Treatment:

The American Academy of Sleep Medicine (AASM) recommends a number of behavioral methods and prescription medications as the main treatments for insomnia. According to the AASM, these treatment options can improve both quality and quantity of sleep for people with insomnia.

Experts agree that behavioral therapies should be the first-line treatment for insomnia. For children in particular, medications should rarely be used as initial treatment. A 2006 study reported that behavioral interventions can provide sustained improvement in over 80% of children with insomnia.

Sleep Hygiene Tips

Proper sleep hygiene should accompany any behavioral method. The term sleep hygiene is used to describe simple behaviors that may help everyone improve their sleep. These include:

• Establish a regular time for going to bed and getting up in the morning. Stick to this schedule even on weekends and during vacations.
• Use the bed for sleep and sexual relations only, not for reading, watching television, or working. Excessive time in bed disrupts sleep.
• Avoid naps, especially in the evening.
• Exercise before dinner. A low point in energy occurs a few hours after exercise; sleep will then come more easily. Exercising close to bedtime, however, may increase alertness.
• Take a hot bath about 1.5 - 2 hours before bedtime. This alters the body's core temperature rhythm and helps people fall asleep more easily and more continuously. (Taking a bath shortly before bed increases alertness.)
• Do something relaxing in the 30 minutes before bedtime. Reading, meditation, and a leisurely walk are all appropriate activities.
• Keep the bedroom relatively cool and well ventilated.
• Do not look at the clock. Obsessing over time will just make it more difficult to sleep.
• Eat light meals, and schedule dinner 4 - 5 hours before bedtime. A light snack before bedtime can help sleep, but a large meal may have the opposite effect.
• Spend a half hour in the sun each day. The best time is early in the day. (Take precautions against overexposure to sunlight by wearing protective clothing and sunscreen.)
• Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate.
• Avoid caffeine in the hours before sleep.
• If one is still awake after 15 - 20 minutes, go into another room, read or do a quiet activity using dim lighting until feeling very sleepy. (Don't watch television or use bright lights.)
• If distracted by a sleeping bed partner, moving to the couch or a spare bed for a couple of nights might be helpful.
• If a specific worry is keeping one awake, thinking of the problem in terms of images rather than in words may allow a person to fall asleep more quickly and to wake up with less anxiety.

Behavioral Therapy Methods

Prevention of sleeplessness depends upon the patient's ability to learn how to relax and sleep well. A number of behavioral methods can help achieve these goals. Behavioral techniques can actually cure chronic insomnia in many cases, and studies report that they help nearly all patients with primary chronic insomnia. The benefits of psychological and behavioral therapy in managing insomnia last long.

Although medications are equally effective for helping people with insomnia to sleep, they cannot cure the condition. In addition, behavioral methods act faster. Behavioral methods work in all age groups, including children and elderly patients.

Behavioral methods include:

• Stimulus control
• Cognitive behavioral therapy
• Progressive muscle relaxation
• Paradoxical intention
• Biofeedback
• Sleep restriction
• Imagery tasks

All behavioral approaches have the same basic goals:

• To reduce the time it takes to go to sleep to below 30 minutes
• Reduce wake-up periods during the night

Studies have reported that 70 - 80% of patients who are treated with non-drug methods have improved sleep, with an average treatment duration of only 5 hours during a 4-week period. Furthermore, studies report that 75% of those who have been taking drugs are able to stop or reduce their use.

Stimulus Control. Stimulus control is now considered the standard treatment for primary chronic insomnia and may be helpful for some patients with secondary insomnia as well. The primary goal of stimulus control is to regain the idea that the bed is for sleeping. It involves the following:

• Go to bed only when ready to sleep or for sex.
• If unable to sleep within 15 - 20 minutes, get up and go into another room. (People who find it physically difficult to get out of bed should sit up and do something relatively arousing, like reading a book.)
• Maintain a regular wake-up time no matter how few hours you actually sleep.
• Avoid naps.

