Insomnia

Description

Alternative Names

Treatment

Prevention of sleeplessness is very much dependent upon the patients ability to relax and learn the art of sleeping well. A number of behavioral methods are aimed at achieving these goals. Behavioral techniques can actually cure chronic insomnia and studies report their effectiveness in nearly all patients with primary chronic insomnia. Although medications are equally effective for helping people with insomnia to sleep, behavioral methods act faster. Behavioral methods are effective in all age groups, including elderly patients. In addition, medications cannot cure this condition and prolonged use frequently results in dependency.

Studies have reported that between 70% and 80% of those who are treated with non-drug methods experience improved sleep with an average treatment duration of only five hours over a four-week period. Furthermore, studies report that 75% of those who have been taking drugs are able to stop or reduce their use.

Specific Behavioral Methods. Proper sleep hygiene is the first step and should accompany any behavioral method. A number of approaches are available, but all have the same basic goals:

• To reduce the time it takes to go to sleep to below 30 minutes.
• Reduce wake-up periods during the night.

Some experts currently list the following behavioral methods in order of effectiveness:

• Stimulus control (standard treatment, which receives a high degree of physician support). It may also be helpful for some patients with secondary insomnia caused by a medical or psychiatric condition.
• Progressive muscle relaxation (studies and physician reports reflect a moderate degree of confidence in its effectiveness). It may be helpful for older individuals and some patients with secondary insomnia caused by a medical or psychiatric condition.
• Paradoxical intention (studies and physician reports reflect a moderate degree of certainty in its effectiveness).
• Biofeedback (studies and physician reports reflect a moderate degree of certainty in its effectiveness).
• Sleep restriction (evidence inconclusive on its value).
• Cognitive behavioral therapy (evidence inconclusive although studies are increasingly reporting benefits not only for improving sleep in the short term, but in help maintain healthy sleep).
• Sleep hygiene, imagery training, and cognitive training only (experts unable to recommend these approaches as sole therapy).

Stimulus Control. Stimulus control is now considered the standard treatment for primary chronic insomnia and may be helpful for some patients with secondary insomnia as well. The primary goal of stimulus control is to regain the idea that the bed is for sleeping. It involves the following:

• Go to bed only when ready to sleep or for sex.
• If unable to sleep within fifteen to twenty minutes, get up and go into another room. (People who find it physically difficult to get out of bed should sit up and do something relatively arousing, such as read.)
• Maintain a regular wake-up time no matter how few hours are spent sleeping.
• Avoid naps.

Progressive Muscle Relaxation. Progressive muscle relaxation is another technique for inducing sleep that is effective for many people. In one study, it was as effective as anxiety management training, a short-term behavioral technique. It takes about 10 minutes and involves the following:

• Focus first on a specific muscle group, typically with the muscles in one foot. Inhale and tense the muscle group for about eight second until the muscles start to shake and be mildly painful. (Do this gently. It is not intended to cause severe muscles contractions.)
• Release the muscles quickly and let them become loose and limp. Stay relaxed for 15 seconds and then repeat the same muscle group.
• Focus on the next muscle group and repeat the sequence. Move progressively from each foot and leg up through the abdomen, chest, then to each hand and arm and then to the neck and shoulders and face.

Paradoxical Intention. Paradoxical intention is a psychological approach that is based on doing the opposite of what one wants or fears and take it to extreme. The first step is to make a plan to take such a paradoxical approach to insomnia.

• Instead of going through activities leading to sleep, the patient prepares for staying awake and doing something energetic.
• In some cases, people may take specific psychological barriers to sleep to an extreme limit. For example, if worry is a factor in insomnia, the patient intensifies the worries.

Biofeedback. Biofeedback is also effective, but requires being monitored with an electroencephalogram (EEG), a device that measures brain waves. Patients are given feedback to recognize certain states of tension or sleep stages so that they can either avoid or repeat them voluntarily.

Sleep Restriction Therapy. Sleep restriction therapy may be effective, although evidence is inconclusive. In one 2001 study, patients practiced sleep hygiene and sleep restriction. Sleep hygiene was very helpful during the first two months while sleep restriction led to sustained benefits and deeper sleep. The approach is a systematic method for achieving sleep and restricting the time spent in bed.

