Sleep. 16(4):344-350
© 1993 American Sleep Disorders Association and Sleep Research Society
Clinical Sleep Research
Consulting About Insomnia: A Method and
Some Preliminary Data
Peter J. Rauri
Sleep Disorders Center. Mayo Clinic. Rochester. Minnesota. U.S.A.
Summary: Sleep specialists are increasingly asked to advise other health care workers and patients about specific
cases of insomnia, even when the patients do not plan to seek actual treatment of their insomnia at a sleep center.
This paper describes a procedure for such one-time consultations. It also provides some preliminary data on the
subjective efficacy of such insomnia consultations by reporting data from follow-up telephone calls placed I, 3 and
12 months after the interview. The patients' estimates of their sleep seemed significantly improved on all three
follow-up contacts, and the telephone calls also provided information on what type of recommendations were
actually tried by the insomniacs and which ones seemed beneficial. Acceptance ofindividual sleep hygiene suggestions
ranged between 68 percent and II percent, but those who tried a given suggestion generally reported its usefulness
to be about 70 percent. Advice to seek relaxation or behavioral therapy and suggestions for various medication
changes were accepted by about half of those insomniacs who received such advice, and about two-thirds of those
who tried them reported them as being helpful. Advice to seek psychotherapy-although quite carefully giventypically was tried by only one-third of those who received it. Overall, the survey shows good patient acceptance
of once-only insomnia consultations. Key Words: Insomnia-Consultations-Sleep hygiene- Behavioral methodsFollow-up.
Treating chronic insomnia typically takes much time,
spaced over many weeks or months. Nevertheless, sleep
clinicians are often asked by other health specialists or
by patients for once-only consultations on individual
insomnia cases. This paper describes the approach to
such requests currently used by our lab. It then gives
some preliminary data about the usefulness of such
once-only insomnia consultations, as seen from the
patient's point of view.
depression or anxiety, they would have been referred
to a psychiatrist rather than a sleep specialist. In any
case, getting to the psychiatric roots of an insomnia
often takes considerable skill, and psychotherapy is
often rejected even when the patient clearly needs it.
Not every insomniac should be treated like every
other. What is one person's "sleep potion" often is
another person's "sleep poison". Advice has to be indi vid ualized.
Initially, in the family practitioner's office, much can
be
accomplished with an insomnia interview lasting
THREE BASIC ASSUMPTIONS
only 5 or 10 minutes. However, by the time the inInsomnia is a symptom, not a disease. In this aspect, somniac has reached a sleep specialist, the easy cases
it is like fever. For a short time it can be eliminated have been dealt with. An adequate insomnia consulwith medication, but in the long run one needs to know tation at our sleep center typically takes 1-2 hours.
the etiology of a specific insomnia and the factors that
are currently maintaining it (1).
PRELIMINARY INFORMATION GATHERING
Psychologically, insomniacs are typically repressors,
denying emotional problems. This may be an artifilct
If there is time, the insomniac is usually sent a packof the selection procedure. Had they admitted their age of questionnaires to be filled out before the interview. This includes a sleep log to be filled out for 1
week, a Stanford sleepiness scale to be taken for 3 days,
Accepted for publication February 1993.
a sleep disorders questionnaire, a Minnesota multiAddress correspondence and reprint requests to Peter J. Hallri,
Ph.D., Sleep Disorders Center, Colonial Building, Mayo Clinic, phasic personality inventory (MMPI) and, possibly,
Rochester, MN 55905, U.S.A.
some other scales, such as the profile of mood stages,
344
CONSULTING ABOUT INSOMNIA
the Hopkins symptom checklist (HCL-90) and Morin's
personal beliefs and attitudes about sleep scale (2).
Because sleep is affected by most organic dysfunctions (e.g. infections, allergies, pain, many endocrine
dysfunctions, etc.), we require a general medical evaluation within 1 year of the insomnia consultation, including a physical examination and routine laboratory
work.
