Psych and behavioral tx are 1st line and gold standard
AASM Recommendations
Standard tx: stimulus control, relaxation training, CBT-I
Some support: sleep restriction, multicomponent tx without cognitive tx, paradoxical intention, biofeedback
Not recommended as stand-alone: sleep hygiene, imagery training, cognitive tx
Stimulus Control: Effective monotherapy based on classical conditioning
In good sleepers, the bed/bedroom acts as a cue for sleep
Pts with insomnia often do sleep-disrupting things in bed: TV, eating, worrying, reading
Pts believe more time in bed = more sleep
These behaviors weaken the bed-sleep association, bed becomes a cue for anxiety and frustration
Techniques used: Use bedroom only for sleep, dressing, sex. Leave bed if awake 15 min, return when sleepy,
Discourage naps, set regular bed and wake times
CI: epilepsy, parasomnias, mania, fall risk
Sleep Restriction: Limits time in bed (TIB) to actual time asleep
Use 2 wks of sleep diary to get avg TIB and TST (SE = TST / TIB x 100)
Good sleeper SE ≥90%
Techniques: Set anchor wake time, same 7 days/wk regardless of how pt slept. Anchor time minus avg sleep time = sleep threshold (earliest bedtime, only if sleepy). Min TIB 5 hrs, 6 hrs in bipolar. Titrate weekly by moving bedtime 15 min. SE ≥90%: move bedtime 15 min earlier. SE 85-89%: no change. SE <85%: delay bedtime 15 min
Mild sleep debt makes sleep onset easier and consolidates sleep
Transient increase in daytime fatigue early on
CI: bipolar, epilepsy, OSA, professional drivers, CFS, migraine, any condition worsened by sleep loss
Sleep Compression: Variation of sleep restriction, TIB reduced gradually
Use when sleep restriction is CI or pt anxiety about restriction is high
Pt picks latest acceptable bedtime, delay 15 min each wk until SE reaches 90%
Relaxation: Reduces pre-bed and in-bed mental and physical tension and hyperarousal
Examples: PMR, guided imagery, meditation, autogenic training
Trial several techniques and combine, e.g. start with PMR, add guided imagery
Techniques take time, practice is key
Paradoxical Intention: Pt follows usual pre-bed routine, then tries to stay awake
Removes frustration and stress of trying to sleep
Cognitive Therapy: Uncovers sleep myths, gives alternate explanations so pt reframes insomnia
Constructive worry time: write worries and solutions before bed to put the day to bed
Teaches techniques for night worries, e.g. thought stopping
Primary aims:
a. Correct misconceptions: pts blame external causes, focus on modifiable internal factors
b. Reduce performance anxiety: trying harder to sleep backfires
c. Faulty beliefs: staying in bed longer, cutting social activity, chasing 8 hrs
d. Unrealistic expectations: sleep need is individual, night-to-night variability is normal
e. Misattribution: fearing daytime consequences amplifies harm, worry can be worse than the insomnia
CBT-I
Multicomponent package, usually ≥3 techniques
Components: sleep education, sleep hygiene, stimulus control, sleep restriction, relaxation, cognitive tx
4-8 weekly sessions, 60-90 min each
Brief courses of 1-2 sessions also supported
Online or in person, individual or group (2-15 people)
Effectiveness
Meta-analyses show moderate to large effect sizes
Reduces SOL and WASO, increases TST
Gains maintained 6-8 months on avg
AASM: insufficient evidence to favor one therapy, or single vs multicomponent
Emerging Tx: None meet AASM standard yet: light tx, mindfulness + CBT-I, acupuncture/acupressure/electroacupuncture, intensive sleep retraining, biofeedback
Comorbid insomnia
Up to 90% of insomnia is comorbid
Treating insomnia directly improves both insomnia and comorbid condition
DSM-5 replaced primary/secondary insomnia with insomnia disorder
CBT-I effective in: chronic pain, fibromyalgia, cancer, depression, psychosis
Alcohol dependence: effective but no change in relapse rates
PTSD: effective when combined with imagery rehearsal tx
Bipolar: effective between affective episodes
- Oxford Handbook of Sleep Medicine 2022