Cognitive-Behavioral Therapy. Cognitive behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts about sleep such as, "I'll never fall asleep." It uses actions intended to change behavior. The goal is to change or correct misconceptions about the ability to fall and stay asleep. Emphasis is on reinforcing the need for 7 - 8 hours of sleep each night and addressing the anxiety that patients with insomnia often develop around sleep. Several studies have shown it to work as well or better than medications, including some of the newer drugs available. Adding medication to CBT did not provide additional benefit in several studies.

Progressive Muscle Relaxation. Progressive muscle relaxation is another technique for inducing sleep that works well for many people. It takes about 10 minutes to perform:

• Focus on one specific muscle group at a time. Most people start with the muscles in one foot. Inhale and tense the foot muscles for about 8 seconds. (Do this gently. It is not intended to cause severe pain or muscle contractions.)
• Relax the foot, and let it become loose and limp. Stay relaxed for 15 seconds, then repeat with the other foot.
• Move up to the next muscle group and repeat the sequence, doing one side of the body at a time. Move progressively from each foot and leg up through the abdomen and chest, to each hand and arm, then to the neck, shoulders, and face.

Paradoxical Intention. Paradoxical intention is a psychological approach that is based on doing the opposite of what one wants or fears and then take it to the extreme. The goal is to remove the performance anxiety associated with insomnia in some patients The first step is to make a plan to take such a paradoxical approach to insomnia:

• Instead of going through activities leading to sleep, the patient prepares for staying awake and doing something energetic.
• In some cases, people may take specific psychological barriers to sleep to an extreme limit. For example, if worry is a factor in insomnia, the patient intensifies the worries.

Biofeedback. Biofeedback requires being monitored with an electroencephalogram (EEG), a device that measures brain waves. Patients are given feedback to recognize certain states of tension or sleep stages so that they can either avoid or repeat them voluntarily. The effectiveness of biofeedback compared to other techniques has not been well evaluated.

Sleep Restriction Therapy. Sleep restriction therapy may be effective, although the evidence is inconclusive. It is suggested as a possible therapy only when there are no psychologic or medical problems underlying the insomnia and when sleep hygiene has failed. The approach is a systematic method for achieving sleep and restricting the time spent in bed, particularly time spent in bed when not asleep.

The first step is to calculate a person's sleep efficiency number:

• Keep a sleep diary for 14 days. Calculate the average hours of actual sleep and hours in bed. Then divide the average hours slept by the hours spent in bed. The result, given as a percentage, is the sleep efficiency number. (For example, if a patient sleeps an average of 5 hours out of 7 hours spent in bed then the result is .714, and the sleep efficiency percentage is 71%.)
• The patient's goal is to achieve sleep efficiencies of 85 - 90%, which means only 10 - 15% of the time is spent staying awake in bed. (Sleep efficiency in older people normally falls to 75 - 85%.)

To achieve this goal, the patient takes the following actions:

• Begin by going to bed 15 minutes later than usual the first week.
• If 85% sleep efficiency isn't reached by the end of the week, add another 15 minutes before going to bed. Refrain from going to bed even if tired, although bedtime should not be reduced below 5 hours.
• Once efficiency reaches 90% or more, begin to go to bed 15 minutes earlier each week.

Other parts of the program include stopping any sleep medications and following good sleep hygiene. People using this treatment have reported lasting improvements after just 8 weeks, and studies suggest that it is significantly more successful than relaxation techniques.

Imagery Tasks. Chronic insomnia may be associated with unwanted thoughts and worries. In imagery therapy, patients are given specific positive mental tasks that gave them a sense of positive control (as opposed to their real life concerns, which can feel out of their control). These images are used to distract patients and allow them to fall asleep faster. In general, there is not enough evidence to clearly support the use of this technique for the treatment of insomnia.

Exercise

Exercise may be one of the best ways to promote healthy sleep. One study found that exercise is as good for inducing sleep as the use of benzodiazepines, a prescription sleep aid. Some research has found that yoga practice may have specific benefits on sleep health. Yoga uses meditation, deep breathing techniques, and movements that emphasize stretching and balance.

Acupuncture

No hi-quality studies have evaluated the use of acupuncture to treat insomnia. Therefore, there is no good evidence to claim that acupuncture is helpful for treating insomnia.