If possible, we obtain 1 week of wrist actigraphy at
home before the consultation to assess the regularity
of bed and arousal times, daytime naps, etc. This often
is more useful than the sleep log, even though in insomniacs wrist actigraphy and polysomnography typically disagree by >40 minutes on the total amount of
sleep that is obtained per night (3).
INFORMATION FLOW DURING THE
CONSULTATION
A chief sleep complaint is elicited first, after the
review of the questionnaire data that the insomniac
has brought in. Things often have to be carefully clarified. For example, a patient with narcolepsy may state
insomnia as his chief complaint, feeling that his daytime sleepiness is secondary to poor sleep at night.
A typical 24-hour period occurring sometime during
the last 2-3 weeks is then explored. The clinician is
not only interested in the patient's usual bedtime (and
its night-by-night variability), sleep latencies, number
of awakenings, total sleep time, etc., but also that patient's typical work hours, naps, daytime feelings of
sleepiness or fatigue and activities during leisure time,
especially activities during the last 2 hours before bedtime. We also need to know the patient's detailed
thoughts, moods and fears as they occur during the 24
hours, especially during long sleep latencies and during
periods of wakefulness at night. The more in detail this
24-hour period is explored, the more useful is the information that is obtained. For example, we know very
little if the patient says only that he typically wakes up
at 2:00 a.m. and remains awake until 4:00 a.m. If we
know, on the other hand, that when he wakes at 2:00
a.m., he usually struggles with himself first in an attempt to act as if still asleep, then glances at the bedroom clock and becomes frustrated because "it's 2:00
a.m., as usual", then tosses and turns for about 10
minutes before getting up and doing 20 knee bends "to
make me tired again", then becomes angry when this
does not help, starts reviewing his life to see why he
should be so severely punished, and so on, then we
have a number of leads to follow for sleep hygiene
advice, behavioral therapy or psychotherapy.
There are some crucial questions to be asked. Where
does the patient sleep best? Sleeping best away from
the bedroom might suggest the need for stimulus control therapy (4). Does he fall asleep when watching TV,
345
reading or when driving? A "yes" suggests that trying
too hard to sleep at night may be an important factor
in his insomnia (5). How much coffee and alcohol does
he drink and when does he drink it? Does he exercise,
and if so, at what time? (Exercising 5 to 6 hours before
sleep is bcst.) Does he allow "make-up sleep" during
the day after a poor night (providing secondary benefits
and disturbing the circadian rhythm)?
A sleep history then explores how the patient slept
as a child, a high school student, a young adult, etc.
Was the patient always a night owl or a lark, suggesting
circadian rhythm problems? How many hours of bedtime were typically obtained before insomnia struck?
Individual needs for sleep change little between ages
20 and 70. If 6 hours in bed was sufficient at age 20
without catch-up sleep on weekends, the patient, now
55 years old, should restrict his bed time to 6 hours,
even during his current bout with insomnia.
A review of attempted remedies is an important part
of the interview. What medications have been tried,
for how long, at what dosage and what was the outcome? What home remedies have been tried, such as
drinking milk, hot baths, reading in bed, etc.? Is there
anything that either helps or hurts sleep, even a little?
A family history of sleep disturbance is then explored, not only for genetic issues but also because it
may have shaped the patient's attitudes on sleep. Attitudes are crucial. A patient who believes that his
insomnia is caused by irreversible brain damage sustained when inhaling toxic fumes during a trip to New
York will need to be approached quite differently from
another who feels that his insomnia is caused by stress
on the job, even if it turns out that the basic cause of
the insomnia is the same in both cases.
The clinician must take a very thorough psychiatric
history, often reading between the lines. Patients often
state that their insomnia came "totally out of the blue"
although it is later found that the onset was associated,
in time, with a specific event, such as a death in the
family, a period of excessive loneliness, or stress in a
marriage. Psychological reasons behind the historic
facts need to be explored. Why must an 80-year-old
lawyer still practice law 65 hours per week? Why has
a 42-year-old businessman not taken a single day's
vacation for the last 10 years? (In both of these cases
the cause was only superficially financial. Persistent
questioning revealed that both problems related to the
same personality issue, i.e. the need to prove oneself
to a domineering father, even though that father had
long since died.)
