- Teks
- Sejarah
It must be noted at the outset that
It must be noted at the outset that there are some substantial
problems with research into the efficacy of treatment for
insomnia. The principal problem is how improvement is
measured. In many studies, success is based on changes to
clients' sleep, either as measured by a polysomnograph or
based on subjective report. However, preliminary research
has shown that distress about sleep can have little relation
to actual sleep disruption (Belicki, Chambers, & Ogilvie,
1997). These findings buttress Edinger and Wohlgemuth's
(1999) suggestion that treatment success should be based on
clients' subjective reports of improved sleep, independent of
objective measures of sleep quantity. Furthermore, Mendelson
(1993) has argued that the benefit of treatment may be
in changing the client's perception of sleep, rather than sleep
itself. Moreover, although the definition of insomnia includes
a component of altered daytime functioning, research rarely
takes improvements to daytime functioning into account (Edinger
& Wohlgemuth, 1999; A. G. Harvey & Tang, 2003). Yet,
in our experience, the desire to improve daytime functioning is
ultimately what propels clients to seek help. Therefore, much
of the literature has perhaps been misdirected in its focus on
the extent of sleep disruption.
That said, the consistent picture from the literature is that
there are treatment approaches that can successfully addresscomplaints of insomnia in many clients. Moreover, these
approaches can be successfully applied not only to primary
insomnia but also to insomnia that is comorbid with other conditions.
We first briefly review some ofthe principal medical,
or physical, treatments available, then tum to the techniques
that can be used by counselors.
Physical Approaches to the Treatment of Insomnia
There are two main approaches to the physical treatment of insomnia:
pharmacotherapy and bright light treatment. Although
some literature has shown that these methods are helpfiil in
alleviating the symptoms of insomnia, there are certain risks
associated with each type of treatment.
Pharmacological treatment. Hypnotic and antidepressant
drugs are the most common form of treatment for insomnia
(Walsh & Schweitzer, 1999). Antidepressants such as
trazadone and amitriptyline are among the top four drugs
prescribed for insomnia. Although they may induce sedation,
there is no research supporting their use for insomnia, and they
are known to have numerous side effects (National Institutes
of Health, 2005). In fact, a recent state-of-the-science review
suggested that the off-label use (i.e., practice of prescribing
Pharmaceuticals for a purpose outside the scope of a drug's
approved label) of antidepressants for insomnia occurs too
frequently, citing the fact that little evidence indicates that
antidepressants are efficacious in this context (National Institutes
of Health, 2005).
Benzodiazepines, such as flurazepam and temazepam,
have been found to be effective on a short-term basis (Hauri,
2000). However, long-term use of these drugs may cause
addiction and/or tolerance, decreased daytime functioning,
poor sleep quality, and rebound insomnia (i.e., insomnia that
reoccurs and worsens) upon discontinuation (Hauri, 2000).
Therefore, recent research has dictated that benzodiazepines
be prescribed less frequently; newer, nonbenzodiazepine
medications have replaced older benzodiazepine medication
as the drug of choice for insomnia.
Nonbenzodiazepine hypnotics (i.e., benzodiazepine receptor
agonists), such as zolpidem (Ambien), zaleplon (Sonata), and
eszopiclone (Lunesta), have thus far proven effective in the
treatment of insomnia. In general, their shorter half-life makes
these drugs less likely to cause dependence, rebound insomnia,
and medication "hangovers" (e.g., malaise and cognitive difficulty)
the following day (National Institutes of Health, 2005).
Zolpidem, in particular, is associated with decreased time to fall
asleep, increased total sleep time, decreased total wake time,
and more efficient sleep (Kryger, Steljes, Pouliot, Neufeld, &
Odynski, 1991). However, eszopiclone is the only one ofthese
drugs that has been studied for its long-term effects, and even
it has only been studied over 6 months (Hair, McCormack, &
Curran, 2008; National Institutes of Health, 2005). Clinicians
should note, however, that people with insomnia are often prescribed
hypnotics for many years, not just 6 months, and the
long-term effects ofthis practice remain unknown.
Furthermore, there is evidence that in the long term, psychological
therapies are more effective in treating insomnia
than pharmacotherapy. For example, Wu, Zhang, Deng, and
Long (2002), in a comparison of four groups (i.e., pharmacotherapy,
cognitive behavioral therapy [CBT], pharmacotherapy
combined with CBT, and placebo control), found that
pharmacotherapy was only effective in the short term, while
psychological treatments were effective over the long term
(Wu et al, 2002). In a more recent study, Vallieres, Morin,
Guay, Bastien, and LeBlanc (2004) showed that when pharmacotherapy
was used only for a short duration and overiapped
slightly with the introduction of CBT, improvements were
superior to using the two sequentially (i.e., pharmacotherapy,
then CBT) or concurrently. In particular, it should be noted
that most improvements occurred after the introduction of
CBT (Vallieres et al., 2004).
