- patients dissociating conditioned responses at bedtime, or
- the inevitable sleep restriction caused by getting out of bed.
Relaxation training. Progressive muscle relaxation is a common behavioral treatment of insomnia. Patients learn to tense and then relax individual muscles, beginning at the feet or head and working their way up or down the body. Patients are taught the difference between tension and relaxation to facilitate a relaxation response at bedtime. Another method is the body scanning technique, in which the patient “talks” to each body part, telling it to “relax… relax… relax.”
Relaxation training is predicated on the belief that insomnia is caused by somatized tension and psychophysiologic arousal. The greatest challenge to effective relaxation training is that patients need extensive daytime practice before they can bring the method to the bedroom.
Remind patients that “practice makes perfect.” Therapists often instruct patients to start practicing their relaxation method during the day while self-monitoring by sleep diary and restricting time in bed at night.2
CBTi is the most extensively investigated nonpharmacologic therapy for insomnia.6 It has been used to effectively manage comorbid insomnia in patients with psychiatric disorders,7,8 such as depression,9 generalized anxiety,10 and alcohol dependence,11 as well as those with breast cancer,12 traumatic brain injury,13 and fibromyalgia.14 Age does not appear to be a limitation; research trials show the technique is effective in elderly patients.15
CBTi incorporates cognitive strategies and behavioral interventions to improve sleep quality. Patient self-monitoring with sleep diaries and worksheets is essential.
CBTi commonly is provided in 5 to 8 sessions over 8 to 12 weeks, although studies have described abbreviated practices that used 2 sessions16 and CBTi delivered over the Internet.17 Highly trained clinical psychologists are at the forefront of therapy, but counselors and nurses in primary care settings have administered CBTi.18 For primary insomnia, CBTi is superior in efficacy to pharmacotherapy:
- as initial treatment19
- for long-term management4
- in assisting discontinuation of hypnotic medication.20
CASE CONTINUED: An effective approach
You refer Ms. H to a clinical psychologist who specializes in CBTi. Ms. H begins self-monitoring with a sleep diary and has 5 CBTi sessions over 8 weeks. Initial interventions reduce time in bed from 9 hours to 7 hours per night. Ms. H learns simple relaxation methods that she practices for 2 weeks before attempting to use them to sleep. The psychologist addresses her dysfunctional beliefs about sleep.
During the last 2 weeks of therapy, Ms. H’s sleep diary reveals a sleep efficiency of 92% and improvements in well being, energy, and perceived work efficiency. At a 3-month booster visit, Ms. H has sustained these gains in sleep and daytime function.
Implementing nondrug therapy
I recommend the following steps when offering psychological and behavioral treatment of chronic insomnia, such as CBTi.
Initial visit. Determine whether your patient needs treatment for depressive or anxiety symptoms. Assess the need for polysomnography. Does the patient have a history of an urge to move the legs (restless legs syndrome), increased kicking behavior at night (periodic leg movements of sleep), or loud, disruptive snoring (obstructive sleep apnea)? It is often helpful to have patients think back to when they were consistently sleeping well to identify factors that might be exacerbating poor sleep.
Session 1 (Week 0). Teach patients about normal sleep, how it changes over the life cycle, and common dysfunctional beliefs and behaviors that worsen sleep. Tell patients that every morning when they wake up they should complete a sleep diary (Table 1); you can download a sample sleep diary by visiting this article on CurrentPsychiatry.com.
Table 1
Insomnia: What to document on a sleep diary
| Daytime fatigue |
| Minutes spent napping |
| Medication use |
| Time the patient first tried to fall asleep |
| How long it took to fall asleep |
| How many times the patient woke up |
| Final waking time |
| Hours slept |
| Sleep quality rating |
| How refreshed the patient feels on awakening |
Session 2 (Week 1). Review the sleep diary. Address infractions of sleep hygiene, such as working until bedtime, using caffeine or alcohol in the evening, excessive smoking, or eating in bed. Discuss and specify mutual therapeutic goals for:
- minutes to sleep onset
- minutes of nighttime wakefulness
- number of awakenings
- improvements in sleep efficiency, morning refreshment/alertness, and daytime functioning.
Therapeutic intervention: Instruct patients to reduce their total time in bed (TIB) to their estimated total sleep time, unless they report <6 hours. Insomnia patients commonly overestimate their amount of wakefulness. Because research indicates daytime performance is adversely affected when sleep falls below 6 hours per night,21 I initially limit TIB to 6 hours and further restrict TIB in future sessions as needed to improve sleep efficiency.