![]() Identify and replace dysfunctional beliefs regarding sleep (e.g., overestimation and apprehension about the number of hours needed for sleep)Ĭombination of cognitive therapy, stimulus control, and sleep restriction therapy with or without relaxation therapyĬombination of stimulus control, relaxation therapy, and/or sleep hygiene educationįocus is to restore sleep-wake cycle patient instructed to wake up at the same time every day, regardless of total amount of sleep, and to avoid daytime napsĬBT-I is a combination of cognitive therapy, stimulus control therapy, and sleep restriction therapy with or without the incorporation of relaxation therapy. Visual or auditory biofeedback therapy: teaches the patient to control specific physiologic factors, such as muscle tension Hypnosis, meditation, yoga, abdominal breathing, progressive muscle relaxation (from the feet up to the facial muscles) Imagery training: focus on pleasant images Limit time in bed to the number of hours actually spent sleeping (not less than five hours) sleep time gradually increases as sleep efficiency improvesĪdvise patient to remain awake to help alleviate the anxiety associated with the pressure to fall asleepĪutogenic training: imagine a calm environment with comforting body perceptions such as warmth and heaviness of the limbs Maintain a consistent sleep-wake cycle (e.g., set the alarm for the same time each morning regardless of how much sleep occurs during the night) Leave the bed if unable to fall asleep within 20 minutes and return when sleepy Lie down to sleep only when feeling sleepyĪvoid wakeful activities at bedtime (e.g., watching television, talking on the phone, eating) Maintain a regular sleep-wake cycle without daytime nappingĪvoid distracting stimuli at bedtime, such as loud noises, bright lights when not being used therapeutically, and extreme temperature variations ![]() Limit caffeine, tobacco, and alcohol intake 16 Underlying problems must be appropriately treated, followed by reevaluation for symptom improvement.Įxercise regularly (not within 4 hours of bedtime)Īvoid large meals and limit fluid intake in the evenings ![]() Additional testing, such as neuroimaging, actigraphy (measures cycles of activity and rest), or polysomnography, may be indicated for further evaluation of a suspected sleep or movement disorder, but is not part of the routine evaluation for insomnia. 7, 16, 20 – 22 Physical examination findings may offer clues to underlying disorders (e.g., a large neck in patients with obstructive sleep apnea). Predisposing, precipitating, and perpetuating factors for insomnia ( Table 3 20 ) should be explored, as well as any prior treatments. 16 The sleep history includes the timing of insomnia, daytime effects and symptoms, sleep schedule, sleep environment, and sleep habits to identify symptoms of other sleep disorders (e.g., kicking during the night may suggest periodic limb movement disorder). Insomnia is a clinical diagnosis therefore, in addition to a medical and psychological history, a detailed sleep history should be obtained from the patient, the patient's partner, or a family member. Referral to a sleep specialist may be considered for refractory cases. Nonpharmacologic therapies include sleep hygiene, cognitive behavior therapy, relaxation therapy, multicomponent therapy, and paradoxical intention. Insomnia can be treated with nonpharmacologic and pharmacologic therapies. Chronic insomnia is associated with cognitive difficulties, anxiety and depression, poor work performance, decreased quality of life, and increased risk of cardiovascular disease and all-cause mortality. Patients with movement disorders (e.g., restless legs syndrome, periodic limb movement disorder), circadian rhythm disorders, or breathing disorders (e.g., obstructive sleep apnea) must be identified and treated appropriately. Treatment of comorbid conditions alone may not resolve insomnia. Psychiatric and medical problems, medication use, and substance abuse should be ruled out as contributing factors. A comprehensive sleep history can confirm the diagnosis. Insomnia is more common in women, especially following menopause and during late pregnancy, and in older adults. Factors associated with the onset of insomnia include a personal or family history of insomnia, easy arousability, poor self-reported health, and chronic pain. The criteria for diagnosis are difficulty falling asleep, difficulty staying asleep, or early awakening despite the opportunity for sleep symptoms must be associated with impaired daytime functioning and occur at least three times per week for at least one month. Short-term, chronic, and other types of insomnia are the three major categories according to the International Classification of Sleep Disorders, 3rd ed. Insomnia affects 10% to 30% of the population with a total cost of $92.5 to $107.5 billion annually.
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