Valerie A Wolfe & Sheri D Pruitt. The Health Psychology Handbook: Practical Issues for the Behavioral Medicine Specialist. Editor: Lee M Cohen. Sage Publications. 2003.
Insomnia and the sleep disorders present a variety of problems. Some are primarily behavioral, whereas others have a dominant biological component. Regardless of etiology, sleep problems are remarkably common. Approximately 65 million Americans suffer each year from transient sleep difficulties, and about 30 million more Americans have chronic insomnia (Hauri & Linde, 1996). Moreover, approximately 35% of adults report some type of sleep disturbance each year, with half of these individuals describing their sleep problems as “serious” (Gallup Organization, 1995; Mellinger, Balter, & Uhlenhuth, 1985).
The cost of sleep disorders is exorbitant. In 1990, the National Commission on Sleep Disorders Research, a commission created by Congress to investigate sleep disorders and their effects on the population, reported the annual cost of sleep problems to be in the tens of billions of dollars (Dement & Vaughan, 1999). In addition, estimates indicate that 24,000 people die each year from accidents related to falling asleep while driving (Dement & Vaughan, 1999). The report generated by the commission advocated extensive training for primary care doctors, a national awareness campaign on insomnia, and increased awareness of the behavioral and medical treatments available for the treatment of sleep disorders.
Despite recommendations from the National Commission on Sleep Disorders Research, physicians rarely receive training in the assessment and treatment of sleep problems. Medical students obtain between 0 and 2 hours of training specific to sleep disorders (Dement & Vaughan, 1999), and this lack of training is reflected in clinical practice. For example, many physicians do not ask about insomnia during office visits (Dement & Vaughan, 1999). Moreover, when insomnia is recognized, physicians defer to medication treatment rather than very efficacious behavioral treatments. In fact, practice guidelines from the American Medical Association, the Canadian Medical Association, and many health maintenance organizations indicate that behavioral interventions should be the treatment of choice for insomnia.
Background and Etiology
The Basics of Sleep, Sleep Architecture, and Sleep Cycles
Sleep is an exceedingly important activity. Although scientists are not certain how sleep helps daytime functioning, it is fairly easy to assess the difficulties associated with sleep deprivation. Without enough sleep, individuals find themselves edgy and irritable. In addition, their concentration and ability to learn new information begin to decline. One of the first symptoms of sleep deprivation is depression. After a few days of no sleep, some people will perform as if they are intoxicated. When people have been denied sleep for about a week, they can experience visual and auditory hallucinations. Sleep deprivation impairs function in nearly everyone. However, the amount of sleep deprivation a single person can tolerate without ill effects varies.
Fatigue also contributes to a host of psychiatric and medical diagnoses. Both anxiety and depression have a strong sleep component. Among patients with depression, 85% report insomnia and 10% to 15% complain of hypersomnia (Ford & Kamerow, 1989). Patients with bipolar disorder frequently function energetically for days or weeks on a few hours of sleep and then have periods of hypersomnia associated with major depressive episodes. Changes in sleep can predict a major depressive episode (Perlis, Giles, Buyesse, Tu, & Kupfer, 1997), and denying sleep to someone who has bipolar disorder can trigger a manic episode (Ford & Kamerow, 1989). Patients with posttraumatic stress disorder also report sleep disturbance, including nightmares and insomnia (American Psychiatric Association, 1994).
Insomnia is also associated with chronic obstructive pulmonary disease, osteoarthritis, asthma, fibromyalgia, headaches, and chronic pain. Between 50% and 70% of patients with a pain diagnosis suffer from a sleep disturbance (Moffitt, Kalucy, Kalucy, Baum, & Cooke, 1991; Pilowsky, Crettenden, & Townley, 1985). Patients with fibromyalgia, rheumatoid arthritis, back pain, and/or headaches have been found to have alpha wave intrusions into their delta sleep, indicating that their deep sleep is interrupted by wakefulness (Gupta, Gupta, & Haberman, 1986; Moldofsky, 1989).
Sleep deprivation can also cause pain. When individuals have their deep delta sleep interrupted, they complain of musculoskeletal tenderness, which resolves after 2 nights of noninterrupted sleep (Hauri & Hawkins, 1973). Sleep is also essential for normal functioning of the body’s immune system and for healthy cell growth. This explains why sleep-deprived individuals are more likely to get sick and tend to heal less rapidly as compared with well-rested individuals (Hauri & Linde, 1996).
The amount of sleep that humans need to function maximally varies both by individual and by age. Whereas newborns need about 16 hours of sleep per day, 2-year-olds need about 13 hours. Teenagers require about 9 hours of sleep per night, and adults need 7 to 8 hours on average. Interestingly, the amount of sleep an individual may require varies from about 5 hours to 11 hours. Therefore, 7 or 8 hours per night reflects an average. Adults over age 65 years need as much sleep as do younger adults, but their sleep tends to be less deep and they tend to wake more during the night. Researchers are not sure why this is the case, but they believe that it may be a natural outcome of aging or that it may be related to decreased activity, medications, and/or having a variable schedule. Approximately half of adults over age 65 years have a chronic sleep disorder.
