Cover Story

It's the end of the day, and you're sitting on the couch, struggling to stay awake to watch television. After dozing off, you decide to skip the 11 o'clock news and head to bed. You go upstairs, brush your teeth, climb into bed...and you feel completely awake.

"I love it when patients tell me this scenario," says sleep psychologist Michael Perlis, PhD, "because I know we can help them."

Many times, say sleep psychologists, people have chronic insomnia because of learned behaviors and patterns that are getting in the way of good sleep. Behavioral sleep medicine specialists like Perlis use a combination of techniques--all standard variants of cognitive behavior therapy that have been well-researched--to help insomnia patients fall asleep faster, wake up less frequently and sleep more efficiently in about six to eight weekly sessions:

  • Sleep education. Many behaviors that would seem to promote sleep actually deter it. Therapists help identify these maladaptive behaviors and how to counteract them. For example, many people with insomnia tend to go to bed earlier and stay in bed later to make up for their sleeplessness. However, the protracted time in bed results in sleep that is less efficient and less rejuvenating for the body. Experts also advise that those with insomnia establish regular sleeping schedules, eliminate napping and avoid nicotine, caffeine, exercise and drinking alcohol for several hours before bedtime.

  • Cognitive therapy. This component is designed to address many negative beliefs and thoughts about sleep that can exacerbate insomnia. For example, many people with insomnia have unrealistic expectations about how long they should be sleeping, mistakenly attribute poor daytime performance solely to their insomnia or perceive the effects of insomnia to be much greater than they really are.

  • Stimulus control. Pioneered by Richard Bootzin, PhD, at the University of Arizona, this facet of therapy is aimed at reducing the anxiety or conditioned arousal clients feel when they go to bed. For example, a man who is unable to fall asleep because he had too much caffeine feels anxious the next night about falling asleep. The anxiety causes him to feel awake when he goes to bed. That bedtime arousal snowballs over time, conditioning him to feel awake whenever he tries to fall asleep in bed. To change that arousal at bedtime to sleepiness, therapists make several suggestions: If you can't fall asleep, get up and leave the room and return only when sleepy. Don't sleep anywhere but in the bedroom. Avoid any activity in bed except sleep and sex.

  • Sleep restriction. To increase a client's sleep efficiency, the therapist curtails the time in bed to the actual amount of time the client sleeps. For example, if a client usually sleeps six hours out of eight spent in bed, the therapist will advise her to go to bed only six hours before she needs to wake up. The restriction initially results in even less sleep than before, because she may still be awake for two of the six hours in bed. However, as her fatigue builds, she falls asleep faster and sleeps in a more consolidated fashion--also countering the conditioned arousal at bedtime. Once her sleep is highly efficient at six hours, the therapist gradually increases the time in bed, resulting in longer, more efficient sleep.

  • Relaxation. Progressive muscle relaxation can reduce muscle tension and contribute to relaxation at bedtime. Some therapists also use breathing techniques that simulate the slow, shallow breathing of sleep onset or autogenic training, which focuses on increasing peripheral blood flow.

Of course, before trying any of these techniques out, it's important to consult a trained sleep medicine specialist.

--D. SMITH