I can’t sleep I should stay in bed and rest,” “My life will be ruined if I can’t sleep.”

Multicomponent therapy [without cognitive therapy] (Guideline) utilizes various combinations of behavioral (stimulus control, relaxation, sleep restriction) therapies, and sleep hygiene education. Many therapists use some form of multimodal approach in treating chronic insomnia.

Sleep restriction (Guideline) initially limits the time in bed to the total sleep time, as derived from baseline sleep logs. This approach is intended to improve sleep continuity by using sleep restriction to enhance sleep drive. As sleep drive increases and the window of opportunity for sleep remains restricted with daytime napping prohibited, sleep becomes more consolidated. When sleep continuity substantially improves, time in bed is gradually increased, to provide sufficient sleep time for the patient to feel rested during the day, while preserving the newly acquired sleep consolidation. In addition, the approach is consistent with stimulus control goals in that it minimizes the amount of time spent in bed awake helping to restore the association between bed and sleeping.

Instructions (Note, when using sleep restriction, patients should be monitored for and cautioned about possible sleepiness):

  • Maintain a sleep log and determine the mean total sleep time (TST) for the baseline period (e.g., 1–2 weeks)
  • Set bedtime and wake-up times to approximate the mean TST to achieve a >85% sleep efficiency (TST/TIB × 100%) over 7 days; the goal is for the total time in bed (TIB) (not <5 hours) to approximate the TST.
  • Make weekly adjustments: 1) for sleep efficiency (TST/TIB × 100%) >85% to 90% over 7 days, TIB can be increased by 15–20 minutes; 2) for SE <80%, TIB can be further decreased by 15–20 minutes.
  • Repeat TIB adjustment every 7 days.

Paradoxical intention (Guideline) is a specific cognitive therapy in which the patient is trained to confront the fear of staying awake and its potential effects. The objective is to eliminate a patient’s anxiety about sleep performance.

Biofeedback therapy (Guideline) trains the patient to control some physiologic variable through visual or auditory feedback. The objective is to reduce somatic arousal.

Sleep hygiene therapy (No recommendation) involves teaching patients about healthy lifestyle practices that improve sleep. It should be used in conjunction with stimulus control, relaxation training, sleep restriction or cognitive therapy.

Instructions include, but are not limited to, keeping a regular schedule, having a healthy diet and regular daytime exercise, having a quiet sleep environment, and avoiding napping, caffeine, other stimulants, nicotine, alcohol, excessive fluids, or stimulating activities before bedtime.

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