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Articles Section
Treating primary insomnia 67
Journal of Cognitive and Behavioral Psychotherapies,
Vol. 9, No. 1, March 2009, 67-82.
TREATING PRIMARY INSOMNIA:
A COMPARATIVE STUDY OF SELF-HELP
METHODS AND PROGRESSIVE MUSCLE
RELAXATION
Bogdan Vasile ALEXANDRU
1
, Balázsi RÓBERT
*1
,
Lupu VIOREL
2
,
Bogdan VASILE
1
1
Babes-Bolyai University, Cluj-Napoca, Romania
2
Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
Abstract
Insomnia is one of the most prevalent psychological disorders worldwide.
Some of the deficiencies of the current treatments of insomnia are: side
effects in the case of sleeping pills and high costs in the case of
psychotherapeutic treatment. Some suggest that self-help treatments could
be a viable alternative, with certain advantages such as low cost, and wide
accessibility to a large number of people. In our study we used a modified
Latin square experimental design for single subject research to verify the
effect of multi-component treatment efficiency in primary insomnia.
Another goal of our study was to compare the effects of the three treatment
techniques (progressive muscle relaxation, sleep hygiene, binaural beats)
included in the multi-component intervention package. Our results reflect
the efficiency of the multi-component treatment. Significant differences
were found only between muscle relaxation and binaural beat. Based on
effects size measures we can say that muscle relaxation and sleep hygiene
have a very similar effect. The effect of binaural beat treatment is lower
than that of the other two types of intervention.
Keywords: insomnia, single subject experiment, progressive muscular
relaxation, sleep hygiene, binaural beats
Insomnia is a disorder characterized by the qualitative reduction of the sleep
duration and efficacy (Morin, Hauri, Espie, Spielman, Buysse, & Bootzin, 1999;
Pallesen, 2003). Out of all psychological disorders, insomnia displays some of the
highest prevalence rates, epidemiological data reporting frequencies as high as
22% (Stinson et al., 2006) and even 33% (Harvey, 2001). Insomnia causes severe
distress, social, interpersonal and professional dysfunction (Harvey, 2002). It
*
Correspondence concerning this article should be addressed to:
E-mail: balazsirobert@psychology.ro
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Alexandru V. Bogdan, Róbert Balázsi, Viorel Lupu & Vasile Bogdan 68
affects well-being and the quality of life (Espie, 1991) and is often associated
with affective disorders, such as irritability and dysphoria (Morin, 2003). The
impredictibility and incontrolability of the sleeping pattern can lead to feelings of
helplessness and to the onset of depressive and anxiety disorders (Morin, 2003;
Neckelmann, 2007). Longitudinal studies conducted by Ford & Kamerow (1989)
showed that persistent untreated insomnia can be a risk factor in the development
of the major depressive disorder.
The global expenses for the treatment of insomnia and its consequences rise
to several billion dollars. For example, in the United States, the cost of insomnia
treatments in 2004 rose to over 2.1 billion dollars, and it is estimated to reach 3.2
billion dollars in 2009 (Gershell, 2006). A cost harder to quantify is due to the
decrease of daytime performance of people affected by insomnia, due to the
reduction of the cognitive and motor performances (Mendelson, Garnett, Gillin &
Weingartner, 1984), as well as to the high rates of work absence (Johnson &
Spinveber, 1983).
Theoretical models in the literature generally attribute insomnia to certain
activating factors that interfere with the sleeping pattern. These factors can be
organized along two dimensions: a. physiological, emotional and cognitive
activation; b. the general level of activation of the person and the person’s
tendency to respond with activation to aversive life events. These models only
consider certain factors in isolation, such as psychological, emotional and
cognitive hyperactivity, level of arousal, excitability and habituation to stimuli,
and the role of the activating events.
According to the integrative model of insomnia recently proposed by Lundh
and Broman (2000), an essential component in the development and maintenance
of insomnia is the physiological and cognitive arousal before sleep. The
physiological processes of sleep interference are those that influence a person’s
sleeping pattern, independently of the way the person interprets the sleeping
pattern and of daytime events (traumatic or stressful events, emotional conflicts,
depression, worries). Psychological insomnia processes influence the way the
person interprets sleep fluctuations, difficulties and daytime events (personal
standards, beliefs and attitudes). The validity of the model was checked by a
series of studies that investigated: the relationship between rumination, mood and
sleep quality (Thomsen, 2003), the efficacy of meta-cognitive observations
during insomnia (Lundh, 2002), the impact of acceptance and mindfulness
therapies in the treatment of insomnia (Lundh, 2005).
At present, the most frequently recommended treatment for occasional
insomnias is medication, but not for chronic insomnia (Jacobs, 2004). This is due
to the side-effects of medication and to the decrease in its efficacy after long
periods of treatment. One of the effects of sleeping pills is the modification of
sleep structure (Morin, 2003). Benzodiazepines improve sleep continuity and, at
the same time, they increase the length of the first two stages of sleep, and
decrease the length of the third and fourth stages (Morin, 2003). This sleeping
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Treating primary insomnia 69
pattern is also observed in the elderly and is perceived as superficial and non-
resting (Morin, 2003). Frequently, high medication levels produces a toxic state
associated with psycho-motor and cognitive delay (Grad, 1995; Roehrs, Merlotti,
Zorick, & Roth, 1994). Side-effects are also noticed in the case of more recent
drugs (Aragona, 2000), and, consequently, their use is not recommended for a
period longer than four weeks (Holm & Goa, 2000).
Beginning with the 1980s, research on sleep disorders, insomnia in particular,
was oriented towards the effectiveness of cognitive-behavioral interventions.
Cognitive behavior therapy includes various combinations of cognitive and
behavioral interventions. The cognitive component is aimed at changing the
patients’ beliefs and attitudes regarding insomnia. The behavioral component
usually includes relaxation training (Morgenthaler et al., 2006). Relaxation
training involves methods which focus on reducing physiological arousal (e.g.,
progressive muscle relaxation, autogenic training) or intrusive thoughts that occur
around bedtime and that interfere with sleep (Lick & Heffler, 1977).
The superiority of cognitive-behavioral interventions as opposed to
medication was proven in several studies (Morin & Schwartz, 1994). A recent
study comparing cognitive-behavioral therapy with Zopiclone (Sivertsen, Omvik,
Pallesen et al., 2006), highlights the superiority of the psychological interventions
over medication. Thus, cognitive-behavioral therapy improved three of the four
investigated parameters, while medication (i.e., Zopiclone) did not lead to
significant changes compared to the placebo group.
Meta-analyses show that these interventions generally produce significant and
long lasting sleep improvements in insomniacs (Morin, Culbert, & Schwartz,
1994; Murtagh & Greenwood, 1995). The Data confirm a significant modification
in the following parameters: sleep latency, and time awake after sleep onset, as a
consequence of this type of intervention.
In their review, Morgenthaler et al. (2006) summarize several studies that
have shown the effectiveness of relaxation methods, even when not combined
with cognitive interventions (Edinger et al., 2001; Lichstein et al., 2001; Means et
al., 2000). These results are also confirmed by a study conducted by Lichstein &
Johnson (1993) that reports a reduction in the dose of medication required by the
relaxation group. Relaxation also proved efficient in improving the sleeping
pattern usually found in the elderly (Riedel & Lichstein, 2001; Rybarczyk et al.,
2002).
Validation studies of cognitive-behavioral interventions are scored with a
high coefficient on the Sackett scale (Sackett, 1993), making this form of
intervention the standard recommendation (Morgenthaler et al., 2006). But even
though the psychological treatment is quite efficient, it is limited in terms of
accessibility. Thus, surveys show that 85% of the individuals affected by
insomnia remain untreated, due to the lack of information or due to financial
reasons (Sivertsen, Omvik, Pallesen et al., 2006). In order to facilitate the access
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Alexandru V. Bogdan, Róbert Balázsi, Viorel Lupu & Vasile Bogdan 70
to these cognitive-behavioral programs, they are often offered on internet (Strom,
Pettersson, & Andersson, 2004; Ritterband, 2008).