Bright light therapy For individuals with insomnia resulting
fi-om circadian factors, bright light therapy may be of some
use. Campbell, Dawson, and Anderson (1993) showed that for
older adults with sleep maintenance insomnia, 12 evenings of
bright light therapy increased sleep efficiency. Subsequently,
Suhner, Murphy, and Campbell (2002) demonstrated that the
same bright light treatment delayed the body temperature
rhythm an average of 94 minutes. Thus, this treatment may
be successñil in alleviating sleep maintenance difficulties by
realigning body temperature rhythms with sleep and wake
times. This therapy should allow people with insomnia to
remain awake longer, thus consolidating subsequent sleep.
Because the body temperature minimum is delayed following
evening bright light therapy, sleep should be easier to maintain
in the early morning. Suhner et al. found, however, that when
bright light exposure was reduced to twice a week, changes to
circadian rhythms were not maintained. This result indicates
that daily exposure, a time-consuming and cumbersome procedure,
is needed to preserve changes to circadian rhythms.
For individuals with sleep-onset insomnia, bright light therapy
should be administered in the morning (Lack & Bootzin,
2003). Early morning bright light exposure advances the
circadian rhythm (Lack & Bootzin, 2003), making the person
with insomnia feel tired earlier. Any individuals planning to
use this technique should be educated about possible side effects,
such as increased cataract risk (Reme, Rol, Grothmann,
Kaase, & Terman, 1996), and should investigate the costs and
other potential disadvantages ofthis technique.
Clearly there are disadvantages to the various physical
approaches to the treatment of insomnia. Fortunately, as discussed
in the following section, numerous studies have shown
that psychological approaches to managing sleep complaints
can be effective.
Psychological Approaches to the
Treatment of Insomnia
Numerous studies have demonstrated the usefulness of CBT
in treating insomnia, although empirical research has indicated
problems with research into the efficacy of treatment for
insomnia. The principal problem is how improvement is
measured. In many studies, success is based on changes to
clients' sleep, either as measured by a polysomnograph or
based on subjective report. However, preliminary research
has shown that distress about sleep can have little relation
to actual sleep disruption (Belicki, Chambers, & Ogilvie,
1997). These findings buttress Edinger and Wohlgemuth's
(1999) suggestion that treatment success should be based on
clients' subjective reports of improved sleep, independent of
objective measures of sleep quantity. Furthermore, Mendelson
(1993) has argued that the benefit of treatment may be
in changing the client's perception of sleep, rather than sleep
itself. Moreover, although the definition of insomnia includes
a component of altered daytime functioning, research rarely
takes improvements to daytime functioning into account (Edinger
& Wohlgemuth, 1999; A. G. Harvey & Tang, 2003). Yet,
in our experience, the desire to improve daytime functioning is
ultimately what propels clients to seek help. Therefore, much
of the literature has perhaps been misdirected in its focus on
the extent of sleep disruption.
That said, the consistent picture from the literature is that
there are treatment approaches that can successfully addresscomplaints of insomnia in many clients. Moreover, these
approaches can be successfully applied not only to primary
insomnia but also to insomnia that is comorbid with other conditions.
We first briefly review some ofthe principal medical,
or physical, treatments available, then tum to the techniques
that can be used by counselors.
Physical Approaches to the Treatment of Insomnia
There are two main approaches to the physical treatment of insomnia:
pharmacotherapy and bright light treatment. Although
some literature has shown that these methods are helpfiil in
alleviating the symptoms of insomnia, there are certain risks
associated with each type of treatment.
Pharmacological treatment. Hypnotic and antidepressant
drugs are the most common form of treatment for insomnia
(Walsh & Schweitzer, 1999). Antidepressants such as
trazadone and amitriptyline are among the top four drugs
prescribed for insomnia. Although they may induce sedation,
there is no research supporting their use for insomnia, and they
are known to have numerous side effects (National Institutes
of Health, 2005). In fact, a recent state-of-the-science review
suggested that the off-label use (i.e., practice of prescribing
Pharmaceuticals for a purpose outside the scope of a drug's
approved label) of antidepressants for insomnia occurs too
frequently, citing the fact that little evidence indicates that
antidepressants are efficacious in this context (National Institutes
of Health, 2005).
Benzodiazepines, such as flurazepam and temazepam,
have been found to be effective on a short-term basis (Hauri,
2000). However, long-term use of these drugs may cause
addiction and/or tolerance, decreased daytime functioning,
poor sleep quality, and rebound insomnia (i.e., insomnia that
reoccurs and worsens) upon discontinuation (Hauri, 2000).
Therefore, recent research has dictated that benzodiazepines
be prescribed less frequently; newer, nonbenzodiazepine
medications have replaced older benzodiazepine medication
as the drug of choice for insomnia.
