Behavioral Treatment of Insomnia

Description of the Strategy

Insomnia involves difficulty falling asleep, problems staying asleep, waking up too early, or nonrestorative sleep, with associated impairment in functioning and fatigue. Insomnia may be situational or acute, follow an intermittent course, or be persistent. It can also be a symptom of another medical or psychological condition or represent a syndrome in itself, as in primary insomnia. Pharmacotherapy is a frequently used treatment option for insomnia. However, behavioral treatments are receiving increased attention, especially for chronic insomnia, because of their efficacy, safety, and patient acceptance.

Insomnia can be viewed as a multidimensional condition. Any given case is likely to involve some combination of predisposing factors (e.g., family history, female gender, older age, hyperarousal) and stressful life events (e.g., personal loss, illness, work stress) that precipitate a bout of poor sleep and a variety of physiologic, behavioral, emotional, and cognitive factors that maintain the poor sleep. The efficacy of behavioral therapies for insomnia is believed to be due specifically to their ability to alter the main factors that perpetuate poor sleep. Perpetuating factors include maladaptive sleep-wake habits, especially sleep scheduling; learned associations of the bed with sleeplessness; and dysfunctional cognitions and other phenomena that prevent sufficient presleep reduction in arousal. Interventions are designed to adjust sleep-wake scheduling to achieve rapid sleep onset and uninterrupted sleep and/or to maximize the association of bedtime with reduced arousal and increased sleep tendency. Some of the behavioral interventions also take advantage of the homeostatic and circadian biological rhythms of sleep tendency, in order to maximize the likelihood of sleep and wakefulness occurring at desired hours.

Behavioral approaches to insomnia generally fall into five categories: stimulus control therapy, sleep restriction, relaxation training, cognitive therapy, and sleep hygiene education.