An alternative to psychotherapy is the self-help treatment, based on
psychological techniques. This intervention method has the advantage of
disseminating information about insomnia to a greater number of people, at a
fairly low cost. Generally, these types of programs are a synthesis of cognitive-
behavioral interventions and those aimed at life-style change (Oosterhuis, 1993;
Morin, 1994; Harvey, 2000).
Studies investigating the impact of self-help insomnia treatments are quite
scarce in the literature. These studies indicate that this kind of intervention is
useful in the reduction of the sleep onset insomnia. Among the techniques used in
these studies are: brochures or manuals and TV programs offering information
about sleep physiology, sleep hygiene, relaxation and stimulus control (Alperson
& Biglan, 1979; Morawetz, 1989; Morin, 1999, 2005; Riedel, Lichstein, &
Dwyer, 1995).
A more recent meta-analysis of Smith et al. (2002) compared stimulus
control interventions with medication. The effect size for subjective measures of
sleep latencies, number of awakenings, wake time after sleep onset, total sleep
time and sleep quality before and after treatment was medium to high. A meta-
analysis on elderly individuals suffering from a sleep disorder confirmed the
validity of the conclusions. Beyond the fact that the improvement of the sleeping
pattern is clinically significant, it is also long lasting (Pallesen, Nordhus, & Kvale,
1998).
In which the education for sleep hygiene is concerned, this strategy is
often incorporated in the treatment of insomnia with the aim of preventing
possible interference from poor sleep hygiene. Data show that, in the absence of
some supplementary intervention methods, the education for the sleep hygiene
has a reduced therapeutic value (Engle-Friedman, Bootzin, Hazlewood, & Tsao,
1992; Guilleminault, Clerk, Black, Labanowski, Pelayo, & Claman, 1995). This
was also confirmed by a meta-analysis conducted by Straten & Cujpers (2009)
who found a small to medium size effect for all sleep parameters.
Programs based on the use of binaural beats music are another type of
self-help intervention. Binaural beats are auditory responses of the cerebral trunk
that originate in the olivary nuclei of the cerebral trunk. They are the result of the
interaction of two separate auditory impulses received from the two ears. The
frequency of the tones must be below about 1,000 to 1,500 hertz for the beating to
be heard. The difference between the two frequencies must be small (below about
30 Hz) for the effect to occur; otherwise, the two tones will be heard separately
and no beat will be perceived (Oster, 1973). Normally, the frequency difference
would offer information about the direction from which the sound comes, but in
the moment of the head set hearing, the brain integrates information about the two
signals, producing the sensation of the third sound, the binaural beat (Oster,
1973).
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Treating primary insomnia 71
According to the model of the extended reticular ascendant activator
system (Newman & Baars, 1993; Newman, 1997), binaural beats generate
modifications in the cortical and subjective conscious experience EEG pattern, as
the cortical-thalamic projections adapt the signals that came from the reticular
formation (Atwater, 2001). This auditory sensation is directed towards the
reticular formation (Swann et al., 1982) and, at the same time, to the cortex,
where it can be objectively measured in frequency (Oster 1973, Smith, Marsh, &
Brown 1975; Smith et al., 1978; Hink et al., 1980).
There are many neurophysiological studies which have documented the
underlying mechanisms of the binaural beats (Newman, 1993, 1997; Oster, 1973;
Smith, 1975, 1978). Despite this fact, the clinical utility of binaural beats is still a
issue of controversy (Iuga & Bogdan, 2008). Binaural beats music has proved
efficient in the management of certain psychological disorders such as alcoholism
(Saxby & Peniston, 1995), neurological conditions (e.g., aphasia) (Barr, Mullin &
Herbert, 1977), and preoperative anxiety (Padmanabhan, Hildreth, & Laws,
2005).
