Treatment for Insomnia

Robert N. Turner

Treating insomnia can be challenging.

Some patients presenting to the sleep disorders clinic have had trouble initiating and maintaining sleep for months or years; consequently, poor sleep-wake habits are often firmly established. Many “self-medicate,” using alcohol or over-the-counter sleep aids for relief of insomnia. Dependency upon sedative-hypnotics also occurs. Others present with personality styles generally associated with enduring, maladaptive patterns of thinking and relating to others and their world. A multitude of interplaying patient characteristics, social and environmental factors as well as medical conditions can contribute to a persistent sleep-wake disturbance. Thus, it is essential to identify the disorder correctly as an initial step in specifying rational interventions for insomnia.

On a broader, conceptual scale, one may question whether nondrug treatments for insomnia are worthwhile or necessary. Although pharmacotherapy has been the mainstay of treatment for decades, patients accept cognitive-behavioral or other nondrug interventions when adequately prepared. Some patients express fears of “becoming addicted” to sleeping pills and prefer to rely on themselves rather than depend upon a medication to sleep. Furthermore, it has become well known that sedative-hypnotics may not be effective in the long-term treatment of insomnia and, if compounds have a short half-life, some can induce “rebound insomnia” when discontinued.

On the contrary, sedatives can be helpful to those with various types of insomnia, and many of these compounds are immediately effective in promoting sleep onset and sleep maintenance. If a patient presents with a disorder of hyperarousal, pharmacotherapy and/or relaxation training may be a rational first-line treatment, providing some quick relief to an overactive sympathetic nervous system (SNS). Both patients and physicians are accustomed to treating insomnia in this manner, although this is not necessarily helpful in the long run or to the patient’s best benefit.

Before addressing techniques associated with the treatment for chronic insomnia, some general observations, derived through clinical work with an outpatient population, are worth mentioning. Many of these issues have not been subject to rigorous systemic evaluation and may not be significant in every case. The following is not an all-inclusive list but highlights important concerns and some practical matters:

The initial diagnostic session generally serves as the foundation for subsequent treatment and may provide some relief to the patient, who has finally initiated steps to manage the problem(s). Building rapport and fostering an alliance with the patient during the first meeting is unquestionably essential.
Some patients actually gain from their misery and suffering, a psychological process called “secondary gain.” These people may receive substantial attention and special consideration from family members because of the misery that insomnia causes.
Patients present to the sleep disorders clinic with wide-ranging and sometimes unrealistic ideas concerning their care. Some expect immediate relief from their long-standing insomnia and may complain bitterly if treatment does not coincide with their expectations.
Many will actively participate in their treatment if they understand the rationale for interventions. Resistance to therapeutic measures requires exploration with the patient.
Because people with insomnia also present with personality disorders and various psychiatric conditions, it is advantageous for the clinician to utilize strategies from several psychotherapeutic orientations, such as psychodynamic, family systems, interpersonal, and cognitive-behavioral. This is especially important in the treatment for patients with “comorbid” insomnias (e.g., depression, anxiety) because concurrent treatment for the primary condition along with sleeplessness can provide substantial benefit to the patient. If the clinician neglects to address the comorbid disorder and focuses entirely upon the patient’s insomnia, another interpersonal (or relational) disappointment will certainly be experienced by some patients.
It is important to understand the principles of sleep hygiene, stimulus control, sleep restriction, relaxation training, and psychotherapy. With sleep hygiene measures, two or three recommendations per session provide the patient time to accommodate to change. Simply furnishing a set of sleep hygiene instructions and/or stimulus control measures rarely provides much benefit to any patient.
Among many primary care providers, pharmacotherapy continues to be the mainstay for treating insomnia. Using cognitive-behavioral interventions with medication management has not, as of yet, become a “usual and customary” procedure.
Nonpharmacologic treatments can benefit people with insomnia associated with medical conditions, especially if combined strategies are implemented (e.g., relaxation training and stimulus control have been helpful to several patients with chronic pain).
Listening empathetically and responding appropriately to patient concerns requires the clinician to remain authentic throughout the process. Patients recognize insincere responses and may feel irritated (at best) by hasty responses. Responding apathetically, challenging beliefs abruptly, or ignoring individual concerns are detrimental to the treatment process.
It is best for the treating practitioner to remain available to patients, yet establish and maintain firm psychological boundaries throughout therapy. Otherwise repeated “critical” telephone calls can occur between sessions.