Nonbenzodiazepine hypnotics (i.e., benzodiazepine receptor
agonists), such as zolpidem (Ambien), zaleplon (Sonata), and
eszopiclone (Lunesta), have thus far proven effective in the
treatment of insomnia. In general, their shorter half-life makes
these drugs less likely to cause dependence, rebound insomnia,
and medication "hangovers" (e.g., malaise and cognitive difficulty)
the following day (National Institutes of Health, 2005).
Zolpidem, in particular, is associated with decreased time to fall
asleep, increased total sleep time, decreased total wake time,
and more efficient sleep (Kryger, Steljes, Pouliot, Neufeld, &
Odynski, 1991). However, eszopiclone is the only one ofthese
drugs that has been studied for its long-term effects, and even
it has only been studied over 6 months (Hair, McCormack, &
Curran, 2008; National Institutes of Health, 2005). Clinicians
should note, however, that people with insomnia are often prescribed
hypnotics for many years, not just 6 months, and the
long-term effects ofthis practice remain unknown.
Furthermore, there is evidence that in the long term, psychological
therapies are more effective in treating insomnia
than pharmacotherapy. For example, Wu, Zhang, Deng, and
Long (2002), in a comparison of four groups (i.e., pharmacotherapy,
cognitive behavioral therapy [CBT], pharmacotherapy
combined with CBT, and placebo control), found that
pharmacotherapy was only effective in the short term, while
psychological treatments were effective over the long term
(Wu et al, 2002). In a more recent study, Vallieres, Morin,
Guay, Bastien, and LeBlanc (2004) showed that when pharmacotherapy
was used only for a short duration and overiapped
slightly with the introduction of CBT, improvements were
superior to using the two sequentially (i.e., pharmacotherapy,
then CBT) or concurrently. In particular, it should be noted
that most improvements occurred after the introduction of
CBT (Vallieres et al., 2004).
Bright light therapy For individuals with insomnia resulting
fi-om circadian factors, bright light therapy may be of some
use. Campbell, Dawson, and Anderson (1993) showed that for
older adults with sleep maintenance insomnia, 12 evenings of
bright light therapy increased sleep efficiency. Subsequently,
Suhner, Murphy, and Campbell (2002) demonstrated that the
same bright light treatment delayed the body temperature
rhythm an average of 94 minutes. Thus, this treatment may
be successñil in alleviating sleep maintenance difficulties by
realigning body temperature rhythms with sleep and wake
times. This therapy should allow people with insomnia to
remain awake longer, thus consolidating subsequent sleep.
Because the body temperature minimum is delayed following
evening bright light therapy, sleep should be easier to maintain
in the early morning. Suhner et al. found, however, that when
bright light exposure was reduced to twice a week, changes to
circadian rhythms were not maintained. This result indicates
that daily exposure, a time-consuming and cumbersome procedure,
is needed to preserve changes to circadian rhythms.
For individuals with sleep-onset insomnia, bright light therapy
should be administered in the morning (Lack & Bootzin,
2003). Early morning bright light exposure advances the
circadian rhythm (Lack & Bootzin, 2003), making the person
with insomnia feel tired earlier. Any individuals planning to
use this technique should be educated about possible side effects,
such as increased cataract risk (Reme, Rol, Grothmann,
Kaase, & Terman, 1996), and should investigate the costs and
other potential disadvantages ofthis technique.
Clearly there are disadvantages to the various physical
approaches to the treatment of insomnia. Fortunately, as discussed
in the following section, numerous studies have shown
that psychological approaches to managing sleep complaints
can be effective.