Concerning its effectiveness in primary insomnia, to our knowledge, there is
only one published research paper. Thus, Levin (1998) records significant pre-
post treatment differences as a consequence of using binaural beats for all the
sleep quality parameters.
Taking into consideration the prevalence of this disorder in the case of adults
(DSM-IV) and the fact that insomnia is not considered a serious enough factor to
justify the call for psychological assistance (especially because of the stigma
associated with these interventions; Stinson et al., 2006), the present study aims to
validate the efficacy of two self-help programs (one based on sleep hygiene and
one based on binaural beats), as compared to a behavioral technique whose
efficacy has already been validated (i.e., progressive relaxation).
The study addressed the following questions: (1) Do patients undergoing a
multi-component treatment improve compared to a baseline level? (2) Will there
be any difference in terms of treatment effect between the three treatment
approaches (sleep hygiene, binaural beats and progressive muscle relaxation)?
Methods
Participants
Participants were recruited from the records of a general practitioner’s
office and by advertisements posted on the psychology students’ groups of the
Department of Psychology at the Babes-Bolyai University in Cluj-Napoca. The
selection was comprised of two consecutive phases. In the first phase the
participants who presented evidence: a) of another sleep disorder, other than
insomnia; b) that the sleep disorder was determined by physiological problems,
which interfered with sleep; c) of frequent use of sleeping medication; d) of
working on shifts, were excluded from the study.
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Alexandru V. Bogdan, Róbert Balázsi, Viorel Lupu & Vasile Bogdan 72
In the second phase participants that remained in the study were evaluated
for their match related to the inclusion criteria: a) aged between 18 and 60; b)
sleep onset insomnia or sleep maintaining insomnia (sleep onset latency or time
spent awake after sleep onset greater than 30 minutes per night for a minimum of
3 nights per week); c) insomnia lasting for at least 1 month; d) discontent
regarding the effects of insomnia during the day (e.g., fatigue, mood disorders,
functional impairments). These criteria are a combination of the diagnostic
criteria described by The International Classification of Sleep Disorders (ICSD)
(American Sleep Disorders Association, 1990) and by the Diagnostic and
Statistical Manual of Mental Disorders (DSM IV) for primary insomnia.
After applying the exclusion criteria, three women, aged 22 (Participant
1), 24 (Participant 2) and 30 (Participant 3) were included in the study.
Experimental design
A modified latin square experimental design for single subject research
was used. As it can be seen Table 1, the design involves a baseline recording
stage (S1), 3 intervention stages (S2, S3 and S4) and a final stage of recording the
persistence of the effect over time. (S5). The three participants were randomly
assigned to each treatment sequence (see Table 1).
Tabel 1. Study Design
Participant/Stage Baseline Intervention Follow-up
S1 S2 S3 S4 S5
Participant 1 B HS MR BB PI
Participant 2 B BB HS MR PI
Participant 3 B MR BB HS PI
S1-S5 – experimental stages, B – baseline, SH – sleep hygiene, MR – muscle relaxation,
BB- binaural beats, and PI – post intervention evaluation.
The design contains one random effect variable (Participant) and two
fixed effect variables (Stage and Treatment). The carryover effect was not taken
into account because the design is not a replicated Latin square. This effect will
be estimated indirectly from the Stage x Treatment interaction. The dependent
variable of the study was sleep onset time.
Procedure
The data collection procedure run over a period of 50 days, divided into
five 10-day stages. In the first 10 days of the experiment (baseline stage) and the
last 10 days (follow-up) each participant monitored their sleep pattern, recording
the relevant parameters in the sleep. In stages 2-4 (treatment phases) each subject
received the treatment procedure corresponding to that stage (see Table 1), and
recorded their sleep pattern in the sleep diary. In each phase, the therapeutic
intervention was supervised by a certified psychological counselor.