There are five stages of sleep that occur in cycles during the night. These are referred to as Stages 1 to 4 and REM (rapid eye movement) sleep. Each stage is defined by depth of sleep, brain wave activity, eye movements, and muscle tone. Stage 1 sleep is a light sleep and is characterized by short fast brain waves (called theta waves) and slow eye movements. This type of sleep occurs at the beginning of the night or during the day with boredom or fatigue. People are easily aroused from a Stage 1 sleep and on wakening can perform cognitive and physical tasks without grogginess. Variable brain wave lengths (called sleep spindles and K complexes) characterize Stage 2 sleep. Eye movements stop and brain activity slows down. Stage 3 sleep is a deeper stage of sleep and is characterized by slower delta waves interspersed with small quick waves. Stage 4 sleep is a very deep sleep and is identified by delta wave activity that is not interspersed with shorter waves. Although it is easy to arouse someone from Stage 1 or 2 sleep, it is much more difficult to wake from Stage 3 or 4 sleep. It is during this deep delta sleep (Stage 4) that bed-wetting and sleepwalking occur.
REM sleep is distinct from the other stages of sleep. Humans are very active physiologically during REM. For example, during REM, the muscles of the body stiffen, eyes move rapidly, and heart rate, blood pressure, oxygen use, and respiration become more rapid and variable. In addition, during REM, reflexes, kidney function, and hormonal patterns change. The body’s temperature regulation is affected such that people will not sweat or shiver. During REM sleep, both genders experience engorgement of the genital region— causing erections in males and clitoral engorgement in females. It is during REM sleep that humans dream.
A typical sleep cycle lasts about 90 minutes, and healthy sleepers complete four to six cycles per night on average. After a few minutes in Stage 1 sleep, Stages 2, 3, and 4 occur. Stage 2 sleep repeats, followed by REM sleep, before the next 90-minute cycle begins. During the early part of the night, a greater amount of time is spent in deep Stages 3 and 4 sleep. Closer to morning, REM sleep is lengthier. During the night, normal adults spend about 5% of the night in Stage 1 sleep, 50% in Stage 2 sleep, 5% in Stage 3 sleep, 10% to 15% in Stage 4 sleep, and 20% to 25% in REM sleep. Most people can function well if they are able to complete four to six sleep cycles during a night (thereby sleeping about 6 to 9 hours).
Insomnia is the most common sleep problem. It is characterized by an inability to fall asleep quickly (generally within 30 minutes), waking during the night with difficulty in returning to sleep, waking too early in the morning, and/or having nonrestorative sleep. In addition, sleep disruption must occur at least 3 nights per week.
Insomnia is typically categorized in terms of chronicity. Transient insomnia typically lasts a few nights to a few weeks. Most people will experience transient insomnia sometime during a year. Transient insomnia can be triggered by a variety of factors, including stress, life changes, illness, a poor sleep environment, shift work, medication changes, jet lag, and poor sleep habits. Transient insomnia can become chronic due to classical conditioning. For example, one patient described insomnia that started after a divorce. He described waking during the night because of stress and sadness; after smoking a cigarette, he was able to fall back asleep. This patient reported that the divorce was finalized 3 years ago. He felt like he had moved on emotionally, but he still awakened during the night and could not fall asleep until he smoked a cigarette. Unfortunately, the attempts made to try to improve sleep often worsen the problem. Chronic insomnia can last from a month to many decades, causing both functional (e.g., decreased concentration, depression) and medical (e.g., headaches, hypertension) complications.
Restless Leg Syndrome and Periodic Limb Movement Disorder
Restless leg syndrome (RLS) is defined as an urge to move or shake the lower extremities because of an uncomfortable sensation. Most often, this affects the legs, but it also is experienced in the arms or in muscles in other parts of the body. The feeling typically is more exaggerated in the evening and often can prevent a person from relaxing enough to fall asleep. Moving the legs relieves the discomfort or aching. Diabetes, anemia, chronic renal failure, and certain medications can cause RLS, but often the root cause is not apparent. RLS may worsen with age.
Periodic leg movement disorder (PLMD) is an insomnia disorder that is accompanied by repetitive episodes of muscle contractions (0.5 to 5.0 seconds in duration) separated by intervals of 20 to 30 seconds. Awakenings may be associated with these movements. Most patients with RLS have PLMD.
The prevalence of RLS and PLMD in the general population is between 9% and 15% (Hening et al., 1999). The number of cases increases as people age and the symptoms can become more intrusive with time. Approximately 43% of people with RLS describe the onset of the disorder before age 20 years (Hening et al., 1999). Prevalence rates for PLMD in people age 60 years or over range from 20% to 58% (Dickel & Mosko, 1990).
The definition of a sleep apnea episode is the cessation of airflow through the nose or mouth that lasts 10 seconds or longer. Sleep apnea can be caused by a variety of conditions and can be exacerbated by alcohol use or allergies. There are three types of sleep apnea: central, obstructive, and mixed. Central sleep apnea is the cessation of breathing due to lack of respiratory effort. Obstructive sleep apnea is characterized by sufficient respiratory effort from the lungs but blockage (obstruction) of the airway. The mixed category refers to apnea in which the obstructive phase follows a central phase, thereby combining both central and obstructive sleep apnea. People of any age can have sleep apnea, although it is more common in older adults and in those who are obese.