Psychological Approaches to the
Treatment of Insomnia
Numerous studies have demonstrated the usefulness of CBT
in treating insomnia, although empirical research has indicated
0/5000
It must be noted at the outset that there are some substantialproblems with research into the efficacy of treatment forinsomnia. The principal problem is how improvement ismeasured. In many studies, success is based on changes toclients' sleep, either as measured by a polysomnograph orbased on subjective report. However, preliminary researchhas shown that distress about sleep can have little relationto actual sleep disruption (Belicki, Chambers, & Ogilvie,1997). These findings buttress Edinger and Wohlgemuth's(1999) suggestion that treatment success should be based onclients' subjective reports of improved sleep, independent ofobjective measures of sleep quantity. Furthermore, Mendelson(1993) has argued that the benefit of treatment may bein changing the client's perception of sleep, rather than sleepitself. Moreover, although the definition of insomnia includesa component of altered daytime functioning, research rarelytakes improvements to daytime functioning into account (Edinger& Wohlgemuth, 1999; A. G. Harvey & Tang, 2003). Yet,in our experience, the desire to improve daytime functioning isultimately what propels clients to seek help. Therefore, muchof the literature has perhaps been misdirected in its focus onthe extent of sleep disruption.That said, the consistent picture from the literature is thatthere are treatment approaches that can successfully addresscomplaints of insomnia in many clients. Moreover, theseapproaches can be successfully applied not only to primaryinsomnia but also to insomnia that is comorbid with other conditions.We first briefly review some ofthe principal medical,or physical, treatments available, then tum to the techniquesthat can be used by counselors.Physical Approaches to the Treatment of InsomniaThere are two main approaches to the physical treatment of insomnia:pharmacotherapy and bright light treatment. Althoughsome literature has shown that these methods are helpfiil inalleviating the symptoms of insomnia, there are certain risksassociated with each type of treatment.Pharmacological treatment. Hypnotic and antidepressantdrugs are the most common form of treatment for insomnia(Walsh & Schweitzer, 1999). Antidepressants such astrazadone and amitriptyline are among the top four drugsprescribed for insomnia. Although they may induce sedation,there is no research supporting their use for insomnia, and theyare known to have numerous side effects (National Institutesof Health, 2005). In fact, a recent state-of-the-science reviewsuggested that the off-label use (i.e., practice of prescribingPharmaceuticals for a purpose outside the scope of a drug'sapproved label) of antidepressants for insomnia occurs toofrequently, citing the fact that little evidence indicates thatantidepressants are efficacious in this context (National Institutesof Health, 2005).Benzodiazepines, such as flurazepam and temazepam,have been found to be effective on a short-term basis (Hauri,2000). However, long-term use of these drugs may causeaddiction and/or tolerance, decreased daytime functioning,poor sleep quality, and rebound insomnia (i.e., insomnia thatreoccurs and worsens) upon discontinuation (Hauri, 2000).Therefore, recent research has dictated that benzodiazepinesbe prescribed less frequently; newer, nonbenzodiazepinemedications have replaced older benzodiazepine medicationas the drug of choice for insomnia.Nonbenzodiazepine hypnotics (i.e., benzodiazepine receptoragonists), such as zolpidem (Ambien), zaleplon (Sonata), andeszopiclone (Lunesta), have thus far proven effective in thetreatment of insomnia. In general, their shorter half-life makesthese drugs less likely to cause dependence, rebound insomnia,and medication "hangovers" (e.g., malaise and cognitive difficulty)the following day (National Institutes of Health, 2005).Zolpidem, in particular, is associated with decreased time to fallasleep, increased total sleep time, decreased total wake time,and more efficient sleep (Kryger, Steljes, Pouliot, Neufeld, &Odynski, 1991). However, eszopiclone is the only one ofthesedrugs that has been studied for its long-term effects, and evenit has only been studied over 6 months (Hair, McCormack, &Curran, 2008; National Institutes of Health, 2005). Cliniciansshould note, however, that people with insomnia are often prescribedhypnotics for many years, not just 6 months, and thelong-term effects ofthis practice remain unknown.Furthermore, there is evidence that in the long term, psychologicaltherapies are more effective in treating insomniathan pharmacotherapy. For example, Wu, Zhang, Deng, andLong (2002), in a comparison of four groups (i.e., pharmacotherapy,cognitive behavioral therapy [CBT], pharmacotherapycombined with CBT, and placebo control), found thatpharmacotherapy was only effective in the short term, whilepsychological treatments were effective over the long term(Wu et al, 2002). In a more recent study, Vallieres, Morin,Guay, Bastien, and LeBlanc (2004) showed that when pharmacotherapywas used only for a short duration and overiappedslightly with the introduction of CBT, improvements weresuperior to using the two sequentially (i.e., pharmacotherapy,then CBT) or concurrently. In particular, it should be notedthat most improvements occurred after the introduction ofCBT (Vallieres et al., 2004).Bright light therapy For individuals with insomnia resultingfi-om circadian factors, bright light therapy may be of someuse. Campbell, Dawson, and Anderson (1993) showed that forolder adults with sleep maintenance insomnia, 12 evenings ofbright light therapy increased sleep efficiency. Subsequently,Suhner, Murphy, and Campbell (2002) demonstrated that thesame bright light treatment delayed the body temperaturerhythm an average of 94 minutes. Thus, this treatment maybe successñil in alleviating sleep maintenance difficulties byrealigning body temperature rhythms with sleep and waketimes. This therapy should allow people with insomnia toremain awake longer, thus consolidating subsequent sleep.Because the body temperature minimum is delayed followingevening bright light therapy, sleep should be easier to maintainin the early morning. Suhner et al. found, however, that whenbright light exposure was reduced to twice a week, changes tocircadian rhythms were not maintained. This result indicatesthat daily exposure, a time-consuming and cumbersome procedure,is needed to preserve changes to circadian rhythms.For individuals with sleep-onset insomnia, bright light therapyshould be administered in the morning (Lack & Bootzin,2003). Early morning bright light exposure advances thecircadian rhythm (Lack & Bootzin, 2003), making the personwith insomnia feel tired earlier. Any individuals planning touse this technique should be educated about possible side effects,such as increased cataract risk (Reme, Rol, Grothmann,Kaase, & Terman, 1996), and should investigate the costs andother potential disadvantages ofthis technique.Clearly there are disadvantages to the various physicalapproaches to the treatment of insomnia. Fortunately, as discussedin the following section, numerous studies have shownthat psychological approaches to managing sleep complaintscan be effective.Psychological Approaches to theTreatment of InsomniaNumerous studies have demonstrated the usefulness of CBTin treating insomnia, although empirical research has indicated
Sedang diterjemahkan, harap tunggu..
