Treatments for sleep disorders generally can be grouped into three categories: 1) behavioral/ psychotherapeutic treatments, 2) medications, and 3) other somatic treatments. None of these general approaches is sufficient for all patients with sleep disorders. Rather, the choice of a specific treatment depends on the patient’s diagnosis, medical and psychiatric history, and preferences, as well as the expertise of the treating clinician. In general, medications and somatic treatments provide more rapid symptomatic relief from sleep disturbances. On the other hand, some emerging evidence suggests that treatment gains with behavioral treatment of insomnia may be more durable than those obtained with medications.
It is also important to note that methodologically rigorous, placebo-controlled treatment studies have not been conducted for many individual sleep disorders. Large, carefully controlled clinical trials of behavioral/psychological treatments have been conducted recently for primary insomnia. Smaller studies have been conducted for narcolepsy, nightmare disorder, and sleepwalking disorder and for patients who would qualify for diagnosis of insomnia related to another mental disorder and substance-induced sleep disorder. Large, well-controlled clinical trials of pharmacological treatments have been conducted for primary insomnia and narcolepsy, and smaller trials have been conducted for restless legs syndrome/periodic limb movement disorder, simulated circadian rhythm sleep disorders, and secondary sleep disorders. However, most of these studies have included a narrow range of outcomes, were of short duration, and were not conducted at multiple sites. Finally, controlled (but not double-blind) studies have been conducted with phototherapy in circadian rhythm sleep disorders. This list does not include several common clinical scenarios, such as the pharmacological treatment of patients with a history of mood disorders. Given the lack of rigorously controlled, empirical studies for many sleep disorders, treatment guidelines frequently rest on common practice rather than empirical data.
Behavioral/Psychotherapeutic Treatments and Principles
Nonpharmacological interventions for sleep disorders consist mostly of cognitive-behavioral therapies. These treatment methods are used predominantly with primary insomnia and target hyperarousal (somatic, cognitive, emotional), learned maladaptive sleep habits, and dysfunctional sleep cognitions. Insight-oriented psychotherapy focusing on predisposing rather than perpetuating factors of sleep disorders has also been advocated, although empirical evidence supporting such treatment is limited. Specific types of behavioral/psychotherapeutic treatments are outlined here.
Stimulus control Stimulus control therapy (Bootzin et al. 1991) consists of a set of instructional procedures designed to curtail sleep-incompatible behaviors and to regulate sleep-wake schedules. These procedures are as follows:
- Go to bed only when sleepy.
- Use the bed and bedroom only for sleep and sex (i.e., no reading, television watching, eating, working, or worrying in the bedroom, either during the day or at night).
- Get out of bed and go into another room whenever unable to fall asleep or return to sleep within 15-20 minutes, and return to bed only when sleepy again.
- Repeat this last step as often as necessary throughout the night.
- Arise in the morning at the same time, regardless of the amount of sleep obtained on the previous night.
According to the stimulus control paradigm, insomnia is the result of maladaptive conditioning in which temporal stimuli (e.g., bedtime) and environmental stimuli (e.g., bed, bedroom) that were previously conducive to sleep have become associated with wakefulness, frustration, and arousal. The main therapeutic objective is to reestablish the associative control between sleep and those conditions under which it previously occurred.
Sleep restriction Poor sleepers often increase their time in bed in a misguided effort to provide more opportunity for sleep, a strategy that is more likely to result in fragmented sleep. Sleep restriction is designed to limit the amount of time spent in bed to the actual sleep time (Spielman et al. 1987). Individualized sleep-wake schedules are determined according to estimated sleep duration from a sleep diary kept for at least 1 week.
For example, if a patient reports sleeping an average of 6 hours per night out of 8 hours spent in bed during baseline, the initial prescribed sleep window (i.e., from initial bedtime to final arising time) for the first week of treatment would be 6 hours. Weekly adjustments in the sleep window are made contingent on sleep efficiency (i.e., total sleep time divided by time in bed multiplied by 100%). The allowable time in bed is increased by 15-20 minutes for a given week when sleep efficiency exceeds 90%, decreased by the same amount of time when sleep efficiency is lower than 80%, and kept stable when sleep efficiency is between 80% and 90%. These adjustments are made periodically until an optimal sleep duration is achieved. The specific criteria used to modify allowable time in bed can be altered according to the needs of each clinical situation. Time in bed should not be restricted to less than 5 hours per night, regardless of sleep efficiency, because of the resulting sleepiness and associated risks the next day.
The main effect of sleep restriction is to produce a mild sleep deprivation, which in turn promotes rapid sleep onset, improved sleep continuity, and deeper sleep. This treatment may produce daytime sleepiness, and caution is advised when using it with patients who perform hazardous activities (e.g., truck drivers). A modified procedure for elderly patients permits a brief midday nap.
Relaxation Relaxation-based interventions share the premise that stress, anxiety, or excessive arousal interferes with sleep. A variety of relaxation methods can be used, depending on which type of arousal - physiological, cognitive, or emotional - is being targeted for treatment. Progressive muscle relaxation, autogenic training, and electromyographic biofeedback methods are primarily concerned with reducing somatic arousal (e.g., muscle tension). Conversely, the focus of imagery training, meditation, and thought stopping is on cognitive arousal (e.g., intrusive thoughts, racing mind). These latter methods consist primarily of attention-focusing procedures aimed at controlling excessive presleep cognitive activity.
