Psychological and Behavioral Treatments for Insomnia

Psychological and Behavioral Treatment for Insomnia

Clinical Context

Insomnia, or difficulty initiating or maintaining sleep associated with daytime functional impairment, is a significant public health problem, The estimated prevalence of insomnia is 30% for people with at least one insomnia complaint and 5%−10% for people with specific insomnia disorders (1). It is defined broadly in the ICD-10 as nonorganic insomnia, but more specifically in ICSD-2 (2) and DSM-5. Those with primary insomnia report, variously, difficulty falling asleep, awakenings, which are sometimes prolonged during the sleep period, or early morning awakenings. Insomniacs report daytime impairments of functioning and preoccupation with sleep difficulties, often leading to self-defeating efforts to get more or better sleep. Impairments of function may be expressed in lapses of memory and attention, fatigue and irritability, accidents, increased alcohol consumption, absenteeism, and lowered mood and motivation.

Many roads lead to insomnia, and some roads lead on from it. Insomnia can be comorbid with medical or psychological pathologies, drug or other substance use/abuse, acute or chronic life stressors, poor sleep/wake habits, circadian rhythm disturbances, or unknown factors. Some people report lifelong sleep difficulties; others can identify precipitating events from which sleep has never recovered. Insomnia may be both a feature of concurrent depression and a predictor of future depression as well as of future anxiety, substance use or dependence, and suicide (3). As many as 40% of insomnia sufferers may have comorbid psychiatric disorders (1).

Treatment Strategies and Evidence

Psychological and behavioral treatments of insomnia, especially cognitive–behavioral treatment (CBT-I), have been effective for both primary insomnia and insomnia which is comorbid with other conditions (4). Although hypnotic medications are generally effective at inducing sleep and can reassure patients that sleep is achievable, many people are uneasy about relying on pills for sleep, being aware of the risks of tolerance, dependence and addiction. In studies of medication versus CBT-I for insomnia, CBT-I produced benefits comparable to medications during active treatment and more enduring benefits in follow-up months and even years (up to 2 years) later (5). Improvements in sleep through CBT-I also seem to have benefits for comorbid depression (6)

The Academy of Sleep Medicine Report of 2006 (4), which is based on peer-reviewed articles dating back to 1999, judged psychological and behavioral interventions to be “effective and recommended” in the treatment of chronic primary insomnia as well as of secondary (comorbid) insomnia. Specific therapies judged as effective and recommended included stimulus control therapy, sleep restriction, relaxation training, cognitive behavior therapy, and multicomponent therapy (without cognitive therapy), paradoxical intention, and biofeedback. The report also recommended that psychological and behavioral interventions be implemented for older adults and for chronic hypnotic users.

Models of Insomnia Supporting CBT-I

Spielman and associates (7) proposed a behavioral model of insomnia based on notions of predisposing, precipitating, and perpetuating factors. Chronic insomnia may be the result of predisposing factors based in physiology and personality. Precipitating factors such as health, work, or family stressors interact with predisposing factors and result in sleep onset or maintenance problems. Ideally, the resolution of precipitating factors allows sleep to recover, but insomnia becomes chronic as a result of perpetuating factors, which can persist long after precipitating factors have resolved. Spielman et al. identified such perpetuating factors as irregular bedtimes and rising times, longer periods spent in bed, worry about sleep and daytime deficits, conditioning that bonds being in bed with being wakeful, and ingestion of caffeine, alcohol, or hypnotics. These identified factors often represent attempted solutions to the problem of disturbed sleep, but since they worsen the problem they become the targets of cognitive and behavioral treatment strategies.

Harvey proposed a cognitive model of insomnia (8) emphasizing the insomnia sufferer’s worry about poor sleep and its aftermaths. Focus on sleep as uncertain results in autonomic arousal and emotional distress. Attention is paid selectively to sleep threats, and “safety behaviors” express efforts to protect sleep from disturbing thoughts, feelings, or actions. These expressions of anxiety and misguided behaviors interfere both with sleep and daytime functioning. Harvey suggests that treatment for insomnia should aim to correct the patient’s mistaken assumptions about sleep, to reduce their focus on threats to sleep and eliminate self-defeating safety behaviors. Thus, both daytime and nighttime factors need to be the targets of treatment.

Borbely’s model of sleep paired daytime and nighttime factors in a two process model of sleep regulation (9). A homeostatic process increases sleep tendency as a function of hours spent awake, and it is offset by an arousal system which provokes alertness when the organism senses some risk. A circadian process originates in the superchiasmatic nucleus (SCN) of the hypothalamus, generating cycles of sleep and wake tendencies. The human sleep-wake cycle is slightly longer than 24-hour clock time, but it is repeatedly reset by regularities of light and darkness and by imposed schedules of daily activity. Mental and physical responses of the insomnia sufferer can interfere with both homeostatic and circadian processes. Excessive self-monitoring of sleep tendencies can trigger alertness via the arousal system, increasing sleep delay through anxiety leading to further alertness. Even normal sleepers sometimes report that they sleep restlessly when foreseeing the need for an earlier than usual rising time and worrying about oversleeping or losing sleep. Circadian regularity can be resistant to scheduling efforts, as in innate delayed sleep phase (night owl) or advanced sleep phase (morning lark) tendencies. It is also affected by such factors as weekday/weekend schedule changes, vacation schedules, and travel across multiple time zones.

