SHAWN R. CURRIE
This chapter provides the reader with a review of self-help approaches for sleep problems. The primary focus will be on self-help for insomnia. The first half of the chapter will overview the scope of insomnia as a problem in the general and clinical populations. This is followed by a review of current empirically supported methods of assessing and treating insomnia with implications for self-help applications. The second half of the chapter will provide readers with an overview of the empirical evidence on self-help treatment of insomnia. Limitations of this evidence will be discussed along with suggestions for future research.
History and Theoretical Basis
Sleep disturbances are very common. In the general adult population, the rate of chronic insomnia is estimated as between 9 and 20% (Ancoli-Israel & Roth, 1999; Ohayon, 2002; Partinen & Hublin, 2000). The variability in prevalence rates is due largely to the inconsistent use of strict diagnostic criteria for defining insomnia. Ohayon (2002) recently estimated the prevalence of DSM-IV-defined insomnia disorder as 6% in the general population. A further 25-30% of adults complain of occasional or transient insomnia (Ancoli-Israel & Roth, 1999; Ohayon, 2002). Insomnia was present in 27% of the 26,000 patients from 15 countries that participated in the World Health Organization (WHO) International Collaborative Study on Psychological Problems in General Health Care (Ustun et al., 1996). Patients reported a significant degree of disability in their daily activities and social roles arising from their sleep problems. Half of the patients followed up one year later still reported significant sleep problems. Prevalence rates of both chronic and transient insomnia increase with age, reaching as high as 50% in the elderly in some studies (Ohayon, 2002).
Insomnia frequently co-occurs with another medical or psychiatric disorder (Lichstein, McCrae, & Wilson, 2003; Zorick & Walsh, 2000). Fifty-two percent of insomnia cases in the WHO general health care study were diagnosed with another mental disorder (Ustun et al., 1996). In epidemiological studies the comorbidity of insomnia and psychiatric disorders occurs in between 40 and 65% of cases (Lichstein et al., 2003; Ohayon, 2002). Specific patient groups have been identified as being particularly vulnerable to sleep disturbances. For example, up to 70% of treatment-seeking chronic pain patients report significant insomnia (Moldofsky, 1990; Pilowsky, Cre-ttenden, & Townley, 1985; Wilson, Watson, & Currie, 1998). High rates of insomnia are associated with major depression (Morawetz, 2003), anxiety disorders (McCall & Reynolds, 2000), and alcohol dependence (Brower, 2001; Currie, Clark, Rimac, & Malhotra, 2003). Historically, disturbed sleep in these populations has been considered a consequence or symptom of the primary disorder. However, insomnia often persists even after the primary disorder resolves (Currie et al., 2003; Lichstein, McCrae, et al., 2003). Furthermore, there is compelling epidemiological evidence that insomnia is a risk factor for the later development of major depression (Ford & Kamerow, 1989) and alcohol abuse (Weissman, Greenwald, Nino-Murcia, & Dement, 1997).
Significant health care costs are associated with insomnia. Medications and other sleep-promoting substances cost the United States about $1.7 billion annually. Health care costs (physician visits, sleep medicine consultations) directly attributed to insomnia are estimated at $12 billion annually (Morin, Bastien, & Savard, 2003). Indirect costs, including lost work time, reduced productivity, and fatigue-related accidents, are estimated at $30 to $35 billion per year in the United States (Chilcott & Shapiro, 1996). Despite the high prevalence and enormous cost associated with insomnia, access to treatment is extremely limited. Screening for sleep disturbances only occurs in about half of patients attending primary care (Ustun et al., 1996). Less than 1% of sleep disordered patients are referred on to sleep clinics. Furthermore, less than 15% of sleep clinics provide psychological treatment for insomnia (Ruyak, Bilsbury, & Rajda, 2004).
