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Treatment of Chronic Insomnia with Yoga: A Preliminary Study with Sleep?Wake Diaries

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There is good evidence for cognitive and physiological arousal in chronic insomnia. Accordingly, clinical trial studies of insomnia treatments aimed at reducing arousal, including relaxation and meditation, have reported positive results. Yoga is a multicomponent practice that is also known to be effective in reducing arousal, although it has not been well evaluated as a treatment for insomnia. In this preliminary study, a simple daily yoga treatment was evaluated in a chronic insomnia population consisting of sleep-onset and/or sleep-maintenance insomnia and primary or secondary insomnia. Participants maintained sleep-wake diaries during a pretreatment 2-week baseline and a subsequent 8-week intervention, in which they practiced the treatment on their own following a single in-person training session with subsequent brief in-person and telephone follow-ups. Sleep efficiency (SE), total sleep time (TST), total wake time (TWT), sleep onset latency (SOL), wake time after sleep onset (WASO), number of awakenings, and sleep quality measures were derived from sleep-wake diary entries and were averaged in 2-week intervals. For 20 participants completing the protocol, statistically significant improvements were observed in SE, TST, TWT, SOL, and WASO at end-treatment as compared with pretreatment values.
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Applied Psychophysiology and Biofeedback, Vol. 29, No. 4, December 2004 (
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2004)
DOI: 10.1007/s10484-004-0387-0
Treatment of Chronic Insomnia with Yoga: A Preliminary
Study with Sleep–Wake Diaries
Sat Bir S. Khalsa
1
There is good evidence for cognitive and physiological arousal in chronic insomnia. Ac-
cordingly, clinical trial studies of insomnia treatments aimed at reducing arousal, including
relaxation and meditation, have reported positive results. Yoga is a multicomponent prac-
tice that is also known to be effective in reducing arousal, although it has not been well
evaluated as a treatment for insomnia. In this preliminary study, a simple daily yoga treat-
ment was evaluated in a chronic insomnia population consisting of sleep-onset and/or
sleep-maintenance insomnia and primary or secondary insomnia. Participants maintained
sleep–wake diaries during a pretreatment 2-week baseline and a subsequent 8-week inter-
vention, in which they practiced the treatment on their own following a single in-person
training session with subsequent brief in-person and telephone follow-ups. Sleep efficiency
(SE), total sleep time (TST), total wake time (TWT), sleep onset latency (SOL), wake time
after sleep onset (WASO), number of awakenings, and sleep quality measures were derived
from sleep–wake diary entries and were averaged in 2-week intervals. For 20 participants
completing the protocol, statistically significant improvements were observed in SE, TST,
TWT, SOL, and WASO at end-treatment as compared with pretreatment values.
KEY WORDS: sleep; relaxation; yoga; insomnia.
INTRODUCTION
A number of contributory factors have been implicated in chronic insomnia, includ-
ing psychological conditioning, constitutional predisposing factors, dysfunctional beliefs
and attitudes, and cognitive and physiological arousal (Morin et al., 1999). The observed
elevated physiological arousal may be related to activation of the stress system in these
patients (Vgontzas et al., 1998) and is the basis for a hyperarousal hypothesis of insomnia
(Bonnet & Arand, 1997). It has been suggested that “insomnia is a disorder of inappropriate
arousal, rather than a disorder of sleep, and that “treatment strategies should be directed
toward normalizing the level of arousal” (Bonnet & Arand, 1995). In support of this hy-
pothesis, cognitive and somatic relaxation techniques have been reported to be effective
1
Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School,
75 Francis Street, Boston, Massachussets 02115; e-mail: khalsa@hms.harvard.edu.
269
1090-0586/04/1200-0269/0
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2004 Springer Science+Business Media, Inc.
270 Khalsa
treatments (Bootzin & Rider, 1997; Morin et al., 1999; Morin, Culbert, & Schwartz, 1994;
Murtagh & Greenwood, 1995).