Hyperarousal may characterize many insomnia sufferers not only as a result of struggles to sleep but also as a predisposing factor. A hyperarousal model of insomnia has been proposed, based on studies of multiple levels of physiological functioning operating in insomniacs during both daytime and nighttime (10).

A metacognitive model of insomnia has been proposed by Ong and colleagues (11), based on the ability of an individual to be aware of mental and physical states associated with insomnia and then to learn to shift mental stances in the direction of balance and flexibility. The focus of treatment based on this model has elements in common with “third wave” approaches to behavior therapy (12) found in mindfulness-based cognitive therapy and dialectical behavior therapy. A metacognitive approach to insomnia treatment encourages the patient to consider alternative assumptions about sleep and to develop mindfulness and acceptance skills in the service of lessened arousal and increased balance. These approaches have not been strongly tested. If effective, they would help the patient allow sleepiness to develop naturally, neither seeking nor resisting sleep, and practice a calmer and more patient anticipation of sleep. Practices such as paradoxical intention (see below) might serve these aims.

Interventions

The first intervention in treatment of insomnia is an adequate initial assessment. Assessment should cover details of the patient’s chief complaint and of current sleep/wake patterns, sleep history, medical history including previous treatments for sleep, self-help strategies already attempted, daily health habits, personal, family, and social history, desired goals of treatment, mental status observations and diagnostic impressions. In many cases, bed partners can also be usefully included in assessment and treatment (13). The clinician’s interest in the details of the patient’s sleep story and the implied message that help will be provided are subtle but important benefits of this first intervention. Patients’ completions of questionnaires are helpful both for initial assessment and in prepost assessments (see Table 1). This article assumes that a medical screening for sleep-related respiratory irregularities, periodic leg movements, seizures, and electroencephalogram (EEG) anomalies has been carried out, supported by nocturnal polysomnography when indicated. Clinicians who are the first to assess an insomnia patient’s complaints should be attentive to signs that a more specialized medical assessment may be called for.

Cognitive Strategies of CBT-I

Hauri and Linde (22) have recommended that the insomnia sufferers be engaged in becoming their own sleep therapists. This implies that patients be encouraged to recognize and describe their own sleep story and learn sleep facts and myths. Useful topics include the stages of sleep, circadian rhythms, sleep requirements and differences among individuals, impacts of daytime life on sleep, and the possible effects of poor sleep on health. A review of sleep hygiene can be a useful vehicle for this education, especially if rationales for sleep hygiene directives are discussed (see Table 2). Dysfunctional beliefs about sleep should be identified and corrected. Dysfunctional Beliefs and Attitudes about Sleep forms, consisting of 30- and 16-items, have been developed (17, 18) to help both patient and therapist identify catastrophizing self-talk or mistaken viewpoints, which lead to self-defeating actions. For instance, those convinced that getting enough sleep on a daily basis is the most important value may disrupt their sleep-wake rhythms by spending hours of extra time in bed. Jacobs (23) recommends the acknowledgment and practice of positive sleep thoughts. These can be formulated and reinforced depending on a patient’s individual difficulties and perspectives (see Table 3). Books written by sleep experts for the lay reader can help patients diagnose their own sleep problems and develop better sleep/wake habits (22, 23).

Paradoxical Intention

The cognitive strategy of paradoxical intention is a strategy considered effective and is recommended by the Academy of Sleep Medicine (4) for chronic difficulty initiating sleep. Its aim is to reduce performance anxiety and allow sleep to come involuntarily, as it must. The directions for applying a paradoxical intention guide the patient to view as absurd catastrophizing images of the results of sleep loss and to accept and welcome wakefulness at night, using nonsleep times for useful or enjoyable activities, or, alternatively, to lie in bed in darkness, keeping the eyes open and intending to stay awake until sleep comes naturally (5). The method of paradoxical intention is related to the metacognitive model of acceptance and mindfulness (11). A patient complaining of insomnia following retirement was frustrated that a sleep expert could not offer a quick sure cure but hinted to him that he was too focused on sleep difficulties. He discovered that he began to sleep well after formulating his own paradoxical intention: “To hell with whether I go to sleep or not.”

