The First Line Treatment Behavioral Changes - Insomnia: Sleep Disorders

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The first-line treatment: Behavioral changes

For chronic insomnia, the treatment of choice is to change your lifestyle and habits. A careful evaluation can pave the way to better sleep by pinpointing habits that keep you up at night. A sleep specialist trained in behavioral medicine can help people with learned insomnia replace their bad habits with positive ones.

Sleep restriction

People with insomnia often find that spending less time in bed promotes more restful sleep and helps make the bedroom a welcome sight instead of a torture chamber. As you learn to fall asleep quickly and sleep soundly, the time in bed is slowly extended until you obtain a full night's sleep.

Some sleep experts suggest starting with five or six hours at first, or whatever amount of time you typically sleep at night. Setting a rigid early morning waking time often works best. If the alarm is set for 7 a.m., a five-hour restriction means that no matter how sleepy you are, you must stay awake until 2 a.m. Once you are sleeping well during the allotted five hours, you can add another 15 or 30 minutes, then repeat the process until you're getting a healthy amount of sleep.

Awaken at the same time every day.

Reconditioning

In the 1970s, a Northwestern University professor developed a technique to recondition people with insomnia to associate the bedroom with sleep. These are the rules:

• Use the bed only for sleeping or sex.

• Go to bed only when you're sleepy. If you're unable to sleep, get up and move to another room. Stay up until you are sleepy, then return to bed. If sleep does not follow quickly, repeat.

• During the reconditioning process, get up at the same time every day and do not nap.

The idea is to train your body to associate your bed with sleep instead of sleeplessness and frustration.

Relaxation techniques

For some people with insomnia, a racing or worried mind is the enemy of sleep. In others, physical tension is to blame. Fortunately, there are ways to release physical tension and relax more effectively. Relaxation techniques that can quiet a racing mind include meditation, breathing exercises, and progressively tensing and relaxing your muscles starting with your feet and working your way up your body — a technique known as progressive muscle relaxation (see "Progressive muscle relaxation" below).

In biofeedback, people use equipment that monitors and makes them aware of involuntary body states (such as muscle tension or hand temperature). Immediate feedback helps people see how various thoughts or relaxation maneuvers affect tension, enabling them to learn how to gain voluntary control over the process.

Biofeedback is usually done under professional supervision. Other relaxation techniques — such as progressive muscle relaxation or meditation — can be learned in behavior therapy sessions or from books, tapes, or classes.

Counseling

Although sleep specialists often recommend that people work with a psychologist or social worker to change behaviors that interfere with sleep habits, many individuals are reluctant to seek such help. They may feel that their symptoms are being ignored or that the doctor is implying that the problems are "all in their head." If a physician immediately advises counseling without first ruling out a medical condition, it may be useful to get a second opinion. But if counseling is recommended as one aspect of comprehensive treatment, there's a good chance that it will help. Cognitive behavioral therapists specialize in helping people learn new ways of doing things. These counselors can provide structure and support while you learn and practice new habits, such as changing stress-inducing thoughts and delaying bedtime if you're unable to fall asleep within 20 minutes. Recent research suggests cognitive behavioral therapy is as effective and provides longer-lasting benefits than sleeping pills. A 2004 study of patients with insomnia who had five 30-minute sessions over six weeks found that they were able to fall asleep in half the time it took before the study began, while patients who received zolpidem (Ambien) reduced that time by 17%.

Counseling also is useful if you experience frequent nightmares. People who seek help for nightmares will encounter diverse approaches. Behavior therapy may involve desensitization, in which the sufferer recalls the details of the nightmare and uses relaxation techniques to overcome fear. The therapist may guide you through typical dream sequences — for example, helping you imagine confronting or driving off a pursuer. A psychoanalytically oriented therapist, on the other hand, may focus on identifying and resolving past and present emotional issues that play themselves out in nightmares. Bad and good dreams can be useful tools for approaching many psychological issues.

Last updated:	January 23, 2007