When necessary, referring patients to appropriate specialists is essential. However, presenting this to patients requires careful consideration. Some with insomnia firmly believe that they cannot be helped. This notion needs to be addressed rather than providing reinforcement when presenting the need for referral.

COGNITIVE AND BEHAVIORAL TREATMENTS

Once a detailed evaluation of underlying factors that could be contributing to difficulty initiating and/or maintaining sleep has been completed, a variety of techniques are available that have been shown to offer improvements (1).

The American Academy of Sleep Medicine’s (AASM) practice parameters for psychological and behavioral treatment of insomnia recommend its use in patients with chronic insomnia (2).

Sleep restriction therapy is based upon the homeostatic regulation of sleep, facilitating sleep initiation and maintenance through partial sleep deprivation. It is important to note that sleep restriction should not fall below 5 hours per night. Additionally, extreme caution should be used with patients for whom sleepiness presents a risk in their profession (e.g., drivers, heavy equipment operators). Restricting the amount of time spent in bed is based upon findings from baseline sleep diaries. The goal is to achieve 85% sleep efficiency (SE). Sleep diaries are reviewed on a weekly basis and if SE goal is met, time in bed is increased by 20 minutes for a week. If SE goal is not met and SE is less than 80%, time in bed is reduced by 20 minutes. Time in bed is kept stable if SE falls between 80% and 85%. Weekly adjustments in the sleep schedule are made until optimal sleep time is reached (3).

Stimulus control therapy includes several instructions that target sleep-incompatible behaviors. Instructions to patients are as follows: Go to bed only when sleepy; get out of bed when unable to sleep, go to another room and return to bed only when sleep is imminent; stop all nonsleep-promoting activities (i.e., watching TV or problem solving); and get up at a regular time every morning despite any problems with sleep during the previous night.

Relaxation therapies center upon reducing cognitive and/or somatic arousal. Progressive muscle relaxation techniques, diaphragmatic breathing, and biofeedback training have all been used among patients with insomnia. Cognitive interventions such as meditation or imagery may also be employed (4). These procedures may be most beneficial to those who experience excessive muscular tension and/or ruminative thought patterns. Relaxation procedures are often described initially and the patient’s chosen and preferred relaxation strategy is encouraged. It is important for these methods to be employed over time (2 to 4 weeks at minimum) and practiced daily.

Cognitive therapy focuses upon changing dysfunctional, arousing thoughts and beliefs regarding sleep and insomnia. Catastrophic thinking is challenged; maladaptive thoughts, which may perpetuate insomnia,
are addressed; and faulty, unrealistic beliefs are discussed. Worry and rumination over the loss of sleep, unrealistic thoughts regarding the effects of partial sleep deprivation, and irrational expectations about sleep requirements are all relevant issues requiring careful examination and modification. Common examples of irrational beliefs might include “I cannot sleep at all,” as well as “My day will be ruined if I do not sleep for at least 8 hours tonight.” Because dysfunctional attitudes and thoughts about sleep can promote arousal, both anticipatory and performance anxiety can also occur, adding to difficulties with sleep onset. Offering suggestions to modify and replace these unrealistic or dysfunctional thoughts with rational ideation should be based upon scientifically proven sleep facts. Cognitive-behavioral therapy has been found to benefit various patients with insomnia (5, 6).

