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��ࡱ�>��	ik����h�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������{�	��0�9bjbjz�z�	4l���1���������.....����BBBB��,B	<�^pppp___�;�;�;�;�;�;�;$�=�g@b�;._____�;..pp��;{{{_�.p.p�;{_�;{{R7��9p�����@�Jh�����I8t;�;0	<&8��@O,�@<�9�9|�@.(:L__{_____�;�;{___	<____���������������������������������������������������������������������@_________� �:	Chronic insomnia and the cognitive behavioral approaches in presence or absence of pharmacotherapy
Mohammad Torabi Nami 
Department of Neuroscience, Institute for Cognitive Science Studies, Tehran, Iran




 Correspondence:
Mohammad Torabi Nami MD, PhD
Dept. of Neuroscience, ICSS, Tehran 15948, Iran
Tel.:+98 2188935056;  Fax.:+98 2188900526
E-mail address: torabi_m@iricss.org


Abstract
Insomnia is a common complaint of patients presenting to primary care providers. Approximately 10 -20% of the general population has chronic insomnia worldwide. About 25% of these patients have primary insomnia. Insomnia is more prevalent among females and the elderly (over 65 years). Pharmacotherapy for insomnia is mainly focused on benzodiazepines and recently, the popular use of over-the-counter sleep aids, mainly melatonin. However these very often are shown to have untoward effects rather than benefits. Once the underlying disorder affecting sleep is addressed, cognitive behavioral therapy, in presence or absence of drug therapy, is demonstrated to be the most effective treatment option for insomnia in some cases.

Keywords: 
Insomnia, Cognitive and behavioral therapy, Sleep hygiene, Recommendations

Abbreviations:
CBTi:   Cognitive-Behavioral Therapy for Insomnia
EMG:   Electromyography
ICSD:   International Classification of Sleep Disorders
SMR:    Sensory-Motor Response




Insomnia; a notable sleep disorder
Based on the International Classification of Sleep Disorders (ICSD), 2nd edition, insomnia  is characterized as �difficulty initiating and/or maintaining sleep, early awakening or non-restorative sleep despite adequate opportunity�. This needs be accompanied by at least one of the following complaints during the day: fatigue and daytime sleepiness, lapses in attention, concentration or impaired memory function, poor performance in social, occupational or academic perspectives, irritability or dysregulation in mood, motivation, energy or initiative.  Moreover, insomniac patients are notably prone to errors or accidents at work or while driving. Reports indicate that insomniacs suffer from tension headaches or GI distress due to sleep loss and worries about sleep [1,2].
The ICSD differentiates insomnia either as primary or secondary. Primary insomnia includes idiopathic insomnia, psycho-physiological insomnia and paradoxical insomnia. Secondary insomnia includes insomnia secondary to psychosocial stressors, psychiatric disorders, medical disorders, various sleep disorders, drug and substance abuse and prescription medications. Misuse of some medications which are thought to help sleep may profoundly lead to poor sleep and unfavorable neuro-cognitive consequences [1, 3, 4, 5].
Over the past few years the term co-morbid insomnia is preferentially used instead of secondary insomnia. Co-morbid insomnia implies that insomnia in subjects with other health conditions is as significant as the underlying disorder and hence requires independent assessment and treatment [4]. 
Consequences of insomnia
Distressed emotion, lack of energy and profound fatigue, sleepiness and impaired functioning during  the daytime, are shown to be some cardinal consequences of insomnia.  Furthermore, impairment is social and occupational performance adversely affects the quality of life. As reports indicate, insomniacs tend to be at increased risk for mental health problems, substance abuse and cardiovascular morbidity [6].
Cognitive and behavioral approaches in  insomnia.
Sleep logs
Sleep logs, when completed properly, are useful not only in the assessment of insomnia but also in its management and in monitoring progress.
Sleep logs provide information on sleep patterns of patients in their own environments. They also assist to assess the impact of therapeutic interventions, help to monitor progress over a period of time and help patients to realize that insomnia may not be as frequent or as severe as they had thought (e.g. paradoxical insomnia) [7].

