Psychological and Behavioral Treatments for Insomnia
Abstract
Psychological and Behavioral Treatment for Insomnia
Clinical Context
Treatment Strategies and Evidence
Models of Insomnia Supporting CBT-I
Interventions
Detailed information: |
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Insomnia Severity Index: a seven-item assessment of the patient’s sleep difficulties on a Likert-type 5-point scale from 0 (no difficulty) to 4 (very severe difficulty) (14). |
Pittsburgh Sleep Quality Index: a 24-item assessment requesting a description of the patient’s usual sleep habits during the previous month. Most items request a response in terms of frequency, from “not during the past month” to “three or more times a week” (15). |
Fatigue Severity Scale: a 9-item Likert-type 7-point scale of fatigue symptoms experienced in the previous week. Each item is rated from 1 (disagree) to 7 (agree) (16). |
Dysfunctional Beliefs and Attitudes about Sleep (DBAS): 30- and 16-item versions are available (18, 19). |
Beck Depression Inventory-II (BDI-II): a 21-item questionnaire regarding symptoms suggestive of depression experienced in the previous 2 weeks. Responses range from 0 to 3 (19). |
Beck Anxiety Inventory (BAI): a 21-item questionnaire regarding symptoms suggestive of anxiety experienced in the previous 1 week. Items are rated “not at all,” “mildly,” “moderately,” or “severely” true (20). |
Sleep Diary or Log. Many forms can be found or adapted, based on the information desired. One form of the basic sleep log contains 14 rows of 24 boxes, each allowing for symbols indicating time in bed, rising time, and estimated time asleep for each of 14 days. Indications of medications taken or other information can be added. See also, The Consensus Sleep Diary (21), based on collaboration among experts who developed two versions of sleep diaries, each asking 8–10 questions about the previous night’s sleep. |
Cognitive Strategies of CBT-I
Tend to the sleep environment: |
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Make the bedroom as dark, comfortably cool, and quiet as possible. Eye shades can be helpful. Consider using a white noise device or some other background sound to help mask disturbing noises (external or internal). |
Separate the sleeping environment from work, study, or worry activities. Hold disagreements and difficult conversations elsewhere. |
If pain is a problem, consider using pillows, wedges, or a softer or harder mattress to support better sleeping posture and decrease pressure on sensitive body areas. |
Tend to sleep-wake rhythms: |
Make the hour or so before bedtime as calm and relaxing as possible. Settle down with a regular pre-bedtime routine. As much as possible, stay in dim light during this time. |
Take a hot bath for 30 minutes within 2 hours of bedtime. |
Do not go to bed either very hungry or very full. A carbohydrate snack or glass of milk at bedtime may help. |
Work toward a regular bedtime, but do not go to bed until sleepy. |
Get up at the same time every day, even if sleep was poor. |
Move into bright light soon after arising. |
If naps are taken, do so only during the middle of waking hours, not within 4 or 5 hours of rising or retiring. |
Tend to health: |
Avoid caffeine in the afternoon or evening. Better yet, avoid it altogether for 2 weeks and see if it makes a difference. |
Exercise regularly, but avoid aerobic exercise close to bedtime. |
Do not use alcohol as a sleep aid; after it clears the system, the second half of the night is likely to be restless. |
Discuss sleep problems with physician, who can investigate possible causes such as pain, sleep apnea, leg movements, or the effects of medications. |
Counteract Tension and Arousal: |
Learn an approach to physical and mental relaxation that works for you. Practice it during the day, not just at bedtime. |
Make lists of worries and things to do and leave them outside of the bedroom. |
When settling down for the night, make a mental list of 20 things to be thankful for; start with “What’s not wrong?” |
If you cannot fall asleep within about 15 minutes, get out of bed and do some quiet activity in a dimly lit room until you feel sleepy again. Repeat as often as necessary. (The worst strategy is to keep trying harder to fall asleep.) |
Dysfunctional beliefs: |
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I will have a bad day tomorrow if I do not get a full night’s sleep tonight. |
If anything during the day upsets me, I’ll never get to sleep that night. |
I need to have unbroken nights of sleep to feel refreshed. |
I should go to bed earlier so I can get more sleep. |
I should sleep later whenever I can so I get caught up on sleep. |
I never get the 8 hours of sleep I need. |
Insomnia is ruining my health. |
