Psychology
Management of Insomnia
The management of insomnia involves various approaches such as cognitive-behavioral therapy, sleep hygiene practices, and medication. Cognitive-behavioral therapy aims to address the underlying thoughts and behaviors contributing to insomnia, while sleep hygiene practices focus on creating a conducive sleep environment and routine. Medication may be prescribed in certain cases to help regulate sleep patterns.
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11 Key excerpts on "Management of Insomnia"
- William T. O'Donohue, Jane E. Fisher, William T. O'Donohue, Jane E. Fisher(Authors)
- 2009(Publication Date)
- Wiley(Publisher)
Whether any of these associations to medical and psychiatric conditions are causal, remains to be determined as does what factors related to insomnia in specific confer and moderate/mediate risk. Nonetheless, given the personal and societal costs of insomnia, it follows that this is a disorder that should be aggressively treated. Fortunately, there are a variety of cognitive and behavioral interventions which are rooted in behavioral and cognitive principles, target insomnia as a clearly defined disease entity and are empirically validated. As will be shown, insomnia is a disorder in which theory, diagnosis, assessment, and treatment are intertwined.THE COGNITIVE BEHAVIORAL MODEL OF INSOMNIA
A theoretical understanding of the etiology and pathophysiology of insomnia is a valuable starting point when considering its behavioral treatments. There is currently more than one “cognitive behavioral model of insomnia.” All such models, however, recognize that insomnia is a condition that develops over time, is related to maladaptive behaviors and cognitions, and whose developmental course is typically a chronic one unless it is treated aggressively in its initial phases (American Academy of Sleep Medicine, 2005; Perlis, Smith, & Pigeon, 2005).The behavioral components of “the model” were originally set forth by Spielman and colleagues (Spielman, Caruso, & Glovinsky, 1987). This model is used as a foundation for most models of insomnia (and for its behavioral treatment). The Spielman model (also known as the “3-P Model”) posits that insomnia occurs acutely in relation to both predisposing and precipitating factors. Thus, an individual may be prone to insomnia due to predisposing characteristics, but experiences actual episodes because of precipitating factors. The acute insomnia becomes sub-chronic when it is reinforced by perpetuating factors (often in the form of maladaptive coping strategies). These strategies, in turn, result in conditioned arousal and chronic insomnia. A graphic representation of this model is presented in Figure 40.1 .Predisposing factors extend across the entire biopsychosocial spectrum. Biological factors include hyperarousal or hyperreactivity. Psychological factors include worry or the tendency to be excessively ruminative. Social factors, although rarely a focus at the theoretical level, include such things as the bed partner keeping an incompatible sleep schedule or social pressures to sleep according to a non-preferred sleep schedule. Precipitating factors, as the name implies, are acute occurrences that constitute stressful life events.