The majority of insomniacs attempt self-management of their condition using nonprescription sleep aids and alcohol (Ancoli-Israel & Roth,
1999). In a 1995 Gallup Survey of sleep problems in America, only 28% of respondents felt they knew the available treatments for insomnia very well or well. The large majority (72%) reported they did not understand current treatments available (Ancoli-Israel & Roth, 1999). These findings suggest there is both the opportunity and need for self-help interventions for sleep problems.
Insomnia is by far the most prevalent of all sleep disorders. Sleep apnea, characterized by the cessation of airflow through the mouth and nose during the sleep period, affects about 2% of adult women and 4% of adult males (Flemons, 1999; Partinen & Hublin, 2000). Because people with apnea breathe normally during the day, this potentially fatal disorder can go undetected for many years. Restless legs syndrome and periodic limb movement appear with approximately the same frequency as sleep apnea, although the majority of cases are considered mild with little functional impairment (Montplaisir, Nicolas, Godbout, & Walters, 2000). The International Classification of Sleep Disorders—Revised (ICSD-R; American Sleep Disorders Association, 1997) lists dozens of other sleep disorders, most of which are extremely rare (e.g., narcolepsy) or occur exclusively in children (Partinen & Hublin, 2000). The non-insomnia sleep disorders usually require medical interventions. As such, self-help treatment for sleep apnea and other non-insomnia disorders would be inappropriate. There is an abundance of educational material available to the general public on these disorders. Much of the educational focus for sleep apnea has been on identifying the disorder and encouraging individuals to seek medical treatment. There are also support groups for the more common sleep disorders (e.g., A.W. A.K.E. network for persons affected by sleep apnea; Restless Legs Syndrome Foundation support network). The impact of these support groups on the course and severity of these sleep disorders has not been evaluated. Similarly, there is no research on the impact of patient-oriented educational material on the identification, course, or severity of non-insomnia disorders. Therefore, the remainder of this chapter will focus on self-help treatments for the insomnia-spectrum disorders.
A basic tenet of the self-help approach is that individuals are able to diagnose themselves. Nevertheless, a concern is that consumers will misdiagnose themselves, apply the wrong intervention, and possibly exacerbate the problem. If the insomnia is the direct result of another medical or psychiatric condition, it is critical to identify the condition to ensure it also receives proper attention and treatment. Furthermore, other sleep disorders can have similar nocturnal and daytime characteristics as insomnia. For example, unrefreshing sleep and daytime fatigue are symptoms of both insomnia and sleep apnea. An individual with undiagnosed sleep apnea attempting to apply behavioral techniques developed for managing insomnia would likely experience little benefit. Most self-help books for insomnia include a section on other sleep disorders with the intention of helping readers to detect and seek treatment for conditions other than insomnia.
Two parallel classification schemes exist for diagnosing sleep disorders. The DSM-IV system (American Psychiatric Association, 1994) is the most widely known but generally not preferred by sleep experts because the criteria do not include any specification for frequency or severity of insomnia symptoms. The DSM-IV criteria for primary insomnia specify a minimum duration of one month of difficulty initiating or maintaining sleep or non-restorative sleep. The sleep problem must interfere with the individual's ability to function during the day or cause clinically significant distress. The ICSD-R definition of psychophysiological insomnia is comparable to the DSM system in terms of the duration and functional impairment criteria. The ICSD-R is similarly vague in the specification for frequency of symptoms (the sleep problem must occur "almost nightly"). Neither system provides specific quantitative criteria for distinguishing normal from abnormal sleep. For many years, researchers have adopted the following quantitative criteria to identify insomniacs: the individual must have a sleep onset latency (SOL) or time awake after sleep onset (WASO) greater than 30 minutes for a minimum of 3 nights per week. In a rigorous sensitivity-specificity analysis, Lichstein, Durrence, Taylor, Bush, and Riedel (2003) provided empirical support for these criteria in identifying "research-grade" insomnia. They also found that a duration specifier of at least 6 months rather than one month is a more defensible criterion for identifying a chronic sleep problem.
