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* Includes chapters on sleep phase disorders, sleep apnea, periodic limb movements, narcolepsy, limit setting disorders in children, enuresis, and night terrors.
* Provides a unique, behavioral approach to sleep medicine.
EDWARD J. STEPANSKI and MICHAEL L. PERLIS
Formally, behavioral sleep medicine (BSM) refers to the branch of clinical sleep
medicine and health psychology that:
1. Focuses on the identification of the psychological (e.g., cognitive and/or
behavioral) factors that contribute to the development and/or maintenance
of sleep disorders
2. Specializes in developing and providing empirically validated cognitive,
behavioral, and/or other nonpharmacologic interventions for the entire
spectrum of sleep disorders
Behavioral sleep medicine is about to become a recognized subspecialty of sleep
medicine, one with its own guidelines for training, board exam, journal, and
now, with this book, its own principles and practice text. Thus, it seems appropriate
to ask: "Where have we come from?" and "Where are we going?" A historical
retrospective serves to help us address the former and acknowledges the
work on which our field has been founded. The proposed commentary allows us
to proactively consider the challenges that lieahead.
TREATMENT DEVELOPMENT AND THE FOUNDATIONS
FOR BEHAVIORAL SLEEP MEDICINE
Behavioral sleep medicine owes its existence as a subspecialty to the efforts to
define and treat insomnia as a cognitive and behavioral disorder. Our field has
two other, less well-recognized, sources:
1. The effort to define and treat pediatric sleep disorders behaviorally
2. The effort to apply cognitive and behavioral principles and practices to the
full spectrum of sleep disorders
Accordingly, any attempt to provide a historical perspective on our field requires
a review of how the various treatment modalities came into existence.
Treatment of Insomnia
Jacobson's well-known work on insomnia can arguably be cited as the beginning
of BSM (1). Jacobson developed the tenets of progressive muscle relaxation
(PMR) based on his work with patients he felt to have stress-related somatic
problems. He theorized that heightened arousal contributed to a number of common
medical complaints. PMR was a central treatment, but other stress management
techniques were included in his treatment programs. The foundation for
Jacobson's work can be traced to his training at Northwestern, Harvard, and the
University of Chicago, where he trained with notable figures such as William
James and Walter Cannon.
Jacobson provides a precise description of what would eventually be called psychophysiological
insomnia in his 1938 book You Can Sleep Well (2). Although
Jacobson is remembered for developing PMR as his major contribution, his writing
also demonstrates a profound understanding of insomnia. In particular, his
description of the behavioral and cognitive factors associated with insomnia is
similar to our current understanding of these dimensions. He describes how the
stresses of a modern society can lead to heightened arousal at night and then, in
turn, to insomnia:
What with electric lighting, automobiles, motion pictures, radios and other innovations,
life after dark has become so attractive that most of the evening hours up
to midnight are commonly occupied by some form of amusement-if only talking
things over with friends and neighbors. (2, p. 182)
Every age has challenges that are in some ways unique but in a broader sense
similar to those faced in every era. Reading Jacobson's case description of a patient
with insomnia 70 years ago gives substance to the adage from psychotherapy
that " the actors change, but the roles remain the same." In today's era, we would
cite the Internet, satellite television, and 24-hour supermarkets as threats to a
normal sleep-wake pattern in our version of modern society.
It is also interesting to note that concerns about pharmacological treatment for
insomnia have not changed much over the years. Practitioners from the earlier
era also expressed concerns about pharmacologic options for the treatment of insomnia
(bromides and barbiturates):
Today in most states sleeping medicines can be obtained only on a doctor's prescription,
and this regulation has some merit because there are a few undisciplined
persons who, if left to their own devices, would take large doses of these
drugs every night without waiting to see if they were necessary for the obtaining
of sleep. Many would rather take a drug than to make an effort to control emotions
and calm down in the evenings. (3, p. 25)
Research aimed at understanding mechanisms underlying insomnia made further
advances in the late 1960s. Much of this research took place at the University
of Chicago under the direction of Rechtshaffen. Monroe (4), Hauri (5), Robinson
(6), and Zimmerman (7) studied how physiological and cognitive arousal contributed
to poor sleep. This research showed increased physiological arousal in
poor sleepers compared to good sleepers, both before sleep onset and during the
night (4). The role of physiological hyperarousal as a contributing factor in
chronic insomnia continues to receive empirical support (8-9), and there is now
evidence that central nervous system (CNS) arousal may also play a role in the disorder
Despite the work of Jacobson and others, through the 1950s, insomnia was
viewed as a consequence of a primary psychiatric or medical disorder. There
was a struggle during the 1960s and 1970s about whether insomnia was always
related to a psychiatric or medical disorder or could be "learned." The view that
a primary psychiatric disorder was always to blame may be found in the writing
of Kales (11). Acceptance of insomnia as a learned behavior was signified in the
original nosological system published by the American Sleep Disorders Association
(12). The term psychophysiological insomnia was used to denote an association
between increased arousal and poor sleep, similar to the prevailing view
that arousal might lead to hypertension or ulcers.
