Behavioral Sleep Consultation: Insomnia Case Studies

Behavioral Sleep Consultation: Insomnia Case Studies

March 6, 2019
Healthy Sleep

Insomnia is a common sleep problem that affects 60 million Americans. Not to be mistaken for a bad night of sleep, insomnia is constant, regular, and crushing. Gayle Greene, an author of Insomniac, explains that sleep is “the fuel of life,” and without it, we are affected in devastating ways. As an individual who suffers from insomnia, Greene has had to learn how to manage the effects of this disease.

“I don’t manage this beast,” Greene writes. “I live with it. I live around it. I bed down with it every night, gingerly, cautiously, careful not to provoke it. I do my best to placate it, domesticate it, dull its claws, avoid its fangs, knowing that at any moment it can pounce on me and tear me to bits.”

So how can someone affected by insomnia “live around” it? One option that is safe and drug-free is behavioral intervention, including relaxation training, stimulus control therapy, sleep restriction therapy, sleep hygiene, paradoxical intention therapy, and cognitive therapies. According to a study by Mahendra P. Sharma and Chittaranjan Andrade in the Indian Journal of Psychiatry, “behavioral interventions are efficacious, effective, and likely cost-effective treatments for insomnia that yield reliable, robust, and long-term benefits in adults of all ages.”

About Insomnia

Insomnia is defined by persistent difficulties falling and staying asleep, resulting in daytime drowsiness, lack of concentration, and even symptoms such as depression, headache, or irritability. It is usually self-diagnosable with lab tests rarely required. Insomnia can be treated, but is not considered curable; however, oftentimes, insomnia is a temporary problem with symptoms that decrease as causes, such as stress, are addressed.

Typically, insomnia is related to poor sleep habits, depression, anxiety, lack of exercise, chronic illness, or certain medications. Treatment usually involves behavior therapy, improving sleep habits, or identifying and alleviating causes. In some cases, sleeping pills are recommended, but only as a short-term solution and only under a doctor’s supervision in order to monitor side effects.

Insomnia Quick Facts

  • Insomnia reportedly occurs in one-third of all adults.
  • Ten to fifteen percent of adults report perpetual sleep issues.
  • Insomnia is more prevalent in women and seniors.
  • Many people who may have insomnia, do not seek treatment.
    • It is estimated that more than half of patients experience insomnia.
    • Of those patients, only one-third report their sleep issues to their doctor.
    • Only about 5% of patients seek treatment.
  • Many patients don’t understand treatment options (67 percent), turn to alcohol (28 percent), or resort to untested over-the-counter remedies (23 percent).

Explanation of Behavioral Treatments

Behavioral interventions sometimes referred to as cognitive-behavioral sleep therapy,  help insomnia patients to develop good sleep habits, and avoid behaviors that interfere with proper sleep patterns. Your sleep therapist may suggest one or a combination of the following intervention options.

Relaxation Training

Relaxation-based treatments involve teaching patients exercises that reduce intrusive thoughts at bedtime or somatic tension (meaning tension in the body). Relaxation training is especially helpful in patients who describe their insomnia as an “inability to relax” or patients who complain of numerous physical aches and pains.

Examples of exercises to reduce intrusive, stressful thoughts, or a racing mind:

  • Meditation – Lowers the patient’s presence of pre-sleep thoughts and worries.
  • Imagery training – This causes the patient to focus his or her attention on something other than the stressful thoughts.

Examples of exercises to relax the body:

  • Progressive muscle relaxation (PMR) – Helps the patient to release stress by systematically contracting and relaxing muscle groups.
  • Autogenic training – Encourages relaxation through a form of self-hypnosis where the patient uses imagery to physically feel changes in his or her body.
  • Biofeedback – Provides sensory feedback, such as a visual or auditory signal, to help patients learn how to control certain physiological symptoms, like muscle tension.

Abdominal breathing may be added to any of these techniques as a method of relaxation, and relaxation therapy can be utilized for difficulty falling asleep or if you wake up in the middle of the night.

Stimulus Control Therapy

The main purpose of stimulus control therapy is to strengthen the bed as a stimulus for sleep while weakening it as a cue for being awake. This includes setting and keeping a consistent sleep routine that involves:

  • Only getting into bed when you are sleepy
  • Getting out of bed if you cannot sleep for at least 20 minutes
  • Only use your bed for sleep or sex (no reading, watching television, etc.)
  • Getting up at the same time each morning
  • Avoiding naps

As a behavioral treatment for insomnia, stimulus control can help the patient achieve a consistent sleep-wake ritual, reinforcing the bedroom as a place for sleep. Patients are taught to recognize signs that they are truly sleepy, rather than just fatigued and still unready for sleep.

Sleep Restriction Therapy

Sleep restriction therapy is a behavioral technique based on an idea known as homeostatic sleep drive or the pressure to sleep. The goal is to keep the patient awake for a period of time until he reaches the point that he will sleep, and then slowly adjusting the scheduled sleep time until sleep efficiency has been reached.

The patient is restricted to a certain time in bed in order to regulate the sleep-wake cycle to match his or her true sleep requirements. Sleep deprivation is never restricted to less than five hours to prevent problems such as daytime drowsiness.

With sleep restriction therapy, the patient is given a scheduled bedtime and wake time, which helps reinforce circadian rhythms. This behavioral therapy type is typically used along with other types of therapy, such as stimulus control therapy.

