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Patients often complain that sleep hygiene hasn't worked for them ­ Professor Colin Espie outlines some alternative strategies

Research shows the majority of people with insomnia already observe sleep hygiene rules, but still have a sleep problem.

Sleep hygiene refers primarily to lifestyle and environmental factors that interfere with sleep. Examples in terms of lifestyle

include drinking caffeinated drinks or exercising too near bedtime.

Sleep hygiene does work in the few cases where people have specific poor habits in the first place, eg drinking excessive amounts of coffee. But in many cases GPs broaching the subject of sleep hygiene are met with the response 'I've tried it all before!'.

CBT for insomnia

Cognitive behaviour therapy is a structured treatment approach that recognises the two-way interaction between mental activity and behaviour in the development and maintenance of disorders. For sleep problems, CBT is about the reconstruction of a new sleep pattern and a new sleep outlook.

CBT for insomnia has been the subject of more than 100 randomised trials, and four meta-analyses of these results show both sleep pattern and sleep quality improve

substantially with CBT. Moreover, they stay improved at long-term follow-up.

The bedroom association

For the person who is a good sleeper, the wind-down to bedtime, the bedroom and the bed itself are all associated with de-arousal. The outcome is successful sleep.

However, the bedroom environment in insomnia is associated with arousal, wakefulness and worry, all reinforced in the context of unsuccessful sleep. One goal of CBT is to change these maladaptive conditioned associations back to normal, a process known as 'stimulus control'.

GPs should stress the best-kept secret about sleep is that good sleepers actually pay very little attention to sleep. It's not something they are good at doing ­ it's not a 'doing' thing. Sleep is something they presume happens naturally and spontaneously (like breathing or walking or talking). That is why the person with insomnia is met with a bewildered look when they ask people how thay manage to sleep well.

This attitude shift is important so the GP should try to emphasise the simplicity of sleep, in the right conditions.

Sleep restriction

Another CBT technique is called 'sleep restriction'. This involves reducing the amount of time spent in bed to equal the average time the person with insomnia is managing to sleep. So, if s/he is in bed for eight hours but sleeping only six hours (sleep efficiency of 75 per cent), a six-hour sleep window is prescribed.

Within a few nights, the sleep efficiency (the proportion of time in bed spent asleep) increases dramatically. Time in bed can then be gradually increased in subsequent weeks to see if more sleep can be added. The aim is to maintain sleep efficiency at greater than 90 per cent.

People with insomnia also develop dysfunctional thought patterns (faulty thinking) that only exacerbate their worry about sleep and their level of mental and emotional arousal. Techniques such as 'cognitive restructuring' are used in CBT to help people challenge negative, intrusive thoughts and ideas and to achieve a more rational and positive frame of mind.

An example of this would be modifying the belief 'I will be totally unable to cope

tomorrow unless I sleep for eight hours' to a less catastrophic one like 'If I don't sleep well tonight I will be extra-tired, but I will get by. Even five or six hours would probably see me through'. The GP should emphasise the strength of habit that develops (around the wrong conditions) in insomnia.

Sleep preoccupation

In particular, people with insomnia are mentally focused on their sleep, or more likely their failure to sleep! They try hard to overcome their insomnia and in so doing usually make things much worse.

In CBT, this sleep preoccupation and sleep effort, which is so unlike normal good sleepers, is challenged to help the person with insomnia return to a more passive approach

to sleep. The point is that good sleep occurs automatically and involuntarily. CBT helps people to return to that mental and behavioural position.

Scheduling a new sleep pattern

This includes elements of stimulus control and sleep restriction. A few of the guidelines in my book are in the box on the left.

Colin Espie is professor of clinical psychology and director of the Sleep Research Laboratory at the University of Glasgow and author of Overcoming Insomnia and Sleep Problems

His book is available in areas where the Books on Prescription scheme applies and throughout Wales under Book Prescription Wales. To buy a copy go to

Competing interests None declared

Scheduling sleep pattern

· Calculate how long you are sleeping on average by keeping a diary for 10 nights

· Create a 'sleep window' (new bedtime to new rising time) that is no longer than this average (If your average sleep is less than five hours then set this window at five hours)

· Don't go to bed or allow yourself to sleep except during this sleep window

· Follow this new sleep schedule for seven nights

· If, however, you don't get to sleep within a quarter of an hour of putting the light out, get up and go into a living room; expect to have to get up, perhaps many times at first

· Use this same quarter of an hour rule if you waken during the night and don't get back to sleep quickly

· Review your progress each week; if you sleep 90 per cent of the time you are in bed, increase your sleep window by 15 minutes for the next week; stop making these weekly increases if your sleep efficiency begins to drop, and accept your final sleep pattern

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