The three main contemporary behavioural treatments of insomnia are Stimulus Control Instructions, Sleep Restriction Therapy, and Sleep Hygiene Techniques. All three approaches attempt to correct the sleep-preventing associations and to provide education about sleep to the patient.

Stimulus Control Instructions

Dr. R. Bootzin pioneered the use of stimulus control instructions as a behavioural treatment for insomnia in 1972. Treatment revolves around the use of a set of six instructions with logical ties to good sleep. The first thing patients are required to do is to attempt to sleep only when they are sleepy. Frustration is often the byproduct of unsuccessful attempts of the completion of any task. Sleep is not exempt of this rule. This instruction not only avoids undue associations of attempting to sleep with frustration and concomitant arousal, but it also sensitizes patients to the internal physiological cues of sleepiness. Patients employ such experience as head nods and droopy eyes to signal bedtime.

Decreased arousal levels are associated with the bed and bedroom by restricting the activities therein to sleep only. According to the second instruction, all arousing activities such as discussions and financial arrangements must be carried out outside of the sleep environment.

The third requirement forces patients to get out of bed if they are unable to sleep. This also reduces the association of the bed with increased arousal due to the frustration of not sleeping. Patients are told to leave the bedroom and to engage themselves in relatively unstimulating tasks and not to return to bed until they feel tired once again. This is a difficult instruction to comply with since it seems counter productive and many insomniacs have developed a pervasive pattern of remaining in bed at all costs. Rule four requires patients to repeat the process of leaving the bedroom when unable to fall asleep and returning only when feeling sleepy as often as necessary throughout the night.

The fifth instruction is to get up at the same time every morning regardless of the quality of sleep during the night. Many insomniacs try to make up for a poor night of sleep by sleeping later in the morning. Sleeping in actually makes the situation worse by increasing sleep onset latency the following night. The last rule instructs patients to avoid all napping.

The last two rules help to regulate the body's sleep rhythm and deprive the patient of sleep. Sleep deprivation decreases sleep onset latency the following night and strengthens the association of sleep to the sleep environment.

Sleep Restriction Therapy

Sleep deprivation leads to decreased sleep onset latency, increased amounts of deep sleep and fewer awakenings. Dr. Spielman and colleagues base their 1987 Sleep Restriction Therapy on these findings. The first step in this therapy is to determine the maximum allowable time to spend in bed through averaging the patient's estimates of his or her total nightly sleep time over a period of one week. The total allowable sleep time is never set below four and a half hours. The wake up time is set at the time the patient generally awakens to start the day. The bedtime is determined by subtracting the total allowable sleep time from the wake up time.

The patient follows this regime of restricted sleep for a period of five days, consistently monitoring the time spent in bed and time spent awake in bed. The patient's mean estimate of sleep efficiency (mean total sleep time/mean total time in bed) for this five day period is determined. If the mean sleep efficiency is greater or equal to 90% then an additional 15 minutes is added to the total allowable sleep time by adjusting the bedtime. The total allowable sleep time is decreased by 15 minutes if the mean sleep efficiency is less than 85%. The patient follows the newly adjusted sleep regime for a second period of five days, once again monitoring subjective sleep efficiency. Adjustments are made to the total allowable sleep time through bedtime manipulation until the patient sleeps efficiently (SE > 90%) for approximately seven hours per night. Throughout the therapy, napping, lying down and sometimes even monotonous sleep-promoting activities are avoided. Patients are allowed to stay up later on weekends. However, the regular wake up time must be maintained.

Sleep Hygiene

Dr. P. Hauri first summarized a basic set of nine better sleep promoting rules in 1977. The rules were developed from a review of the existing literature and became known as Sleep Hygiene. The principles supporting many of the rules are used in Stimulus Control Instructions and Sleep Restriction Therapy discussed above. First, in order to promote better sleep, patients are to limit the time in bed. This rule is based upon sleep restriction principles. By not staying in bed longer to make up for poor sleep this rule leads to decreased sleep onset latency. Patients are also told never to try and sleep. Actively pursuing sleep increases arousal which decreases the likelihood of sleep. Patients therefore, attempt to concentrate on doing something in bed other than trying to sleep. They are told to do this activity as long as they can stay awake. The activity must be something relatively monotonous such as reading or watching television in order to avoid further arousal.

The third rule is to eliminate time pressures by removing the bedroom clock. Late afternoon or early evening exercise is recommended in the fourth rule. The timing of exercise is crucial. People sleep better during the naturally occurring temperature decreases that are a part of human circadian rhythms. Vigorous exercise leads to an increase in core body temperature which is compensated for by a temperature drop four to six hours later. The goal is to create an artificial temperature trough that occurs at bedtime and aids sleep.

The fifth rule is to avoid all stimulants. This includes all sources of caffeine and nicotine. Alcohol is also to be avoided since after promoting sleep, it disturbs sleep. This disrupted sleep leads to feeling unrefreshed upon awakening.

The sixth rule is to regularize bedtime and wake-up time. Humans' circadian rhythms are not exactly 24 hours. Therefore, the body does not want to sleep at the same time every night. Younger people have circadian rhythms that are longer than 24 hours. This postpones the time at which this cohort begins to feel tired. This group must regularize their wake-up time just slightly before they have had enough sleep to combat the greater than 24 hour day. The consistent small amounts of sleep deprivation help to promote short sleep onset at the desired time. Elderly people have circadian rhythms that are shorter than 24 hours which makes them feel tired at increasingly earlier times. In order to avoid advancing bedtimes and waking up very early in the morning, the elderly must regularize bedtime a little later than desired. Both adjustments help to regularize sleep. A seventh rule prescribes eating a light snack. Some researchers feel that digestive hormones have a sedative effect, while others feel that tryptophan being converted into serotonin is involved in promoting sleep. In the very least a light snack helps to avoid being disturbed by hunger.

The eighth rule is to explore napping. For some people napping can help; for others it can hinder. Napping should be systematically studied for each patient through the use of sleep logs documenting the quality of sleep over one week trial periods. One group in particular, the elderly, can occasionally benefit from napping. For this group it helps to bolster the total amount of sleep as well as postpone bedtime to an appropriate hour.

The final rule sets out guidelines for the use of sedative-hypnotic medication. First, the chronic use of this medication is to be avoided as habituation occurs rapidly and withdrawal from it can cause rebound insomnia. Therefore, the use of sleep medication is recommended only after the patient has experienced three consecutive nights of poor sleep. On the fourth night, the medication is to be administered at the beginning of the night, before attempting to sleep. This helps the patient to get a good sleep right away and aids in extinguishing arousal and negative associations with the attempt to sleep. Medication is also permitted on the night of an important event, such as a wedding or examination. Once again, on these nights the medication is to be administered before attempting to sleep.

Other Behavioural Techniques

The three behavioural treatments discussed above are the most widely used therapies designed expressly for psychophysiological insomnia. Some behavioural treatments that have demonstrated success in treating non-sleep related disorders have also been used to treat insomnia. These treatments include relaxation training to reduce somatized tension, cognitive strategies to correct sleep damaging cognitions, systematic desensitization, hypnosis, classical conditioning, bright light therapy, and biofeedback.

Sonno - Spring 2003 Issue