CENTER ON BEHAVIORAL MEDICINE

ADDITIONAL MATERIAL

EFFECTIVE TREATMENTS

   Traditional Approaches-Psychological:  Related Paper

Effective Treatments Index

Treatment of Primary Insomnia


Permission graciously given by the author to reproduce this paper.

Treatment of Primary Insomnia

Matthew Jones
2006

          Insomnia is defined as the “chronic inability to fall asleep or remain asleep for an adequate length of time” (Thomas, 1997, p. 1000). Insomnia may also manifest itself through frequent night awakenings, early morning awakenings or poor sleep quality. The effect of chronic insomnia can be detrimental to an individual’s health, mood and general ability to function during the day (Bootzin, 2000).

          Insomnia can be described in terms of a symptom or a syndrome. Insomnia can present as an underlying symptom of a medical, psychiatric or environmental condition. Conditions such as sleep apnea, depression or jet lag would be the primary diagnosis in which insomnia would be a secondary result. Primary insomnia is defined as sleeplessness which is not attributed to either a medical, psychological or environmental cause. Primary insomnia is viewed in terms of a syndrome and would be treated as the principal cause of sleeplessness (Eddy & Walbroehl, 1999).

            An alternative name used for primary insomnia is psychophysiology insomnia or even sometimes referred to as learned insomnia. As these alternative names indicate, primary insomnia is a physiological condition caused by psychological elements. These maladaptive sleep patterns are acquired through a conditioned response. Most cases of primary insomnia initially develop in response to a stressful event or time period. The stress induces wakefulness and heightened arousal and an individual begins to associate sleeplessness with their sleeping environment. This learned response causes individuals to feel alert and wakeful each time they enter their sleeping environment. This maladaptive response is further reinforced by feelings of frustration when dealing with the persistent inability to sleep. This response usually persists long after the resolution of the original stressful event that initiated the conditioning and often requires some type of intervention (Eddy & Walbroehl, 1999).

Intervention

            There are two main intervention approaches to managing primary insomnia; there is the pharmaceutical approach and the psychological approach. The pharmaceutical method of intervention focuses on inducing sleep through chemical and biochemical interactions. The most common type of sleep medications are the benzodiazepine receptor agonists. These drugs fall into two distinct categories, the hypnotics which are the benzodiazepines like estazolam, flurazepam, quazepam, temazepam and triazolam and the non-hypnotics like zaleplon, zolpidem and eszopiclone that act on benzodiazepine receptors but do not have a benzodiazepine structure. All of these drugs, with the exception of eszopiclone, have only been shown to be effective at treating short term insomnia. These medications also have significant adverse effects associated with their use, such as residual daytime sedation, cognitive impairment, motor impairment, dependence and rebound insomnia. Most importantly, effectiveness is often limited to current use of the therapeutic agent and insomnia usually returns on cessation of the medication (National Institutes of Health, 2005).

            The psychological approach to treating primary insomnia focuses on changing maladaptive sleep habits, reducing autonomic arousal and altering dysfunctional beliefs, which have been shown to cause and maintain sleeplessness (Walsh & Benca, 1999).  A number of psychological therapies have been proven to be efficacious at treating primary insomnia, such as relaxation therapy, sleep restriction therapy, stimulus control therapy, paradoxical intention therapy, biofeedback therapy and cognitive therapy (Simon, 2002, Walsh & Benca, 1999). Numerous research studies have shown psychological interventions to be at least as effective and usually better than pharmacotherapy at treating short-term insomnia and significantly more effective at treating long-term insomnia (Jacobs, Pace-Schott, Stickgold, & Otto, 2004, Miller, 2005, Smith et al. 2002).

CBT-I

            Psychological interventions to treat chronic insomnia have developed from the various theoretical approaches to gives us a number of therapeutic techniques that have been shown to be extremely effective at treating sleep issues. In the past few years there has been an increased interest in combining the various therapeutic techniques into a multi-component approach.

The term for this combined approach is cognitive behavioral therapy for insomnia (CBT-I) (Smith & Perlis, 2006).

          CBT-I consists of the most widely used and empirically validated psychological interventions for treating insomnia. These techniques are stimulus control therapy, sleep restriction therapy, relaxation therapy and cognitive therapy. These techniques are explained as follows. Stimulus control therapy focuses on re-associating the sleep environment as an area that would stimulate sleep rather than stimulate states of arousal. Sleep restriction therapy allows an individual to consolidate fragmented sleep by initially shortening their sleep opportunity and then gradually increasing the amount of sleep as sleep efficiency is reached (Smith & Perlis, 2006). Relaxation therapy assists individuals in reducing states of arousal through progressive muscle relaxation techniques. Cognitive therapy is aimed at modifying maladaptive sleep-related beliefs or managing intrusive pre-sleep cognitions (Benca, 2005).