Patients should be evaluated for sleep apnea if they are experiencing excessive daytime sleepiness. This manifests in falling asleep at inopportune times, for example, while driving or during meetings. Sleep apnea sufferers also tend to snore loudly. The consequences of sleep apnea can be severe because patients not only will lack sufficient oxygen in the blood but also will have excess carbon dioxide. They frequently have comorbidities, including cardiac arrhythmia, headache, malaise, fatigue, weight gain, and night sweats. In addition, sleep apnea sufferers are frequently awakened through the night as they try to clear their airways; they rarely complete 90-minute sleep cycles. To clear their airway, sufferers may gasp or describe a feeling of drowning. They tend to be the most fatigued patients referred to sleep clinics for evaluation.
Narcolepsy is a disorder distinguished by the rapid onset of a sleep cycle, typically triggered by periods of excitement. People often have their first episode of narcolepsy between ages 10 and 30 years (Hauri & Linde, 1996). Reports indicate that there are 100,000 to 600,000 narcoleptics in the United States (Hauri & Linde, 1996).
Narcolepsy is characterized by cataplexy (i.e., lack of muscle tone), hypnagogic hallucinations (i.e., dreamlike hallucinations), and sleep paralysis. During a narcoleptic episode, the patient immediately will go into REM sleep. Patients with narcolepsy often report vivid dreams or hallucinations. Obviously, this disorder is an extremely dangerous condition given that people can fall asleep without warning while driving or operating heavy machinery.
The cause of narcolepsy appears to be genetic, and treatment is usually medication. Both stimulants and antidepressants have been prescribed, and some patients find relief by taking naps during the day. More recently, modafinil has improved wakefulness in patients with this problem. Although untreated narcoleptic patients fall asleep rapidly and without warning during the day, they often report difficulty in falling asleep at night.
Dreams, Nightmares, Sleep Terrors, and Sleepwalking
People dream during REM sleep; therefore, dreams typically occur at the end of the night when REM sleep is longer. People dream for about 2 hours every night and recall dreams if awakened quickly from REM sleep. Dreams can also be remembered through specific training strategies designed to enhance recall.
Throughout history, people have looked to their dreams for meaning and prophecy. There are varying theories as to the importance of dreams; some psychologists (e.g., Carl Jung) have spent much of their careers investigating the role of dreams as a window to the unconscious. Other professionals believe that dreams are simply people’s interpretations of the physiological arousal that occurs with REM sleep (Walsleben & Baron-Faust, 2000). Regardless, many laypeople believe that dreams are meaningful and are disturbed when they have anxiety-producing dreams or nightmares.
Sleep terrors typically occur in children. Unlike nightmares, sleep terrors occur earlier in the evening during the deep delta sleep (Stages 3 and 4). Nightmares tend to occur toward the end of the night when REM sleep is longer. Because children have more delta sleep than do adults, children are more prone to night terrors.
Assessment and Treatment
Because the etiologies of sleep disorders are multifaceted, a thorough evaluation is imperative to ensure appropriate treatment planning. An initial interview should include questions regarding sleep onset, number of awakenings, total hours of sleep achieved, sleep habits, snoring, and level of fatigue during the day. Diet, caffeine, alcohol, tobacco, medications, herbs, medical conditions, and exercise should also be evaluated. It is important to note that patients will frequently underestimate the amount of sleep they achieve. Therefore, it can be useful to interview a spouse to corroborate the information given. Another method of evaluating sleep patterns is to have the patient complete a sleep journal. Unfortunately, patients often have difficulty in complying with this recommendation, or they report inaccurate information.
When self-report techniques are insufficient for diagnosis and treatment planning for a sleep disorder, a patient may benefit from a polysomnogram test. A polysomnogram involves using electroencephalography (EEG) to monitor brain and muscle activity, heart rate, and respiration. By interpreting brain waves and muscle activity, a specialist can identify the type of sleep disorder.
If a patient complains of loud snoring and reports periods of no breathing followed by gasps for air, an evaluation for possible sleep apnea should be arranged. A test for blood oxygen levels, called oximetry, is often used to evaluate for sleep apnea.
Treatment of Insomnia
Treatment of insomnia integrates sleep hygiene (i.e., good sleep habits), stimulus control, relaxation training, and sleep restriction components. These behavioral strategies are effective for 70% to 80% of patients with primary insomnia (Morin et al., 1999). In a review of the literature on the use of nonpharmacological treatments for insomnia, Morin and colleagues (1999) found that patients treated with behavioral interventions were “better off” (i.e., they fell asleep faster after treatment) than approximately 80% of untreated controls. In addition, patients taught cognitive-behavioral skills slept longer, awakened less frequently and for shorter time periods, and reported higher sleep quality after treatment than did 50% to 70% of untreated controls (Morin et al., 1999).
Improvements in sleep were maintained on follow-up. After 3 and 6 months, patients given cognitive-behavioral intervention maintained gains realized in sleep onset and number of awakenings (Morin et al., 1999). In fact, some studies show that patients actually sleep longer at night 6 months following treatment than during the initial posttreatment assessment (Morin et al., 1999). This may be because patients need a few months to fully integrate behavioral strategies into their lives. Additional long-term benefits of cognitive-behavioral training for insomnia include a reduction in medication use and increased independence from medical intervention (Morin et al., 1999).
