Behavioral Treatments for Insomnia in Primary Care Settings

Joshua Fogel, PhD


Topics in Advanced Practice Nursing eJournal. 2003;3(4) 

In This Article


Medication is commonly used to treat insomnia while behavioral therapies are often not adequately tried. Many clinicians are not aware of the usefulness, effectiveness, and proper way to treat insomnia without using medications.[14] In the immediate short term (ie, first week), medications can produce improvement at a much greater rate than nonmedication treatments.[15] However, in the intermediate term (ie, 3-8 weeks), a meta-analysis indicates that behavioral treatment for insomnia is just as effective as medication treatment.

There is the possibility that this effectiveness of behavioral treatment is because it is more intensive than medication treatment in that there is a greater duration of contact with the healthcare professional.[6] Over the long term (ie, 6-24 months), patients receiving nonpharmacologic therapies enjoy long lasting relief while many of those treated with medication return to their baseline insomnia levels.[15] In summary, behavioral therapy is best for chronic insomnia and helpful for all types. This article will focus on the behavioral treatment approaches and benefits of their use for insomnia.

In practice parameters for nonpharmacologic treatments for chronic insomnia, the American Academy of Sleep Medicine recommends stimulus control as the approach with the best scientific evidence for effectiveness. Progressive muscle relaxation, paradoxical intention, and biofeedback are 3 treatments that have the next best scientific evidence for effectiveness, while sleep restriction and multicomponent cognitive behavioral therapy are recommended as options. Focusing on sleep hygiene and single component cognitive therapy may also be effective, but these approaches do not currently have sufficient scientific evidence to recommend them as evidence-based treatment. This is due to the insufficient number of clinical trials studying the effectiveness of these treatments alone, without their being part of any combined treatment regimen.[14]

The American Psychological Association also has criteria for empirically validated treatments. The treatments of stimulus control, progressive muscle relaxation, and paradoxical intention are considered empirically validated. The treatments of biofeedback, sleep restriction, and multicomponent cognitive behavioral therapy are considered as "probably efficacious" treatments.[15] Below are the theoretical bases for each of the behavioral treatments, the descriptions of the behavioral treatments along with clinical recommendations, and a brief discussion of the supporting scientific evidence for their use.

Stimulus control treatment. Stimulus control treatment is based on the concept that insomnia is a conditioned behavior to bedtime and bed/bedroom cues associated with sleep. The idea of this treatment is to retrain the individual with insomnia to associate the bed and bedroom with rapid sleep onset. This is accomplished by limiting activities not compatible with sleep that serve as cues for staying awake and also by adhering to a consistent sleep-wake schedule.[15]

Stimulus control treatment consists of the behavioral instructions of: (1) going to bed only when sleepy, (2) using the bed and bedroom only for sleep and sex, (3) whenever one is unable to fall asleep after 15-20 minutes, getting out of bed and going into another room and only returning when sleepy, (4) having a regular time to get out of bed in the morning even if one only had a little sleep the night(s) before, and (5) not taking naps during the day.[15]

Meta-analytic studies indicate that stimulus control treatment can reduce the average self-reported time for sleep onset from 64 minutes before treatment to 33 minutes after treatment. Also, the average total time awake after sleep onset is reduced from 84 minutes before treatment to 44 minutes after treatment.[15]

Relaxation techniques. Relaxation techniques, such as progressive muscle relaxation and biofeedback, are based on the idea that those with insomnia have high arousal levels. Relaxation techniques help deactivate this arousal system. Progressive muscle relaxation is a technique of tensing and relaxing all the muscle groups of the body in a systematic way. Biofeedback uses electronic or computer signals through either visual or auditory feedback to signal when an individual has relaxed that part of the body being measured. Both progressive muscle relaxation and biofeedback help reduce somatic arousal.[15]

Other relaxation techniques exist to reduce cognitive arousal (eg, intrusive thoughts, racing mind with fears about sleep) such as imagery training and thought-stopping. The techniques of progressive muscle relaxation, biofeedback, imagery training, autogenic training (a particular form of imagery training), and meditation have been evaluated and have been shown to be effective. For example, in 17 studies of progressive muscle relaxation as the sole treatment, 16 studies show it to be more effective than placebo, wait list, and no-treatment controls.[15]

Abdominal breathing, hypnosis, and thought-stopping techniques have not been sufficiently studied to determine whether there is a scientific basis for their effectiveness in treating insomnia. Also, relaxation training techniques have not been found to be that effective with elderly individuals.[15] Among those with disabilities or pain, progressive muscle relaxation may be contraindicated. Biofeedback, imagery training, autogenic training, and meditation, all treatments that do not involve any physical tensing, may be more effective for those with disabilities or pain.