Yoga is a comprehensive system whose aim is the achievement of physical, psychologi-
cal, and spiritual health and well-being, and incorporates a wide variety of postural/exercise,
breathing, and meditation techniques (Goyeche, 1979). Yoga has also been used as a thera-
peutic treatment (“yoga therapy”; Khalsa, 2004; Sharma & Singh, 1989) as it is believed that
different techniques can produce unique psychophysiological effects and that this speci-
ficity can be used to target specific disorders. Basic research on yoga has suggested that it is
effective in influencing psychophysiological, neuroendocrine, and autonomic parameters,
and therefore, has mostly been used to treat disorders that have a strong psychosomatic or
psychological component (Arpita, 1990; Funderburk, 1977; Goyeche, 1979; Khalsa, 2004;
Murphy & Donovan, 1999; Sharma & Singh, 1989). Research on the efficacy of yoga has
been reported on its component techniques independently, as well as on its practice as
a comprehensive multicomponent discipline (Funderburk, 1977; Goyeche, 1979; Khalsa,
2004; Patel, 1993; Raub, 2002; Sharma & Singh, 1989).
Despite the current popularity of yoga (Saper, Eisenberg, Davis, Culpepper, & Phillips,
2004), there is little evidence of its clinical use in insomnia (Estivill-Sancho & Jaraba,
1991). A few peer-reviewed studies have reported on the effectiveness of meditation as an
insomnia treatment either alone (Carr-Kaffashan & Woolfolk, 1979; Schoicket, Bertelson, &
Lacks, 1988; Woolfolk, Carr-Kaffashan, & McNulty, 1976), or as part of a multicomponent
treatment (Jacobs et al., 1993; Jacobs, Benson, & Friedman, 1993, 1996); one study has
reported on the effectiveness of a breathing technique (Choliz, 1995). Only two uncontrolled
studies have evaluated the effectiveness of a yoga treatment for insomnia. One of these
revealed significant improvement in objective and subjective sleep measures but has been
published only in abstract form (Koch, Volk, Heidenreich, & Pflug, 1998). The other brief
report used an undefined insomnia population with a relatively coarse measure of nocturnal
wakefulness (Joshi, 1992). As in many yoga-intervention studies, both studies required
attendance at multiple practice sessions and involved significant input on the part of the
investigators delivering the treatment.
The reported ability of yoga to reduce arousal suggests that it could be an effective
insomnia treatment. This suggestion is reinforced if the contention that yoga techniques
can be used as tailored treatments for specific disorders is true (Anand, 1991). The purpose
of this preliminary pilot study was to evaluate the potential suitability and effectiveness of
a simple set of yoga exercises requiring minimal training that can be practiced individually
on a daily basis by patients with chronic insomnia.
METHODS
Participants Recruitment
Participants with a complaint of difficulty initiating sleep (sleep onset insomnia)
and/or maintaining sleep (sleep maintenance insomnia, early morning awakenings) were
recruited from referrals by physicians and sleep specialists, and institution-wide e-mail
advertisements. The insomnia criteria for inclusion in this analysis were consistent with the
criteria for DSM-IV Primary Insomnia and Insomnia Related to Another Mental Disorder
and typical of criteria used in insomnia research (Lichstein, Durrence, Taylor, Bush, &
Treatment of Insomnia with Yoga 271
Riedel, 2003; Martin & Ancoli-Israel, 2002). The insomnia complaint had to be chronic
and persistent in nature with a prior history of at least 6 months duration. Typical or average
sleep onset latency had to be at least 30 min and/or the amount of wakefulness between
sleep onset and time out of bed had to total at least 30 min. To preclude any potential
expected sleep disruptions during the study protocol, all participants had to affirm that
they did not anticipate any planned life stressors (moving, divorce, etc.), shift work, or
transcontinental travel during the protocol, and would not undergo any other concurrent
nonpharmacological treatment for insomnia during the course of the protocol. Participants
had to be physically and medically capable of practicing the techniques safely. Participants
with prior experience with meditation or yoga were not excluded. Participants were not
remunerated for their participation.
Experimental Protocol
Following informed consent, participants who had not previously been evaluated with a
sleep history interview by a sleep specialist and diagnosed with chronic insomnia underwent
a sleep history interview by the investigator to determine the presence of chronic insomnia.