Reflecting the breadth of literature supporting the use of behavioral treatments for insomnia and the side effect profiles of most hypnotics, current best practice guidelines from the American Medical Association and the Canadian Medical Association indicate that behavioral treatment should be the frontline treatment for insomnia. However, because of inadequate provider training and an overreliance on the “quick fix” (i.e., medication), physicians rarely use structured behavioral treatments to treat insomnia. Instead, most people who suffer from insomnia use over-the-counter medications or prescription sleep aids.
Core Components of Cognitive-Behavioral Treatment for Insomnia
Stimulus Control Therapy. Stimulus control therapy teaches patients to use environmental cues to augment, rather than inhibit, sleep. The premise of the therapy is that individuals will be reconditioned to sleep efficiently when sleep-incompatible activities are reduced and sleep-associated activities are increased. Patients receive the following basic rules pertaining to the bedroom environment. First, they are to use their beds for sex and sleep only; they are not to read, watch television, or do business or other work in bed; and they are not to stay in bed if awake for longer than 20 minutes at a time. Second, they are to go to bed only when sleepy. Third, they are to maintain a regular wake-up time. Fourth, they are to avoid napping during the day.
Sleep Restriction. The goal of sleep restriction is to train patients to sleep more efficiently by limiting the amount of time spent in bed. This strategy capitalizes on fatigue so as to train their bodies to fall asleep quickly and to sleep through the night. Patients are first instructed to compute their sleep efficiency by dividing their time spent sleeping by their time spent in bed. They estimate the average amount of time they spend sleeping at night. Next, they choose a wake-up time that they will adhere to every day of the week. Additional recommendations are to avoid napping and to get out of bed if still awake after 20 minutes (e.g., from stimulus control training). After the assessment and setup phase, patients select one of the following techniques.
Significantly delay going to bed. This strategy is the most difficult because it requires the patient to go to bed much later than usual while keeping his or her wake-up time constant. First, the patient determines a wake-up time that can be adhered to strictly. The initial bedtime is established using the average number of hours of sleep a patient achieves. For example, if a woman typically spends 9 hours in bed but only sleeps 6 hours because of waking, the recommendation is to spend only 6 hours in bed. If her wake-up time is 6:00 a.m., she would go to bed at midnight the first night. She would follow the stimulus control strategy and get up if she is not asleep within 20 minutes. She would also get out of bed if she wakes for longer than 20 minutes during the night. The patient then would continue to go to bed at midnight until she achieves 90% sleep efficiency. When this marker is reached, she would go to bed 15 minutes earlier, stopping at the hour at which she can maintain a sleep efficiency of 85% or better and wake feeling rested and refreshed. The first night of this program is the most difficult because patients who are already fatigued have a difficult time staying up later than usual. Napping during the day or falling asleep briefly before bedtime will usually sabotage this strategy.
Delay bedtime by 15 minutes. This strategy advises the patient to go to bed 15 minutes later than usual every night until he or she is able to fall asleep quickly and sleep through the night. Therefore, the previously mentioned patient would still have a consistent wake-up time of 6:00 a.m. and would still follow the 20-minute rule, but instead of going to bed at 9:00 p.m., she would go to bed at 9:15 p.m. If she cannot achieve 85% sleep efficiency after a few nights, she would go to bed at 9:30 p.m. Eventually, this patient may find that if she goes to bed at 10:45 p.m., she is able to fall asleep quickly and sleep through the night.
Use an intermediate delay in going to bed. The third strategy is an intermediate one between the first two strategies. The patient first sets a consistent wake-up time, avoids napping, and follows the 20-minute rule. The patient is then instructed to go to bed as late as possible. This intermediate strategy works well for many patients because they cannot stay up late enough to use the first strategy. Also, this third strategy tends to work more quickly than the second strategy. The previously mentioned patient would continue to stay up late until she achieves above 85% sleep efficiency. Then, she would go to bed 15 minutes earlier until she found the time when she could maintain good sleep efficiency and feel rested during the day.
These sleep restriction techniques capitalize on patients’ fatigue to help them learn, adopt, and maintain good sleep habits. Many insomniacs actually cause their own insomnia by going to bed too early and by failing to maintain a consistent sleep schedule. Typically, patients will have one or two bad nights of sleep because of a transient event and will adjust their bedtime to be earlier because they feel fatigued. This is problematic because the body is not accustomed to spending additional time in bed, and in an attempt to accommodate the change in bedtime, sleep cycles are altered and sleep becomes less efficient.
When informed of this pattern, patients often identify that their sleep difficulties began when they initiated a change in their bedtime by going to bed earlier due to a partner’s schedule, an illness, or a stressful period. With appropriate information, patients learn after a few nights of poor sleep to go to bed a little later. They understand that attempts to address a few nights of poor sleep by going to bed earlier is not effective, even though going to bed earlier makes intuitive sense if a person is fatigued.
Sleep Hygiene (i.e., good sleep habits). Sleep hygiene refers to health practices (e.g., diet, exercise, substance use) and environmental factors (e.g., noise, light, a comfortable bed, ambient temperature) that may be inhibiting sleep. In terms of health practices, patients are instructed to reduce caffeine use to less than five cups of coffee or tea a day and to avoid using any caffeine after 2:00 p.m. Caffeine has a half-life of 4 hours; therefore, half of the caffeine consumed at 4:00 p.m. will still be in the body at 8:00 p.m., and a quarter of the initial cup of coffee or tea consumed at 4:00 p.m. will be in the body at midnight.
Patients should also limit nicotine intake and never smoke if they wake during the night. This suggestion will help to eliminate waking to smoke. Frequently, smokers classically condition themselves to wake at the end of each 90-minute sleep cycle for a cigarette. Finally, patients are told to refrain from using alcohol as a sleep-inducing aid. Although alcohol can make people feel sleepy, it inhibits good sleep cycles and can cause nighttime waking.
In terms of sleep hygiene, patients are also educated about the benefits of daily exercise for sleep but are cautioned to avoid vigorous exercise too close to bedtime. Exercising intensely before going to bed can cause problems with falling asleep because people may find themselves too energized (due to the release of the endorphins) or too hot to sleep. The body naturally cools as it prepares to sleep. Therefore, if people are too hot due to exercise or hot summer temperatures, they often have a hard time sleeping.
In addition, individuals need to make sure that their rooms are dark and quiet and that their beds are comfortable. Because light helps to reset the biological clock, it is essential to avoid bright lights in the evening and to expose the body to bright light in the morning. Shift workers can have a difficult time falling asleep after the “graveyard shift,” particularly if they drive home in the morning light without sunglasses.
Patients sometimes state that their partners snore or that there is intermittent noise coming from the street that keeps them awake at night. Unfortunately, intermittent noise is the worst type of noise for sleep. The body can acclimate to consistent noise (e.g., the sound of crickets or of a nearby freeway) or to total quiet, but intermittent noise can cause waking. Suggestions for managing this include using white noise (e.g., turning on a fan or a fish tank) and using earplugs. It is not uncommon for couples to sleep apart if one snores loudly or has PLMD.
Most often, sleep hygiene rules are integrated into a treatment program. A few studies have evaluated the effectiveness of using sleep hygiene education alone and have found a modest effect (Morin et al., 1999). One study found that approximately 27% of patients improved when given sleep hygiene education (Schoicket, Bertelson, & Lacks, 1988), but other studies have found a more modest response to this intervention (Morin et al., 1999). In general, sleep hygiene is considered a necessary part of an intervention but insufficient as a stand-alone treatment.
Relaxation-Based Interventions. Relaxation techniques have also proved to be useful in insomnia treatment. Studies have shown that progressive muscle relaxation, biofeedback, imagery training, and thought stopping all can reduce autonomic arousal and facilitate sleep (Morin et al., 1999). Biofeedback and progressive muscle relaxation help individuals to relax the muscles of the body and activate the parasympathetic nervous system or relaxation response. Imagery training and thought stopping help to retrain the mind to focus on calming thoughts, thereby reducing the sympathetic nervous system response and hopefully activating the parasympathetic nervous system. Although other relaxation-based interventions have been advocated for insomnia (e.g., diaphragmatic breathing, meditation, hypnosis), these have not been adequately evaluated (Morin et al., 1999).
Relaxation-based interventions are important in facilitating sleep. Many insomniacs become so anxious about falling asleep that they activate the sympathetic nervous system, thereby releasing endorphins, tensing the muscles, and increasing heartbeat and respiration rate. As one might expect, this response is incompatible with falling asleep. Through classical conditioning (i.e., anxiety regarding falling asleep that is then paired with one’s bed), a transient sleep problem can become chronic. Insomniacs who have developed a strong association between anxiety and their beds often say that they can fall asleep easily in a hotel room or in the guest room but can never fall asleep quickly in their own beds. The primary goal of the relaxation therapies is to reassociate the bed with a restful state and help reduce the anxiety or autonomic arousal associated with sleep.
Paradoxical Intention. Paradoxical intention is a cognitive technique in which the patient is requested to stay awake. If the patient is instructed to stay awake, falling asleep is no longer the anxiety-producing goal. Thus, by prescribing the patient’s worst fear—staying awake—the patient paradoxically responds by falling asleep more quickly. In essence, this intervention helps to reduce the performance anxiety associated with sleeping.
Developing a Cognitive-Behavioral Sleep Improvement Program
Most of the treatment programs in use today include multiple sessions and integrate stimulus control, sleep hygiene, relaxation training, and sleep restriction components. These programs are often six to eight sessions in length and may require additional sessions for screening and paperwork. Evaluations of these programs are often dependent on patient self-report through sleep diaries, although a few studies use polysomnogram tests to measure outcome.
At Kaiser Permanente in Sacramento, California, a single-session treatment program was developed and evaluated using individual (n = 20) and group (n = 72) formats (Wolfe & Helge, 2002). Primary care physicians referred patients to a health psychologist, who administered an insomnia treatment protocol. Individual sessions were 25 minutes, and the group sessions were 90 minutes. Before treatment, each patient completed a brief questionnaire that included queries about sleep onset, awakenings, daytime fatigue, and sleep habits. In addition, there were questions regarding substance use, diet, and exercise. Approximately 75% of referred patients attended the program (Wolfe & Helge, 2002).
The first section of the intervention was informational, including information about sleep cycles, sleep architecture, individual variations in sleep, and sleep changes over the life cycle. The second section of the intervention included information regarding stimulus control, sleep restriction, and thought stopping. The final section included a review of sleep hygiene, exercise, sleeping pills, herbs, and melatonin. The information regarding sleep cycles and sleep architecture was designed to provide the supporting rationale for implementation of sleep restriction, stimulus control, and sleep hygiene. Patients created a personalized sleep plan during the group and individual appointments (Wolfe & Helge, 2002).
One month after treatment, patients’ progress was assessed by telephone follow-up. Results indicated that 90% of the patients who had individual appointments and 74% of the patients who attended group appointments improved the amount of time spent sleeping at night (Wolfe & Helge, 2002). Individuals gained an average of 1.78 hours of sleep per night, and group members gained an average of 1.90 hours of sleep per night (Wolfe & Helge, 2002). A second cohort of patients (n = 35) who participated in the same treatment protocol, but with a different health psychologist, had results slightly better than participants in the initial cohort (Wolfe, Helge, & Jacobs, 2002). One month after treatment, 87% of these patients reported improved sleep by an average of 2.38 hours per night (Wolfe et al., 2002). All participants were to be reassessed 1 year following treatment to determine whether treatment gains were maintained.
Anecdotal comments from participants were interesting. A common theme was skepticism about the techniques. For example, a typical remark was “I thought what you suggested was silly, but I decided to try it anyway.” Another typical patient comment was “I did not think it would work, but I was amazed at the results.” Finally, some patients noted benefits from the information about insomnia: “I thought I had depression, but now I realize I was just sleep deprived.”
This intervention was developed with the purpose of efficiently and effectively treating primary care patients with insomnia. The groups were not limited to specific populations; any patients complaining of sleep problems were considered appropriate. However, if a physician believed that a patient would not do well in a group setting, or if a patient could not attend because of scheduling conflicts, the patient was seen individually. The findings of this uncontrolled clinical trial indicate that a single-session brief intervention that integrates evidence-based interventions can be extremely effective for primary care patients experiencing insomnia. However, because this study is limited from a methodological perspective, further research regarding the utility of brief, behaviorally based interventions in primary care is essential.
Medications Used to Treat Insomnia
In today’s “quick fix” society, patients and providers alike have a penchant for medications as the frontline treatment for insomnia. Even before office visits, patients have often tried over-the-counter medications such as diphenhydramine and Tylenol PM (a combination of diphenhydramine and Tylenol) for sleep. If these medications were as effective as advertised, it is unlikely that patients would continue to seek assistance from their primary care providers.
Benzodiazepines are commonly prescribed for sleep. These agents replaced barbiturates and barbiturate-like substances that were associated with addiction, respiratory problems, and occasional deaths. A benefit of benzodiazepines and other hypnotics used for insomnia is that they work quickly. However, hypnotics can cause daytime sedation, tolerance, and rebound insomnia.
Current guidelines from the National Institutes of Health (1984, 1991) suggest that short-term use of hypnotic medications may be indicated for acute insomnia, but these medications should be used with caution. If prescribed for sleep, hypnotics should not be taken for more than 2 weeks. At the time of prescribing, a tapering strategy should be in place to minimize risk for potential problems. One strategy to avoid tolerance is to have the patient use the medication only 3 or 4 nights a week and to use the lowest effective dose. A patient who has an abuse history or who has to perform tasks that require alertness and quick reaction times (e.g., driving) on awakening should be cautioned when prescribed sleep aids. Finally, hypnotics prescribed to elder adults require extra care.
Trazadone is an antidepressant frequently prescribed for people who have insomnia and a depressive disorder. However, the Food and Drug Administration has not approved the use of trazadone for people with insomnia. Trazadone should be used with caution because it can cause daytime sedation, priapism, and hypotension.
Melatonin is a hormone often used for insomnia. It is released by the pineal gland into the bloodstream and is produced from tryptophan. Tryptophan is converted to 5-hydroxytrypto-phan, then to serotonin, then to N-acetylsero-tonin, and finally to melatonin. Melatonin regulates the body’s sleep cycle, circadian rhythm, and endocrine production and is essential for sexual maturation, growth control, pain control, balance, and regulation of sexual activity (Natural Medicines Comprehensive Database, 2002). People produce more melatonin when it is dark, thereby stimulating the onset of sleep. It may be an effective agent to help some adults with sleep onset. Moreover, melatonin may be useful for symptoms of jet lag, for shift workers, and for insomniacs with blindness. However, data demonstrating the efficacy of melatonin are inconclusive.
Although most consider melatonin relatively safe, it is not for use in children because it may affect their maturation. There also is concern that taking melatonin may increase daytime somnolence. In addition, melatonin may interfere with the effectiveness of cardiac medication and medications used to reduce immune system response (e.g., steroids, other cortisone drugs). There is some indication that melatonin can help depression, particularly when the depression comes with insomnia, but other studies indicate that melatonin can make depressive symptoms worse (Natural Medicines Comprehensive Database, 2002). Interestingly, it has been documented that patients with depression and patients diagnosed with fibromyalgia can have low levels of melatonin (Natural Medicines Comprehensive Database, 2002).
