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Insomnia
GUIDED IMAGERY FOR INSOMNIANovember, 2005
Definition
One can be said to have insomnia if it takes more than 30 minutes to get to sleep, awakens for than 30 minutes, or awakens earlier than desired, resulting in fatigue and drowsiness during the day, recurring during a 30 day or longer period (Lacks, 1987).
Dimensions of the Problem
About one-third of American experience insomnia, with about 10 million visiting physicians each year for the problem. It takes people, on average, 14 years to seek professional help for insomnia, but some people wait as long as 30 years (Lacks, 1987). In one survey, 32% of respondents in Los Angeles complained of insomnia at time of survey, while another 10% said they had insomnia in the previous month (Bixler, Kales, Scharf, Kales, &Leo, 1976).
The National Commission on Sleep Disorders Research reported almost $16 billion as direct cost of sleep disorders and sleep deprivation, with another $50-$100 billion in indirect costs, mostly from accidents (Overview of the Findings, 2003). In European studies, drowsiness was established to be a bigger traffic hazard than drinking alcohol (Haraldsson, Akerstedt, 2001). According to one source, in 1999 Americans spent $1.1 billion on sleep products, split about 50/50 between prescription medicines and herbal sleep aids.
A 1991 survey of 1308 workers found that insomnia was the most predictable factor of absenteeism at work, with those experiencing insomnia having an average monthly sick absence rate 2.8 times that of the total group (Leigh, 1991). The estimated annual loss of productivity due to insomnia in the U.S. was $41.1 billion in 1988 (Stoller, 1994).
Causes
Chronic insomnia is usually a behavioral or psychophysiological problem, although causative medical conditions like sleep apnea or restless legs syndrome must always be ruled out. Temporary sleeplessness often occurs during stressful times and can lead people to forming a link between bedtime and worrying. Those with insomnia usually have higher than normal levels of anxiety and depression, and have overly high self-expectations and low self-efficacy -- any of which can cause or effect sleeplessness. Hormonal changes and drug use (including prescription drugs), cigarettes, and alcohol can also cause insomnia (Lacks, 1987).
Pharmaceutical Treatment
Pharmaceutical treatment of insomnia is often less than satisfactory to both patient and clinician. Older sleep medications had many risks, including building up tolerance in as little as 2 weeks. That period of time has been extended with newer medications, but medications often work for only a short while then lose their effectiveness. In the elderly population, there is a risk of sleep medications causing falls or breathing complications. Sleep aids can also interact with other medications or alcohol, and can disrupt circadian rhythms. There is often a rebound effect after people stop taking them (Hauri, 1982). The next-day after-effects of sleep aids can make people feel just as bad as a lack of sleep does (Lacks, 1987). Recently introduced medications like zalpidem (Ambien), zaleplon (Sonata) have less dangerous side effects than benzodiazepine and tranquilizers. While they’re frequently effective for short-term episodes, they are not recommended for chronic insomnia. A newer hypnotic, eszopiclone (Lunesta), is approved for long-term use.
Non-pharmacologic Treatment Including Relaxation and Guided Imagery
Behavioral therapy has repeatedly demonstrated its efficacy as the most effective long-term approach to chronic insomnia (Backhaous, Hohagen, Voderholzer, Reimann, 2001; Dashevsky, Kramer, 1998; Jansson, Linton , 2005).
McClusky, Milby, Switzer, Williams, Wooten, 1991; Morin, Mimeault, Gagne, 1999; Smith, Huang, Manber, 2005 ). Cognitive Behavioral Therapy (CBT) alone or in combination with medication has been shown effective many times (Montgomery, Pennis, 2003); Ediger, Wohlgemuth, Radtke, Marsh, Quillian, 2001b; Espie, Inglis, Harvey, 2001; Perlis, Sharpe, Smith, Greenblatt, Giles, 2001; Morin, Blais, Savard, 2002). One research has said that "CBT has emerged as 'the treatment of choice'" for sleep/wake (CBT) has emerged as a "treatment of choice" for managing the sleep/wake aspects of primary insomnia (Edinger, Means, 2005).
The main categories of behavior therapy for insomnia are stimulus control (using the bed only for sleeping), a sleep hygiene program, keeping a sleep log, cognitive control, and progressive relaxation. These methods are often combined to maximize effectiveness.
Relaxation can reduce sleep-onset insomnia, with or without stimulus control measures (Cannici, Malcolm, Peek, 1983; Viens, DeKonick, Mercier, Sto-Onge, Lorrain, 2003). Effects are better when the two are combined (Jacobs, Rosenberg, Friedman, Matheson, Peavy, Domar, Benson, 1993). Patients were able to stay asleep longer when they used CBT and relaxation techniques (Edinger, Wohlgemuth, Radtke, Marsh, Quillian, 2001a). Similar results were reported in a 2002 study of older patients; 54% of those who took part in classroom CBT, and 35% of those who took part in a home-based audiotaped relaxation program achieved clinically significant changes (Rybarczyk, Lopez, Benson, Alsten, Stepanski, 2002).
One study demonstrated that when subjects combined progressive relaxation and learned new sleep habits, they became less depressed, achieved a greater sense of control, fell asleep faster, and slept better, even two years follow-up (Engle-Friedman, Bootzin, Hazelwood, Tsao, 1992).Both progressive relaxation and autogenic training helped cancer patients experiencing insomnia, with subjects in using those interventions benefiting with moderate-or large-scale effects on sleep latency (p<0.001), sleep duration (p<0.001), sleep efficiency (p<0.001), sleep quality (p<0.001), sleep medication (p<0.05) and daytime dysfunction (p<0.05). (Simeit)
Hypnosis, consisting of relaxation and imagery laden suggestions, helped subjects in one study sleep better (Younus, Simpson, Collins, Wang, 2003); imagery helped subjects in another study fall asleep faster and have less intrusive “mind-racing” prior to sleep (Harvey, Payne, 2002).
Three reviews of the literature of mind-body techniques including relaxation, meditation, guided imagery or biofeedback led their authors to conclude that there is, respectively, either “considerable,” "moderate," or “sufficient” evidence of their effectiveness in insomnia (Astin, Shapiro, Eisenberg, Forys, 2003; Barrows, Jacobs, 2002; Mamtani, Cimino, 2002). A 2003 study found that at-home use of relaxation tapes was effective in improving subjects’ sleep (Hanley, Stirling, Brown, 2003).
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