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Behavioral Therapies for the Treatment of Insomnia
October 15, 2007
by Milton K. Erman, MD
Psychiatry Weekly, Volume 2, Issue 39

Insomnia can be a symptomatic complaint or a disorder. When insomnia presents as an uncomplicated symptomatic complaint, ie, transient insomnia associated with travel or stress, the use of a hypnotic medication as a ?solo therapy? may not only be appropriate, but advisable. However, when patients suffer from the disorder of insomnia, it is a gross disservice for clinicians to simply provide a medication with no effort made to help patients change perceptions and behaviors that will otherwise play a role in promoting a persistent insomnia condition.

Stimulus Control
Most physicians are familiar with the elements of stimulus control. The aim of stimulus-control therapy is to break the negative associations of being in bed unable to sleep. It is especially helpful for patients with sleep-onset insomnia and prolonged awakenings. This approach utilizes specific techniques such as not remaining in bed if unable to sleep, avoiding naps, and getting up from bed if one is unable to sleep. It can be very effective as a treatment approach, although it does not incorporate any efforts at changing cognitive perceptions with regard to insomnia and sleep needs.

Sleep Restriction
Another strictly behavioral approach is sleep restriction. In this approach, patients completed questionnaires to determine the amount of sleep that they report obtaining per night on a regular basis. They are then restricted to this amount of sleep and asked to stay up to a late bedtime hour in order to obtain this amount of sleep in a single consolidated period of sleep. For example, a patient who reports sleeping only 5 hours per night may be asked to stay up until 2:15 AM, and then allowed to sleep until 7:15 AM. If the patient has demonstrated success at obtaining these 5 hours of sleep per night on a regular basis, the amount of time that they are allowed to spend in bed is increased. Patients must first agree to a model of treatment that may not conform to their perception of how sleeplessness affects them, ie, that no matter how little sleep they obtain on a given night, they will not sleep the next night. If their sleep deprivation does cause them to feel sleepy, they must still restrict their sleep to their allowed nighttime hours. They are not allowed to take naps in the daytime, or to ?sleep in.?

Progressive Muscular Relaxation
Various types of relaxation therapies have been utilized in the treatment of insomnia, although few have been formally tested. Simple approaches such as progressive musuclar relaxation may be helpful for patients as part of a regimen intended to reduce arousal immediately before bedtime and can generally be taught to patients with the aid of ?relaxation tapes? or compact discs. Other relaxation techniques that may be beneficial to some individuals include self-hypnosis, yoga, meditation, and focused imagery.

Conclusion
If generalizations can be made about treatment of insomnia, they are that no patients should be given the message that a medication alone is the solution to their insomnia problem. A clinician?s goal with all patients should be to emphasize the role that cognitive and behavioral strategies may play in promoting better sleep habits and sleep hygiene, whether or not medications are utilized. Ideally, patients will be able to reduce their reliance on the use of medications over time, relying on them on an as needed basis, but utilizing cognitive and behavioral techniques to promote good sleep and prevent a recurrence of insomnia symptoms.
 

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