eBook - ePubCognitive Behavior Therapy
Applying Empirically Supported Techniques in Your Practice
- William T. O'Donohue, Jane E. Fisher, William T. O'Donohue, Jane E. Fisher(Authors)
- 2008(Publication Date)
- Wiley(Publisher)
Whether any of these associations to medical and psychiatric conditions are causal, remains to be determined as does what factors related to insomnia in specific confer and moderate/mediate risk. Nonetheless, given the personal and societal costs of insomnia, it follows that this is a disorder that should be aggressively treated. Fortunately, there are a variety of cognitive and behavioral interventions which are rooted in behavioral and cognitive principles, target insomnia as a clearly defined disease entity and are empirically validated. As will be shown, insomnia is a disorder in which theory, diagnosis, assessment, and treatment are intertwined.THE COGNITIVE BEHAVIORAL MODEL OF INSOMNIA
A theoretical understanding of the etiology and pathophysiology of insomnia is a valuable starting point when considering its behavioral treatments. There is currently more than one “cognitive behavioral model of insomnia.” All such models, however, recognize that insomnia is a condition that develops over time, is related to maladaptive behaviors and cognitions, and whose developmental course is typically a chronic one unless it is treated aggressively in its initial phases (American Academy of Sleep Medicine, 2005; Perlis, Smith, & Pigeon, 2005).The behavioral components of “the model” were originally set forth by Spielman and colleagues (Spielman, Caruso, & Glovinsky, 1987). This model is used as a foundation for most models of insomnia (and for its behavioral treatment). The Spielman model (also known as the “3-P Model”) posits that insomnia occurs acutely in relation to both predisposing and precipitating factors. Thus, an individual may be prone to insomnia due to predisposing characteristics, but experiences actual episodes because of precipitating factors. The acute insomnia becomes sub-chronic when it is reinforced by perpetuating factors (often in the form of maladaptive coping strategies). These strategies, in turn, result in conditioned arousal and chronic insomnia. A graphic representation of this model is presented in Figure 36.1 .Predisposing factors extend across the entire biopsychosocial spectrum. Biological factors include hyperarousal or hyperreactivity. Psychological factors include worry or the tendency to be excessively ruminative. Social factors, although rarely a focus at the theoretical level, include such things as the bed partner keeping an incompatible sleep schedule or social pressures to sleep according to a non-preferred sleep schedule. Precipitating factors, as the name implies, are acute occurrences that constitute stressful life events.
eBook - PDFTinnitus Treatment
Clinical Protocols
- Richard S. Tyler, Ann Perreau, Richard S. Tyler, Ann Perreau(Authors)
- 2022(Publication Date)
- Thieme(Publisher)
6 The Psychological Management of Tinnitus-Related Insomnia Laurence McKenna and Elizabeth Marks Abstract Many tinnitus patients report sleep disturbances or insomnia that can significantly impact overall function. This chapter overviews our approach to addressing sleep disturbances using cognitive behavioral therapy that includes information on group and individual therapy sessions. We also discuss sleep titration, sleep hygiene, and relaxa-tion techniques for improved sleep. Keywords : insomnia, tinnitus, sleep, cognitive behavioral therapy, sleep management 6.1 Introduction Insomnia is a sleep – wake disorder that can involve a range of problems. These include di ffi culty in getting to sleep, staying asleep, waking too early; insu ffi cient duration of sleep, or feeling that sleep is nonrestorative or otherwise of poor quality. These problems occur despite an adequate oppor-tunity to sleep. Insomnia has daytime e ff ects that can include impaired functioning, tiredness, and distress. Like tinnitus, insomnia is very prevalent in the general population, 1 a ff ecting up to 30% of adults. 2 Sleep disturbance is one of the most impor-tant aspects of tinnitus complaint among adults 3,4 and children, 5,6 with most studies indicating at least 40% of tinnitus patients report insomnia. 7 Tinnitus tends to be more distressing when it is associated with di ffi culties sleeping. 8,9,10,11,12,13 There is an ob-vious need to address the issue of tinnitus-related insomnia and its management, and recent research suggests that a cognitive behavioral (CB) approach is likely to be e ff ective. 6.2 The Cognitive Behavioral Model A case can be made for the use of pharmacological treatment of insomnia in the short term, that is, up to 2 weeks (National Institute for Health and Care Excellence [NICE] guidelines) 14 to break an unhelpful cycle of sleeplessness and worry. There are strong arguments against pharmacological treatment of insomnia beyond the short term.
eBook - ePubEating, Sleeping, and Sex
Perspectives in Behavioral Medicine
- Albert J. Stunkard, Andrew S. Baum, Andrew S. Baum, (Authors)
- 2020(Publication Date)
- Routledge(Publisher)
10THE COGNITIVE-BEHAVIORAL TREATMENT OF INSOMNIA
Peter Hauri Ph.D.