This was then reviewed with the participant and a board-certified sleep specialist to verify
the insomnia diagnosis and the appropriateness of the subject’s participation in the study.
The sleep history interview determined the prior duration of the insomnia, the potential
relationship of its onset to prior life events, its severity over time, a history of prior attempts
to treat the insomnia either pharmacologically or behaviorally, the subject’s habitual daily
sleep–wake schedule, the typical/average sleep onset latency, the typical/average number
and duration of mid-sleep awakenings, the nature of cognitive activity during the sleep
onset period and during mid-sleep awakenings, the timing, frequency, and duration of
any daytime naps, the use of caffeine and other substances and medications, the presence
and severity of daytime fatigue or sleepiness, any symptoms consistent with other sleep
disorders (i.e., sleep apnea, narcolepsy, parasomnias, restless legs syndrome, periodic leg
movements, etc.), and a brief medical and psychiatric history.
Participants began the study protocol with a pretreatment 2-week baseline evalua-
tion during which time they maintained their habitual daily schedule and completed daily
sleep–wake diaries. This was followed by a 1-hr yoga treatment training session, which
described and demonstrated the exercises to be performed. Participants were not instructed
in or informed about any other behavioral treatment recommendations for insomnia (e.g.,
stimulus control, sleep hygiene, sleep restriction, etc.). Participants then began daily prac-
tice of the yoga treatment and returned approximately 1 week later for a brief in-person
evaluation of their practice of the exercises, at which time small adjustments were made
and any questions or difficulties addressed. Subsequent follow-ups by telephone, usually
less than 15 min in duration, occurred every 2 weeks, or more frequently if needed. Dur-
ing these follow-up telephone contacts, the subject’s compliance with the treatment was
reviewed from the practice time entries in previously submitted sleep diaries (see below)
and from their verbal report of practice over the previous week. Both daily regularity and
the duration of the daily practice sessions were reviewed. Problems or difficulties with the
exercises or compliance were discussed and potential solutions and strategies to encourage
and improve compliance were proposed, implemented, and followed up on subsequent
interactions.
272 Khalsa
Yoga Treatment
The yoga exercises used were from the Kundalini Yoga style (as taught by Yogi Bhajan)
that emphasizes meditation and breathing techniques in addition to postures, which is easy
to perform and is practiced widely. The exercises chosen were selected because they
were specifically recommended for improving sleep and were easy to learn and perform
with minimal instruction. The same set of exercises was performed every day during the
intervention. All exercises were done in the seated posture, with instructions to maintain
the spine erect but relaxed, with all breathing through the nose, and with eyes closed unless
otherwise specified. Special attention in the initial training session was devoted to specific
instructions on the practice of long, slow abdominal breathing to insure that participants
understood this breathing pattern. Participants were instructed to breathe as slowly as
was comfortable. The basic cognitive process of meditation was also described in detail.
Participants were instructed to maintain a relaxed mental focus either on their breathing or
a mantra, returning their attention to this focus in a relaxed manner when they found their
thoughts wandering.
The full set of exercises included the following: (1) long, slow, abdominal breathing
with meditation on long, slow abdominal breathing for 1–3 min; (2) arms extended upwards
at a 60
degree angle with the palms flat and facing upwards with meditation on the breath
for 1–3 min; (3) arms extended horizontally to the sides with the wrists bent upwards
and the palms facing away with meditation on the breath for 1–3 min; (4) hands clasped
together at the sternum with the arms pushing the palms together with meditation on the
breath for 1–3 min; (5) a breathing meditation called “Shabad Kriya. Palms are resting
in the lap facing upward with right over left and the thumbs touching. Eyes are 1/10 open
and gaze is downwards past the tip of the nose. The inhale is in 4 segments or “sniffs,
followed by breath retention for 16 counts, and an exhale in 2 segments, so that the ratio
of inhale:hold:exhale is 4:16:2. During the inhale, the mantra “Sa, Ta, Na, Ma” is mentally
recited with each segment. During the breath retention, this mantra is mentally repeated four
times. During the exhale the mantra “Wahe Guru” is mentally recited concurrently with each
exhale segment. Participants are encouraged to maintain the overall breathing frequency as
slow as is comfortable, while maintaining the specified ratio of inhale:hold:exhale for up
to 11 min.
