Medical Care: The management of insomnia depends on the etiology of the insomnia.
" If the patient has a medical, neurologic, or sleep disorder, direct treatment at the disorder. In particular, adequate pain control can greatly relieve the insomnia associated with pain syndromes.
" If the patient has a psychiatric disorder, direct treatment at the disorder. This may involve medications, psychotherapy, and possible referral to a psychiatrist, psychologist, or therapist.
" If the insomnia is related to medication or drug abuse, withdrawing the offending medication or drug is appropriate therapy.
" The treatment of psychophysiologic insomnia begins with an educational discussion about sleep and adequate sleep hygiene.
" Before instituting therapy, most patients are asked to keep a sleep log for 2-4 weeks. This log, in which the patient records bed and wake times, sleep duration, and daytime naps and activities, gives the physician a clearer picture of the degree of sleep disturbance and allows him or her to better tailor the treatment.
" Behavioral therapy is now considered the most appropriate treatment for patients with primary insomnia. Therapies are based on the fact that primary insomnia is associated with physiologic, emotional, and cognitive arousal and conditioning to arousal in bed. The 3 primary behavioral therapies are as follows:
o Relaxation therapies
" In progressive relaxation, the patient is taught to recognize and control tension through a series of exercises that consist of first tensing and then relaxing each muscle group in a systematic way.
" Guided imagery and meditation teach the patient how to focus on neutral or pleasant targets in place of racing thoughts.
" Biofeedback techniques can also be used. They have the advantages of providing patients with immediate feedback regarding their levels of tension and more quickly teaching them how to relax.
o Stimulus control therapy: This therapy works to reassociate the bed with sleepiness instead of arousal. Rules for its use include the following:
" The patient uses the bed only for sleeping and sexual activity (no reading, television, eating, or working in bed).
" The patient lies down only when sleepy.
" If the patient is unable to fall asleep in 15-20 minutes, he or she leaves the bed to do something relaxing until sleepy.
" The previous step is repeated as often as necessary.
" The patient does not spend more time in bed than is needed.
o Sleep-restriction therapy: This therapy is based on the fact that excessive time in bed often perpetuates insomnia. Limiting the time in bed leads to more efficient sleep that is both consolidated and more regular and predictable. Time in bed is allowed to increase as the patient demonstrates a continuing ability to sleep in an efficient and consolidated fashion.