Behavioral Strategies of CBT-I

Stimulus Control Treatment

The most thoroughly studied behavioral strategy of CBT-I is Bootzin’s Stimulus Control Treatment (SCT) (24). This strategy aims to overcome the conditioned arousal, which besets many insomniacs upon retiring to bed, i.e., “I’m tired, I’m sleepy, I can’t wait to get in bed, and then I get into bed and it’s show time!” SCT helps the patient re-establish an automatic connection between the bed/bedroom/bedtime and falling asleep. As with many strategies of behavior change, it can be a challenging commitment. Bedroom activities other than sleep are avoided: no more television, computer work or play, phone calls, eating, or schedule planning; sexual activity is the only exception. If the patient is not asleep within 10 minutes of bedtime and lights out, he/shen leaves the bedroom. Some recent versions of these instructions recommend a 15 or 20-minute wait before getting up (see Table 4 for instructions to the patient). The reward for those who persist in SCT is gradually shorter sleep latency and increased confidence about falling asleep easily and automatically.

Sleep Restriction Treatment

For patients whose sleep is broken by awakenings, Spielman and colleagues proposed a restriction of time in bed (25). This approach has become standard for sleep maintenance difficulties. Sleep restrictions work by initially reducing sleep time thereby increasing sleep drive. The regular timing of sleep reinforces a more consistent sleep-wake cycle. Psychologically, efforts to get to sleep or stay asleep are replaced by efforts to stay awake until the prescribed bedtime. Patients who have been wakeful in bed until 2:00 or 3:00 a.m. begin to struggle to stay up until 12:00 or 1:00 a.m. As in other behavioral treatments, a plausible theory or analogy for sleep restriction will support the patient’s adherence to the sleep schedule. For instance, the patient imagines that sleep is like a river. Bedtime can be seen as similar to one bank of a river and rising time is the opposite bank. Banks that are far apart result in shallows and sand bars of wakefulness; drawing banks closer together (i.e., shorter times in bed) results in a deeper flow of sleep (see Table 5 for instructions to the sleep specialist).

Relaxation Training

When asked how they relax, many insomnia patients will list sedentary or active pastimes. Relaxation in the sense used by Benson (26) as “a physiologic state of quietude,” may not be experienced in these activities. Based on his study of practices of transcendental meditation (TM), Benson recommends for multiple health benefits the practice of four basic elements: a quiet environment, a comfortable (usually sitting) position, an object or word to dwell on, and a passive attitude. Practice periods of at least 20 minutes are ideal, and the practitioner’s patient acceptance of distractions is essential.

Given the anxiety that insomnia sufferers usually bring to bed, relaxation is best practiced earlier in the day or evening. Because time spent in the relaxation response can feel like doing nothing or wasting time, insomnia sufferers often need support to try out (including in the provider’s office) strategies of quieting and relaxation. A self-imposed “clearing” of the mind is usually unachievable and frustrating to strive for, but having nothing much on the mind can be an irresistible invitation for drowsiness.

Resources for relaxation training abound in print and in digital formats (see Table 6 for a sampling).

Biofeedback

Biofeedback training, an operant conditioning strategy, could be seen as bridging cognitive and behavioral approaches to insomnia treatment. Given information from instruments monitoring physiological processes that are usually out of awareness, motivated patients learn by trial and error to exercise some control in these areas. The aims of biofeedback commonly have been to reduce stress and induce relaxation, a benefit among insomniacs who are tense at bedtime. Biofeedback instruments can singly or in combination monitor muscle activity, finger temperature, skin conductance, and heart rate. Neurofeedback, which is a more recent development, monitors cortical arousal measured by electroencephalography (EEG). People with insomnia have shown higher cortical arousal during waking and sleeping times, and neurofeedback has shown promise for affecting waking as well as sleeping EEG (32).

Recent Developments

Computerized CBT-I

Despite its effectiveness, trained providers of CBT-I for insomnia sufferers appear to be limited and the geographical distribution of sleep experts is uneven. Cheng and Dizon (33) reported a review and meta-analysis of randomized control trials (RCTs) of computerized CBT-I treatment (CCBT-I), which took place in several countries. They report on six studies that met selection criteria; three studies were from the United States and one each from Canada, Sweden, and Japan. The studies involved 433 participants, and overall adherence rate was 78%. It was concluded that CCBT-I is a mildly/moderately effective self-help treatment for persistent insomnia.

The American RCT tested a fully automated CCBT-I, Sleep Healthy Using the Internet program (SHUTi), which incorporates behavioral, educational, and cognitive techniques (34). Twenty-two Internet participants were compared on outcomes to 22 control subjects. Sleep diary data showed significant improvement among the Internet group in sleep efficiency, wake after sleep onset, and number of nighttime awakenings. The study’s authors acknowledged some limitations of the study, such as their sample being small and without comorbidities and all data being based on self-report, but they concluded that an Internet-based program can provide effective delivery of CBT for insomnia.