After the first 10 participants had successfully completed the experimental protocol
using this 30-min set of exercises, it was decided to increase the treatment duration to a
45-min session for subsequent participants in order to evaluate whether such an increase
would yield greater improvements in sleep. This 45-min intervention used the same exer-
cises as the 30-min intervention, except that only Exercises 2–5 above were performed,
and exercise 5 was extended in duration to up to 31 min. Participants were instructed to
perform the treatment in the evening, preferably just before bedtime. If, on occasion, the
subject’s evening schedule made it difficult to incorporate the treatment, participants were
to practice the treatment at another time of day.
Outcome Measures
Participants completed daily sleep–wake diaries throughout the 2-week baseline and
the 8-week treatment phase. They were instructed to complete the diaries shortly after
Treatment of Insomnia with Yoga 273
awakening on a regular basis and to avoid completing them during the night. Participants
recorded the time in and out of bed, sleep onset latency, the number and duration of all
nocturnal awakenings, the timing of any daytime naps on the previous day, the timing of the
yoga treatment practice (during the 8-week treatment phase), hypnotic medications taken,
and the quality of nocturnal sleep and restedness at wake time on a scale of 1–5. Completed
diaries were brought in by the participants following the baseline, and the first week of the
treatment, and then mailed in on a weekly basis for the remainder of the treatment phase.
For the 2-week interval of the baseline and for each of the four consecutive 2-week
intervals in the treatment phase, average values were calculated for the daily sleep diary
entries for total wake time (TWT), total sleep time (TST), sleep efficiency (SE), sleep
quality (scale of 1–5), sleep onset latency (SOL), number of awakenings, wake time after
sleep onset (WASO; calculated as the total duration of all awakenings from sleep onset to
the final terminal awakening), and quality of restedness at wake time (scale of 1–5). To
assess treatment compliance and duration of practice, the sleep diaries also had an entry for
the times they began and finished each daily treatment session (except for the first subject
in the study who completed an earlier version of the sleep diary without this entry). A
two-way repeated measures analysis of variance (ANOVA) was conducted on each of the
following outcome measures: TWT, TST, SE, sleep quality, SOL, number of awakenings,
WASO, and quality of restedness at wake time.
RESULTS
A total of 40 participants (34 females) meeting the criteria of chronic insomnia de-
scribed above signed informed consent and were enrolled into the study. Of these, 6 par-
ticipants withdrew prior to initiating the treatment phase. Of the 34 participants who
completed the 2-week baseline evaluation and underwent the treatment training session,
all of them found the treatment to be acceptable and agreed to implement it. A total of
13 participants withdrew during the treatment phase. Reasons for withdrawal included
change in life circumstances precluding continued time for and/or commitment to the
protocol (e.g., illness, family emergency, moving, etc.; 7 participants), unknown/lost to
follow-up (4 participants), did not wish to continue committing time to the treatment
(1 subject), and dislike of the treatment (1 subject). Of the 21 participants who successfully
completed the treatment, 1 subject had insufficient evaluable sleep–wake diary data, and
20 participants completed the 8-week treatment protocol with evaluable data.
The 20 participants completing the protocol with evaluable data consisted of 2 men
and 18 women with an average age of 48.1 years (±10.0 SD) and an age range of 30–
64 years. They reported durations of chronic insomnia from 0.6 to 43.6 years (average =
12.2 years, SD = 12.6 years). Two participants reported concurrent depression at the time
of study and were on antidepressant medication during the study. Two participants had
symptoms consistent with restless legs syndrome, and three participants reported suffering
from mild to moderate anxiety at the time of study. Thirteen participants had previously
seen a sleep specialist and six of these had previously undergone at least one overnight
sleep study performed in the course of the diagnosis and management of their insomnia.
Ten participants had undergone previous trials with one or more prescription hypnotic
medications to treat their insomnia, and one of these continued regular hypnotic medication
during the study.