Mayo Medical SchoolChronic and serious insomnia is a widespread problem. The incidence rate of patients complaining seriously about insomnia has been consistently placed at about 15 percent of the general U.S. population. About six percent of the population complain to their physicians about insomnia, and about three percent receive prescription hypnotics (Institute of Medicine, 1979).Although there are some insomniacs whose problem lies beyond the scope of behavioral intervention, the majority of chronic insomnias are related to stress, anxiety, mild depression, maladaptive conditioning, and poor sleep hygiene. These are factors that are obviously treatable with behavioral techniques. Despite this, however, there are few behavioral insomnia clinics in this country in the same sense as there are behavioral pain or headache clinics. Rather, if chronic insomnia is treated at all, it is most often treated with hypnotics. This is unfortunate, because treatment with hypnotics is effective only in the short and intermediate range—days, weeks, months (Kales, Bixler, Tan, Scharf, & Kales, 1974)—while chronic insomnias typically last years or decades.This paper will focus on some of the problems and issues in the behavioral treatment of insomnia. The goal is to explore some of the reasons why we do not yet have thriving behavioral insomnia clinics. After a short review of the behavioral treatments and concepts about insomnia that are currently available, some basic neurological mechanisms of sleep induction will be discussed. This is done because it appears that behavioral therapists are not currently using up-to-date knowledge on insomnia. Finally, the paper calls attention to a very individualized cognitive treatment of insomnia. It appears that such a treatment can be quite effective if it is well focused on the individual insomniac’s specific problem.
eBook - PDF- Alon Y. Avidan, Cathy Alessi, Alon Y. Avidan, Cathy Alessi(Authors)
- 2008(Publication Date)
- CRC Press(Publisher)
Source : Adapted from Ref. 7. that insomnia may become functionally independent from the original precipitat-ing event (see Fig. 1). For example, although pain is a common precipitating factor of sleep disturbances in older adults, spending excessive amounts of time in bed or napping during the day may perpetuate the sleep problem over time. Treatment should then focus on these maintaining factors, even if the precipitating factors may still be instrumental in maintaining the sleep difficulties. According to this model, behavioral and psychological factors are almost always involved in perpetuating insomnia over time, regardless of the nature of the precipitating event. In older adults, as in any age group, such features may include poor sleep habits, irregular sleep–wake schedules, and misconceptions and unreal-istic expectations about normal sleep. Figure 2 schematizes the interplay of different behavioral and cognitive factors hypothesized to maintain insomnia and how they interact to form a vicious cycle. COGNITIVE-BEHAVIORAL THERAPY FOR INSOMNIA Several behavioral, cognitive, and psychological interventions have been validated for the treatment of insomnia in later life: sleep restriction, stimulus control ther-apy, relaxation-based interventions, cognitive therapy, and combined CBT. These interventions are not incompatible with each other and multicomponent therapy such as CBT, which typically combines a behavioral intervention (i.e., stimulus con-trol, sleep restriction, and, sometimes, relaxation), a cognitive (cognitive restruc-turing therapy), and an educational component (sleep hygiene), is becoming the standard approach to treating insomnia (3–5,8,9). CBT thus aims at curtailing sleep-incompatible behaviors, attenuating arousal, and altering sleep-related dysfunc-tional cognitions and thoughts, all of which are hypothesized to play a major role in maintaining and exacerbating insomnia over time.