Harus dicatat di awal bahwa ada beberapa substansial
masalah dengan penelitian khasiat pengobatan untuk
insomnia. Masalah utama adalah bagaimana perbaikan
diukur. Dalam banyak penelitian, keberhasilan didasarkan pada perubahan
tidur klien, baik yang diukur dengan polysomnograph atau
berdasarkan laporan subjektif. Namun, penelitian awal
telah menunjukkan bahwa stres tentang tidur dapat memiliki sedikit hubungan
dengan gangguan tidur yang sebenarnya (Belicki, Chambers, & Ogilvie,
1997). Temuan ini memperkuat Edinger dan Wohlgemuth ini
(1999) saran bahwa keberhasilan pengobatan harus didasarkan pada
laporan subjektif klien ditingkatkan tidur, independen dari
ukuran objektif kuantitas tidur. Selanjutnya, Mendelson
(1993) berpendapat bahwa manfaat dari pengobatan mungkin
dalam mengubah persepsi klien tidur, bukan tidur
itu sendiri. Selain itu, meskipun definisi insomnia termasuk
komponen fungsi siang hari berubah, penelitian jarang
mengambil perbaikan ke siang hari berfungsi memperhitungkan (Edinger
& Wohlgemuth, 1999; AG Harvey & Tang, 2003). Namun,
dalam pengalaman kami, keinginan untuk meningkatkan fungsi siang hari
akhirnya apa yang mendorong klien untuk mencari bantuan. Oleh karena itu, banyak
literatur telah mungkin telah salah arah dalam fokus pada
sejauh mana gangguan tidur.
Yang mengatakan, gambar yang konsisten dari literatur adalah bahwa
ada pendekatan pengobatan yang berhasil dapat addresscomplaints insomnia pada banyak klien. Selain itu, ini
pendekatan dapat berhasil diterapkan tidak hanya untuk utama
susah tidur, tetapi juga insomnia yang komorbiditas dengan kondisi lain.
Kami pertama secara singkat beberapa ofthe kepala medis,
perawatan atau fisik, tersedia, maka tum ke teknik
yang dapat digunakan oleh konselor .
Pendekatan fisik untuk Pengobatan Insomnia
Ada dua pendekatan utama untuk pengobatan fisik insomnia:
farmakoterapi dan pengobatan cahaya terang. Meskipun
beberapa literatur telah menunjukkan bahwa metode ini helpfiil di
mengurangi gejala insomnia, ada risiko tertentu
yang terkait dengan setiap jenis pengobatan.
Farmakologi pengobatan. Hypnotic dan antidepresan
obat adalah bentuk paling umum dari pengobatan untuk insomnia
(Walsh & Schweitzer, 1999). Antidepresan seperti
trazadone dan amitriptyline berada diantara empat obat
yang diresepkan untuk insomnia. Meskipun mereka dapat menyebabkan sedasi,
tidak ada penelitian yang mendukung penggunaannya untuk insomnia, dan mereka
dikenal memiliki banyak efek samping (National Institutes
of Health, 2005). Bahkan, negara-of-the-ilmu review baru-baru
menyarankan bahwa penggunaan off-label (yaitu, praktek resep
Pharmaceuticals untuk tujuan di luar lingkup dari obat
label disetujui) antidepresan untuk insomnia terjadi terlalu
sering, mengutip fakta yang sedikit bukti menunjukkan bahwa
antidepresan yang berkhasiat dalam konteks ini (National Institutes
of Health, 2005).
Benzodiazepin, seperti flurazepam dan temazepam,
telah ditemukan untuk menjadi efektif dalam jangka pendek (Hauri,
2000). Namun, penggunaan jangka panjang obat ini dapat menyebabkan
kecanduan dan / atau toleransi, penurunan fungsi siang hari,
kualitas tidur yang buruk, dan rebound insomnia (yaitu, insomnia yang
reoccurs dan memperburuk) setelah penghentian (Hauri, 2000).