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Treating primary insomnia 73
In the sleep hygiene condition subjects were instructed, during a one hour
session, how to apply, on a day-to-day basis, the principles of stimulus control,
fostering a healthy lifestyle, favorable to satisfactory sleep, as well as how to use
sleep restriction. At the end of the session they were given the sleep hygiene
brochure as a reminder for all the principles discussed.
In the progressive muscle relaxation condition, subjects were listening to
an audio tape containing a relaxation session. The length of a relaxation session
was based on the standards of an abbreviated progressive muscle relaxation
session (30 minutes) (Bernstein, 2007). Before the intervention stage there was a
learning session in which the participants learned how to apply the relaxation
technique, supervised by the same psychological counselor.
In the binaural beats condition the subjects were listening to an audio tape
containing binaural beat music. The length of the binaural beats music was
matched to the length of the muscle relaxation session. Subjects were instructed to
listen the tapes each day while lying in bed before sleep. Before the intervention
stage there was an informative session regarding the underlying mechanism of
binaural beats and the proper methodology of using the tape.
In order to get an accurate idea of how the intervention was going,
subjects were interviewed regarding their difficulties with the treatment procedure
of the corresponding stage every three days. The minor difficulties that appeared
during the implementation of the treatment were solved by short correction
periods, which did not exceed the standard limits of the interventions.
Measures and materials
The Sleep Diary used in this study is an adapted version of Morin (2003).
It is a practical and economical instrument, frequently used in the sleep research
(Lacks & Morin, 1992; Lichenstein & Riedel, 1994). The sleep diary included
information regarding: bedtime, wake time, sleep onset, the number of
awakenings during the night, time spent awake during the night, time spent asleep
during the day. Because the main sleep problem of each participant was sleep
onset insomnia we focused our attention on a single item of the sleep diary,
namely sleep onset. Many studies have shown that subjective estimation on the
sleep onset item gives a reliable and valid index of insomnia, even though it does
not reflect the absolute values obtained by polysomnography (Coates et al., 1982).
The sleep hygiene brochure adapted after Morin (2003) contained: a short
introduction regarding the neurological mechanisms of sleep and healthy lifestyle
factors that facilitate a good night sleep; myths about sleep; rules for a good night
sleep; healthy sleep related lifestyle and the proper environment for sleep.
The progressive muscle relaxation audio tape was based on a protocol
that contained suggestions regarding the sequential relaxation/tension of thirteen
muscle groups, while being aware of the differences between the two states
(Bernstein, 2007). There is extensive empirical evidence that a similar relaxation
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Alexandru V. Bogdan, Róbert Balázsi, Viorel Lupu & Vasile Bogdan 74
protocol was used with success in the treatment of various psychological
disorders (Sherman, 1979; Cheung et. al., 2002).
The binaural beats audio tape used is a product of Brainsync, by Kelly
Howell, and it is called Sound Sleep. The basic principle on which binaural beats
audio tapes are based is a progressive process that begins with a frequency
difference, between the two sounds arriving at the two ears, which correspond to
the brainwaves that characterize the actual state of consciousness (awake). From
this point onward, the frequency difference is reduced progressively until it
reaches the values of the brainwaves typical to deep sleep state (theta / delta
waves) (Thaut, 2003). Binaural beats music has been previously used in the
management of some psychological disorders, such as alcoholism (Saxby &
Peniston, 1995), neurological conditions (e.g., aphasia) (Barr, Mullin, & Herbert,
1977), and preoperative anxiety (Padmanabhan, Hildreth, & Laws, 2005). To our
knowledge, this is the first study attempting to validate its efficacy in sleep
disorders.