Treatment of RLS and PLMD
Behavioral strategies for treating RLS and PLMD include moderate amounts of exercise in the evening, hot baths, and distraction. Walking before bedtime has been helpful for some patients. However, intense exercise appears to exacerbate the symptoms for many sufferers. Hot baths are effective for some patients, and distraction exercises (i.e., tasks that require intense concentration) have support for symptom reduction. In addition, some patients find relief from massage or vibrating stimulation before sleep, and there is some evidence that reducing caffeine and improving sleep habits are useful. Most of the published literature has focused on medication treatment for RLS and PLMD, but there is some evidence to support integrating behavioral strategies with pharmacological regimens.
Unfortunately, many of the medications used in treating RLS and PLMD have limited effectiveness and can cause tolerance and rebound symptoms. There are five classes of medications typically prescribed: dopaminergic medications, opioids, benzodiazepines, adrenergic medications, and anticonvulsant medications. A review of the costs and benefits of these agents is beyond the scope of this chapter, but Hening and colleagues (1999) provided an excellent review of the treatments for RLS and PLMD.
Folic acid and iron supplements have proved to be effective for patients with RLS and PLMD who are deficient in these minerals. Some reports suggest that the selective serotonin reuptake inhibitor (SSRI) or tricyclic medications reduce symptoms of RLS, whereas other reports indicate that these medications can aggravate the disorder (Hening et al., 1999).
Treatment of Sleep Apnea
Treatment of sleep apnea is dependent on the etiology. For example, in children, a common cause of sleep apnea is enlarged tonsils. With tonsil removal, the apnea can be relieved. Other surgical techniques, lauded as permanent cures for obstructive sleep apnea, have not been as effective as originally expected. With patients who are obese, the best treatment is weight reduction because this serves to open adequate space for airflow. One of the most successful treatments for other patients with obstructive sleep apnea is the continuous positive airway pressure machine (CPAP).
The CPAP provides continuous positive airway pressure through the nostrils to force the airway clear, enabling the patient to breathe. This treatment is effective for many people, but a major complaint is discomfort in wearing the apparatus. In fact, many of the patients given a CPAP do not adhere to recommendations to use it. It is critical that the facemask fits properly and that the patient acclimates to the machine. This is often done by training the patient in relaxation techniques and having him or her use the machine while awake but during sedentary activities such as watching television. Having a machine force air through one’s nose can be extremely uncomfortable, especially while trying to initiate sleep onset. Therefore, adequate training and problem solving are essential given that the consequences of living with untreated sleep apnea are unfortunate and avoidable.
Light therapy has been investigated as a treatment for patients with a variety of problems, including seasonal affective disorder, shift work sleep, delayed sleep phase syndrome, and advanced sleep phase syndrome. Light therapy also has been evaluated as a potential solution for sleep complaints in the elderly (Chesson et al., 1999).
In general, light therapy is effective in treating delayed sleep phase syndrome and advanced sleep phase syndrome (Chesson et al., 1999). With delayed sleep phase syndrome, the individual has difficulty in initiating sleep at the appropriate time and awakens too late. With advanced sleep phase syndrome, the patient falls asleep too early at night and awakens too early in the morning. With both sleep phase disorders, the release of hormones and the level of body temperature indicate that the person’s sleep phase is not oriented correctly. Having individuals expose themselves to bright light in the morning and wear darkened glasses at night appears to be effective in resetting the circadian rhythm and resuming a regular sleep schedule (Chesson et al., 1999). In addition, light therapy appears to be useful with seasonal affective disorder (Chesson et al., 1999). Light therapy is described as a safe intervention when used according to American Academy of Sleep Medicine guidelines. It may be useful for shift work problems, jet lag, and non-24-hour sleep/wake syndrome in some blind patients (Chesson et al., 1999).
Napping and Sleep Deprivation
Approximately a quarter of all Americans are sleep deprived (National Sleep Foundation, 2002). This translates into billions of dollars in lost productivity and accidents. In response to this pervasive sleep debt, many businesses have created special environments for napping, and there have been articles in the popular press describing the benefit of quick “power naps.”
Sleep “debt” can be “repaid” with a brief nap during waking hours; however, there is an optimal strategy for napping. Ideally, a nap should last between 15 and 40 minutes or be 2 hours in length. A brief nap can be very restorative. The most favorable time to take a nap is early afternoon. This is when people’s natural biological clock indicates that it may be time for a sleep cycle. Some patients successfully time their naps halfway between the time they awaken in the morning and the time they go to bed, finding a 15- or 20-minute nap to be adequate to renew their concentration and energy. However, insomniacs should be wary of napping. Napping late in the afternoon can negatively influence nighttime sleep. If an insomniac has rested during the day, he or she might not be fatigued enough to fall asleep quickly at night.