Sleep hygiene education focuses upon practices and patterns that can promote or disrupt sleep. The goal is to optimize sleep-wake patterns and habits. Encouraging patients to adopt a regular time of going to bed (with 1- to 2-hour variations) and, more importantly, instructing the patient to get up at about the same time every day are helpful. Avoiding stimulants such as caffeine or tobacco several hours before bedtime, limiting alcohol near bedtime, exercising regularly, providing a time to wind down at least 1 hour before bedtime, and managing stress are other useful suggestions. Environmental variables, such as noise, light, sleep surface, and ambient temperature, can also be addressed. Specific instructions including moving the bedroom clock out of sight, not exercising too close to bedtime, and stopping intense efforts to try to sleep often result in clinical improvement. The latter remains particularly important because the more one tries to sleep, the more aroused one becomes. It is, therefore, less likely that sleep will ensue easily (7).

Bright light therapy can be useful for those with circadian rhythm sleep disorders, such as delayed sleep phase syndrome or advanced sleep phase syndrome (8). Patients with delayed sleep phase syndrome benefit from bright light therapy in the morning to phase-advance their sleepiness time to an earlier time (e.g., from 3:00 a.m. to 12:00 midnight). Patients with advanced sleep phase syndrome benefit from bright light therapy in the evening (about 6:00 to 8:00 p.m.) to phase-delay their sleep time from the early evening to a more appropriate time (e.g., about 10:00 or 11:00 p.m.). However, the utility of bright light therapy among patients with primary insomnia has not, as of yet, been clearly and firmly established.

Paradoxical intention approaches are recommended only sparingly and probably are best implemented by very well-trained clinicians who have developed a strong working alliance with the particular patient (9). In utilizing these approaches, the clinician prescribes the symptom; with insomnia patients, this translates to essentially telling the patient to try to sleep poorly and utilizing measures contradictory to treating insomnia. These approaches can be helpful among those who generally function adequately or “need to rebel.” Some reasonably mentally healthy patients find these humorous. Others, however, consider these interventions cynical, insincere, and insulting or “just plain crazy.” It cannot be overemphasized that the treating clinician needs to be reasonably certain of some positive benefit to the patient when utilizing the paradoxical intention approaches.

Biofeedback therapy has also been applied to the treatment for disturbances in initiating and maintaining sleep (10). Years ago, several researchers investigated its utility from varying perspectives. Hauri (11) evaluated frontalis electromyogram, electroencephalogram theta, and sensorimotor rhythm biofeedback in the treatment for insomnia. Overall, patients who were more aroused appeared to benefit more than those who were less aroused.

Other strategies rely upon scores of possible folk remedies or beliefs. Aromatherapy and acupuncture can be included here. These interventions may have little or no empirical support, yet could potentially facilitate treatment for some patients. Additional examples of these varied “treatments” may include listening to soft music, prayer, and meditation. If previously helpful, these are worth exploring and using, along with the more recognized and scientifically validated therapies.

PHARMACOTHERAPY

Sedative-hypnotics have long been used in the treatment for insomnia. Older preparations included the bromides, chloral hydrate, glutethimide, and numerous other compounds. Barbiturates were also used throughout the 1950s. The departure of these agents from clinical use probably evokes little nostalgic remorse because several serious problems occurred with many of them. Among other concerns, gastric disturbances, the development of tolerance to their therapeutic effects, risks of dependence and abuse, lethality in overdose due to a limited therapeutic margin of safety, and the potential for convulsions or seizures upon withdrawal were noteworthy reasons for avoiding some of these older hypnotics. The potential for barbiturate abuse and overdose also became well publicized after the death of Marilyn Monroe. Another compound, thalidomide, was responsible for severe birth defects, such as children born without limbs. The latter disaster apparently stimulated more stringent regulations in drug testing in the United States.

With the advent of sleep laboratory technology and methodology, direct objective evaluation of hypnotics
became possible. The earliest studies began in the mid-1960s with Oswald and Priest (12) describing rapid eye movement (REM) sleep rebound and nightmares following drug withdrawal. Kales and associates (13, 14) published important work describing methodology and hypnotic efficacy and later reported on the ineffectiveness of several medications over 2 weeks of use (15, 16). The latter research group has also been credited with describing rebound insomnia (17) following discontinuation of several hypnotics, particularly Dalmane. Through these and numerous other studies, several research designs were developed and used in evaluating dosage, efficacy, tolerance, withdrawal, and potential dependence issues of sleep-promoting medications.

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