Results
Data processing involved three phases. In the first phase we checked the
resemblance of our data with the assumptions that would allow us to perform
linear statistical models (Morley & Adams, 1989). In the second phase we
verified if the therapeutic intervention as a whole had an effect, by statistically
comparing the baseline, treatment and follow-up phase. Finally, in the third phase
we used a GLM model for a latin square design to estimate the relative efficiency
of each treatment procedure (Kutner, Nachtscheim, Neter, & Li, 2005).
Following Morley and Adams (1989) we applied to each baseline data
set: the Turning Point Test (Bradley, 1968) to evaluate if the baseline data only
reflect random fluctuations of performance, with no regularity or specific
tendency; and the Record Test (Foster & Stewart, 1954), which verifies if there is
a tendency or a change in baseline variance. Results are shown in Table 2.
Tabel 2. The results of the Turning Point Test and the Record Test for each participant’s
baseline scores
Turning Points Test Record test
T p d z s p
Participant 1 5 0.54 2 1.01 4 0.70
Participant 2 5 0.54 0 0.00 4 0.70
Participant 3 5 0.54 0 0.00 2 0.14
All the cumulative distributions of the statistics presented in Table 2
followed the normal distribution, and as such, their values and cumulative
probabilities could be interpreted as any other z test. The turning points test
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Treating primary insomnia 75
column indicates that neither of the computed p value drops below the critical
value p=.05, meaning that baselines data reflect random fluctuations only
(Kratochwill & Levin, 1992). This conclusion is confirmed by the other statistics
in the table: the z value calculated for each d test and the probability associated
with each s tests. All values are statistically insignificant, meaning that there are
no signs of tendency or variance fluctuations in the baseline.
To confirm these patterns we computed an autocorrelation coefficient
using tag-1 in order to detect the presence of a tendency in the data (Franklin,
Allison, & Gorman (1997). Correlation values range between 0.01 – 0.21, all of
them being statistically insignificant. These results re-confirm that baseline data
were not affected by any source of systematic variation.
Consequently, we proceeded to the next phase concerning the effect of
treatment phase (2-4) as a whole. In order to get an answer to the first question of
the study, regarding the effects of the multi-component treatment, we used a 3x3
ANOVA, with two independent variables – the Subject variable, with three levels
(participant 1, participant 2, participant 3) and the Treatment variable, with three
levels (baseline, treatment and follow-up). Results are shown Table 3.
Table 3. Mean sleep onset (in minutes) in baseline and follow-up phase
Participant Mean Std. Deviation
1 33.89 9.61
2 31.50 14.34
Baseline
3 35.30 17.87
1 17.96 3.51
2 19.33 8.39
Treatment
3 29.00 9.88
1 12.78 4.41
2 15.00 4.08
Follow-up
3 18.50 7.09
The calculated value of the Mauchly test for the within subject variable
(Treatment) was W = 0.85; the approximated value is χ²=4.76 (df=2, p=0.13),
satisfying the assumption of sphericity. The statistical analysis indicates an effect
of the treatment, F(2,52) = 27.09 (p=0.001, η² = 0.51), and its magnitude reflects a
high effect size (Cohen, 1982). No significant effect of the subject variable was
observed, F<1, meaning that all subjects improved their sleep onset time in the
same amount. This conclusion is also confirmed by the insignificant value of the
interaction between treatment x subject, F(2,52) = 0.73 (p = 0.57, η² = 0.05).
The results of the Sidak post-hoc are presented in Table 4. All statistical
comparisons were significant. This means that the mean sleep onset time
progressively decreases from m=33.55 (sd=14.06) at Baseline, to m=22.04
(sd=9.09) during Treatment and to m=15.52 (sd=5.72) at Follow-up.
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Alexandru V. Bogdan, Róbert Balázsi, Viorel Lupu & Vasile Bogdan
76
Table 4. Sidak post-hoc pair wise comparison for the main stages of the study
Stage Treatment Mean Difference Sig.