Treatment of Nightmares and Night Terrors
Nightmares tend to be more common when patients are under stress. There are two main treatments to help patients cope with undesirable dreams. The first involves reassurance that intense dreams are common and that dreaming about something is not an indication that one would act in a similar manner in real life. Often, patients present with sexual or violent dreams and express concern that these dreams are indicative of underlying desires. Through reassurance and normalization, their distress can be reduced. Recommendations to avoid the daily news, violent movies, and other negative images before bedtime also are helpful. In addition, patients can learn to dream about pleasant scenes by rehearsing these images before bed.
For recurrent nightmares (e.g., being chased or pummeled by a foe), patients are instructed to return to the dream and change the ending. This is particularly helpful with children who are taught to imagine themselves as their favorite superhero and then turning on the foe and winning the battle. For this strategy to be effective, the patient should create the image that makes the most sense to him or her to be victorious. Nightmares can also be reduced through psychotherapy that addresses underlying anxiety.
“John Doe,” a 39-year-old male, presented to his primary care physician with symptoms of anxiety, irritability, decreased concentration, headaches, and insomnia. He stated that his problems began about 5 years ago when he relocated, married, and changed his job. He reported feeling happy with his current situation and satisfied with his marital relationship and his job, but he revealed that he felt “run down.”
When queried about sleep habits, John denied having difficulty in falling asleep but stated that he awakened frequently during the night. He said that he went to bed at 9:30 p.m. because he was “too tired to stay up any later,” but then he awakened at 3:30 a.m. and drifted in and out of sleep until it was time to get ready for work at 6:30. He was concerned that he may be depressed because he felt “worn out and sad” even though his life was good.
John noted that his sleep habits changed following his marriage. When single, he would go to bed at midnight and get up at 6:30 a.m. He reported that with this schedule, he felt rested and refreshed. However, when he married, he began to go to bed at 10:00 p.m. because this was his wife’s bedtime. During the past year, he altered his bedtime to 9:30 p.m. in an effort to combat his ever-present fatigue. He was concerned that his lack of energy was beginning to affect his work and relationships.
A physical examination determined that John was in good health. Laboratory results were within normal limits. The patient was instructed to use sleep restriction to retrain his body to sleep well. Specifically, he was to go to bed later in the evening until he could fall asleep quickly and sleep through the night. He was reminded that he felt rested after 6.5 hours of sleep and that his previous sleep schedule of going to bed at midnight and waking at 6:30 a.m. was effective for him.
After 1 week, John reported feeling much better. He stated that going to bed later was very difficult at first because he was so tired, but after 3 nights his sleep had improved and he began to feel better. In addition, he started walking daily at lunch and found that his energy level and mood had improved. During a follow-up visit, his progress was reviewed and recidivism was discussed. John was quite pleased with his improvements because he felt more like himself again. In addition, he reported that his mood and concentration were better and that his headaches had decreased. One year later, he denied any ongoing problems with sleep. He noted that during periods of transient insomnia, he continued to use sleep restriction strategies that provide him with rapid improvement.
Night terrors can be particularly alarming to parents. They often involve brief periods of screaming; children may open their eyes, begin perspiring, and appear to be experiencing a state of panic. After a few minutes, a calm state of sleep returns. Usually, an individual experiencing a night terror will not awaken and will not remember the incident in the morning. Night terrors are more frequent during periods of stress. They cause no harm to the individual, so an optimal coping strategy is reassurance for the parents. Parents are instructed to either gently comfort the child or ignore the disruption altogether.
Three additional strategies can be helpful in reducing night terrors. First, psychotherapy for stress reduction is useful. Second, advising the patient to sleep for a longer period, thereby reducing the amount of deep delta sleep, can help. Third, physicians may prescribe a benzodiazepine, such as diazepam, for a few days to reduce the delta sleep associated with night terrors. This last strategy may be helpful if a child is sleeping away from home and is concerned about arousing others. However, benzodiazepines should always be used with caution.
Sleepwalking is also associated with delta sleep and is more common with children than with adults. It is also more frequent when people are under stress or sleep deprived, and it can be a result of certain medications. Sleepwalking can be quite dangerous. Treatments include reducing stress, getting adequate sleep, ensuring a safe sleeping environment, and taking medication.
Each year, sleep disorders affect millions of people and cost billions of dollars in lost productivity, health care, and accidents. For the majority of sleep problems, including insomnia and nightmares, cognitive-behavioral intervention is the treatment of choice. For other sleep disorders, such as sleep apnea, RLS, and PLMD, behavioral interventions play a significant role. However, it is far from routine practice for patients with sleep problems to receive these interventions or learn about them during visits to primary care clinics.
Enhanced training during medical school has been recommended as one strategy to improve assessment and intervention for patients with sleep problems (Dement & Vaughan, 1999). Unfortunately, physician training continues to be limited in this regard, and this deficiency is reflected in clinical practice; medications continue as the first line of intervention for sleep problems that would be better treated with behavioral interventions. This observation is not too surprising. Physicians generally report difficulties in identifying behavioral problems in their patients and frustration with implementing behavioral change strategies (Alto, 1995).
A realistic practice solution is access to behavioral experts who can provide effective cognitive-behavioral interventions in primary care. This strategy is practical because many patients with a sleep disorder will also present with medical and psychiatric complaints. A behavioral-medical approach, the integration of medical and behavioral sciences, appears to be an excellent solution for the sizable population of those suffering with sleep disorders.