Cognitive therapy Cognitive therapy attempts to alter dysfunctional beliefs and attitudes about sleep. Increasing evidence suggests that the content and affective valence of cognitions (beliefs, expectations, and attributions) are important mediating factors of insomnia. Poor sleepers tend to endorse state (presleep) and trait (daytime) measures that reflect an anxious, dysphoric, or worrisome cognitive style, which in turn heightens their affective response to poor sleep. For example, the fear of not sleeping or excessive concerns about the consequences of insomnia are common features among individuals with insomnia. In turn, these dysfunctional sleep cognitions heighten emotional arousal and exacerbate sleep disturbances.
The objective of cognitive therapy is to short-circuit the vicious cycle of insomnia, emotional distress, dysfunctional cognitions, and further sleep disturbances. Specific targets for intervention include the following (Morin 1993):
Unrealistic sleep expectations (“I must have 8 hours of sleep to feel refreshed and function well during the day”)
Misconceptions about the causes of insomnia (“I believe that insomnia is essentially the result of a chemical imbalance”)
Misattributions or amplifications of the consequences of insomnia (“I am concerned that chronic insomnia may have serious consequences on my physical health”)
Performance anxiety resulting from excessive attempts at controlling the process of sleep (“I get overwhelmed by my thoughts at night and often feel I have no control over this racing mind”)
Learned helplessness associated with the perceived unpredictability of sleep (“I feel that insomnia is ruining my ability to enjoy life”)
Cognitive therapy involves identifying patient-specific dysfunctional sleep cognitions, challenging their validity, and replacing them with more adaptive substitutes. Restructuring techniques include reattribution training, decatastrophizing, hypothesis testing, reappraisal, and attention shifting (Beck 1995).
Sleep hygiene education Sleep hygiene (Hauri 1991) is concerned with health practices (e.g., diet, exercise, and substance use) and environmental factors (e.g., light, noise, temperature, and mattress) that may be either detrimental or beneficial to sleep. Although these factors are rarely of sufficient severity to be the primary cause of chronic insomnia (Reynolds et al. 1991), they may complicate an existing sleep problem and hinder treatment progress. Sleep hygiene guidelines include the following:
Caffeine and nicotine are both central nervous system stimulants and should be discontinued 4-6 hours before bedtime.
Alcohol is a depressant, and although it may facilitate the onset of sleep, it produces more fitful sleep later in the night.
Regular exercise in the late afternoon or early evening may deepen sleep, but exercising too close to bedtime should be avoided.
Ear plugs, window blinds, or an electric blanket or air conditioner should be used to minimize noise, light, and excessive temperature during the sleep period.
Although poor sleepers are generally better informed about sleep hygiene, they also engage in more unhealthy practices than good sleepers. Thus, the objective of sleep hygiene education is not only to heighten the patient’s awareness and knowledge of these factors but, most important, to promote better sleep hygiene practices.
Chronotherapy and sleep scheduling Chronotherapy is a rescheduling technique designed to reset the circadian rhythm of individuals with a phase-delay sleep problem. While keeping the sleep window constant to 8 hours, this procedure consists of delaying bedtime by 3 hours every day until it has been shifted around the clock to a more acceptable time (Czeisler et al. 1981). For example, if a patient is unable to fall asleep before 3:00 a.m., the initial prescribed sleep window would be from 6:00 a.m. to 2:00 p.m., the next day from 9:00 a.m. to 5:00 p.m., and so forth until a more desirable bedtime is reached. Chronotherapy may be difficult to implement for patients with other scheduled daytime activities. Moreover, recent findings show that environmental light has phase-shifting effects on the human circadian system at a broader range of times and at lower light intensities than previously thought (Boivin et al. 1996; Jewett et al. 1997). These effects can diminish the therapeutic effect of chronotherapy.
A simple sleep-scheduling procedure can be useful for patients with narcolepsy. Because of the sudden and repetitive nature of sleep attacks in patients with narcolepsy, scheduled naps of 10-15 minutes at regular intervals may prevent sleep attacks that might otherwise occur at more inappropriate and unpredictable times. A similar procedure can also be helpful for patients with primary hypersomnia.
Insight-oriented psychotherapy Psychotherapy may serve as a useful adjunct in the management of sleep disorders that are caused or exacerbated by psychological difficulties. Situational insomnia caused by family, marital, or occupational stressors is best treated by addressing the underlying difficulties. Problem-solving and supportive therapy focusing on precipitating factors would be most appropriate in such circumstances.
Some sleep experts argue that even for chronic sleep disorders, particularly insomnia, insight-oriented psychotherapy is an essential ingredient of successful treatment (A. Kales and Kales 1984). They postulate that insomnia stems from internalized conflicts that are channeled into physiological arousal and somatized tension. Treatment must then target the underlying emotional conflicts and foster a more adaptive style for expressing emotions. Unlike cognitive-behavioral therapies, which concentrate on perpetuating factors, and more problem-solving therapies, which address precipitating circumstances, the main therapeutic focus of insight-oriented psychotherapy is on predisposing factors or characterological features of the patient (Buysse and Reynolds 1990). Despite the face validity of this conceptual model, no current empirical evidence shows that psychotherapy, as the only treatment modality, is effective in the management of sleep disorders.
Revision date: June 21, 2011
Last revised: by Sebastian Scheller, MD, ScD