          Treatment programs for insomnia using CBT-I vary to some degree, but in general they follow a basic standard of care that has been proven efficacious. The course of treatment is commonly 4-6 weeks and the patients are usually seen 2-3 times a week. The determination of the specific treatment is facilitated by the use of a sleep diary. The patient is instructed to record their sleep pattern for a prescribed number of days that is reviewed by the therapist. Depending on the results of the sleep diary and the clinical evaluation, the therapist would then decide on a course of treatment which often consists of a combination of psychological techniques associated with CBT-I (National Sleep Foundation, 2006).

          CBT-I has been clinically proven to be effective at treating primary insomnia in 70% to 80% of patients undergoing treatment (Morin et al. 1999). This outstanding rate of success indicates that CBT-I should be a first line treatment for primary insomnia (Jacobs, Pace-Schott, Stickgold, & Otto, 2004). Despite the proven effectiveness, CBT-I may not be appropriate for all individuals. CBT-I is effective at treating primary insomnia but has not been proven to be effective at treating insomnia due to medical or psychological reasons. The medical or psychological cause of the insomnia should be the primary focus of treatment. CBT-I requires that patients commit to the guidelines and instructions of a program. Patients unwilling to change sleeping habits or meet regularly with a clinician will not likely benefit from the therapy (National Sleep Foundation, 2006).

Conclusion

          Primary insomnia is the result of maladaptive sleep patterns that are acquired through a stress initiated conditioned arousal response (Eddy & Walbroehl, 1999). Due to a psychological origin of this condition, the most effective treatment requires a psychological intervention rather than a pharmaceutical intervention. This has been proven through numerous research studies comparing psychological interventions to pharmaceutical interventions (Jacobs, Pace-Schott, Stickgold, & Otto, 2004, Miller, 2005, Smith et al. 2002). The effectiveness of treating insomnia has further been increased in the past few years by combining most widely used and empirically validated psychological interventions to form the therapy known as CBT-I. The 70% to 80% effectiveness of CBT-I has prompted many clinicians to adopt it as a first line treatment for insomnia (Jacobs, Pace-Schott, Stickgold, & Otto, 2004, Morin et al. 1999). This should mean that more individuals should be able to be effectively treated for insomnia and consequently benefit from a happier and healthier life.

References

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Bootzin, R. R. (2000). Insomnia. In Encyclopedia of psychology (Vol. 4). Washington, DC: American Psychological Association.

Eddy, M., & Walbroehl, G. S. (1999). Insomnia. American Family Physician, 59(7), 123-127.

Jacobs, G. D., Pace-Schott, E. F., Stickgold, R., & Otto, M. W. (2004). Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Archives of Internal Medicine, 164(17), 1888-1896.

Miller, K. E. (2005). Cognitive behavior therapy vs. pharmacotherapy for insomnia. American Family Physician, 72(2), 330.

Morin, C. M., Hauri, P. J., Espie, C. A., Spielman, A. J., Buysee, D. J., & Bootzin, R. R. (1999). Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine Review, 1-23.

National Institutes of Health (2005). NIH state of the science conference statement on manifestations and management of chronic insomnia in adults. Washington, DC: U.S. Government Printing Office.

National Sleep Foundation. (2006). Cognitive behavioral treatment for insomnia: the medicine-free approach to treating insomnia. Retrieved March 11, 2006, from http://www.sleepfoundation.org/hottopics/index.php?secid=8&id=366

Simon, H. (2002, June 30). What are behavioral and other non-drug treatments for insomnia? Retrieved March 11, 2006, from http://umm.edu/patiented/article/what_behavioral_other_non-drug.htm

Smith, M. T., & Perlis, M. L. (2006). Who is a candidate for cognitive-behavioral therapy for insomnia? Health Psychology, 25(1), 15-19.

Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., & Buysse, D. J. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy fro persistent insomnia. American Journal of Psychiatry, 159, 5-11.

Thomas, C. L. (1997). Insomnia. In Taber's Cyclopedic Medical Dictionary (18th ed.). Philadelphia: F. A. Davis Company.

Walsh, J. K., & Benca, R. M. (1999). Insomnia: assessment and management in primary care. American Family Physician, 59(11), 1-13.