Sleep Hygiene

As a behavioral sleep option, sleep therapy is essentially educational in nature. The goal is to inform the patient about healthy sleep practices and environmental factors including:

  • Diet
  • Exercise
  • Substance use
  • Light
  • Noise
  • Temperature
  • Bedding

Sleep hygiene is typically effective when used with any or all other therapy options because although poor sleep hygiene is not usually the sole cause of insomnia, it definitely can frustrate one’s ability to get a good night’s sleep.

Paradoxical Intention Therapy

Paradoxical intention therapy may appear to go against what every other therapy teaches; however, it has a long history of success in treating insomnia patients, particularly those who exhibit intense anxiety and preoccupation with their sleep loss issues.

This intervention option is based on the idea that a patient is having trouble sleeping because of “performance anxiety” about falling asleep. They obsess about getting into bed and falling asleep. They dread the setting sun, knowing that it will bring a night of tossing and turning.

With paradoxical intention treatment, the patient is told to do the opposite of what is expected: get into bed and stay awake. By placing the patient in the situation that they most fear – staying awake – then performance anxiety about falling asleep will decrease. Once the fear is faced and insomnia is dispelled, the patient can resume sleeping comfortably.

Cognitive Therapies

Cognitive therapies help to address dysfunctional attitudes and incorrect beliefs about sleep, which often manifests in insomnia. They can include a number of types of therapies, including:

  • Didactic focus
  • Distraction and imagery techniques
  • Cognitive restructuring

Cognitive therapies are most effective for patients who may obsess and stress over their insomnia and its effects, particularly if their understanding of sleep is incorrect or flawed.

For instance, an individual may experience anxiety because he fears that he will be unable to function without eight hours of sleep or that he can only fall asleep with the help of a sleeping pill or drink of alcohol. His continuous stress over these thoughts may further inhibit his ability to fall or stay asleep.

Instead, through cognitive therapy, the patient is helped to understand realities about sleep and reimagine his or her own related beliefs, which will ease the anxiety that can interfere with bedtime.

Behavioral Sleep Case Studies

Insomnia can present in numerous ways, and sleep professionals have an arsenal of options for treating this illness. The National Institute of Health provides several case studies and optional treatments, which are explained below.

Case One: Mr. Tan

Mr. Tan is a 45-year-old man who experiences difficulty falling and staying asleep. The problem began after the passing of his sister, prior to which he had no sleep problems. His doctor prescribed him a low-dose antidepressant, but Mr. Tan is unable to manage the side effects of drowsiness and dry mouth. Mr. Tan typically drinks about four cups of coffee daily and lately has resorted to drinking alcohol to help him sleep.


Mr. Tan was diagnosed with an adjustment sleep disorder, a temporary sleep problem that is often caused by stress, conflict, or change. This type of insomnia only lasts until the individual copes with the stress, which is usually around two weeks to three months. Additionally, poor sleep hygiene (coffee, alcohol, nighttime stress) could be contributing to the problem.


Treatment for Mr. Tan should include discussing his grief and symptoms of depression. Counseling may be needed. Discuss sleep hygiene information with the patient. Change the type of antidepressant to something that Mr. Tan can tolerate, such as Ativan, and prescribe for a short period of around two weeks.

Case Two: Ms. Suraya

A 40-year-old teacher named Puan Suraya has had trouble falling asleep for over two years. She gets in bed at 10:00 pm, but can’t fall asleep until 1:00 am, in addition to waking up three to five times per night. Each time she wakes up, it takes her at least 30 minutes to fall asleep again.

Symptoms include daytime fatigue and trouble concentrating. She doesn’t snore and has no excessive or repetitive limb movements at night. She vaguely remembers a family property dispute that caused her stress around the time that she first began experiencing sleep issues. She states that before bed, she starts worrying about her insomnia, and she also tends to watch the clock at night. She does not take sleeping pills and has no symptoms of depression. She reports that she does not experience sleep issues when away from her home bedroom, such as at a relative’s house or in a hotel.


Ms. Suraya is diagnosed with psychophysiological insomnia, otherwise known as learned insomnia or behavioral insomnia. This type of insomnia begins with a traumatic experience that triggers the sleeping difficulties; however, chronic insomnia remains even after the stressful event is resolved. The patient develops sleep-related stress, associating bedtime, and the bedroom with agitation, frustration, and worry. When outside their usual routine or home environment, these patients will see an improvement in sleep patterns.


Ms. Suraya should be started on behavioral sleep therapies to improve her insomnia, possibly including an emphasis on improved sleep hygiene and relaxation techniques like:

  • Progressive muscle relaxation
  • Imagery training
  • Biofeedback
  • Meditation

In this case, stimulus control therapy should be implemented to help Ms. Suraya improve her associations with the bedroom and sleep, re-learning the proper responses to bedtime. A short-term prescription, such as Ativan, can be prescribed to help alleviate the patient’s anxiety until the behavioral techniques begin to be effective, after about two to three weeks.

Cognitive-behavioral therapies may also assist in removing unrealistic expectations regarding bedtime which may perpetuate Ms. Suraya’s insomnia.


Millions of Americans are affected by insomnia, whether as a short-term result of a particular stressor or as a chronic condition. A behavioral sleep consultation can ease symptoms and return a patient back to a normal sleep pattern; however, many people affected by insomnia do not receive treatment, either because the condition is misdiagnosed or they do not report the symptoms to their general practitioner.

Doctors and researchers have determined that behavioral therapies – including relaxation training, stimulus control therapy, sleep restriction therapy, sleep hygiene, paradoxical intention therapy, and cognitive therapies – are effective interventions in treating insomnia.

See your doctor if you are regularly experiencing trouble falling or staying asleep. Most behavioral sleep techniques can be taught to patients in just a few weeks’ time, giving you control over your insomnia and helping you get back to a good night’s sleep.

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