Throughout the interview the clinician establishes
not only facts, but also listens for the openness of the
patient to possible interventions. For example, observing the patient's response when asked whether the
insomnia might be related to a divorce 3 years ago
Sleep. Vol. 16. No.4. 1993
P. J. HAURI
346
TABLE 1. Sleep be/ore and after the interview
After
Before 1 month 3 months 12 months
n
Sleep latency (minute)
Total sleep (minute)
# Awakenings/night
# Poor nights/week
Seriousness of insomnia"
Effects on daytimeh
Has sleep changed?c
62
66
283
3.2
6.2
7.3
5.5
62
45
331
2.3
3.7
5.4
3.9
+4.0
60
51
335
2.2
3.5
4.9
3.7
+4.7
45
42
344
2.2
3.1
4.S
3.S
+5.0
" 1 = normal sleep, 10 = the worst insomnia imaginable.
1 = normal daytime functioning, 10 = unable to get out of bed.
c - 10 = much worse, 0 = no change, + 10 = a total cure.
All pairwise comparisons between before and after measures are
significant at p < 0.01 (matched t tests), except for sleep latency at
3 months (p = O.OS) and except for the number of awakenings at 12
months (p = 0.06).
h
gives hints about the likelihood that psychotherapy, if
recommended, might be successful.
A tentative summary statement to the patient concludes the assessment phase. This is usually presented
as the sleep clinician's current working diagnosis, and
the patient is asked to respond to it. Disagreements
can often be clarified. Therapeutic interventions are
rarely successful unless both therapist and patient agree
on the cause of insomnia that is to be addressed by
that specific treatment, and a few minutes of clarifying
things at this time often saves considerable time later.
INITIAL RECOMMENDATIONS
By this time in the interview, the focus of discussion
often has shifted away from the insomnia to issues of
lifestyle. The clinician explores questions such as the
meaning of retired life in a person whose entire self
esteem was derived from work, or discusses the options
available to a mother of three teenage girls, all drifting
towards chemical dependency while the patient's own
marriage is floundering. In a large minority of cases,
insomnia becomes a secondary issue and counseling
about problems of living becomes primary.
At our clinic, patients for whom insomnia remains
the primary focus typically leave the insomnia interview with two to four well-understood recommendations for changes in sleep hygiene, with some knowledge of their possible pharmacologic options and with
some understanding of how their own lifestyle and
their psychologic/psychiatric issues affect their sleep
and what might be done about it.
Recommendations are often presented as suggestions to be empirically tested. Research on insomnia
treatment is not advanced far enough to say with certainty what intervention will work with a given patient.
For example, most insomniacs should not nap during
the day, but there seems to be a minority of patients
Sleep. Vol. 16, No.4, 1993
who sleep considerably better at night if they have
taken a short afternoon siesta. Therefore, it often seems
useful to encourage insomniacs to become their own
"sleep scientists" by experimenting with different recommendations. For example, they might take a nap
every day for a week and note on a sleep log how they
then slept on the subsequent nights. During the next
week, they might take no naps, and the sleep log will
show whether that particular insomniac should,or
should not nap.
In an attempt to get some information on the efficacy
of these initial recommendations, data will now be
presented on feedback obtained from insomnia patients who were seen at the Mayo Clinic in 1989-1990.
METHODS
A total of 62 consecutive patients were referred to
the Mayo Sleep Disorders Center for once-only consultations for chronic insomnia during a 9-month period in 1989-1990. All 62 patients (32 female) are
included in this study. Mean age was 52 (range 2278). The patients' final insomnia diagnoses were as
follows: 14 psychophysiologic insomnia, 14 insomnia
associatedwith psychiatric disorders, 10 associated with
stress, 7 associated with drugs and alcohol, 5 insomnia
with restless legs syndrome and 12 with miscellaneous
other types of insomnia.