274 Khalsa
On the basis of averages derived from the 2-week baseline sleep–wake diaries, 6 partic-
ipants had a WASO >30 min with a SOL <30 min (i.e., pure sleep maintenance insomnia),
1 subject had a SOL >30 min with WASO <30 min (i.e., pure sleep onset insomnia),
12 participants had a WASO >30minwithaSOL>30 min, and 1 participant had a WASO
and a SOL both <30 min.
A two-way repeated measures analysis of variance (ANOVA) was conducted on each
of the following outcome measures: TWT, TST, SE, sleep quality, SOL, number of awak-
enings, WASO, and quality of restedness at wake time. For each outcome variable, the
ANOVA compared the first 10 participants with the 30-min treatment and the last 10 par-
ticipants with the 45-min treatment for averages determined during the 2-week baseline,
and each of the four subsequent 2-week averages during the 8-week treatment phase. For
all outcome variables, there was no significant main effect for group F (1,18) all <2.4, all
p>.14, or for Group × Time interaction, F (4,72) all <1.6, all p>.18, and therefore, all
of the data below are presented for all 20 participants combined.
Significant main effects for time were observed for TWT, F (4, 76) = 9.14; p<.001;
TST, F (4, 76) = 6.02; p<.001; SE, F (4, 76) = 8.86; p<.001; SOL, F (4, 76) = 4.42;
p<.003; and WASO, F (4, 76) = 6.42; p<.001, with all p<.05 after Bonferroni cor-
rections for the eight comparisons. Main effects for time for sleep quality, F (4, 76) = 3.14;
p = .02, the number of awakenings, F (4, 76) = 2.94; p = .03, and quality of restedness at
wake time, F (4, 76) = 2.30; p = .07, were not statistically significant at the p = .05 level
after Bonferroni correction. The group averages with standard errors for all time points are
shown in the graph in Fig. 1 for TWT, TST, SE, and sleep quality, and reveal progressive
Fig. 1. Averaged data over 2-week intervals for the pretreatment baseline and the 8-week treatment are plotted
for total wake time (TWT), total sleep time (TST), sleep efficiency (SE), and sleep quality. Error bars represent
standard errors of the mean.
Treatment of Insomnia with Yoga 275
improvements in each measure over time. TWT decreased by 0.7 hr (26.6%), TST increased
by 0.6 hr (12.2%), SE increased by 8.3%, and sleep quality increased by 0.3 units. Overall,
SOL decreased by 15.2 min (30.1%) and WASO decreased by 22.4 min (34.5%). Duncan’s
post hoc tests comparing the baseline values with all subsequent values during treatment
revealed significant (p<.05) improvements at end-treatment (Weeks 7–8) for TWT, TST,
SE, SOL, and WASO.
To assess clinical effectiveness in terms of SOL and WASO, the proportion of partici-
pants achieving reductions of 50% and posttreatment values less than 30 min was evaluated
(Morin et al., 1999). Of the 13 participants with a SOL >30 min at baseline, 4 (31%) had
at least a 50% reduction in SOL and 5 (38%) had a SOL <30 min at end-treatment, with a
total of 5 participants meeting either criterion and 4 participants meeting both criteria. Of
the 18 participants with a WASO >30 min at baseline, 5 (28%) had at least a 50% reduction
in WASO, 3 (17%) had a WASO <30 min at end-treatment with a total of 6 participants
(33.3%) meeting either criterion and 2 participants meeting both criteria. Using 80 and
85% as clinical markers of improved sleep efficiency (Morin et al., 1999), three partici-
pants (15%) and six participants (30%) had sleep efficiencies greater than 85 and 80%,
respectively; average total sleep times at end-treatment for these two groups of participants
were 6.8 hr (±1.1 SD) and 6.7 hr (±1.2 SD), respectively.
For the nine participants undergoing the 30-min treatment and recording treatment
practice times, the overall average daily treatment duration during the 8-week intervention
was 24.4 min. For the 10 participants undergoing the 45-min treatment the average was
28.7 min. A two-way repeated measures ANOVA comparing the two groups over the four
2-week intervals over the treatment phase revealed no significant main effect of group,
F (1, 17) = 1.34; p = .26. A repeated measures ANOVA on all 19 participants showed a
significant main effect for time, F (3, 54) = 3.06; p<.04, with the overall average of all
19 participants decreasing from 28.6 to 27.4 to 24.8 to 25.8 min in the 2-week intervals
during the treatment. The slope of a linear regression analysis correlating average daily
treatment time with the improvement in sleep efficiency from pre- to end-treatment did not
reach statistical significance (r = .37, slope = .35, p = .12).
