Stimulus control and imagery training in treating sleep-maintenance insomnia.

This study compared the relative efficacy of stimulus control and imagery training with a wait-list control condition for treating 21 sleep-maintenance insomniacs. Stimulus control was more effective than either imagery training or no treatment in reducing both the frequency and duration of night-time awakenings. Further reductions were made by the stimulus control group on both measures at 3-month follow-up, but these were only partially maintained at the 12-month follow-up. Although imagery training had minimal effects on both sleep measures during treatment, substantial reductions over baseline levels of awakening duration were obtained at follow-up. These findings suggest that behavioral and cognitive procedures, previously found effective in treating sleep-onset insomnia, are also beneficial in alleviating maintenance insomnia. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Countercontrol treatment of sleep-maintenance insomnia in relation to age.

Administered countercontrol behavioral therapy for sleep-maintenance insomnia to 34 insomniacs (aged 35–78 yrs) in small groups. 22 Ss received immediate and 12 received delayed treatment. Three self-report measures of sleep disruption were collected on daily sleep diaries at baseline, termination of treatment, 1-mo follow-up, and 12-mo follow-up. Although amount of time awake at night was correlated with age, response to treatment was not. Even though older Ss experienced more time awake after sleep onset prior to treatment, they were able to profit from therapy as well as the younger insomniacs. Countercontrol therapy reduced the sleep complaint for the total group by about 30% at the end of treatment, with gradual improvement continuing through a 4-wk follow-up. It is suggested, however, that sleep-maintenance insomnia may be more difficult to treat than sleep-onset problems. (21 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological treatment of secondary insomnia.

Psychological treatment of insomnia has focused on primary insomnia (i.e., having a psychological origin). Secondary insomnia, sleep disturbance caused by a psychiatric or medical disorder, although it is more common than primary insomnia, has received very little attention as a result of the belief that it would be refractory to treatment. The present study randomly assigned older adults with secondary insomnia to a treatment group, 4 sessions composed of relaxation and stimulus control, or a no-treatment control group. Self-report assessments conducted at pretreatment, posttreatment, and a 3-month follow-up revealed that treated participants showed significantly greater improvement on wake time during the night, sleep efficiency percentage, and sleep quality rating. The authors hypothesize that treatment success was probably due in part to difficulty in diagnostic discrimination between primary and secondary insomnia. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavioral and cognitive treatments of geriatric insomnia.

Geriatric insomnia is a prevalent problem that has not received adequate controlled evaluation of psychological treatments. The present study evaluated behavioral and cognitive methods, relative to a wait-list control condition, for treating 27 elderly subjects (mean age?=?67 years) with sleep-maintenance insomnia. Both treatment methods, stimulus control and imagery training, produced significant improvement on the main outcome measure of awakening duration. Stimulus control yielded higher improvement rates than either imagery training or the control condition on awakening duration and total sleep-time measures. Sleep improvements were maintained by the two treatment methods at 3- and 12-month follow-ups. The results were corroborated by collateral ratings obtained from significant others. Subjective estimates of awakening duration and sleep latency correlated highly with objective measures recorded on an electromechanical timer. The findings suggest that geriatric insomnia can be effectively treated with psychological interventions and that behavioral procedures are more beneficial than cognitive procedures for sleep maintenance problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Disqualified and qualified poor sleepers: Subjective and objective variables.

Investigated discrepancies between subjective reports and EEG measures in patients complaining of insomnia in order to aid in the clinical management and research of insomniacs. 30 laboratory-qualified poor sleepers (QPSs [mean age 20.5 yrs]) and 30 laboratory-disqualified poor sleepers (DPSs [mean age 19.7 yrs]), all male students at the Naval School of Health Sciences, were compared on subjective report, mood, and all-night sleep laboratory variables. Results show that QPSs had significantly lower sleep efficiency and total sleep time in the laboratory due to longer sleep latencies. QPSs gave accurate morning estimates of their laboratory sleep latencies, whereas DPSs were significantly more likely to exaggerate their sleep latencies. Although ways of predicting which poor sleepers would show sleep-onset insomnia in the sleep laboratory were not identified, it was found that in the population used there were poor sleepers who gave accurate reports of severe sleep-onset insomnia. (25 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of sleep-maintenance insomnia in older adults: Sleep period reduction, sleep education, and modified stimulus control.

