Intervention

Goal

Description

Stimulus control

To recondition maladaptive sleep-related behaviors

Patient is instructed to go to bed only when sleepy, not use the bed for eating or watching television, get out of bed if unable to fall asleep, return to bed only when sleepy, get up at the same time each morning, not take naps during the day.

Sleep restriction

To improve sleep efficiency (time asleep over time in bed) by causing sleep deprivation

Patient first collects a 2-week sleep diary to determine average total daily sleep time, then stays in bed only that duration plus 15 minutes, gets up at same time each morning, takes no naps in the daytime, gradually increases time allowed in bed as sleep efficiency improves.

Cognitive interventions

To change misunderstandings and false beliefs regarding sleep

Patient’s dysfunctional beliefs and attitudes about sleep are identified; patient is educated to change these false beliefs and attitudes, including normal changes in sleep with increased age and changes that are pathologic.

Relaxation techniques

To recognize and relieve tension and anxiety

In progressive muscle relaxation, patient is taught to tense and relax each muscle group. In electromyographic biofeedback, the patient is given feedback regarding muscle tension and learns techniques to relieve it. Meditation or imagery techniques are taught to relieve racing thoughts or anxiety.

Bright light

To correct circadian rhythm causes of sleeping difficulty (ie, sleep-phase problems)

The patient is exposed to sunlight or a light box. Best evidence is from treatment of seasonal affective disorder (from 2500 lux for 2 hours/day to 10,000 lux for 30 minutes/day). For delayed sleep phase, 2 hours early morning light at 2500 lux. For advanced sleep phase, 2 hours evening light at 2500 lux. Shorter durations may be as effective. Routine eye examination is recommended before treatment; avoid light boxes with ultraviolet exposure.