Oleh karena itu, penelitian terbaru memiliki menentukan bahwa benzodiazepin
diresepkan lebih jarang; baru, nonbenzodiazepine
obat telah menggantikan obat benzodiazepine tua
sebagai obat pilihan untuk insomnia.
hipnotik Nonbenzodiazepine (yaitu, reseptor benzodiazepine
agonis), seperti zolpidem (Ambien), zaleplon (Sonata), dan
eszopiclone (Lunesta), sejauh ini terbukti efektif dalam
pengobatan insomnia. Secara umum, lebih pendek setengah-hidup mereka membuat
obat ini cenderung menyebabkan ketergantungan, rebound insomnia,
dan obat-obatan "mabuk" (misalnya, malaise dan kesulitan kognitif)
pada hari berikutnya (National Institutes of Health, 2005).
Zolpidem, khususnya, dikaitkan dengan penurunan waktu untuk jatuh
tertidur, peningkatan waktu tidur total, penurunan total waktu bangun,
dan tidur lebih efisien (Kryger, Steljes, Pouliot, Neufeld, &
Odynski, 1991). Namun, eszopiclone adalah satu-satunya ofthese
obat yang telah dipelajari untuk efek jangka panjang, dan bahkan
itu hanya telah dipelajari selama 6 bulan (Hair, McCormack, &
Curran, 2008; National Institutes of Health, 2005). Dokter
harus mencatat, bagaimanapun, bahwa orang dengan insomnia sering diresepkan
hipnotik selama bertahun-tahun, bukan hanya 6 bulan, dan
efek jangka panjang ofthis praktek tetap tidak diketahui.
Selain itu, ada bukti bahwa dalam jangka panjang, psikologis
terapi yang lebih efektif dalam mengatasi insomnia
daripada farmakoterapi. Misalnya, Wu, Zhang, Deng, dan
Panjang (2002), dalam perbandingan empat kelompok (yaitu, farmakoterapi,
terapi perilaku kognitif [CBT], farmakoterapi
dikombinasikan dengan CBT, dan kontrol plasebo), menemukan bahwa
farmakoterapi hanya efektif dalam jangka pendek, sementara
perawatan psikologis yang efektif dalam jangka panjang
(Wu et al, 2002). Dalam penelitian yang lebih baru, Vallieres, Morin,
Guay, Bastien, dan LeBlanc (2004) menunjukkan bahwa ketika farmakoterapi
digunakan hanya untuk jangka waktu pendek dan overiapped
sedikit dengan pengenalan CBT, perbaikan yang
unggul menggunakan dua berurutan (yaitu, farmakoterapi,
maka CBT) atau bersamaan. Secara khusus, perlu dicatat
bahwa sebagian besar perbaikan terjadi setelah pengenalan
CBT (Vallieres et al., 2004).
Terapi cahaya terang Bagi individu dengan insomnia yang disebabkan
faktor sirkadian fi-om, terapi cahaya terang mungkin dari beberapa
digunakan. Campbell, Dawson, dan Anderson (1993) menunjukkan bahwa untuk
orang dewasa yang lebih tua dengan pemeliharaan tidur insomnia, 12 malam dari
terapi cahaya terang peningkatan efisiensi tidur. Selanjutnya,
Suhner, Murphy, dan Campbell (2002) menunjukkan bahwa
perlakuan cahaya terang yang sama tertunda suhu tubuh
ritme rata-rata 94 menit. Dengan demikian, pengobatan ini dapat
menjadi successñil dalam mengurangi kesulitan pemeliharaan tidur dengan
menyelaraskan ritme suhu tubuh dengan tidur dan bangun
kali. Terapi ini harus memungkinkan orang dengan insomnia untuk
tetap terjaga lebih lama, sehingga konsolidasi tidur berikutnya.
Karena minimum suhu tubuh tertunda berikut
malam terapi cahaya terang, tidur harus lebih mudah untuk mempertahankan
di pagi hari. Suhner dkk. ditemukan, bagaimanapun, bahwa ketika
paparan cahaya terang dikurangi menjadi dua kali seminggu, perubahan
irama sirkadian tidak dipertahankan. Hasil ini menunjukkan
bahwa paparan harian, prosedur memakan waktu dan rumit,
diperlukan untuk melestarikan perubahan irama sirkadian.
Bagi individu dengan insomnia tidur-onset, terapi cahaya terang
harus diberikan di pagi hari (Kekurangan & Bootzin,
2003). Pagi paparan cahaya terang kemajuan
ritme sirkadian (Kurangnya & Bootzin, 2003), membuat orang
dengan insomnia merasa lelah sebelumnya. Setiap individu berencana untuk
menggunakan teknik ini harus dididik tentang kemungkinan efek samping,
seperti peningkatan risiko katarak (Reme, Rol, Grothmann,
Kaase, & Terman, 1996), dan harus menyelidiki biaya dan
kerugian potensial lainnya ofthis teknik.
