RESEARCH FINDINGS USING GUIDED
IMAGERY FOR
INSOMNIA
August, 2006
What
is Insomnia?
Insomnia is defined as taking
more than 30 minutes to get to sleep, waking for a period
of more than 30 minutes, or waking earlier than desired,
with feelings of fatigue and drowsiness during the day,
recurring over at least a 30 day period (Lacks, 1987).
Dimensions
of the Problem
About 10
million people visit physicians a year complaining of
insomnia. The average time it takes people to seek
professional help for insomnia is 14 years, but some people
wait as long as 30 years (Lacks, 1987). Around one-third of Americans
are experiencing insomnia at any given time. In a typical
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, et al,
1976).
The National Commission on Sleep Disorders Research
reported $15.9 billion as direct cost of sleep disorders
and sleep deprivation, with an estimated $50 to $100
billion in indirect costs, mostly from accidents
(1998). In
European studies, drowsiness was found to be a greater
traffic hazard than drinking alcohol (Haraldsson and
Akerstedt, 2001).
Americans spent $1.1 billion on
sleep products in 1999, split about 50/50 between
prescription medicines and herbal sleep aids, according to
the National Sleep Foundation.
A 1991 survey on 1308 workers found that insomnia was the
most predictable factor of absenteeism at work. Insomniacs
had 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
of Chronic Insomnia
Although a number of medical conditions can cause insomnia
chronic insomnia is most commonly a behavioral or
psychophysiological problem (Lacks, 1987). Temporary
sleeplessness during stressful times can lead people to
leads to form a link between bed and worrying. Insomniacs
tend to have higher than normal levels of anxiety and
depression, expect too much from themselves, and low
self-efficacy -- all of which can be either cause or effect
of sleeplessness. Hormonal changes and drug use, including
prescription drugs, cigarettes, and alcohol, can also cause
insomnia (Lacks).
Medical
Treatment
Until recently, sleeping pills
have had as many risks as benefits. With the older pills
people can build up a tolerance to them in about 2 weeks.
With the new ones, it can take about 4 weeks. In elderly
patients, sleep medications cause falls or breathing
complications. Sleep aids can interact with other
medications or alcohol, and can disrupt natural sleep/awake
cycles (circadian rhythms).
There is a rebound effect after people stop taking them
(Hauri, 1982). The next-day, the after-effects of sleep
medications can make people feel as bad as not sleeping
does (Lacks, 1987).
Recently introduced medications like zalpidem (Ambien) and
zaleplon (Sonata) have less dangerous side effects.
Although they’re often effective for short-term (7-10 days)
episodes, they’re not recommended for chronic insomnia.
Escopiclone (Lunesta), a newer hypnotic, is approved for
long-term use, as is ramelteon (Rozerem). All but
ramelteon are controlled substances.
Non-medication
Treatment Including Guided Imagery
"CBT [cognitive behavioral
therapy] has emerged as 'the treatment of choice'" for
managing the sleep/wake aspects of primary insomnia,
according to one research team (Edinger & Means, 2005).
Behavioral therapy has been repeatedly demonstrated the
most effective long-term approach to chronic insomnia
(Backhaous, Hohagen, et al., 2001; Dashevsky and Kramer,
1998; Jansson & Linton, 2005; McClusky, Milby et al,
1991; Morin, Mimeault and Gagne, 1999; Smith, Huang &
Manber, 2005).
CBT proved superior to zopiclone in both short- and
long-term outcome (Sivertsen, Omvik, et al, 2006).
Cognitive Behavioral Therapy (CBT) alone or in combination
with medication has been shown effective many times, and
across different age populations (Irwin, Cole &
Nicassio, 2006) including those with comorbid conditions
(Ediger, Wohlgemuth, et al, 2001b; Espie, Inglis &
Harvey, 2001; Perlis, Sharpe, et al, 2001; Montgomery &
Pennis, 2003; Morin, Blais & Savard, 2002; Savard,
Simard, et al, 2006).
The
main categories of behavior therapy for insomnia are
stimulus control – using bed only for sleep – a sleep
hygiene program, keeping a sleep log, cognitive control,
and progressive relaxation. These methods are often
combined.
The use of relaxation has been found to reduce sleep-onset
insomnia, with or without stimulus control measures
(Cannici, Malcolm & Peek, 1983; Viens, DeKonick, et al,
2003). Effects are better when the two are combined
(Jacobs, Rosenberg, et al, 1993).
Patients using CBT and
relaxation therapy had improvement in how long they were
able to stay asleep (Edinger, Wohlgemuth, et al, 2001).
Similar results were reported in a 2002 study of older
patients, with 54% of patients who received classroom CBT,
and 35% of patients who used home-based audio relaxation
treatment achieving clinically significant changes
(Rybarczyk, Lopez, et al 2002). In older adults, both sleep
hygiene combined with stimulus control was as effective as
sleep hygiene combined with relaxation tapes (Pallesen,
Nordhus, 2003).
Since
CBT and relaxation (including audio tapes) are both
effective, evidence suggests that combining the two would
yield greater benefits. One study demonstrated that
progressive relaxation and learning new sleep habits helped
patients become less depressed. Subjects achieved a greater
sense of control, fell asleep quicker, and slept better,
even two years later (Engle-Friedman, Bootzin, et al,
1992).
Subjects in one study who used
hypnosis slept better (Younes, Simpson, et al, 2003);
subjects in another study who used imagery fell asleep
faster and had less intrusive “mind-racing” prior to sleep
(Harvey and Payne, 2002). Cognitive distraction – a major
component of guided imagery, hypnosis, and similar
techniques, can be instrumental in avoiding worry and
anxiety (Harvey & Payne, 2002; Ree, Harvey, et al,
2005).
Progressive relaxation and autogenic training improved
insomnia in cancer patients; subjects had moderate or large
improvements in sleep latency, duration, efficiency,
quality, use of medication, and daytime dysfunction
(Simeit, Deck, et al, 2004). CBT was effective in
significantly improving Sickness Impact Profile, Sleep
Evaluation Form, and Dysfunctional Beliefs and Attitudes
About Sleep in both groups and individuals.
Hypnosis improved sleep onset in 90% of children; a
cessation in awakenings from nightmares in 52% of children
and improvement in an additional 38%; improvement in
somatic complaints in 41% (Anbar and Slothower,
2006).
Mindfulness meditation improved sleep in post-transplant
patients (Gross, Kreitzer, et al, 2004).
Authors of three reviews of the literature of mind-body
techniques (including techniques such as relaxation,
meditation, biofeedback) concluded that there is,
respectively, either “considerable,” “sufficient,” or
“moderate” evidence of their effectiveness in insomnia
(Astin, Shapiro, et al, 2003; Barrows & Jacobs, 2002;
Mamtani & Cimino, 2002). A 2003 study found that at-home
use of relaxation tapes was just as effective as massage in
improving subjects’ sleep (Hanley, Stirling & Brown,
2003).
Conclusion
A
low-cost guided imagery program can help patients cope with
chronic insomnia, and may save resources spent on
prescription sleep medications, especially when behavioral
recommendations are also followed.
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