Scientific trials have demonstrated strong efficacy of behaviorally based therapies for the primary treatment of insomnia. The most widely practiced and best-studied behavioral approach to insomnia is cognitive behavioral therapy (CBT-I), which uses a multipronged program of awareness promoting exercises and techniques to identify the underlying causes of insomnia and reconstruct healthy behaviors and attitudes relating to sleep. CBT-I, either alone or in combination with short-term hypnotic medications, significantly improves insomnia symptoms, and in contrast to most medication approaches, CBT-I has demonstrated sustained symptomatic improvement well beyond termination of therapy. Head-to-head comparisons have shown no difference in outcomes when CBT-I is compared to medications used to treat insomnia, such as zolpidem, and the advantages in terms of cost and adverse side effects of CBT-I as compared to medications are myriad.
Maintain a Routine and Limit Sleep Distracting Behaviors
Stimulus control is aimed at restricting bedroom activities to sleep and intimacy. The bed is primarily the vehicle for sleep, and the intent of stimulus control is to limit any association with stimulating behavior. Participates are advised to go to bed only when tired and to leave the bedroom anytime they lay awake in bed for more than 10 minutes. Although bedtimes may vary depending on sleepiness, morning wake-ups should remain constant. Daytime napping is strongly discouraged.
Sleep hygiene is the basic structure for maintaining an environment conducive to good, quality sleep. The National Sleep Foundation (NSF) provides the following tips for a good sleep hygiene practice:
A. Forego daytime napping. Most adults require seven to eight hours of sleep per night to be well rested. Try to maintain a consistent sleep schedule seven days per week
B. Avoid stimulants like caffeine, nicotine and alcohol too close to bedtime. While alcohol is known to speed the onset of sleep, it disrupts sleep in the second half of the night as the body begins to metabolize the alcohol, often causing withdrawal symptoms and increased arousals. Remember, chocolate is a source of caffeine.
C. Exercise can promote good sleep, but exercising within three hours of bedtime can be deleterious because it raises body temperature. Try to schedule vigorous exercise for the morning or late afternoon. A relaxing exercise, like yoga, can be done before bed to help initiate a restful night’s sleep.
D. Going to bed either too hungry or too full can disrupt sleep. Stay away from large, high-caloric meals close to bedtime, but a small healthy snack prior to bed may be appropriate. Avoid dishes that may predispose to reflux or stomach upset, such as meals that are excessively spicy.
E. Light exposure helps maintain a healthy sleep-wake cycle. As night falls, blue light disappears and helps promote the body’s natural sleep-initiating mechanisms. Use of computers, smartphones or tablet devices can introduce blue light too close bedtime and delay sleepiness. For night owls, properly timed early-morning light exposure may be helpful in advancing bedtime. For early birds, natural light in the early evening may help delay sleepiness and bedtime.
F. Establish a regular, relaxing bedtime routine. Try to avoid emotionally upsetting conversations, emails and activities before trying to go to sleep. Don’t dwell on your problems in bed.
G. Associate your bed with sleep. It’s not a good idea to use your bed to watch TV, listen to the radio or read.
H. Make sure that the sleep environment is pleasant and relaxing. The bed should be comfortable, the room should be cool and dark, and disruptions related to pets may necessitate them being excluded from the bedroom.
Other Behavioral Interventions
Sleep restriction is a controversial component of CBT-I and involves restricting overall sleep time to maximize sleep efficiency, which is the total sleep time divided by the overall time spent in bed. At its extreme, sleep restriction may decrease total sleep time to as little as 4.5 hours per night in order to achieve a goal sleep efficiency of 90 percent. Time in bed is increased by 20 to 30 minutes per week as long as the goal sleep efficiency is maintained. The process may take weeks to months, and daytime sleepiness is a common consequence of sleep restriction.
Relaxation therapy varies and may employ biofeedback, meditation, hypnosis and guided imagery to suppress triggers that delay sleep onset.
Finally, cognitive therapy aims to improve sleep quality through education regarding dysfunctional beliefs and attitudes related to sleep. Worry and rumination are common precipitants of insomnia, and efforts aimed at deconstructing irrational beliefs can be highly effective.
The major downside to CBT-I is availability of board certified behavioral sleep medicine providers and the variability of insurance coverage for their services. Here is a list of providers: http://www.absm.org/BSMSpecialists.aspx
Online resources for CBT-I are increasingly prevalent. Efficacy for sites like Sleepio.com, CBT- Coach, CBTforinsomnia.com and SHUTi have been validated in clinical peer-reviewed trials, and they are often less costly and more convenient alternatives to traditional CBT-I.