Jelas ada kerugian untuk berbagai fisik
pendekatan untuk pengobatan insomnia. Untungnya, seperti yang dibahas
di bagian berikut, banyak penelitian telah menunjukkan
bahwa pendekatan psikologis untuk mengelola keluhan tidur
bisa efektif.
Pendekatan psikologis untuk
Pengobatan Insomnia
Sejumlah penelitian telah menunjukkan kegunaan CBT
dalam mengobati insomnia, meskipun penelitian empiris telah menunjukkan
masalah dengan penelitian khasiat pengobatan untuk
insomnia. Masalah utama adalah bagaimana perbaikan
diukur. Dalam banyak penelitian, keberhasilan didasarkan pada perubahan
tidur klien, baik yang diukur dengan polysomnograph atau
berdasarkan laporan subjektif. Namun, penelitian awal
telah menunjukkan bahwa stres tentang tidur dapat memiliki sedikit hubungan
dengan gangguan tidur yang sebenarnya (Belicki, Chambers, & Ogilvie,
1997). Temuan ini memperkuat Edinger dan Wohlgemuth ini
(1999) saran bahwa keberhasilan pengobatan harus didasarkan pada
laporan subjektif klien ditingkatkan tidur, independen dari
ukuran objektif kuantitas tidur. Selanjutnya, Mendelson
(1993) berpendapat bahwa manfaat dari pengobatan mungkin
dalam mengubah persepsi klien tidur, bukan tidur
itu sendiri. Selain itu, meskipun definisi insomnia termasuk
komponen fungsi siang hari berubah, penelitian jarang
mengambil perbaikan ke siang hari berfungsi memperhitungkan (Edinger
& Wohlgemuth, 1999; AG Harvey & Tang, 2003). Namun,
dalam pengalaman kami, keinginan untuk meningkatkan fungsi siang hari
akhirnya apa yang mendorong klien untuk mencari bantuan. Oleh karena itu, banyak
literatur telah mungkin telah salah arah dalam fokus pada
sejauh mana gangguan tidur.
Yang mengatakan, gambar yang konsisten dari literatur adalah bahwa
ada pendekatan pengobatan yang berhasil dapat addresscomplaints insomnia pada banyak klien. Selain itu, ini
pendekatan dapat berhasil diterapkan tidak hanya untuk utama
susah tidur, tetapi juga insomnia yang komorbiditas dengan kondisi lain.
Kami pertama secara singkat beberapa ofthe kepala medis,
perawatan atau fisik, tersedia, maka tum ke teknik
yang dapat digunakan oleh konselor .
Pendekatan fisik untuk Pengobatan Insomnia
Ada dua pendekatan utama untuk pengobatan fisik insomnia:
farmakoterapi dan pengobatan cahaya terang. Meskipun
beberapa literatur telah menunjukkan bahwa metode ini helpfiil di
mengurangi gejala insomnia, ada risiko tertentu
yang terkait dengan setiap jenis pengobatan.
Farmakologi pengobatan. Hypnotic dan antidepresan
obat adalah bentuk paling umum dari pengobatan untuk insomnia
(Walsh & Schweitzer, 1999). Antidepresan seperti
trazadone dan amitriptyline berada diantara empat obat
yang diresepkan untuk insomnia. Meskipun mereka dapat menyebabkan sedasi,
tidak ada penelitian yang mendukung penggunaannya untuk insomnia, dan mereka
dikenal memiliki banyak efek samping (National Institutes
of Health, 2005). Bahkan, negara-of-the-ilmu review baru-baru
menyarankan bahwa penggunaan off-label (yaitu, praktek resep
Pharmaceuticals untuk tujuan di luar lingkup dari obat
label disetujui) antidepresan untuk insomnia terjadi terlalu
sering, mengutip fakta yang sedikit bukti menunjukkan bahwa
antidepresan yang berkhasiat dalam konteks ini (National Institutes
of Health, 2005).
Benzodiazepin, seperti flurazepam dan temazepam,
telah ditemukan untuk menjadi efektif dalam jangka pendek (Hauri,
2000). Namun, penggunaan jangka panjang obat ini dapat menyebabkan
kecanduan dan / atau toleransi, penurunan fungsi siang hari,
kualitas tidur yang buruk, dan rebound insomnia (yaitu, insomnia yang
reoccurs dan memperburuk) setelah penghentian (Hauri, 2000).
Oleh karena itu, penelitian terbaru memiliki menentukan bahwa benzodiazepin
diresepkan lebih jarang; baru, nonbenzodiazepine
obat telah menggantikan obat benzodiazepine tua
sebagai obat pilihan untuk insomnia.
hipnotik Nonbenzodiazepine (yaitu, reseptor benzodiazepine
agonis), seperti zolpidem (Ambien), zaleplon (Sonata), dan
eszopiclone (Lunesta), sejauh ini terbukti efektif dalam
pengobatan insomnia. Secara umum, lebih pendek setengah-hidup mereka membuat
obat ini cenderung menyebabkan ketergantungan, rebound insomnia,
dan obat-obatan "mabuk" (misalnya, malaise dan kesulitan kognitif)
pada hari berikutnya (National Institutes of Health, 2005).