Research studies that evaluate self-help materials have generally screened participants in person using recognized diagnostic instruments such as structured interviews, sleep diaries, and questionnaires (Pittsburgh Sleep Quality Index; Buysse, Reynolds, Monk, Berman, & Kupfer, 1989; and Sleep Impairment Index; Morin, 1993, are two popular insomnia questionnaires). Consumers of self-help books do not usually have the luxury of a professional consultation. Some self-help books include a self-diagnostic test to identify insomnia. Table 10.1 contains the brief assessment tool from my own book :60 Second Sleep Ease (Currie & Wilson, 2002). The items and scoring for this tool are taken directly from the DSM-IV criteria for primary insomnia. Unfortunately, there is no evidence that consumers can reliably and accurately self-diagnose insomnia using such
Table 10.1 Example of a Self-Diagnostic Test for Insomnia
1. a. In a typical week, do you have nights when it takes you more than 30 minutes to fall asleep? _Yes _No b. If you answered yes, how many nights in a typical week does this happen?
_Three times or more
2. a. In a typical week, do you have nights when wake up through the night and have a problem getting back to sleep? _Yes _No b. If you answered yes, how many nights in a typical week does this happen?
_Three times or more
3. a. In a typical week, do you have mornings when you wake up earlier than you wanted to and have a problem getting back to sleep? _Yes _No b. If you answered yes, how many nights in a typical week does this happen?
_Three times or more
4. a. In a typical week, do you wake up feeling like your sleep was not restful? _Yes _No b. If you answered yes, how many nights in a typical week does this happen?
_Three times or more
5. Do you feel your sleep problem is a direct cause of:
_significant distress for you
_missing time at work
_not doing your job well when at work
_missing social functions
_problems getting along with friends, family, or coworkers
6. Have your sleep difficulties been going on for more than one month? _Yes _No
If you answered yes to questions 1, 2, 3, or 4 and indicated that the sleep problem happens three times per week or more for at least one of these questions, then you do indeed have some significant symptoms of insomnia. If you checked off at least one of the problems listed in question 5 and indicated on question 6 that this has been going on for more than one month, then there is a good chance you have an insomnia disorder. A disorder means that the insomnia symptoms are severe enough to cause problems in your life.
Note: From 60 Second Sleep Ease: Quick Tips to Get a Good Night's Rest, by S. R. Currie and K. G. Wilson, 2002, 16-17. Far Hills, NJ: New Horizon Press. Reprinted with permission a test. It should also be noted that many books include no self-diagnostic tests for sleep problems.
Until about 20 years ago, the only treatment available for insomnia was medication. At present, medication remains the most commonly used form of treatment for insomnia and related sleep disorders. A contributing factor is the paucity of health professionals trained in psychological methods for improving sleep, combined with the difficulty patients often experience in accessing such professionals (Morin et al., 2003). As noted, even sleep clinics provide relatively little treatment for insomnia (Ruyak et al., 2004). The services of a psychologist or sleep medicine specialist are not always covered by health insurance plans. In contrast, sleep medication is widely available and relatively inexpensive. These facts provide further justification for developing and testing self-help interventions for insomnia to give patients more accessible and affordable alternatives to drug therapy.
The most common medications for sleep are the benzodiazepine receptor agents, which include the traditional benzodiazepines (e.g., oxazepam, triazolam) and several newer hypnotics that are not labeled benzodiaze-pines (e.g., zolpidem, zopiclone) but act on the same neuroreceptor. Sedating antidepressants (e.g., trazodone, amitriptyline) are also used as sleep aids primarily among depressed patients. The majority of over-the-counter sleep medications contain diphenhydramine as the active ingredient. Empirical support for the benzodiazepine receptor agents as short-term sleep aids is very good (Smith et al., 2002). Older medications suppress slow-wave sleep, which can decrease sleep quality and increase daytime fatigue. The newer hypnotics and the sedating antidepressants seem to have less impact on slow-wave sleep (Roehrs & Roth, 1997). Evidence of long-term efficacy is lacking with all the sleeping pills (Smith, Smith, Nowakowski, & Perlis, 2003). Over time, individuals can develop a tolerance to the hypnotic effects. There is also the risk of drug dependence and daytime impairment (drowiness, memory problems, dizziness, etc.). Sleep medications are recommended for short-term (<4 weeks) use only and are contraindicated as a monotherapy in the treatment of chronic insomnia (Morin et al., 2003).