Paradoxical intention treatment. Paradoxical intention treatment is based on the concept that performance anxiety helps prevent proper sleep. The treatment involves persuading the individual with insomnia to engage in the most feared behavior, which to that individual is "staying awake." As the patient stops trying to fall asleep, the performance anxiety of trying to fall asleep slowly disappears. Four of 6 studies show this approach is more effective than control groups.[15]

Sleep restriction treatment. Similar to paradoxical intention treatment, sleep restriction treatment uses a paradoxical approach where less time is spent in bed. If an individual reports spending an average of 5 hours actually asleep, while spending 7 hours in bed, then that person should only be in bed for 5 hours and, after that point, must get out of bed (and should have an alarm clock set to remind oneself). The idea is to create a mild state of sleep deprivation that will eventually cause a more rapid sleep onset, more efficient sleep, and consistent sleep duration. Roughly on a weekly basis, time in bed is either increased by 15-20 minutes (when sleep efficiency increases) or decreased by 15-20 minutes (when sleep efficiency decreases). Time in bed is kept unchanged when sleep efficiency is roughly between 80% and 90%. Numerous studies support the effectiveness of this approach, including 1 study that showed it to have twice the improvement rate of the relaxation treatment group.[15] Many clinicians report sleep restriction treatment to be a very useful treatment in their clinical practice.

Cognitive behavioral treatment. Multicomponent cognitive behavioral therapy treatment involves the use of cognitive behavioral therapy combined with other behavioral treatments to help change incorrect beliefs and attitudes about sleep. It involves identifying dysfunctional sleep cognitions, challenges the validity of them, and replaces beliefs and attitudes with more adaptive substitutes. This is accomplished through techniques of cognitive restructuring such as reattribution training, "decatastrophizing," hypothesis testing, reappraisal, and attention shifting.

Common faulty beliefs and expectations that can be modified include: (1) unrealistic sleep expectations (eg, I need to have 9 hours of sleep each night), (2) misconceptions about the insomnia causes (eg, I have a chemical imbalance causing my insomnia), (3) amplifying the consequences (eg, I cannot do anything after a bad night's sleep), and (4) performance anxiety after trying for so long to have a good night's sleep by controlling the sleep process. Numerous studies have been done combining cognitive behavioral therapy treatment with treatments such as stimulus control and the relaxation therapies with positive outcomes. However, there is little scientific research showing the use of cognitive behavioral therapy by itself in helping to reduce insomnia.[15]

Sleep hygiene education. Sleep hygiene involves educating the patient about health practices such as diet, exercise, substance use, and environmental factors such as light, noise, temperature, and mattress that can be positive or negative for one's sleep. Although alone, poor sleep hygiene may not be the sole cause of insomnia, it can perpetuate the insomnia problem.[15] The NIH publication Insomnia: Assessment and Management in Primary Care [13] offers a table with a variety of sleep hygiene instructions. Probably because poor sleep hygiene alone is not the cause for insomnia, a few studies have shown it to be ineffective as the sole option for treating insomnia. In clinical practice, sleep hygiene education is often added to other established known beneficial treatments. Sleep hygiene education is a necessary but probably insufficient treatment for insomnia.[15]

Primary care brief treatment. Recently, Edinger and Sampson[16] conducted a randomized trial of primary care patients with insomnia. Their abbreviated behavioral therapy of two 25-minute sessions was compared with a control group receiving 2 sessions of standard sleep hygiene instructions. Those in the treatment group had greater improvements in their sleep efficiency and reductions in their time awake after sleep onset than the control group. The description of this brief treatment is shown in the Table . The authors of this study[16] state that this treatment can be successfully done by nonmental health professionals such as nurses and physicians working in primary care settings.


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