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In Sleep and Sleep Disorders Dr. Edward J. Stepanski describes and demonstrates his approach to treating clients with sleep problems. His multidisciplinary approach involves an understanding of the nature of sleep; the pharmacological treatments available for sleep disorders; and how medical, nutritional, behavioral, and cognitive components all can affect how a client sleeps.
In this session, Dr. Stepanski works with a 34-year-old woman who has experienced insomnia since high school. He surveys all the possible influences on her sleep problem and then suggests various ways she might improve her sleep, including pre-bedtime relaxation strategies, changes to the way she reacts to sleepless times, and other cognitive and behavioral coping strategies.
Approach
Cognitive–behavioral therapy (CBT) programs that combine specific single therapies have been shown empirically to be effective in the treatment of primary insomnia. These multicomponent programs may be delivered in either an individual or a group format, and the duration of treatment may be up to 8 weekly sessions. Gains for patients with insomnia receiving CBT were maintained at a 2-year follow-up; these results were superior to those from pharmacotherapy. Although CBT has been recommended for patients with primary insomnia, data have shown its effectiveness in patients with secondary insomnia. In secondary insomnia, a primary medical or psychiatric disorder is assumed to be causing the insomnia.
Individual behavioral therapies for insomnia may include sleep restriction therapy, stimulus control therapy, and relaxation therapy. Sleep restriction therapy increases homeostatic sleep drive by decreasing the time in bed available for sleep. The sleep–wake schedule is manipulated on the basis of the amount of sleep achieved over the previous several nights until an optimal schedule is determined. Stimulus control therapy seeks to break the negative conditioning associated with the bedroom environment by requiring that patients not spend time in bed when they are wide awake. They are instructed to leave the bedroom, engage in relaxing activities, and return to bed only when drowsy. Many relaxation therapies are used for insomnia, including progressive muscle relaxation, guided imagery, and autogenic training.
Cognitive therapy for insomnia is aimed at modifying patients' unrealistic expectations about their sleep as well as their irrational fears about the consequences of poor sleep.
Edward J. Stepanski obtained his PhD in clinical psychology from Bowling Green State University in 1985. He is currently the director of the Sleep Disorder Service at Rush-Presbyterian-St. Luke's Medical Center in Chicago and also is an associate professor of psychology and medicine at Rush Medical College. Dr. Stepanski serves as secretary-treasurer of the American Board of Sleep Medicine, and he is chairman of the Behavioral Sleep Medicine Committee of the American Academy of Sleep Medicine. His research interests include cognitive–behavioral interventions for insomnia and the effects of sleep fragmentation.
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Suggested Readings
Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001). Cognitive-behavioral therapy for treatment of chronic primary insomnia. Journal of the American Medical Association, 285, 1856–1864.
Morin, C. M. (1993). Insomnia: Psychological assessment and management. New York: Guilford Press.
Morin, C. M., Colecchi, C., Stone, J., Sood, R., & Brink, D. (1999). Behavioral and pharmacological therapies for late-life insomnia: A randomized controlled trial. Journal of the American Medical Association, 281, 991–999.
Murtagh, D. R., & Greenwood, K. M. (1995). Identifying effective psychological treatments for insomnia: A meta-analysis. Journal of Consulting and Clinical Psychology, 63, 79–89.
Stepanski, E. (2000). Behavioral therapy for insomnia. In M. Kryger, T. Roth, & W. Dement (Eds.), Principles and practice of sleep medicine (3rd ed., pp. 647–656). Philadelphia: W. B. Saunders.
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