Psychological management techniques have been available for many years but only recently have come into the forefront as the preferred treatment for chronic insomnia. Cognitive-behavioral treatment (CBT) of insomnia has been well researched in the last 15 years (Morin, Hauri, et al., 1999) with recent studies published in high-profile, non-sleep journals such as the Journal of the American Medical Association (Edinger,
Wohlgemuth, Radtke, Marsh, & Quillian, 2001; Morin, Colecchi, Stone, Sood, & Brink, 1999), Journal of Consulting & Clinical Psychology (Currie, Wilson, Pontefract, & deLaplante, 2000; Mimeault, & Morin, 1999), and American Journal of Psychiatry (Smith et al., 2002). More than 50 clinical trials (involving over 2000 patients) have been conducted that demonstrate the efficacy of CBT approaches to managing insomnia. Robust changes in sleep onset latency, nocturnal wakefulness, and sleep quality ratings have been reported. The results of two meta-analyses (Morin, Cul-bert, & Schwartz, 1994; Murtagh & Greenwood, 1995) revealed changes in sleep parameters with large effect sizes. Approximately 75% of insomnia patients benefit from CBT, with an average decrease in time to fall asleep and wake time after sleep onset of 50% (Currie, Wilson, & Curran, 2002; Morin et al., 2003). Posttreatment and follow-up values for sleep latency and wake after sleep onset are generally below or near the 30-minute cutoff criterion used to distinguish normal from problematic sleep. The rate of clinically significant change, defined as achieving normal sleep according to the current criteria, ranges from 18 to 50% with lower rates for persons with comorbid conditions (Morin et al., 2003). Furthermore, CBT can be effective in getting 50-84% of patients to wean off hypnotics (Currie, Clark, Hodgins, & el-Guebaly, 2004; Currie et al., 2000; Espie, Inglis, & Harvey, 2001; Gustafson, 1992; Jacobs, Benson, & Friedman, 1996). There is sufficient empirical evidence to support the classification of CBT for insomnia as a well-established treatment according to the American Psychological Association's task force criteria for Empirically Supported Therapies (Morin et al., 2003).
Psychological treatment for insomnia has its origins in cognitive-behavior therapy with four key interventions that continue to dominate treatment approaches: stimulus control, sleep restriction, relaxation training, and cognitive restructuring. All the self-help materials used in research applications include one or more of these key interventions. Many of the untested materials include variations of these interventions, often in a diluted or more generic form. For example, the stimulus control principles are sometimes summarized as "good sleep habits." Unfortunately, many self-help books integrate stimulus control with a great deal of untested advice.
Stimulus control and sleep restriction are intended to reestablish the bed as the dominant cue for sleep, regulate sleep-wake schedules, and consolidate sleep over a shorter period of time. Stimulus control consists of directing patients to avoid napping, to go to bed only when sleepy, to use the bedroom only for sleep and sex, to establish a presleep routine to be used every night, and to get out of bed when unable to fall asleep within 20 minutes. Although these rules appear simple, adherence and regular nighttime application can be a challenge for insomniacs (Morin et al., 2003). For example, the rule concerning getting out of bed when not sleeping should be practiced throughout the night, which may require the individual to leave her bed 3 or 4 times during a particularly bad night of sleeplessness. Noncompliance with the stimulus control guidelines is associated with poor outcome (Riedel & Lichstein, 2001).