eBook - PDFClinical Handbook of Psychological Disorders
A Step-by-Step Treatment Manual
- David H. Barlow(Author)
- 2021(Publication Date)
- The Guilford Press(Publisher)
American Psycholo- gist, 65(2), 73–84. Miller, W. R., & Rollnick, S. (2002). Motivational interview- ing: Preparing people to change. New York: Guilford Press. Montgomery, P., & Dennis, J. (2003). Cognitive behavioural interventions for sleep problems in adults aged 60+. Co- chrane Database of Systematic Reviews, 1, CD003161. Morin, C. M. (1993). Insomnia: Psychological assessment and management. New York: Guilford Press. Morin, C. M., Blais, F., & Savard, J. (2002). Are changes in beliefs and attitudes about sleep related to sleep improve- ments in the treatment of insomnia? Behaviour Research and Therapy, 40, 741–752. Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J., D., Espie, C. A., & Lichstein, K. L. (2006). Psychological and behavioral treatment of insomnia: An update of recent evi- dence (1998–2004). Sleep, 29, 1396–1406. Morin, C. M., Culbert, J. P., & Schwartz, S. M. (1994). Non- pharmacological interventions for insomnia: A meta-anal- ysis of treatment efficacy. American Journal of Psychiatry, 151, 1172–1180. Morin, C. M., & Espie, C. A. (2007). Insomnia: A clinical guide to assessment and treatment. New York: Springer Sci- ence & Business Media. Morin, C. M., Gaulier, B., Barry, T., & Kowatch, R. A. (1992). Patients’ acceptance of psychological and pharma- cological therapies for insomnia. Sleep, 15, 302–305. Morin, C. M., Koetter, U., Bastien, C., Ware, J. C., & Woo- ten, V. (2005). Valerian–hops combination and diphen- hydramine for treating insomnia: A randomized placebo- controlled clinical trial. Sleep, 28(11), 1465–1471. Morin, C. M., Vallieres, A., Guay, B., Ivers, H., Savard, J., Merette, C., et al. (2009). Cognitive behavioral therapy, singly and combined with medication, for persistent in- somnia: A randomized controlled trial. Journal of the American Medical Association, 301(19), 2005–2015. Morin, C. M., Vallieres, A., & Ivers, H. (2007). Dysfunction- al Beliefs and Attitudes about Sleep (DBAS): Validation of a brief version (DBAS-16).
eBook - ePub- Richard B. Berry, Mary H. Wagner, Mary H Wagner(Authors)
- 2014(Publication Date)
- Saunders(Publisher)
Fundamentals 38 Behavioral Treatment of Insomnia
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Fundamentals 38: Behavioral Treatment of Insomnia
The two major categories of insomnia treatment are (1) cognitive-behavioral treatment of insomnia (CBT-I) and (2) hypnotic medications. These treatments are not mutually. However, only one study has suggested that combination therapy is more effective than CBT-I alone.Cognitive and Behavioral Therapy for Insomnia (CBT-I)
CBT-I is safe and effective for sleep-onset and sleep-maintenance insomnia as well as complaints of poor sleep quality.1 – 4 The efficacy of CBT-I is equal to or better than results from pharmacotherapy.5 , 6 Unfortunately, many locales do not have physicians, nurses, or psychologists skilled at this form of treatment. The 2006 update of the American Academy of Sleep Medicine (AASM) practice parameters for behavioral treatment of chronic insomnia state: “Psychological and behavioral interventions are effective and recommended in the treatment of chronic primary insomnia, secondary insomnia (due or associated with other medical or psychiatric disorders), insomnia in older adults, and chronic hypnotic users (Standard).”2 In 2008, the Clinical Guidelines for the Evaluation and Management of Chronic Insomnia in Adults 1 recommended that CBT-I be utilized as initial treatment of insomnia if possible.Elements of CBT-I
Cognitive Therapy
Cognitive therapy is aimed at changing the patient’s belief and attitudes about insomnia.1 , 3 These dysfunctional cognitions are often identified by using questionnaires such as the Dysfunctional Beliefs About Sleep (DBAS) questionnaire.7 , 8 Cognitive therapy uses a psychotherapeutic method to reconstruct cognitive pathways with positive and appropriate concepts about sleep and its effects. Common cognitive distortions that are identified and addressed in the course of treatment include “I can’t sleep without medication,” “I have a chemical imbalance,” “If I can’t sleep, I should stay in bed and rest,” and “My life will be ruined if I can’t sleep.”7 , 8