We evaluated a behavioral treatment package consisting of sleep period restriction, sleep education, and modified stimulus control in the treatment of sleep-maintenance insomnia in older adults. A multiple baseline design was used with 4 chronic insomniac subjects, ages 59, 65, 65, and 72. Sleep diaries and an objective behavioral measure of sleep were used to monitor improvement. Results revealed clinically significant reductions in time awake after sleep onset in 3 subjects, coincident with the initiation of treatment. These improvements were maintained at 2- and 6-month follow-ups. The 4th subject showed little improvement; however, a polysomnogram conducted on this subject at the end of the study revealed a fragmented sleep pattern secondary to periodic movements of sleep (nocturnal myoclonus). These encouraging but preliminary results call for further controlled evaluations of the efficacy of this behavioral treatment package for sleep-maintenance insomnia. The importance of conducting polysomnographic studies on elderly insomniacs is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavioral treatment of chronic insomnia in psychiatrically ill patients

BACKGROUND: Psychiatric patients often have residual intractable insomnia as a serious problem. METHOD: Forty-eight psychiatrically ill patients (DSM-IV diagnoses) who had failed to respond to medicinal treatment for chronic insomnia were referred for and completed behavioral therapy as an adjunct to the pharmacologic treatment of their insomnia. The behavioral treatments included structured sleep hygiene, progressive muscle relaxation, stimulus control, and sleep restriction. The treatment program was accomplished in 6 sessions over 2 months. Follow-up evaluations were completed at 2, 6, and 12 months from the beginning of the treatment program. The outcome of the treatment program was evaluated in terms of the change in (1) self-reported specific sleep parameters, (2) self-ratings of sleep-related day-time state, (3) self-rating of quality of sleep, (4) the use of sleep medication, and (5) the therapist's global rating of improvement. RESULTS: There was a statistically significant change from the baseline in all self-reported specific sleep parameters after 2 months that was sustained after 6 and 12 months. Sleep-related characteristics of daytime state showed statistically significant changes after 2 and 6 months that were maintained after 12 months. Sleep quality had a statistically significant change after 2 months, continued to improve statistically after 6 months, and was maximum after 12 months. Over half the patients (52.7%; 20 of 38) either reduced their sleep medication by half or stopped it completely. The therapist's global rating showed an improvement in 29.2% (N = 14) of patients after 2 months, 56.2% (N = 27) after 6 months, and 68.7% (N = 33) after 12 months. CONCLUSION: The use of concomitant behavioral and pharmacologic treatment of chronic insomnia in psychiatrically ill patients results in improving sleep and sleep-related state and reduces the risk of return of insomnia for 10 months after finishing active treatment.     

Efficacy of an outpatient treatment program for insomnia: A preliminary report.

Evaluated 20 patients who suffered from chronic insomnia and who completed all phases of a 1-yr treatment program. The treatment, which consisted of 5 weekly, 1-hr group sessions and a follow-up 1 mo later, provided education about sleep, instruction in relaxation techniques, stimulus control instructions, and training in sleep hygiene. Self-monitoring data collected by the Ss showed general improvement across a variety of sleep parameters. (9 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Internet-Based Treatment for Insomnia: A Controlled Evaluation.

This study investigated the effects of an Internet-based intervention for insomnia. Participants who met criteria for insomnia (N = 109) were randomly assigned to either a cognitive-behavioral self-help treatment or a waiting list control condition. The 5-week intervention mainly consisted of sleep restriction, stimulus control, and cognitive restructuring. Sleep diary data were collected for 2 weeks at baseline and at posttreatment. The dropout rate was 24% (n = 28). Results showed statistically significant improvements in the treatment group on many outcome measures, including total sleep time, total wake time in bed, and sleep efficiency. However, improvements were also found in the control group. Overall, between-groups effect sizes were low, with the exception of the Beliefs and Attitudes About Sleep Scale (Cohen's d = .81). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nonpharmacological interventions for insomnia in older adults: A meta-analysis of treatment efficacy.