Positive cognitions: |
I am learning what to do and not do to be a better sleeper. |
Even good sleepers often wake up during the night. |
Even with sleep difficulty, I usually function well the next day. |
I am probably underestimating the amount of sleep I am getting. |
I am probably overestimating the amount of sleep I need. |
It is better to go relax in the living room until I am sleepy than toss and turn in bed. |
Learning to relax during the day can help me relax better at night. |
Paradoxical Intention
Behavioral Strategies of CBT-I
Stimulus Control Treatment
Application: Difficulty initiating sleep, especially when this is presumed to arise from a conditioned response of increased alertness upon retiring to bed. |
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1. Establish a rising time, set an alarm, and be prepared to get up promptly, regardless of the amount or quality of sleep you have gotten. |
2. Go to bed at night only when sleepy. |
3. If you are still awake after 15 minutes, get out of bed. Do something quiet without the aid of computer, phone, or other electronics. You might read, draw, play solitaire (not on computer), listen to music, meditate, or do something else minimally stimulating. Stay in dim rather than bright light. |
4. Go back to bed only when you are sleepy again. If still awake in 15 minutes, repeat Step 3. Do so as often as necessary. Do not sleep past your planned rising time. |
5. Persist in this practice in subsequent nights, and do not take daytime naps. Use the bed only for sleep or sex. |
This is a well-researched strategy designed to help your mind/body relearn how to fall asleep quickly once you are in bed. Initially, difficult nights will lead to daytime fatigue and sleepiness, but this will help you fall sleep more quickly the next night. |
Sleep Restriction Treatment
Application: Difficulty maintaining sound sleep; multiple awakenings, some of which may be prolonged. Wakefulness upon getting into bed or before rising time also may be part of the pattern. |
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1. Based on patient’s sleep logs, calculate average nightly total sleep time for past 2 weeks. This average dictates the number of hours that your patient will spend in bed each night. Do not restrict time in bed to less than 5 1/2 hours, however, and be even less restrictive if safety is a concern. |
2. Plan with your patient the rising time to be followed. Counting back from that, derive the prescribed bedtime. Daytime naps are not permitted. This schedule should be followed 7 days a week. |
3. Let your patient know that daytime fatigue and sleepiness will be normal and, combined with limited hours in bed, will increase the likelihood of sleep being more sound. Advise caution about driving or other risky activities during this period of sleep restriction. |
4. Recommend that your patient phone in each day the previous night’s hours spent in bed and total hours of sleep. Calculate the nightly “sleep efficiency score,” or the percentage of time in bed when he/she was asleep. (Hours of sleep divided by hours in bed × 100. For example, 5 hours sleep/8 hours in bed × 100 = 62.5% sleep efficiency.) Some patients are likely to be willing and motivated to do this calculation and report it to you on a weekly basis. |
5. On a weekly basis, calculate average sleep efficiencies for the previous week. When average sleep efficiency is >90%, more sleep is allowed by setting bedtime 15 minutes earlier. When this average is <85%, bedtime is set 15 minutes later. Total time in bed should not be reduced below 5 hours. |
6. Aim at consistent weekly sleep efficiencies at 85% or above, with good daytime alertness. Advise the patient to maintain the sleep schedule, avoiding extended times in bed, and call you about difficulties with these instructions. |
Relaxation Training
Books: |
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Hauri and Linde (22). Also issued in a workbook format. |
Jacobs (23) |
Espie (27) |
Benson (26) |
Bharati (28). This is a form of yoga that involves no physical movement, only awareness of parts of the body. Many people find it very relaxing. Other versions in book and CD forms are available by different authors. |
Websites: |
Naparstek (29) |
This website has many other audio resources for mental and physical health, meditation, stress management, and sleep for children and adults. |
Ortiz (30) |
CDs: |
www.headspace.com (31) teaches a mindfulness approach to meditation gradually, beginning with 10 free 10-minute meditations guided by Andy Puddicombe. For modest fees, interested persons can sign on for more extended guided meditations. |
Biofeedback
Recent Developments
Computerized CBT-I
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