eBook - PDFSleep Disorders in Neurology
A Practical Approach
- Sebastiaan Overeem, Paul Reading, Sebastiaan Overeem, Paul Reading(Authors)
- 2010(Publication Date)
- Wiley-Blackwell(Publisher)
PART II Management of Sleep Disorders This page intentionally left blank 55 CHAPTER 5 Pharmacological treatment of nocturnal sleep disturbances Sue Wilson and David Nutt Psychopharmacology Unit, University of Bristol, Dorothy Hodgkin Building, Whitson Street, Bristol, UK Introduction In neurological practice the full range of sleep disorders is commonly encountered. This chapter will focus on the pharmacological treatment of nocturnal sleep problems of which chronic insomnia, as defined by impaired sleep onset and/or maintenance, is commonest. The treatment, if required, of parasomnias will also be covered. Although parasomnias are generally divided into those arising from either non-REM or REM sleep, treatment options do not differ greatly. Sleep-onset and sleep-maintenance insomnia Overall, insomnia is the most common sleep disorder in the general popu- lation with somewhere around 10–15% of the adult population reporting chronic symptoms [1,2]. Symptomatically, insomnia is rather loosely defined as a persistent problem, lasting at least one month, of sleep initiation, consol- idation, duration, or quality despite the opportunity to sleep adequately [3]. Overall, it is estimated that primary insomnia accounts for about 15% of all insomnia cases. The majority (85%) have secondary factors which promote or even cause the sleep disturbance. These include neurological, psychiatric, and other medical conditions, substance abuse, as well as lifestyle factors. Whether insomnia is predominantly “primary” or “secondary,” assuming provoking factors have been addressed, available drug treatments are essen- tially very similar. However, it is important to recognize the precise nature of a patient’s insomnia with respect to sleep onset or sleep maintenance as this will influence the choice of drug. Problems staying asleep are particularly common in the elderly and will more often be seen in neurological practice. Sleep Disorders in Neurology. Edited by S. Overeem and P.
eBook - PDFCommon Pitfalls in Sleep Medicine
Case-Based Learning
- Ronald D. Chervin(Author)
- 2014(Publication Date)
- Cambridge University Press(Publisher)
REFERENCES 1. Krystal AD. A compendium of placebo-controlled trials of the risks/benefits of pharmacological treatments for insomnia: the empirical basis for US clinical practice. Sleep Med Rev 2009;13:265–74. 2. NIH State-of-the-Science Conference Statement on mani- festations and management of chronic insomnia in adults. NIH Consensus State Sci Statements 2005;22:1–30. 3. Morin CM. Insomnia: psychological assessment and man- agement. New York, NY: Guilford;1993. 4. Jefferson C, Drake C, Scofield H, et al. Sleep hygiene prac- tices in a population-based sample of insomniacs. Sleep 2005;28:611–15. 5. Bélanger L. Management of hypnotic discontinuation in chronic insomnia. Sleep Med Clin 2009;4:583–92. 6. Licata SC, Rowlett JK. Abuse and dependence liability of benzodiazepine-type drugs: GABA A receptor modulation and beyond. Pharmacol Biochem Behav 2008;90:74–89. 7. Spielman AJ, Caruso LS, Glovinsky PB. A behavioral per- spective on insomnia treatment. Psychiatric Clin North Am 1987;10:541–53. 8. Mitchell M, Gehrman P, Perlis M, Umscheid C. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Fam Pract 2012;13:40. 9. Morin CM. Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. Am J Psychiatry 2004;161:332–42. Section 7: Diagnosis and treatment of chronic insomnia 167 28 Overlooking insomnia in a depressed patient can interfere with effective treatment for the mood disorder Edward D. Huntley and J. Todd Arnedt Approximately half of all Americans will fulfill diagnos- tic criteria for a mental disorder at some point in their life. The lifetime prevalence estimate for depression is 16.2%. 1 Individuals who experience depression and insomnia generally fare worse than do people with depression only, and patients commonly continue to report insomnia even after successful treatment of their depression.