Zolpidem, khususnya, dikaitkan dengan penurunan waktu untuk jatuh
tertidur, peningkatan waktu tidur total, penurunan total waktu bangun,
dan tidur lebih efisien (Kryger, Steljes, Pouliot, Neufeld, &
Odynski, 1991). Namun, eszopiclone adalah satu-satunya ofthese
obat yang telah dipelajari untuk efek jangka panjang, dan bahkan
itu hanya telah dipelajari selama 6 bulan (Hair, McCormack, &
Curran, 2008; National Institutes of Health, 2005). Dokter
harus mencatat, bagaimanapun, bahwa orang dengan insomnia sering diresepkan
hipnotik selama bertahun-tahun, bukan hanya 6 bulan, dan
efek jangka panjang ofthis praktek tetap tidak diketahui.
Selain itu, ada bukti bahwa dalam jangka panjang, psikologis
terapi yang lebih efektif dalam mengatasi insomnia
daripada farmakoterapi. Misalnya, Wu, Zhang, Deng, dan
Panjang (2002), dalam perbandingan empat kelompok (yaitu, farmakoterapi,
terapi perilaku kognitif [CBT], farmakoterapi
dikombinasikan dengan CBT, dan kontrol plasebo), menemukan bahwa
farmakoterapi hanya efektif dalam jangka pendek, sementara
perawatan psikologis yang efektif dalam jangka panjang
(Wu et al, 2002). Dalam penelitian yang lebih baru, Vallieres, Morin,
Guay, Bastien, dan LeBlanc (2004) menunjukkan bahwa ketika farmakoterapi
digunakan hanya untuk jangka waktu pendek dan overiapped
sedikit dengan pengenalan CBT, perbaikan yang
unggul menggunakan dua berurutan (yaitu, farmakoterapi,
maka CBT) atau bersamaan. Secara khusus, perlu dicatat
bahwa sebagian besar perbaikan terjadi setelah pengenalan
CBT (Vallieres et al., 2004).
Terapi cahaya terang Bagi individu dengan insomnia yang disebabkan
faktor sirkadian fi-om, terapi cahaya terang mungkin dari beberapa
digunakan. Campbell, Dawson, dan Anderson (1993) menunjukkan bahwa untuk
orang dewasa yang lebih tua dengan pemeliharaan tidur insomnia, 12 malam dari
terapi cahaya terang peningkatan efisiensi tidur. Selanjutnya,
Suhner, Murphy, dan Campbell (2002) menunjukkan bahwa
perlakuan cahaya terang yang sama tertunda suhu tubuh
ritme rata-rata 94 menit. Dengan demikian, pengobatan ini dapat
menjadi successñil dalam mengurangi kesulitan pemeliharaan tidur dengan
menyelaraskan ritme suhu tubuh dengan tidur dan bangun
kali. Terapi ini harus memungkinkan orang dengan insomnia untuk
tetap terjaga lebih lama, sehingga konsolidasi tidur berikutnya.
Karena minimum suhu tubuh tertunda berikut
malam terapi cahaya terang, tidur harus lebih mudah untuk mempertahankan
di pagi hari. Suhner dkk. ditemukan, bagaimanapun, bahwa ketika
paparan cahaya terang dikurangi menjadi dua kali seminggu, perubahan
irama sirkadian tidak dipertahankan. Hasil ini menunjukkan
bahwa paparan harian, prosedur memakan waktu dan rumit,
diperlukan untuk melestarikan perubahan irama sirkadian.
Bagi individu dengan insomnia tidur-onset, terapi cahaya terang
harus diberikan di pagi hari (Kekurangan & Bootzin,
2003). Pagi paparan cahaya terang kemajuan
ritme sirkadian (Kurangnya & Bootzin, 2003), membuat orang
dengan insomnia merasa lelah sebelumnya. Setiap individu berencana untuk
menggunakan teknik ini harus dididik tentang kemungkinan efek samping,
seperti peningkatan risiko katarak (Reme, Rol, Grothmann,
Kaase, & Terman, 1996), dan harus menyelidiki biaya dan
kerugian potensial lainnya ofthis teknik.
Jelas ada kerugian untuk berbagai fisik
pendekatan untuk pengobatan insomnia. Untungnya, seperti yang dibahas
di bagian berikut, banyak penelitian telah menunjukkan
bahwa pendekatan psikologis untuk mengelola keluhan tidur
bisa efektif.
Pendekatan psikologis untuk
Pengobatan Insomnia
Sejumlah penelitian telah menunjukkan kegunaan CBT
dalam mengobati insomnia, meskipun penelitian empiris telah menunjukkan
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