Aside from more basic research, many treatment outcome studies were conducted
during the 1970s and early 1980s on relaxation-based treatment approaches
to the treatment of insomnia. Progressive muscle relaxation was the
approach most often studied. Studies using self-report measures of sleep tended
to find a greater magnitude of change (13-15) than did those studies obtaining
EEG measures of sleep (16-18). In general, it has been found that relaxation treatments
generally did not show large effect sizes and were not better than placebo in
some trials (19-20). The American Academy of Sleep Medicine (AASM) practice
parameter paper for chronic insomnia rated PMR as empirically validated and
well established (21).
One variant on "exercise"-oriented relaxation techniques (PMR, autogenics,
and diaphragmatic breathing) is the use of biofeedback to diminish the hyperarousal
that is thought to be associated with insomnia. Hauri published the best
studies on the efficacy of biofeedback in the early 1980s (22-23). This research
was particularly notable because he was able to show that increased arousal,
measured by electromyography (EMG) levels, predicted successful treatment
with EMG biofeedback but not sensory-motor rhythm (SMR) biofeedback. SMR
biofeedback trains the individual to increase the 12 to 14 Hz type brain activity
that tends to be associated with cortical synchronization and deeper sleep. This
remains the only study to successfully show that treatment can be tailored based
on patient characteristics. Other attempts to tailor treatment have not been successful
and even showed that the nonpreferred treatment modality provided
greater benefit than the predicted treatment (24). The AASM practice parameter
paper rated biofeedback as empirically validated and probably efficacious as
a treatment for chronic insomnia (21).
Over the past 15 years, relaxation therapies have gradually been replaced by
other behavioral approaches and multicomponent cognitive-behavioral therapy
(CBT) programs as described later. Biofeedback in particular appears to have
fallen into disuse as a treatment for insomnia-probably because of the time-intensive
nature of this treatment, with 15 to 62 one-hour sessions of training
required for successful treatment (22).
Stimulus Control Therapy
Systematic intervention research investigating treatments for chronic insomnia
had a renaissance in the 1970s. Principles of behavioral theory were applied to
the problem of insomnia, and many new treatment approaches were formulated
at this time. Bootzin used learning theory to create stimulus control therapy
(SCT) for insomnia (25). Many investigators included SCT in their outcome research
on treatment efficacy and showed significant improvement using self-report
measures of sleep initiation and maintenance (15, 26). SCT continues to
be one of the most commonly used behavioral treatments for insomnia and is included
in multicomponent treatment programs for the treatment of insomnia.
The AASM practice parameter recommendations for behavioral treatment of insomnia
found that SCT had strong empirical evidence to support its efficacy and
rated it as empirically validated and well established (21).
A list of rules to follow to promote better sleep in patients with insomnia
was published and called sleep hygiene by Hauri in 1977 (27). This approach is
extremely popular, and sleep hygiene education is almost universally recommended
for the treatment of insomnia (28). The rules considered to constitute
sleep hygiene have evolved over the years. There are few studies of sleep hygiene
as a stand-alone treatment, and, instead, it appears to be considered a necessary,
but not sufficient, approach in the treatment of insomnia (29).
The principles of paradoxical intention (PI ) were used to formulate a treatment
approach to insomnia (30). With PI, patients are instructed to stay awake for as
long as possible after going to bed at night. Several studies reported positive results
with PI using subjective outcome measures (30-32). In fact, the standards
of practice statement rate this treatment as an empirically validated treatment
based on an analysis of the literature, according to guidelines of the American
Psychological Association (APA; 33). While overall effective, the research on
PI as a treatment for insomnia suggests a highly variable treatment response
Sleep Restriction Therapy
In the 1980s, sleep restriction therapy (SRT) was developed by Spielman and
colleagues (34). This behavioral treatment systematically reduces time in bed to
increase homeostatic drive for sleep and then increases time in bed once sleep
efficiency is increased. SRT has become a widely used treatment and is routinely
included as part of CBT treatment programs for insomnia.
An important theoretical model for understanding the formation of chronic insomnia
and its evolution over time was proposed in 1986 (35). This model classifies
factors contributing to chronic insomnia as predisposing, precipitating, or
perpetuating. Each of these types of factors plays a role in the formation and maintenance
of insomnia, and the relative importance of these factors changes over the
course of the insomnia. The least understood factors are predisposing factors although,
as discussed previously, physiological hyperarousal appears to be a strong
candidate as a predisposing factor for the development of chronic insomnia. Precipitating
factors might be medical factors (e.g., pain), psychological factors (e.g.,
increased job stress), environmental factors (e.g., noise in the bedroom), or anything
else (e.g., shift work) that would reasonably disrupt sleep acutely. These are
the factors typically focused on in the nosological system for diagnosing sleep disorders
(36). Perpetuating factors are behavioral and cognitive features of insomnia
that typically develop when an individual has been struggling with insomnia for
days or weeks. Examples include increasing time in bed to achieve more sleep, increasing
use of caffeine to counteract daytime fatigue, self-medicating with alcohol,
and ruminating throughout the day about the need to obtain additional sleep.