eBook - ePub- Imran H. Iftikhar, Ali I. Musani, Imran H. Iftikhar, Ali I. Musani(Authors)
- 2001(Publication Date)
- Bentham Science Publishers(Publisher)
Fig. (3)) Simulated sleep diary illustrating changes in time in bed (TIB) and total sleep time (TST) while implementing sleep compression.Cognitive Therapy
The rationale for the use of cognitive therapy in treating insomnia is that thoughts, beliefs, and attitudes about sleep can be significant perpetuating factors for chronic insomnia. A negative appraisal of the situation (poor sleep, insomnia) leads to emotions that are wake-promoting, which results in a vicious cycle of insomnia and negative thoughts/emotions.There are often numerous negative or unhelpful thoughts about sleep and insomnia to address during cognitive therapy. Some of the most common are assumptions about the cause of their insomnia (“My insomnia was caused by a chemical imbalance”), unrealistic expectations for sleep (“I keep hearing 8 hours is the magic number for sleep so I need 8 hours”), and worry about sleep’s influence on daytime functioning (“I won’t be able to go to work if I don’t sleep well tonight”).Often dysfunctional cognitions that were present initially during treatment are effectively addressed during education about sleep and insomnia. Unhelpful thoughts may also improve spontaneously while implementing stimulus control and sleep restriction. For example, stimulus control provides a behavioral experiment that challenges the belief “If I get out of bed I’ll be awake the rest of the night.” Likewise, improvement in sleep quality during sleep restriction provides evidence to counter the belief “I need to be in bed 8 hours in order to get enough sleep.” Conversely, there are also patients for whom dysfunctional beliefs and negative emotions are so severe that addressing those thoughts must take precedence over behavioral changes. Sleep diaries may even be counterproductive if these significantly increase sleep-related anxiety. For such patients, cognitive therapy should be prioritized as the initial component of CBT-I.
No longer available |Learn more- Kenneth L. Lichstein, Charles M. Morin, Kenneth L. Lichstein, Charles M. Morin(Authors)
- 2000(Publication Date)
- SAGE Publications, Inc(Publisher)
Drawing on conventional cognitive therapy, as that of Beck, it seeks to correct faulty cognitions to relieve daytime worrying and bed-time arousal. Additional interventions (e.g., drug therapy) for sleep disturbance in late life are also covered in this book, but the main focus of our discussion here is the selection of a nonpharmacological treatment for primary in-somnia. Specific issues surrounding the indications and contraindica-tions, as well as the risks and benefits, of pharmacotherapy for late-life insomnia are discussed in Chapter 10. Some Issues in Clinical Procedure Selecting Treatments Armed with five insomnia treatments, how does the therapist select treatments for different kinds of insomnia? The research literature pro-vides some general guidance but no definitive answers. For example, the 114 INTERVENTION STRATEGIES Table 4.1 Matching Common Treatments With Common Insomnia Characteristics Based on Likelihood of Success Insomnia Type Insomnia Cause Insomnia Effect Common Treatments Onset Insomnia Maintenance Insomnia Cognitive Arousal Somatic Arousal Impaired Daytime Functioning Sleep hygiene X X X X X Sleep restriction X X Stimulus X X X X X control Relaxation X x x X Cognitive therapy x x x X few insomnia studies that matched different methods of treatment with different client characteristics were unsuccessful in identifying reliable matches (Espie, Brooks, & Lindsay, 1989; Sanavio, 1988). We can, how-ever, glean from the large body of insomnia research that some treat-ments are expected to work better with some types of clients, and these data can help guide treatment decisions. The following recommenda-tions derive from such data, from our clinical experience, and from edu-cated guesses. Treatment selection decisions cannot be delayed until an adequate empirical foundation surfaces. Table 4.1 will serve as a heuristic for this discussion.
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