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Medical Author:

Aparna Ranjan, MD

Coauthor:

Angela Gentili, MD

Medical Editor:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Behavioral therapy is now considered the most appropriate treatment for persons with sleeplessness without any medical, psychiatric, or environment cause.

It consists primarily of short-term cognitive behavioral therapies. The focus is primarily on sleep hygiene or factors presumed to cause insomnia. As such, these therapies seek to modify maladaptive sleep habits and to educate persons about healthier sleep practices.

Stimulus control therapy

The purpose of this therapy is to reestablish the connection between the bed and sleep by prohibiting the person from engaging in nonsleep activities while in bed. The following instructions are given:

• Go to bed only when sleepy.
• Use the bed and bedroom only for sleep and intimacy.
• Avoid trying to force sleep (go into another room whenever unable to fall asleep within 20 to 30 minutes, and return to bed only when sleepy again).
• Get up at the same time each morning regardless of how much one has slept the previous night.
• Avoid daytime napping.

Sleep restriction therapy

This involves limiting the amount of time the person spends in bed to the actual amount of time the person usually spends sleeping. This results in sleep deprivation, which accumulates and causes more rapid sleep onset on subsequent nights. As sleep improves, the person is allowed to gradually increase time in bed by 15 to 30 minutes.

Relaxation therapies

The person is taught to identify and control tension. Relaxation-based interventions are advised based on the observation that persons with insomnia often display high levels of arousal both at night and during the daytime. The various techniques available to deactivate the arousal system are:

• The person is taught progressive muscle relaxation through a series of exercises that consist of first tensing and then relaxing each muscle group in a systematic way.
• The biofeedback technique is a training technique that enables an individual to gain some element of voluntary control over certain body parameters (for example, heart rate, rate of breathing). This technique provides an immediate feedback regarding the levels of tension and teaches a person how to relax in a short time.
• Imagery training and thought stopping teaches the person how to focus on neutral or pleasant things instead of focusing on racing thoughts.

Cognitive therapy

This consists of identifying person-specific activities associated with thinking that disrupts sleep, challenging their validity, and replacing them with substitutes such as reattribution training (a simple technique that has been used successfully to help persons to recognize that their minds play a part in causing their physical symptoms), reappraisal, and attention shifting.

Paradoxical intention

This method consists of persuading a person to engage in his or her most feared behavior (for example, staying awake). This serves to eliminate performance anxiety so that sleep may come more easily.

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