The first step is to calculate a person's sleep efficiency number:

• Keep a sleep diary for 14 days. Then calculate the average hours of actual sleep and hours in bed. Then divide the average hours slept by the hours in bed. The result, given as a percentage, is the sleep efficiency number. (For example, if a patient sleeps an average of five hours out of seven hours in bed then the result is .714 and the sleep efficiency percentage is 71%.)
• The patient's goal is to achieve sleep efficiencies of between 85% and 90%, which means only 10% to 15% of the time is spent staying awake in bed. (Sleep efficiency in older people may fall normally somewhere between 75% to 85%.)

To achieve this goal, the patient takes the following actions:

• Begin by going to bed 15 minutes later than usual the first week.
• If 85% sleep efficiency isn't reached by the end of the week, add another 15 minutes before going to bed. Refrain from going to bed even if tired, although bedtime should not be reduced below five hours.
• Once efficiency reaches 90% or more, then begin to go to bed 15 minutes earlier each week.

Other parts of the program include stopping any sleep medications and following good sleep hygiene. People using this treatment have reported lasting improvements after just eight weeks and studies report that it is significantly more successful than relaxation techniques.

Cognitive-Behavioral Therapy. Cognitive behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts about sleep (such as, Ill never fall asleep). It also employs actions intended to change behavior. Studies have been mixed on its effectiveness, although a major 2003 analysis of six trials suggested that it might be helpful for older adults. As another example, a 2002 study reported that CBT used alone or in combination with medications resulted in improved sleep efficiency and better on-going maintenance of healthy sleep compared to medication alone or sham treatment. In other studies, CBT has even helped post-traumatic stress victims and people with insomnia caused by chronic pain, who are all commonly resistant to most therapeutic maneuvers. The success of this approach rests strongly on the skill of the therapist. The long-term benefits of CBT are not known, and refresher sessions may be needed.

Using Imagery. A 2002 study enrolled people whose chronic insomnia was associated with unwanted thoughts and worries. They were given specific positive mental tasks that gave them a sense of positive control (as opposed to their real life concerns, which felt out of their control.) Those images distracted them and allowed them to fall asleep faster. In support of this approach, a 2002 study evaluated patients with insomnia who were given a problem before sleep. One group was asked to think of the problem in images and the other in words. The group who used imagery fell asleep more quickly and woke up with less anxiety.

Sleep Hygiene. The term sleep hygiene is used to describe simple behaviors that may help everyone improve their sleep.

Exercise

Exercise may be one of the best ways to promote healthy sleep, including in adults over 60 who are not precluded from exercise for medical reasons. One study found that exercise is as good for inducing sleep as the use of benzodiazepines, a prescription sleep aid. Some research has found that yoga practice may have specific benefits on sleep health. Yoga uses meditation, deep breathing techniques, and movements that emphasize stretching and balance. A government-sponsored clinical trial is underway to determine if yoga helps people with insomnia.

Light Therapy

The circadian rhythm is more a function of darkness and light rather than actual time of day. Bright light can discourage drowsiness, and darkness can cause sleepiness, day or night. The use of a special light box may be helpful.

The procedure is noninvasive and simple. The patient sits a few feet away from a box-like device that emits very bright fluorescent light (over 4,000 lux) for about 30 minutes every day. The following people might benefit from light therapy in specific ways.

• Shift workers. Light therapy should be maximized during hours they are at work and minimized when they need to sleep.
• Frequent travelers. Light therapy may be useful for adjusting to new time zones and reducing jet lag.
• Nursing home patients.
• People with delayed sleep-phase syndrome. (These people have a natural tendency to fall asleep very late at night or in early morning hours, but then sleep normally.)

Everyone should check with his or her physician before using light therapy. The following people should avoid it or use it only under a physician's direction:

• Anyone with eyes or skin that are highly sensitive to light.
• Anyone taking medications that increase the risk for photosensitivity.
• People with bipolar disorder.

Timing of the therapy depends on the type of insomnia or sleep schedule of the individual. For example, in people who cannot get to sleep at night, light therapy in the morning and restricting bright light at night may be helpful. People who wake up early in the morning may benefit from light therapy performed in the evening, although a 2002 study reported that it had no effect in this group. Some light boxes have dawn/dusk simulators that help determine the correct brightness.

Alternative Techniques

Some alternative approaches that may be helpful for some patients include hypnosis, meditation, guided imagery and other imagery methods, and acupuncture. One study reported some benefits from pulses of weak electromagnetic fields applied to the brain.