Behavioral Treatments for Insomnia in Primary Care Settings

Joshua Fogel, PhD


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

In This Article

Case Vignette

Mrs. X is a 45-year-old woman who works as a certified public accountant for an accounting firm. She has lived her whole life in a large city in the Northeastern portion of the United States. She is happily married with 2 children aged 12 and 10 years. She has never had any psychiatric or significant medical problems. She has come into the primary care clinic for an annual checkup and a nurse practitioner (NP) takes her health history.

The NP asks, "How have you been sleeping recently?" Mrs. X is slow to answer and then starts crying and says that she has not been able to sleep as well as she did previously. The NP then asks, "When did the problem begin?" and Mrs. X responds that it has gradually happened over the past 3 months and she just does not know what to do about it. The NP follows with the question, "Does this affect you during the daytime?" Mrs. X answers that she finds herself taking naps during her lunch break where she places her head on her desk to rest for the whole lunch hour.

The NP follows up with the question, "Do you experience dozing off or difficulty staying awake during routine tasks, especially while driving?" and Mrs. X responds that recently while driving home from work, she finds herself slowly nodding off and it is frightening, as this has never happened before. The NP then performs a review of systems and a standard physical examination to see if Mrs. X has any other medical or psychological difficulties at this time, but the findings are negative.

The NP reassures Mrs. X that this sleeping difficulty might be a medical condition called insomnia and that she believes that she can help Mrs. X with this condition. The NP teaches Mrs. X how to keep a sleep diary and to calculate her daily sleep efficiency score. For example, if one night her sleep obtained was 5 hours and she had gone to bed at 11:00 PM and arose at 7:00 AM (she was lying in bed for 8 hours), her sleep efficiency would be 5/8 * 100 = 62.5%. The NP reminds Mrs. X that it is best to complete the sleep log in the morning in the few minutes after Mrs. X arises from bed. After giving Mrs. X 2 sleep logs to complete over the next 2 weeks, she schedules the patient for a follow-up visit 2 weeks later.

Two weeks later, Mrs. X returns with her completed weekly sleep log. Her daily sleep efficiency values range from 65% to 70%. The NP recognizes that this is below the acceptable range of 80% to 85%. The NP also notices that it takes Mrs. X 1 hour to fall asleep each night and that Mrs. X takes naps each day. The NP inquires about this, and Mrs. X explains that over the past few months her workload has increased. Since she wants to be home at 6:30 PM to have dinner with her family, she has taken work home. She starts to do this work only after her children go to sleep and often finds that she is doing her work in her bed while trying to relax at that late hour. Her daytime naps are needed because she feels tired during the day and wants to catch up on her sleep.

The NP explains to Mrs. X that everyone has different sleep needs. There is no fixed number of hours for each person to sleep each night, as each person's biology dictates the proper number of hours for adequate sleep. The NP explains to Mrs. X the concept of stimulus control, which dictates use of the bed and bedroom only for sleep and sex. Mrs. X should not do her office work in the bed as this is associating her bed with the daily stresses of her office and now she no longer finds her bed relaxing. She should also go to bed only when sleepy. If Mrs. X has difficulty falling asleep after 15-20 minutes, she should get out of bed, go into another room and only return to her bedroom when she is sleepy. Mrs. X should also have a regular time to get out of bed in the morning, even if she only had a little sleep the night before. She should avoid naps during the day, even if she feels sleepy. The NP schedules Mrs. X for a follow-up appointment 2 weeks later and again gives her a few new sleep diaries to complete.

At this follow-up appointment, Mrs. X brings her sleep log and the NP notices that Mrs. X's sleep efficiency scores range from 75% to 80%. The NP inquires about Mrs. X's sleep, and Mrs. X says with a smile that after a few days of trying these suggestions, she feels that her sleep has started to improve. Mrs. X says that she also notices from her sleep efficiency scores that her sleep is improving. The NP and Mrs. X discuss the potential challenges of adhering to this program such as the times when Mrs. X wants to read a novel in bed. Mrs. X agrees that she wants to condition herself to recognize the bed as a place of sleep and will even not read a book in bed. The NP schedules Mrs. X for a follow-up visit 6 weeks later and gives her enough sleep logs to complete over that time period.

At the 6-week follow up, Mrs. X has sleep efficiency scores of 95% and says that her sleep has returned to the way it was previously. She no longer feels the need to take a daytime nap and also does not feel sleepy while driving her car. She thanks the NP for her treatment and the NP does not see the need to schedule any further follow-up visits.


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