Sleep hygiene
Sleep hygiene refers to a set of instructions that help patients fall and stay asleep. Sleep hygiene measures, on their own are not effective in the treatment of insomnia. However, they provide a framework for other therapeutic interventions. Some of sleep hygiene measures that can be recommended to patients include maintaining a regular waking time and removing from the bedroom anything that could impair sleep. Patients are usually advised to strictly avoid alcohol, caffeine, nicotine and heavy exercise several hours before sleep time. Patients should neither take large meals before going to sleep nor go to bed hungry or thirsty, and finally they should avoid naps during the day [8].
Stimulus control
The goal of stimulus control is to assist patients re-associate bed with sleep. Some of the recommended behaviors include not going to bed until ready to sleep, using bed only for sleep ( sex is an exception). Patients should avoid reading, watching TV or eating in bed and are recommended to set an alarm to get up at the same time every morning [8, 9].
Biofeedback
There is compelling interest in using biofeedback as a technique to train individuals in order to improve their health by means of developing better awareness or voluntary control over the physiological processes which are affected by anxiety or stress. In this technique, the level of anxiety or stress is measured by fixing electrodes or sensors on the scalp, forehead, around the trunk and on the fingertips that record biological signals. The biofeedback setup and the type of sensors used depend of what specific technique is applied.
With regard to the treatment of insomnia, two types of biofeedback are commonly used: EMG biofeedback and sensory-motor rhythm (SMR) biofeedback. EMG biofeedback is found to be effective in anxious individuals who have sleep-onset insomnia, and SMR biofeedback is found to be effective in non-anxious individuals who have sleep maintenance insomnia. The therapist acts as a coach by facilitating patient relaxation, which further reduces stress and anxiety [10, 11]. Relaxation is a key component in biofeedback [11].

Sleep restriction
Sleep restriction is based on the premise that time spent in bed awake makes insomnia worse. When appropriately applied, sleep restriction is shown to improve sleep efficiency by almost 85% and to consolidate sleep. Subjects are trained to stay in bed only when they are asleep. They are then allowed to increase �time in bed� by 15-20 minutes each night, only if their sleep efficiency exceeds 90%. Consequently, the time they spend in bed should be 15-20 minutes each night in case their sleep efficiency is below 90% [9].
Cognitive and behavioral therapy for insomnia (CBTi)
Other than sleep hygiene consideration in changing life style and behaviors enacted before going to bed, CBTi is an effective non-pharmacological approach to treat insomnia. The main behavioral and cognitive ingredients of CBTi are as follow:
 Stimulus control: the rationale is to establish associative links between bed and sleep, overcoming the existing conditioned inability to sleep. e.g.  the 15 minutes rule for getting out of bed.
Sleep timings: patients are encouraged to maintain a sleep schedule compatible with their sleep regulating systems also during weekends avoiding compensative attempts to sleep.
Reduction of the time spent in bed, i.e. sleep restriction

Relaxation: simple techniques like progressive muscular relaxation and meditation are promoted within the CBTi program. 
Cognitive restructuring and control: experience-based revision of worries about insufficient sleep; simple strategies to avoid the presence of intrusive thoughts in bed before sleeping.
Paradoxical intentions:  the effort to stay awake can be used to contrast the effort to sleep, typically reported by insomniacs.

The therapeutic process in CBTi encompasses restoration of dysregulation in processes C and S plus behavioral and cognitive changes. The goal of cognitive therapy for insomnia is to identify and correct dysfunctional beliefs and attitudes relating to sleep. Patients can be taught facts and techniques: 1) Sleep needs differ -- not everyone needs eight hours of sleep a night; 2) Learn not to worry or get frustrated if you are not sleeping; 3) Learn to do thinking and worrying during the day instead of at night � in bed at night, use thought stopping and thought switching to reduce worries; 4) Lying in bed resting peacefully is nearly as restorative as sleep, and it is much more restorative than lying there thinking and worrying; 5) for patients who have not been helped by other methods, paradoxical injunction can be used (to reduce the anticipated anxiety associated with trying hard to sleep, patients are requested to stay awake as long as possible) [12-14].