DISCUSSION
The results of this preliminary study indicate that the yoga treatment generated sta-
tistically significant improvements in most of the important subjective sleep measures.
However, it would be premature to express high confidence about the effectiveness of
this treatment on the basis of the preliminary nature of this study. As an uncontrolled
study, there are a number of significant limitations to the interpretation of the results and
their comparison with those of previous randomized controlled trials reported in the lit-
erature. The potential confounding contributions due to any self-selection of participants
with high allegiance, positive attitudes toward and/or expectations for the yoga treat-
ment, the disproportionate number of female participants, any potential influence of the
investigator, any effects of regression to the mean or temporary resolution of insomnia
symptoms due to its natural episodic occurrence were not controlled for in this study.
Furthermore, the results have not taken into account the drop-out rate from the study; there-
fore, from an intention-to-treat perspective the improvements observed may be relatively
inflated.
276 Khalsa
A comparison of the relative degree of sleep improvement in this study to previous
insomnia studies is problematic given that most studies have recruited participants from
the general population with primary insomnia and exclude insomnia secondary to other
medical/psychological conditions. The population in this study consisted of a mix of both
primary and secondary insomnia, the majority of whom were referrals from other sleep
specialists, 6 of which had previous sleep studies performed, and 10 had previous unsuc-
cessful trials with hypnotic medications. A disproportionate share of the population in this
study consists of participants who may be considered previous treatment failures.
With this caution in mind, a comparison with two previous meta-analyses of controlled
behavioral treatment studies of primary insomnia reveal that the 12.2% increase in TST in
this study is comparable to the improvements in both meta-analyses, whereas the 30.1%
decrease in SOL and the 34.5% decrease in WASO are smaller. However, the improvements
in WASO in this study appear to be slightly better than for either somatic or cognitive
relaxation techniques alone in the meta-analyses. A more appropriate comparison can
be made with another uncontrolled study in a clinical population with mixed primary
and secondary insomnia that used a multicomponent nonpharmacological intervention
(Verbeek, Schreuder, & Declerck, 1999). The improvement in TST in this study was
greater than reported in that study (4%), whereas the improvements in SOL, WASO and
pre–post difference in SE were less than in that study (43%, 46%, 15.1%, respectively). The
percentage of participants meeting the <30-min clinically significant improvement criteria
for SOL and WASO in this study (38 and 17%, respectively), is similar to the overall 19%
reported in that study.
In general, most all participants found the yoga intervention easy-to-learn and tolerable
to perform. The participants instructed in the 45-min treatment did not show greater benefit
than those instructed in the 30-min treatment. However, this may be due to the fact that the
actual amount of average daily practice time was very similar between the participants in
each treatment (28.7 min vs. 24.4 min, respectively) and also that the sample size was too
small to detect a difference.
A key advantage of the yoga intervention used in this study is that it is simple and
easy for participants to learn in a single 1-hr training session. Generally, only minor adjust-
ments needed to be made during the brief single in-person follow-up, and few participants
required much interaction on the subsequent telephone follow-ups. If the yoga intervention
in this study is superior in effectiveness to previously studied relaxation techniques, then
incorporation of this treatment into current cognitive behavioral treatment programs may
yield a more highly effective treatment requiring less therapist intervention. The current
popularity of yoga, and its recognition as a health maintenance practice, should also add
to the attractiveness of such a treatment for insomnia patients. Further evaluation of this
intervention with a more homogenous insomnia population in a randomized controlled trial
is needed.
ACKNOWLEDGMENT
The author is indebted to Yogi Bhajan, a master of Kundalini Yoga, who originally
taught the techniques employed in this study, and to Gurucharan Singh Khalsa for their
assistance with and consultation on the yoga intervention. The author is grateful to Jack
Edinger and John Winkelman, who provided consultation on the study design, data analysis,
Treatment of Insomnia with Yoga 277
and on the manuscript. Hari Mandir K. Khalsa and Ian Nagus provided technical assistance.