The benefit of nonpharmacological interventions for insomnia in old age was investigated. A total of 13 single-outcome studies from 1966–1998 involving 388 patients (mean age exceeding 60 years, minimum age in sample, 50 years) were included in a meta-analysis of treatment efficacy. This analysis demonstrated that behavioral interventions produce improvements in sleep parameters of older insomniacs, measured in terms of sleep-onset latency, number of nocturnal awakenings, time awake after sleep onset, and total sleep time. Clinical improvements seen at posttreatment were maintained at followups (averaging 6 months). It is concluded that behavioral treatments produce significant and long-lasting improvements in the sleep pattern of older insomniacs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of active immunization of sheep against an amino terminal peptide of the inhibin alpha C subunit on intrafollicular levels of activin A, inhibin A and follistatin

This article reviews issues involved in the diagnosis of insomnia and discusses treatment options, including pharmacologic treatment, which is indicated mainly in acute insomnia. Sleep hygiene is then discussed. Finally, the various behavioral treatments are reviewed, including light therapy, relaxation training, cognitive therapy, sleep curtailment, and stimulus control therapy.     

A comparison of progressive relaxation and autogenic training as treatments for insomnia.

Evaluated 2 relaxation techniques, progressive relaxation and autogenic training, as treatments for insomnia. No-treatment, a baseline control group, and a self-relaxation group designed to control for nonspecific therapeutic elements were employed. Ss were 30 adult insomniacs who had chronic and severe difficulties in falling asleep. As indicated by global measures of improvement and by reduction in time to fall asleep, progressive relaxation and autogenic training were equally effective as treatments and superior to both control groups. At a 6-mo follow-up, treatment gains had been maintained in time to fall asleep but not in self-reported global improvement, while control Ss showed no spontaneous improvement on either of the measures. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Barriers to engagement in sleep restriction and stimulus control in chronic insomnia.

Sleep restriction (SRT) and stimulus control (SC) have been found to be effective interventions for chronic insomnia (Morgenthaler et al., 2006), and yet adherence to SRT and SC varies widely. The objective of this study was to investigate correlates to adherence to SC/SRT among 40 outpatients with primary or comorbid insomnia using a correlational design. Participants completed a self-report measure of sleepiness prior to completion of a 6-week cognitive behavioral treatment group for insomnia. At the posttreatment period, they rated their ability to engage in SC/SRT using a survey. Results from standard multiple regression analyses showed that perceiving fewer barriers (i.e., less boredom, annoyance) to engaging in SC/SRT and experiencing less pretreatment sleepiness were each associated with better adherence to SC/SRT. Adherence to SC/SRT was associated with outcome. Implications of these findings are that more work is needed to make SC/SRT less uncomfortable, possibly by augmenting energy levels prior to introducing these approaches. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evidence-based psychological treatments for insomnia in older adults.

The review describes evidence-based psychological treatments (EBTs) for insomnia in older adults. Following coding procedures developed by the American Psychological Association's Committee on Science and Practice of the Society for Clinical Psychology, two treatments were found to meet EBT criteria: sleep restriction-sleep compression therapy and multicomponent cognitive-behavioral therapy. One additional treatment (stimulus control therapy) partially met criteria, but further corroborating studies are needed. At the present time, there is insufficient evidence to consider other psychological treatments, including cognitive therapy, relaxation, and sleep hygiene education, as stand-alone interventions beneficial for treating insomnia in older adults. Additional research is also needed to examine the efficacy of alternative-complementary therapies, such as bright light therapy, exercise, and massage. This review highlights potential problems with using coding procedures proposed in the EBT coding manual when reviewing the existing insomnia literature. In particular, the classification of older adults as persons age 60 and older and the lack of rigorous consideration of medical comorbidities warrant discussion in the future. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The differential functions of imagery and verbal thought in insomnia.

