Behavioral Interventions for Insomnia: Theory and Practice

By Sharma, Mahendra; Andrade, Chittaranjan | Indian Journal of Psychiatry, October-December 2012 | Go to article overview

Behavioral Interventions for Insomnia: Theory and Practice


Sharma, Mahendra, Andrade, Chittaranjan, Indian Journal of Psychiatry


Byline: Mahendra. Sharma, Chittaranjan. Andrade

Insomnia is a general clinical term that refers to a difficulty in initiating or maintaining sleep. Insomnia is widely prevalent in the general population, especially in the elderly and in those with medical and psychiatric disorders. Hypnotic drug treatments of insomnia are effective but are associated with potential disadvantages.This article presents an overview of behavioral interventions for insomnia. Behavioral interventions for insomnia include relaxation training, stimulus control therapy, sleep restriction therapy, sleep hygiene, paradoxical intention therapy, cognitive restructuring, and other approaches. These are briefly explained. Research indicates that behavioral interventions are efficacious, effective, and likely cost-effective treatments for insomnia that yield reliable, robust, and long-term benefits in adults of all ages. Detailed guidance is provided for the practical management of patients with insomnia.

Introduction

Insomnia is the most common sleep disorder. Insomnia is a general clinical term that refers to the difficulty in initiating or maintaining sleep. It may present as an independent problem (primary insomnia) or as part of a coexisting medical or psychiatric condition (secondary insomnia). According to ICD-10, [sup][1] nonorganic insomnia (F 51.0) is defined as a problem in initiating and/or maintaining sleep or the complaint of nonrestorative sleep that occurs on at least three nights a week for at least a month, and is associated with daytime distress or impairment. The diagnosis primary insomnia (307.42) in DSM-IV [sup][2] is used to distinguish insomnia that is considered to be a distinct diagnostic entity from insomnia that is a symptom of an underlying medical and/or psychiatric condition. The DSM lists insomnia related to other Axis I or Axis II disorders as distinct from primary insomnia.

Primary insomnia is referred to as "psychophysiologic insomnia" in the international classification of sleep disorders-revised (ICSD-R) proposed by the American Sleep Disorders Association and endorsed by the American Academy of Sleep Medicine. [sup][3] The ICSD-R definition is more directly tied to the etiological underpinnings of the disorder and it suggests how insomnia is initiated and maintained. Psychophysiologic insomnia is described as "a disorder of somatized tension and learned sleep preventing associations that results in a complaint of insomnia and associated decreased functioning during wakefulness." [sup][4] "Somatized tension" refers to either the patient's subjective sense of, or objective measures of, somatic hyperarousal while attempting to sleep. Somatic hyperarousal is characterized by peripheral nervous system activity which is commonly marked by increased muscle tension, rapid heart rate, sweating, and related symptoms. "Learned sleep-preventing associations" refer to the pattern of pre-sleep arousal that appears to be classically conditioned to the bedroom environment, where intrusive presleep cognitions, racing thoughts, and rumination are often taken as indicators of presleep arousal. [sup][4]

Magnitude of the Problem

Insomnia is widely prevalent and is reported to occur in up to one-third of the adult population. [sup][5] Persistent sleep problems have been reported by 10-15% of adults. [sup][6],[7] The prevalence of sleep problems among women and older adults is even higher. [sup][8],[9] Although more than half of primary care patients may experience insomnia, only about one-third report this problem to their physicians [sup][10] and only 5% seek treatment. [sup][6] Despite the very high economic cost of insomnia in terms of lost productivity and accidents, [sup][11] the vast majority of persons with insomnia remain untreated. [sup][7] Two-thirds of patients with insomnia report a poor understanding of treatment options, and many turn to alcohol (28%) or untested over-the-counter remedies (23%). …

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