Treatment 11.46 .001 Baseline
Follow-up 18.13 .001
Baseline -11.46 .001 Treatment
Follow-up 6.67 .006
Baseline -18.13 .001 Follow-up
Treatment -6.67 .006
We have shown that the treatment phase as a whole has a significant
effect, but we were also interested to analyze the independent effect of each
treatment type compared to baseline. Thus, we compared each treatment type in
stage 2 (first treatment intervention) with the baseline, using a repeated measure t
test. Results are: t = 10.26 (df=9, p=0.001) for sleep hygiene, t = 6.28 (df=9,
p=0.001) for binaural beats and t = 5.89 (df=9, p=0.001) for muscle relaxation.
In the last phase of data analysis we transformed the design into a simple
Latin square using a dependent variable obtained by computing the differences
between baseline score and each intervention stage score (see Table 5). Data were
analyzed using a GLM for Latin square, with one random factor (Participant) and
two fixed effect factors (Stage and Treatment type).
Table 5. Baseline - Stage mean differences for each treatment type
Participant/Stage S2 S3 S4
8.5 16.5 20 Participant 1
SH MR BB
3 16.5 17 Participant 2
BB SH MR
13.3 -9.7 15.3 Participant 3
MR BB SH
S2-S4 – intervention stages, SH – sleep hygiene, MR – muscle relaxation and BB -
binaural beats
The most important finding is that no significant Stage x Treatment
interaction effect was observed, F(2,81)=2.18 (p=0.065), meaning that the effect
of treatment type is not influenced by the stage in which it was introduced. Since
each stage involved a different treatment type for each subject, we can assume
that the effect of the stage is not influenced by the treatment type variable. There
is a significant main effect of Treatment, F(2,81)=3.24 (p=0.04) which means that
there is a difference in the effectiveness of different treatment interventions. To
find out which one is the most efficient, we conducted a Sidak pot-hoc pair wise
comparison (see Table 6).
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Treating primary insomnia
77
Table 6. Sidak post-hoc pair wise comparison for the treatment types
Treatment Treatment Mean
Difference Sig.
Muscular Relaxation -2.16 .95 Sleep Hygiene
Binaural Beats 9.00 .15
Sleep Hygiene 2.16 .95
Muscular Relaxation
Binaural Beats 11.16 .04
Sleep Hygiene -9.00 .15 Binaural Beats
Muscular Relaxation -11.16 .04
Data in Table 6 indicate that the only significant difference is between
Muscular relaxation and Binaural beats, while all other comparisons are
insignificant. The effect of Sleep Hygiene could not be differentiated from that of
Binaural Beats and relaxation.
Discussion
The main objective of this study was twofold: to compare the effect of
two types of self-help treatment (i.e., sleep hygiene, binaural beats) with the effect
of progressive muscle relaxation in the treatment of primary insomnia; we were
also interested in the relative efficacy of two self-help methods (i.e., sleep
hygiene, binaural beats).
The research design was a modified latin square experimental design for
single subject research. This design allows valid inferences regarding treatment,
and has a high practical value in clinical research (Kutner, Nachtsheim, Neter, &
Li, 2005).
The significant main effect of treatment and the significant differences
between baseline, treatment phase and follow-up indicate that treatment improves
sleep onset time for all the participants. These results support the already-proven
effect of multi-component interventions in primary insomnia (Morgenthaler et al.,
2006). The post-hoc differences between follow-up and treatment phase indicate
that, during the intervention, all subjects gained some abilities that improved their
sleep onset time over the treatment phase. This feature is common to all
therapeutic interventions and, moreover, it is a desirable outcome (Beck, 1995).
To prove that this global effect could not be explained by the high effect
size of only one intervention (e.g., progressive muscle relaxation combined with
insignificant effect of hygiene and binaural beats), we compared each treatment
type with the baseline scores. Our results show statistically significant effects for
each treatment type.