Assessment of sleep
In this study, each insomniac was first asked during
the interview to give a retrospective baseline for the
past week. The following information was elicited: how
long had it taken, on average, to fall asleep; how much
total sleep was obtained; how many awakenings had
there been per night and how many poor nights during
that week. Each patient was also asked to estimate the
. seriousness of the insomnia and its effects on daytime
functioning on a scale from 1-10. Exactly the same
questions were later asked of these patients during the
telephone follow-up interviews held 1 month, 3 months
and 12 months after the initial interview (see Table 1).
In addition, during these later telephone interviews,
patients were asked how their sleep had changed since
the interview, using a 21-point scale from -10 (much
worse) to 0 (no change) to + 10 (a total cure).
Assessment of recommendations
During the follow-up phone interviews, patients were
asked what recommendations they remembered from
the insomnia interview, whether they had actually tried
that recommendation and whether it had been helpful
(see Table 2). Following this, insomniacs were re-
CONSULTING ABOUT INSOMNIA
minded of the other recommendations that had been
made during the interview but may have been forgotten by the patient and they were encouraged to try
them as well. Occasionally, the technologist who did
the telephone interview re-explained a recommendation to a patient who might have misunderstood it. On
rare occasions, when things seemed to be going quite
badly « 5% of the interviews), the sleep specialist (P.H.)
then called the patient to provide some additional telephone counsel.
Because patients typically were given more than one
recommendation to try, there may be skepticism about
their ability to determine in a scientific, objective way
what helped and what did not. Subjectively, however,
patients were often quite adamant about what they
perceived as helpful, and this is what will be reported
in this paper.
SLEEP RESULTS FROM THE
TELEPHONE INTERVIEW
Table 1 reports the subjective data on sleep during
the retrospective I-week baseline obtained during the
initial interview and on the three follow-up telephone
calls. Follow-ups at 1, 3 and 12 months were each
compared with baseline reports by t tests. Each data
point in Table 1 is significant at p < 0.01, except for
sleep latency at 3 months (p = 0.08) and except for the
number of awakenings per night at 12 months (p =
0.06). The average improvement over the 12 months
after the interview seems stable, occurring within the
first month and then being maintained for the next 11
months. However, this was not true for all individual
insomniacs. Some showed marked initial improvement that was gradually lost over the year, whereas
others showed gradually improving sleep over the 12
months.
RESULTS CONCERNING SPECIFIC SLEEP
HYGIENE RECOMMENDATIONS
Table 2 reports on the recommendations that were
made, and how patients fared over the 12 months. On
average, insomniacs received 2.9 sleep hygiene recommendations, tried 2.1 of them during the first month
and found 1.4 of them helpful. With the telephone
interviews, they received encouragement to try the other ones as well. At 12 months, 1.7 helpful suggestions
were reported.
In Table 2, recommendations are ranked according
to the number of times they were given to one of the
62 insomniacs in this study. They are briefly discussed
here.
347
TABLE 2. Recommendations given to patients in once-only
consultations for chronic insomnia
ABC
Involving sleep hygiene
Read in bed or watch t.V.
Increase evening exercise
Daytime lifestyle changes
Curtail or regulate time in bed
Schedule "worry time" in evening
Avoid bedroom clock
Misc., e.g. decrease coffee
Involving professional help
Relax training & behavioral therapy
Occasional hypnotic, <once/week
Other med. changes
Psychotherapy, inc!. supportive
Sleep lab evaluations
68
63
42
40
34
31
II
D
E
69 69 67 71
69 78 65 70
58 67 72 80
84 71 72 57
81 77 47 50
79 40 57 45
57 75
0 67
53 61 60 67 53
45 68 84 81 82
44 74 75 57 55
39 33 75 70 70
17 62 69 69 69
A: % of clients to whom this was recommended (n = 62); B: % of
column A who actually tried this recommendation (n = 62); C: %
of column B who reported that it helped after I month (n = 62); D:
% of column B who reported that it helped after 3 months (n = 60);
E: % of column B who reported that it helped after 12 months
(n = 45). All numbers are given in percentages.