The combination of cognitive and behavioral therapies for insomnia (CBTi) has not only been shown to be more effective, but also the effects last longer compared to pharmacological treatment. This has also demonstrated  to positively affect polysomnographic variables. These improved variables  include increased total sleep time (lights out to lights on time spent asleep) and sleep efficiency ( total sleep time/ time in bed in minutes expressed in percentage) and decreased sleep onset latency ( time in minutes to the first epoch of sleep from lights out) and wake time after sleep onset ( time in minutes awake after the first epoch of sleep) [12,13].
Comment
Primary care physicians seem to need to optimize their knowledge and practice with regard to pharmacological and non-pharmacological approaches in treating insomnia. CBTi has been found to offer valuable therapeutic benefits when applied for the right patients and in the right settings. Apart from the need to run basic etiopathophysiological studies to further explore the underlying causes of insomnia and other neuroscience related researches to elucidate further the nature of this disorder, incorporating continuous medical education (CME) courses on sleep, insomnia and hypersomnia in educational course planning is expected to add to the practice quality of the primary care physicians in our community.




References:
American Academy of Sleep Medicine. International classification of sleep disorders, 2nd ed. (2005). Diagnostic and coding manual, American Academy of Sleep Medicine, Westchester, IL.
HYPERLINK "http://chestjournal.chestpubs.org/search?author1=Michael+O.+Summers&sortspec=date&submit=Submit" Summers, M.O., HYPERLINK "http://chestjournal.chestpubs.org/search?author1=Maria+I.+Crisostomo&sortspec=date&submit=Submit"Crisostomo,  M.,HYPERLINK "http://chestjournal.chestpubs.org/search?author1=Edward+J.+Stepanski&sortspec=date&submit=Submit" Stepanski E.J. (2006). Recent Developments in the Classification, Evaluation, and Treatment of Insomnia. CHEST, 130 (1), 276-286
Carney, C.E., Edinger, J.D. (2006). Identifying Critical Beliefs about Sleep in Primary Insomnia. SLEEP, 29(4),444-453
HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=%22Culpepper%20L%22%5BAuthor%5D"Culpepper, L. (2006). Secondary insomnia in the primary care setting: review of diagnosis, treatment, and management. HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/16834824" \o "Current medical research and opinion.", 22(7), 1257-1268.
Torabi Nami, M., Madadi, G. (2011). Medication Induced Poor Sleep And Neurocognitive Consequences In Allergic Rhinitis: A Brief Review. The Internet Journal of Family Practice. 9(2) 
Roth T (2007). Insomnia: Definition, Prevalence, Etiology, and Consequences. J Clin Sleep Med. 3(5 Suppl): S7�S10
Lande RG, Gragnani C (2010). Nonpharmacologic Approaches to the Management of Insomnia. JAOA . 110(12):695-701
Torabi Nami  M (2011). "Sleep Hygiene" The Gateway for Efficient Sleep: A Brief Review . WebmedCentral BRAIN. 2(9):WMC002245
Vincent N, Samantha L,Heather F (2008). Barriers to Engagement in Sleep Restriction and Stimulus Control in Chronic Insomnia. Journal of Consulting and Clinical Psychology. 76(5): 820-828 
Bootzin RR. Perlis M (1992).Nonpharmacologic treatmant of insomnia.J Clin Psychiatry. 53(6s):37-41
Hauri P,Percy L,Hellekson C (1982). The treatment of psychologic insomnia with biofeedback: A replication study.biofeedback and self regulation.7(2): 223-235
Morin CM,Stone J,Trinkle D (1993). Dysfunctional beliefs and attitudes about sleep among older adults with and without insomnia complaints. Psychol Aging. 8:463-467
Morin CM,Blais J,Savard J (2002). Are changes in beliefs and attitudes about sleep related to sleep improvement in the treatment of insomnia. Behavior research and therapy.40:741-752 
Morawetz, D.(2003). Insomnia and depression: which comes first? Sleep Research Online., 5(2),77-81

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