This model is important because it provides a framework for understanding what is
otherwise a disparate set of findings about the causes and consequences of insomnia.
Additionally, it can serve to organize clinical interventions by targeting the appropriate
set of factors based on the status of an individual patient.
Although the cognitive component of insomnia has been noted for decades, formalized
cognitive therapy for insomnia is an innovation from the 1990s. A book
on insomnia written by an editorial board of physicians for laypeople, notes that:
Relaxation is more likely to come if the would-be sleeper hasn't any fear of insomnia;
hence the physician does well when he keeps reminding a patient that
nothing terrible need happen to him if he does not sleep. There are thousands of
persons working hard and enjoying fair health who haven't had a good night's
sleep for years. They do not go insane or come to any bad end. (3, p. 16)
In addition to the fear of insomnia, Jacobson notes that "many fear incapacity
through fatigue" (37, p. 182). Indeed, the fear of being awake itself and the fear
of daytime impairment are common among patients with insomnia. The interaction
between cognitive and behavioral factors was also acknowledged in a 1938
book on insomnia:
Nostrums, then, in insomnia are those pet schemes or remedies by whose aid the
insomniac thinks to outwit his enemy, without realizing that often through his
devoted attention to them he is setting up a ritual for himself which is fully calculated
to keep the enemy in power. For these nostrums represent an attempt to
defeat wakefulness or to avoid the anxiety incidental to lying awake, and as such
signify that the individual is attempting to escape his anxiety through the use of
some semi-magical device, thus turning his back on the need for understanding
the problem and working out its solution along informed and intelligent lines.
(38, pp. 134-135)
Patients themselves are also more likely to attribute their sleep difficulty to
heightened cognitive arousal, rather than somatic arousal (39). A formal description
of programmatic cognitive therapy designed for patients with insomnia
is best described by Morin (40). Morin describes how misattributions,
unrealistic expectations, and various cognitive errors contribute to emotional
arousal and, ultimately, to insomnia. He then applies cognitive restructuring
techniques that have been effective in the treatment of anxiety disorders and
depression to changing these maladaptive cognitions that accompany insomnia.
Excerpted from Treating Sleep Disorders
Copyright © 2003 by Michael L. Perlis, Kenneth L. Lichstein.
Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Section I: Introduction to Behavioral Sleep Medicine.
Chapter 1 A Historical Perspective and Commentary on Practice Issues (Edward J. Stepanski and Michael L . Perlis).
Section II: Assessment.
Chapter 2: The Measurement of Sleep (Leisha J. Smith, Sara Nowakowski, James P. Soef fing, Henry J. Orf f, and Michael L . Perlis).
Section III: Sleep Medicine.
Chapter 3: Sleep Apnea: A Challenge for Behavioral Medicine (Rosalind D. Cartwright).
Chapter 4: Periodic Limb Movements: Assessment and Management Strategies (Jack D. Edinger).
Chapter 5: The Symptomatic Management of Narcolepsy (Ann E. Rogers and Janet Mullington).
Chapter 6: Treatment Efficacy of Behavioral Interventions for Obstructive Sleep Apnea, Restless Legs Syndrome, Periodic Leg Movement Disorder, and Narcolepsy (Tracy F. Kuo and Clete A. Kushida).
Section IV: Behavioral Sleep Medicine.
Part 1: Behavioral Principles and Behavioral Sleep Medicine.
Chapter 7: Behavioral-Cognitive Science: The Foundation of Behavioral Sleep Medicine (Kenneth L . Lichstein and Sidney D. Nau).
Part 2 Adult Sleep Disorders and Behavioral Sleep Medicine.
Chapter 8: Evaluation of Insomnia (Arthur J. Spielman, Deirdre Conroy, and Paul B. Glovinsky).
Chapter 9: Primary Insomnia: Diagnostic Issues, Treatment, and Future Directions (Michael T. Smith, Leisha J. Smith, Sara Nowakowski, and Michael L . Perlis).
Chapter 10: Current Status of Cognitive-Behavior Therapy for Insomnia: Evidence for Treatment Effectiveness and Feasibility (Charles M. Morin, Célyne Bastien, and Josée Savard).
Chapter 11: Secondary Insomnia: Diagnostic Issues, Cognitive-Behavioral Treatment, and Future Directions (Kenneth L . Lichstein, Christina S. McCrae, and Nancy M. Wilson).
Chapter 12: Circadian Rhythm Factors in Insomnia and Their Treatment (Leon C. Lack and Richard R. Bootzin).
Part 3: Pediatric Sleep Disorders and Behavioral Sleep Medicine.
Chapter 13: Clinical Assessment of Pediatric Sleep Disorders (Avi Sadeh).
Chapter 14: Behavioral Insomnias of Childhood—Limit Setting and Sleep Onset Association Disorder: Diagnostic Issues, Behavioral Treatment, and Future Directions (Daniel S. Lewin).
Chapter 15: Parasomnias (Gerald M. Rosen, Daniel P. Kohen, and Mark W. Mahowald).
Chapter 16: Efficacy of Behavioral Interventions for
Pediatric Sleep Disturbance (Brett R. Kuhn and Amy J. Elliott).