In which muscle relaxation and sleep hygiene are concerned, our results
are in line with the conclusions of other empirical studies (Engle-Friedman,
Bootzin, Hazlewood, & Tsao, 1992; Guilleminault, Clerk, Black, Labanowski,
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Alexandru V. Bogdan, Róbert Balázsi, Viorel Lupu & Vasile Bogdan 78
Pelayo, & Claman, 1995). The main component of these two techniques is based
primarily on behavior modification. The target of progressive muscle relaxation is
to reduce arousal before falling asleep, which is an important component of the
integrative model of insomnia (Lundh & Broman, 1999).
The second procedure has a behavioural component which consists in
stimulus control, sleep restriction and adopting a healthy lifestyle favourable to a
good night sleep. Lifestyle change is focused on avoiding high arousal prior to
sleep (e.g., limiting physical exercise after 6 P.M., limiting caffeine and alcohol
intake in the afternoon, etc.). Based on stimulus control and sleep restriction, the
individual can develop a healthy sleep-related cognitive schema. For example,
through sleep restriction the patient will associate staying in bed only with sleep
and not with other activities such as eating, watching TV, etc. (Bower, Black, &
Turner, 1979; Miclea, 2003). The convergence of these two mechanism results in
an improvement of sleep quality which was demonstrated in the present and in
many other studies (Harvey, 2001; Stepanski, 2003).
The empirical data regarding the utility of binaural beats in treating
primary insomnia in particular, and other types of disorders is nearly missing,
notwithstanding the fact that the underling physiological mechanism of this
phenomenon is relatively well-known (Newman, 1993, 1997; Oster, 1973; Smith,
1975, 1978). According to the theoretical model of the binaural beats (Lane,
Kasian, Owens, & Marsh, 1998) the statistically significant difference between
baseline and binaural beats condition could be explained by neural-level
phenomena which take place in the presence of these particular beats (for a detail
description see Newman, 1997).
Regarding the statistical significant effect of binaural beats, there is a
possible confounded variable which might affect our conclusion. During the
binaural treatment, each subject listened to an audio tape playing music and
background binaural beats. It is possible that the significant reducing in sleep
onset time is explained by the effect of the relaxation music itself, not by the
presence of the binaural beats. This explanation would contradict the findings
reported by Padmanabhan et al. (2005) in a study comparing the effect of binaural
beats music, control, and placebo (i.e., same music without binaural beats) in
treating of preoperative anxiety. They found significant differences between the
experimental group and both control and placebo group.
Regarding the relative effect of the three treatment types, progressive
muscle relaxation, sleep hygiene and binaural beats, our results indicate that there
is a significant difference only between muscle relaxation and binaural beats. We
did not find any significant differences between muscle relaxation and sleep
hygiene, binaural beats and sleep hygiene. This lack of difference could be
explained by the moderate effect size reported in most studies using progressive
muscle relaxation and low to moderate effect size of self-help treatment. To verify
this, we computed the effect size of our post hoc comparisons and found an effect
size of d=0.23 for the difference between muscle relaxation and sleep hygiene and
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Treating primary insomnia 79
an effect size of d=0.96 between sleep hygiene and binaural beats. According to
Cohen’s norms, the first calculated effect size is low, and we can say that the
effect of the two interventions is nearly similar.
In which the difference between hygiene and binaural beats is concerned, a
beta type error is more probable. Probably this effect size would have been
observed by an increase in statistical power (i.e., increasing the number of
evaluations in each stage) or, by using a replicated Latin square design instead of
simple one, which allows a more precise evaluation of the carryover effect
(Kutner, Nachtsheim, Neter, & Li, 2005).
Summarizing our findings, we can say that the cognitive behavioral
intervention and the self-help treatment have both proved to be efficient related to
baseline. The effect of the cognitive behavioral intervention is very similar to the
effect of hygiene and it is very probable that the effect of binaural beat is
somewhat reduced compared to the other two. Based on the above mentioned
empirical evidence, we believe that self-help treatment strategies could offer a
viable alternative in the treatment of primary insomnia for individuals who do not
have the possibility or chose not to enter cognitive behavioral treatment.
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