Types of Treatments

Treatments for sleep disorders generally can be grouped into three categories: 1) behavioral/ psychotherapeutic treatments, 2) medications, and 3) other somatic treatments. None of these general approaches is sufficient for all patients with sleep disorders. Rather, the choice of a specific treatment depends on the patient's diagnosis, medical and psychiatric history, and preferences, as well as the expertise of the treating clinician. In general, medications and somatic treatments provide more rapid symptomatic relief from sleep disturbances. On the other hand, some emerging evidence suggests that treatment gains with behavioral treatment of insomnia may be more durable than those obtained with medications.

It is also important to note that methodologically rigorous, placebo-controlled treatment studies have not been conducted for many individual sleep disorders. Large, carefully controlled clinical trials of behavioral/psychological treatments have been conducted recently for primary insomnia. Smaller studies have been conducted for narcolepsy, nightmare disorder, and sleepwalking disorder and for patients who would qualify for diagnosis of insomnia related to another mental disorder and substance-induced sleep disorder. Large, well-controlled clinical trials of pharmacological treatments have been conducted for primary insomnia and narcolepsy, and smaller trials have been conducted for restless legs syndrome/periodic limb movement disorder, simulated circadian rhythm sleep disorders, and secondary sleep disorders. However, most of these studies have included a narrow range of outcomes, were of short duration, and were not conducted at multiple sites. Finally, controlled (but not double-blind) studies have been conducted with phototherapy in circadian rhythm sleep disorders. This list does not include several common clinical scenarios, such as the pharmacological treatment of patients with a history of mood disorders. Given the lack of rigorously controlled, empirical studies for many sleep disorders, treatment guidelines frequently rest on common practice rather than empirical data.

Behavioral/Psychotherapeutic Treatments and Principles

Nonpharmacological interventions for sleep disorders consist mostly of cognitive-behavioral therapies. These treatment methods are used predominantly with primary insomnia and target hyperarousal (somatic, cognitive, emotional), learned maladaptive sleep habits, and dysfunctional sleep cognitions. Insight-oriented psychotherapy focusing on predisposing rather than perpetuating factors of sleep disorders has also been advocated, although empirical evidence supporting such treatment is limited. Specific types of behavioral/psychotherapeutic treatments are outlined here.

Stimulus control Stimulus control therapy (Bootzin et al. 1991) consists of a set of instructional procedures designed to curtail sleep-incompatible behaviors and to regulate sleep-wake schedules. These procedures are as follows: