Behavioural therapy for insomnia – Information for GPs
Behavioural therapies for insomnia include sleep hygiene education, stimulus control, relaxation and sleep restriction therapy.108
Sleep hygiene refers to actions that tend to improve and maintain good sleep.108,195,196
- Sleep as long as necessary to feel rested (usually 7–8 hours for adults), then get out of bed.
- Maintain a regular sleep schedule.
- Try not to force sleep.
- Avoid caffeinated beverages after lunch.
- Avoid alcohol near bedtime (late afternoon and evening).
- Avoid smoking or other nicotine intake, particularly during the evening.
- Adjust the bedroom environment as needed to decrease stimuli (eg reduce ambient light, turn off the television or radio).
- Resolve concerns or worries before bedtime
- Exercise regularly for at least 20 minutes, preferably more than 4–5 hours prior to bedtime.
- Avoid daytime naps, especially if they are longer than 20–30 minutes or occur late in the day.
- Avoid going to bed until you are drowsy and ready to sleep.
- If you are not asleep within 15–20 minutes, get out of bed and return only when drowsy.
Patients with insomnia may associate their bed and bedroom with the fear of not sleeping or other arousing events, rather than the more pleasurable anticipation of sleep. The longer you stay in bed trying to sleep, the stronger the association becomes. This perpetuates the difficulty of falling asleep.108
Stimulus control therapy is designed is to disrupt this association by enhancing the likelihood of sleep.197 Patients should not go to bed until they are sleepy and should use the bed primarily for sleep (and not for reading, watching television, eating or worrying). They should not spend more than 20 minutes in bed awake. If they are awake after 20 minutes, they should leave the bedroom and engage in a relaxing activity, such as reading or listening to soothing music. Patients should not engage in activities that stimulate them or reward them for being awake in the middle of the night, such as eating or watching television. In addition, they should not return to bed until they are tired and feel ready to sleep. If they return to bed and still cannot sleep within 20 minutes, the process should be repeated. An alarm clock should be set to wake the patient at the same time every morning, including weekends. Daytime naps are not allowed. Patients may not improve immediately. However, accumulating sleepiness will facilitate sleep during successive nights.108
Stimulus control instructions
- Go to bed only when sleepy.
- Get out of bed if unable to sleep after 15–20 minutes, leave the bedroom and do something relaxing (eg reading or listening to soothing music). Avoid stimulating activities such as eating or watching TV. Return to bed only when sleepy. (Repeat as necessary.)
- Use the bed/bedroom only for sleep (not reading, watching TV or worrying).
- Arise at the same time each day (including weekends).
- Do not take naps during the day.108
Sleep restriction therapy
Some patients with insomnia stay in bed longer to try to make up for lost sleep. This causes a circadian shift and a reduction in the homeostatic drive that makes sleep onset the following night more difficult and results in the need to stay in bed even longer.108
Sleep restriction therapy counteracts this tendency by limiting the total time allowed in bed, including naps and other sleep periods outside of bed, in order to increase the drive to sleep.198 This consolidates sleep and improves sleep efficiency (the percentage of time in bed that the patient is asleep).108
Sleep restriction therapy begins by decreasing the time spent in bed to the same amount of time that the patient reports sleeping (usually determined from sleep diaries or logs completed by the patient), but not less than 5 hours per night. On a daily basis, the patient reports the amount of sleep obtained the previous night and the amount of time spent in bed. The clinician then computes the sleep efficiency, which is the reported time asleep divided by the time in bed. The time in bed is increased by 15–30 minutes once the sleep efficiency exceeds 85%. This process is repeated until the patient reports improved sleep without residual daytime sleepiness.108 Naps are not permitted.
To improve compliance, the rationale for the therapy needs to be carefully explained to patients. Some care needs to be used to determine and schedule the time in bed in a manner that maximises the ability to sleep that is acceptable to the patient. Older patients tend to have more difficulty maintaining sleep even when restricted; therefore, they are given more lenient criteria.108
Relaxation therapy may be implemented before each sleep period. There are two common techniques for relaxation therapy: progressive muscle relaxation and the relaxation response.108
Progressive relaxation is based on the theory that an individual can learn to relax one muscle at a time until the entire body is relaxed. Beginning with the muscles in the face, the patient contracts the muscles gently for 1–2 seconds and then relaxes. This is repeated several times. The same technique is used for other muscle groups, usually in the following sequence: jaw and neck, upper arms, lower arms, fingers, chest, abdomen, buttocks, thighs, calves and then feet. This cycle is repeated for approximately 45 minutes, if necessary.108
The relaxation response begins by lying or sitting comfortably. The eyes are closed and relaxation is allowed to spread throughout the body. A relaxed, abdominal breathing pattern is established. Thoughts are redirected away from everyday thoughts and toward a neutral mental focusing device, such as a peaceful word or image.108
Patients who are awake at night commonly become concerned that they will perform poorly the next day if they do not obtain adequate sleep. This worry can exacerbate their difficulty falling asleep, creating a vicious cycle of wakefulness and concern. A person may begin to blame all negative events in their life on poor sleep. During cognitive therapy, a person works with a therapist to deal with anxiety and catastrophic thinking, while establishing realistic expectations related to insomnia and the need for sleep.108
Cognitive behavioural therapy (CBT) is a strategy that combines several of the previously described approaches over several weeks.199 A sample, 8-session CBT program may include an introductory sleep education session, followed by two sessions that focus on stimulus control and sleep restriction. These may be followed by two sessions that focus on cognitive therapy and then a session on sleep hygiene. Finally, there may be a session that reviews and integrates the previous session and a session that addresses future problems, such as stress and relapse.200
Patients are encouraged to complete sleep logs as they learn and apply the various strategies. This allows improvement to be measured. The advantage of the educational nature of CBT is that it provides patients with the tools to apply it in the future. Disadvantages of CBT include the duration of therapy, and the relatively few clinicians who are skilled at all of its components.108
The benefit of CBT may be reduced when it is administered by less experienced clinicians.108,201