Cognitive Behavioral / Psychological Treatment of Insomnia
There is extensive research demonstrating the effectiveness of nonpharmacological, cognitive behavioral (psychological) treatment of insomnia. More than 66 treatment outcome studies have evaluated the effectiveness of several behavioral treatments. The results of these studies indicate that psychological treatments of insomnia produce considerable enhancement in both sleep patterns and the subjective experience of sleep. All of the psychological treatments studied produced therapeutic gains superior to placebo therapies. Patients who were not regular users of sedative hypnotics had greater levels of sleep improvement (Murtagh & Greenwood, 1995). A recent (September 2004, Archives of Internal Medicine) study conducted at Beth Israel Hospital demonstrated that CBT was MORE effective than a commonly prescribed medication, Ambien.
Overview of Sleep Problems
(Based on the International Classification of Sleep Disorder-ICSD)
- Psychophysiological Insomnia: Insomnia due to anxiety, nervousness, or body tension.
- Sleep State Misperception: Previously called pseudoinsomnia. Complaint of insomnia is inconsistent with objective sleep assessment showing normal sleep.
- Idiopathic Insomnia: This is a lifelong inability to obtain needed sleep which is presumably due to neurological dysfunction.
- Inadequate Sleep Hygiene: Sleep is disrupted by poor daytime habits such as caffeine use or naps.
- Environmental Sleep Disorder: Result of nonconducive physical environment such as a noisy neighborhood or uncomfortable bed.
- Adjustment Sleep Disorder: Temporary life stressor disrupt sleep of individuals who generally have no difficulty sleeping.
- Hypnotic-Dependent Sleep Disorder: Chronic use of sleep medication disrupts sleep.
- Stimulant Dependent Sleep Disorder: Use of a stimulant medication disrupts sleep.
- Alcohol-Dependent Sleep Disorder: Chronic alcohol use disrupts sleep.
Types of Psychological / Behavioral Treatment
- Relaxation Training: The use of Progressive Muscle Relaxation (PMR), deep breathing techniques, imagery, and self-hypnosis. PMR is the most widely researched treatment for insomnia and involves helping the individual to sequentially tense and relax the body’s major muscle groups while concentrating on and contrasting sensations of tension and relaxation. Daily practice of relaxation techniques between therapy session is essential and tends to enhance the effective of the treatment.
- Cognitive Therapy: The term cognitive therapy can be broadly applied to mean interventions that aim to help the individual identify and correct inappropriate thoughts and beliefs that may contribute to insomnia. Often includes providing proper information about sleep norms, age-related sleep changes, reasonable sleep goals, and the influence of naps and exercise.
Stimulus Control (SC): SC derives from the belief that insomnia may be related to the bedroom becoming a poor discriminative stimulus. That is, the bedroom may have become associated with other things besides sleep.
- Bedtime Restriction: Sleep-Restriction Therapy (SRT) is based on the belief that excess time in bed perpetuates insomnia. This technique consists of limiting a person’s time in bed.
- Sleep Hygiene: Sleep hygiene refers to lifestyle behaviors and environmental conditions that influence sleep, including exercise, napping, and diet. A therapist works with an individual to evaluate the potential influence of these factors and make appropriate changes.
There is some evidence that relaxation training treatments are the most effective behavioral treatments for sleep onset problems. However, the effects for relaxation training may take longer to become evident than other approaches. Looking at all 66 research studies together indicated that the average person reduced the time it took them to fall asleep from 61 to 37 minutes.
Total Sleep Time
Relaxation training appears to be important to lengthening of sleep. Relaxation training combined with other approaches may be the most effective approach to helping individuals lengthen their typically time sleeping. In the 66 treatment studies, the number of times each person woke during the night decreased from an average of 1.63 times to .44 times per person, per night.
Quality of Sleep
Research suggests that behavioral/psychological treatments for insomnia have their greatest impact on an individuals own sense of the quality of their sleep.