Individuals with insomnia were exposed to a stressor (speech threat) prior to getting into bed and were instructed to think about the speech and its implications in either images (Image group, n = 14) or verbal thought (Verbal group, n = 17). Participants completed questionnaires about speech anxiety, arousal, and sense of resolution. Measures were taken of subjective (sleep diary estimates) and objective (actigraphy) sleep-onset latency. In the short term, the Image group reported more distress and arousal relative to those in the Verbal group. In the longer term, the Image group estimated that they fell asleep more quickly and, the following morning, reported less anxiety and more comfort about giving the speech compared with the Verbal group. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Controlled investigation of the effects of progressive and hypnotic relaxation on insomnia.

37 female college students with insomnia were matched on latency of sleep onset and assigned to 1 of 4 treatment conditions: progressive relaxation, hypnotic relaxation, and waiting-list no-treatment control. After 3 therapy sessions, progressive and hypnotic relaxation groups showed significantly greater improvement than no-treatment controls, while self-relaxation produced nearly equal improvement. Physiological changes during therapy were unrelated to outcome change. Results are discussed in terms of demand characteristics, placebo effects, and attention focusing. (16 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effects of presleep stress on sleep-onset insomnia.

10 sleep-onset (SO) insomniacs and 11 noninsomniacs (18–21 yrs old) slept undisturbed for 3 nights but were exposed to brief cognitive stressors before SO on the next 2 nights. Significant between-group differences were found in responses to the cognitive stressors on self-report but not objective measures of SO latency (SOL). Noninsomniac Ss evidenced an increase and insomniac Ss a decrease in SOL on stress nights. Insomniac Ss demonstrated a significantly higher mean heart-rate response before and after the stressors. A variable expressing the relationship between objective and subjective measures of SOL (pseudoidiopathic dimension) for each S was not significantly related to Ss' responses to stress. Results are inconsistent with the hypothesized role of presleep stress in SO insomnia but are consistent with other studies indicating higher levels of physiological arousal of insomniac vs noninsomniac Ss. (22 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Active and placebo effects in treatment of moderate and severe insomnia.

Examined the efficacy of relaxation training and a highly credible placebo in the treatment of both severe and moderate sleep onset insomnia. The placebo treatment was designed to elicit an expectation for improvement comparable with that of relaxation training. Expectancy of improvement was further controlled by informing Ss to expect improvement only after the 3rd wk of therapy, thus allowing comparisons of the treatments to be made during the counterdemand period (1st 3 wks) and the positive demand period (4th wk and beyond). Responses of 30 18–76 yr old severe and moderate insomniacs were similar across treatment conditions, over weeks, and in response to the counterdemand/positive demand manipulation. Only Ss trained in relaxation techniques improved significantly during the counterdemand period. The active treatment was significantly more effective than the placebo in reducing sleep onset latency during the counterdemand period. After the introduction of positive expectancy of therapy outcome, relaxation was no longer superior to placebo. Findings are discussed in terms of the methodological difficulties inherent in controlling for S expectancy of therapeutic effects in treatment studies of insomnia. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Insomnia.

Insomnia is a heterogeneous disorder variously caused by a number of psychological, environmental, and biological factors. A growing literature on the 2 subtypes of insomnia most likely associated with predominantly psychological factors (psychophysiological and subjective insomnia) has suggested the possible role of physiological hyperactivity, cognitive intrusions, unusual sleep phenomenology, and deficient sensorimotor rhythm in the origins and maintenance of some forms of the disturbance. Preliminary evidence indicates that relaxation techniques, biofeedback, paradoxical intention, and stimulus control all contain active ingredients effective in reducing the subjective complaint of insomnia, with additional EEG documentation in the case of relaxation and biofeedback. (87 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)