Read in bed or watch TV
This was suggested in an attempt to break up the
patient's pattern of lying in bed frustrated. This recommendation is used especially when patients report
that they fall asleep easily when reading or watching
TV in the evening, but become wide awake when they
then go to bed. Such patients are advised not only to
read or watch TV in bed, but also to fight sleep, just
as they would fight sleep when watching a particularly
good TV show in the evening. Paradoxically, we often
observe that the harder they try to remain awake, the
more likely sleep overpowers such insomniacs. If a bed
partner objects to reading or watching TV, the couple
is advised to go to bed together, but when the wellsleeping partner has fallen asleep, the insomniac might
go to another bedroom to carry out the recommendation and fall asleep there. The goal is to develop a
bedtime ritual that consistently leads to sleep. As Table
2 indicates, about two-thirds of the insomniacs in this
sample received this recommendation. Of those who
received it, about two-thirds found it useful throughout
the entire year.
Increase evening exercise
Monroe (6) has shown that, in a poor sleeper, metabolism does not slow down during the night as much
as it does in a good sleeper. Aerobic exercise increases
metabolism and core body temperature, and about 46 hours later there is a compensatory drop, which appears to lead to sounder sleep (7). Thus, exercise in the
morning is not beneficial because the compensatory
drop in core temperature and metabolism occurs long
Sleep, Vol. 16, No.4, 1993
348
P. J. HAURI
before bedtime. Home and Reid (8) have also shown
that passive heating accomplishes a similar goal. However, it appears that the compensatory drop in core
temperature occurs earlier after passive heating than
after active exercise. This suggests that a hot bath should
be taken 2-3 hours before going to bed if the patient
cannot exercise 4-6 hours before bedtime.
In our sample, the recommendation to increase exercise in the early evening was given to about twothirds of all patients, and about two-thirds of those
who received it felt it was beneficial.
Daytime lifestyle changes
Avoid the bedroom clock
No matter what time the clock shows, glancing at it
is almost always a reason for an emotional reaction in
an insomniac. Either it causes desperation because it
is late and the insomniac has not yet slept, or it causes
elation when the clock indicates that some sleep must
have occurred. Neither reaction is conducive to further
sleep. Therefore, each of these insomniacs is advised
to set the alarm clock for the desired wake-up time
and then to hide the clock, together with the watch and
other possible indicators of time. About one-third of
our patients received this recommendation, many tried
it, but only about half of them found it useful.
Insomniacs often live daytime lifestyles that are incompatible with good sleep. Included in this category
RECOMMENDATIONS INVOLVING
of recommendations are suggestions to learn stress
PROFESSIONAL HELP
management techniques, to schedule time off with
Because this paper deals with once-only insomnia
friends or family, to drop a second job and to stop
working in the late evening. About 40 percent of all consultations, no professional treatment was actually
insomniacs received such a recommendation concern- given. Rather, recommendations for such treatment
ing their lifestyle and about 60 percent of them carried were given directly to the patient or forwarded to the
through with it. Although it initially may be quite referring physician, to be carried out by local professtressful to change the daytime lifestyle, changing day- sionals.
time behavior has an increasingly beneficial effect the
longer it is carried through, as the figures in Table 2 Relaxation training and behavioral therapy
suggest.
About half of the insomniacs received recommendations
to seek the help of a behavioral therapist, either
Curtail and regulate time in bed
for relaxation training, for Glovinsky and Spielman's
It appears that the longer we stay in bed, the more sleep curtailment (9) or for Bootzin et al.'s stimulus
shallow and fragmented sleep becomes (less delta sleep, control therapy (4). Fewer than two-thirds of the pamore stage 1). Also, relatively regular sleep hours help tients actually followed through with this recommenthe circadian rhythm, whereas wildly fluctuating sleep dation, and fewer than two-thirds of those who did felt
hours are disruptive. Forty percent of this sample of. it to be helpful. These figures are considerably lower
insomniacs received recommendations to curtail or to than efficacy figures published elsewhere (1,4,5). It
regularize sleep, and most of them tried it initially. seems that the transfer from the sleep laboratory conThese recommendations seemed to help, but by the sultant to an outside behavior therapist did complicate
end of the year many insomniacs had slipped back into matters. In the studies cited above (1,4,5), the consultant usually was the behavior therapist as well.Seektheir previous routines.
ing behavior therapy from a person affiliated with the
sleep disorder center would probably improve the yield
Schedule "worry time" in the evening
from this recommendation.