With sleep restriction, participants are directed to reduce their time in bed to the total sleep time recorded during the baseline self-monitoring period. The "sleep window," never less than 5 hours, is increased in 15- to 30-minute increments in subsequent weeks, with the goal of achieving 85% sleep efficiency within 3 to 4 weeks. The purpose of sleep restriction is to help the individual concentrate his or her sleep into a shorter period of time spent in bed. A variation of sleep restriction has the patient gradually decrease time in bed over several nights rather than all at once. This approach may be more palatable to severe insomniacs, but there is greater risk of noncompliance. With proper application, sleep restriction reduces sleep fragmentation and increases sleep quality. Total sleep time may also show a small gain of 25 to 30 minutes with consistent application of both stimulus control and sleep restriction (Morin, Hauri, et al. 1999). However, patients are told not to expect a large increase in total sleep duration. Behavioral management of insomnia generally aims to increase the quality but not necessarily quantity of sleep time.
Relaxation techniques are used as a form of counterconditionining to reduce physiological arousal in the sleep setting. The rationale for relaxation therapy is based on the strong evidence of hyperarousal in insomniacs both at night and during the daytime. Compared to good sleepers, insomniacs show higher metabolic rates, muscle tension, cardiovascular activity, and cortical activation (Bonnet & Arand, 1997; Morin, 1993). Cognitive arousal is strongly implicated in the etiology of poor sleep. Compared to good sleepers, insomniacs demonstrate overactive cognitive activity (e.g., racing thoughts, instrusive cognitions) during the presleep period (Harvey, 2002). Moreover, the content of their thoughts is typically negative, often filled with excessive worries about lack of sleep and related consequences. Cognitive hyperarousal contributes to heightened physiological arousal that can disrupt the normal transition from awake to sleep. Over time, the arousal becomes associated with the bedroom environment. Conditioned arousal is the primary rationale underlying stimulus control, which aims to break the association between the bedroom and sleeplessness.
Several methods of relaxation are available: progressive muscle relaxation (PMR), imagery training, meditation, and hypnosis are the most common. All have the same goal of reducing arousal before bedtime and faciliating sleep onset. The most researched method is progressive muscle relaxation, a technique involving the systematic tensing and relaxing of muscles in the body. Studies comparing the relative efficacy of relaxation methods have produced largely equivocal results. Imagery-based relaxation may have an advantage over PMR in addressing cognitive arousal in insomniacs, although apart from a single study (Woolfolk & McNulty, 1983) there is no strong evidence of superior outcomes. The basic premise of relaxation for sleep induction has strong face validity among insomniacs (in contrast to sleep restriction, which many insomniacs find counterintuitive). The instructions are simple and easily presentable in a written format. Consequently, the majority of self-help books for insomnia include a relaxation script. Readers are often encouraged to read the relaxation instructions into a tape recorder to produce their own relaxation tape. Commercial audiotapes of relaxation exercises are also widely available.
Cognitive restructuring interventions, adapted from Aaron Beck's work in the treatment of depression, were added to insomnia treatment based on the work of Charles Morin at Laval University and recently expanded upon by Alison Harvey at Oxford University (Harvey, 2002). Compared to imagery relaxation, which indirectly targets the problem of excessive cognitive arousal in insomniacs, restructuring methods help patients to modify the content of negative thoughts contributing to sleeplessness. Many insomniacs have maladaptive beliefs about sleep and the consequences of insomnia (Morin, 1993). Erroneous thoughts about sleep and insomnia can increase the level of sleep-related performance anxiety and promote adoption of counterproductive compensatory behaviors (Smith et al., 2003). For example, an insomniac may cope with a bad night of sleep by napping during the day or going to bed earlier in an attempt to recover lost sleep. Insomniacs can also use the bedroom as a "worry zone," often lying in bed at night ruminating about negative life events and personal problems. Cognitive interventions for insomnia focus on decatastrophiz-ing insomniacs' thoughts about sleep and the consequences of insomnia. Basic education on the nature of sleep, the individuality of sleep needs, and importance of sleep quality over sleep quantity can be helpful in getting patients to challenge some of their beliefs about sleep. Nevertheless, cognitive interventions can be difficult to translate into a self-help format.
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