Insomnia

Table 8A. Psychological and Behavioral Therapy Options Treatment Description Evidence Grade* Stimulus control Go to bed only when sleepy; maintain regular schedule; avoid naps; use bed only for sleep; if unable to fall asleep or back asleep within 20 minutes, get out of bed, engage in relaxing activity until drowsy, then return to bed (repeat this as necessary) Methodical tensing and relaxing different muscle groups throughout patient's body; useful in patients displaying high levels of arousal both at night and in daytime Altering patient's faulty beliefs and attitudes about sleep, using multiple patient-specific techniques to replace identified dysfunctional concepts about sleep with more appropriate ones; increasingly used as part of other therapies Maintain a sleep log; determine mean total sleep time (TST) for baseline period; initiate total time in bed (TIB) [TIB = baseline mean TST (not < 4.5 h)]; for sleep efficiency (SE) [SE = TST/TIB] > 90% over 5-7 d, increase TIB by 15 min; for SE < 80%, decrease TIB by 15 min; repeat TIB adjustment q5-7d Training patient to confront most feared behavior, deliberately trying to remain awake when sleep desired; eliminates performance anxiety that inhibits sleep onset Varying combinations of psychological (aimed at changing patient's beliefs and attitudes about insomnia) and behavioral (eg, stimulus control, progressive muscle relaxation, sleep restriction) interventions Providing visual and/or auditory feedback to assist patient in controlling some physiologic parameters (eg, muscle tension) to seek reduction in somatic arousal Maintain regular sleep-wake schedule; do not nap, especially close to bedtime; avoid "sleeping in" after a poor night; avoid watching the clock; do not lie awake in bed for prolonged periods (see stimulus control); avoid excessive liquids and heavy evening meals; exercise regularly, but not within 3-4 h of bedtime; minimize/avoid caffeine (none after noon), and alcohol, tobacco, stimulants Standard Progressive muscle relaxation Cognitive therapy (coupled with behavioral treatments) Sleep restriction Paradoxical intention Multicomponent CBT-I (cognitive-behavioral treatment of insomnia) Biofeedback Sleep hygiene education Standard Standard Guideline Guideline Guideline Guideline No recommendation *Based on evidence-based practice parameters: Standard = highest grade of evidence; Guideline = second highest grade; No recommendation = insufficient evidence to recommend as a stand-alone treatment intervention.

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