Patients who are prone to worry or to plan at night
for upcoming activities are instructed· to schedule a Medication changes
regular 30 minutes of "worry time" early in the eveIn about half the cases, an occasional hypnotic (less
ning. During this time they are not only asked to collect
all their worries on paper, but also to decide for each than once per week) was recommended. About twoworry what they are actually going to do about it to- thirds of those who received this recommendation tried
morrow and to write out the resolutions. About one- it, and the reported success rates at 1, 3 and 12 months
third of the insomniacs received this recommendation, were the highest of all recommendations.
Interpreting this finding requires some caution. Most
and over 80 percent of them tried it. However, despite
initial success, only about half of those who received other recommendations involve changes the patient
this recommendation found it still beneficial 3 months makes every night, but the recommendation to use a
hypnotic no more than once per week is by definition
or 12 months after the interview.
Sleep. Vol. 16. No.4. 1993
CONSULTING ABOUT INSOMNIA
349
intermittent. Patients may have evaluated this recommendation based on its effectiveness on the drug
night only, not on its effect on insomnia overall.
In other cases, other medication changes were suggested, e.g. a low dose of an antidepressant, a switch
from a stimulating drug for a medical condition to
another medication with more sedating side effects.
Less than half of the patients received this recommendation and three-fourths of those tried it, but in the
long run only slightly more than 50 percent derived
benefit from it.
them. The main goal in this work with insomniacs is
the attempt to break up maladaptive patterns that have
developed around sleep and to substitute different ones.
The individual steps in this breakup have to be plausible to the insomniac, otherwise they will not be tried.
Even with the highly individualized approach that is
described here, not all recommendations were carried
through. When interviewed 1 month later, patients
said they had tried only 72 percent of the recommendations that were made. In part, this may be associated
with psychological needs to maintain the insomnia or
with reality factors (e.g. not finding a behavioral therapist). However, patients may also find it difficult to
Psychotherapy
remember all that is recommended in a· 90-minute
interview. Because of this, we now routinely send our
Although psychiatric conditions are the most frepatients a computer-generated follow-up letter describquent cause of insomnia, psychotherapy was recoming in considerable detail what had been recommended
mended for only 40 percent of the patients because so during the interview. We have rarely found it useful
many insomniacs were adamantly apposed to trying to give insomniacs a complete list of all possible recpsychotherapy. Even among the very carefully selected ommendations for sleep hygiene, mainly because they
group to whom it was suggested, only one-third ac- then focus on many irrelevant suggestions and give the
tually followed through by starting psychotherapy. Of few crucial ones less attention.
those who did, about three-fourths felt it was beneficial.
To summarize, a specialized one-time interview
leading to some individually tailored recommendations seems to be an efficient first line of defense for
Sleep lab evaluation
patients suffering from chronic insomnia who are reHow many insomniacs to study in the Sleep Dis- ferred to a sleep disorders center. In many cases this
orders Center is currently an issue of hot debate. In one-time contact is all that is necessary. Obviously, if
our series of insomniacs, we recommended a sleep study the response is not satisfactory, then more intense
in about one-sixth of our patients. Two-thirds of them treatment is indicated. Such treatment may involve
followed our recommendation. In about two-thirds of Bootzin et al.'s stimulus control therapy (4), Glovinsky
those who did, the recommendation was useful (by and Spielman's sleep curtailment (9), intensive relaxdiscovering periodic leg movements, alpha intrusion ation training (5), pharmacotherapy, psychotherapy or,
into sleep, etc.).
more recently, treatment with bright light (10,11).
However, it would seem wasteful to initially use these
more time-consuming approaches when a one-time 6090-minute attempt at sleep-related advice might be all
DISCUSSION
that may be necessary.
Obviously, our data on the efficacy of the sleep consultation is flawed because it is based on the insomniac's subjective report, not on objective data. Much
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