This work was supported by grants 5K01AT000066 and 1R21AT000266 to SSK from the
National Center for Complementary and Alternative Medicine of the NIH.
REFERENCES
Anand, B. K. (1991). Yoga and medical sciences. Indian Journal of Physiology and Pharmacology, 35, 84–87.
Arpita (Harrigan, J.). (1990). Physiological and psychological effects of Hatha Yoga: A review of the literature.
The Journal of the International Association of Yoga Therapists, 1, 1–28.
Bonnet, M. H., & Arand, D. L. (1997). Hyperarousal and insomnia. Sleep Medicine Reviews, 1, 97–108.
Bonnet, M. H., & Arand, D. L. (1995). 24-Hour metabolic rate in insomniacs and matched normal sleepers. Sleep,
18, 581–588.
Bootzin, R. R., & Rider, S. P. (1997). Behavioral techniques and biofeedback for insomnia. In M. R. Pressman
(Ed.), Understanding sleep: The evaluation and treatment of sleep disorders. Application and practice in
health psychology (pp. 315–338). Washington, DC: American Psychological Association.
Carr-Kaffashan, L., & Woolfolk, R. L. (1979). Active and placebo effects in treatment of moderate and severe
insomnia. Journal of Consulting and Clinical Psychology, 47, 1072–1080.
Choliz, M. (1995). A breathing-retraining procedure in treatment of sleep-onset insomnia: Theoretical basis and
experimental findings. Perceptual and Motor Skills, 80, 507–513.
Estivill-Sancho, E., & Jaraba, G. (1991). The treatment of chronic insomnia: A program of creative relaxation
and body consciousness as adjuvant of pharmacotherapy. Psiquis: Revista de Psiquiatria Psicologia y
Psicosomatica, 12, 52–57.
Funderburk, J. (1977). Science Studies Yoga: A review of physiological data. Glenview, IL: Himalayan International
Inst.
Goyeche, J. R. (1979). Yoga as therapy in psychosomatic medicine. Psychotherapy and Psychosomatics, 31,
373–381.
Jacobs, G. D., Benson, H., & Friedman, R. (1993). Home-based central nervous system assessment of a multifactor
behavioral intervention for chronic sleep-onset insomnia. Behavior Therapy, 24, 159–174.
Jacobs, G. D., Benson, H., & Friedman, R. (1996). Perceived benefits in a behavioral-medicine insomnia program:
A clinical report. American Journal of Medicine, 100, 212–216.
Jacobs, G. D., Rosenberg, P. A., Friedman, R., Matheson, J., Peavy, G. M., Domar, A. D., et al. (1993). Multifactor
behavioral treatment of chronic sleep-onset insomnia using stimulus control and the relaxation response. A
preliminary study. Behavior Modification, 17, 498–509.
Joshi, K. S. (1992). Yogic treatment of insomnia: An experimental study. Yoga Mimamsa, 30, 24–26.
Khalsa, S. B. S. (2004). Yoga as a therapeutic intervention: A bibliometric analysis of published research studies.
Indian Journal of Physiology and Pharmacology, 48, 269–285.
Koch, U., Volk, S., Heidenreich, T., & Pflug, B. (1998). Yoga treatment in psychophysiological insomnia. Journal
of Sleep Research, 7(Suppl. 2), 137.
Lichstein, K. L., Durrence, H. H., Taylor, D. J., Bush, A. J., & Riedel, B. W. (2003). Quantitative criteria for
insomnia. Behaviour Research and Therapy, 41, 427–445.
Martin, J. L., & Ancoli-Israel, S. (2002). Assessment and diagnosis of insomnia in non-pharmacological inter-
vention studies. Sleep Medicine Reviews, 6, 379–406.
Morin, C. M., Culbert, J. P., & Schwartz, S. M. (1994). Nonpharmacological interventions for insomnia: A
meta-analysis of treatment efficacy. American Journal of Psychiatry, 151, 1172–1180.
Morin, C. M., Hauri, P. J., Espie, C. A., Spielman, A. J., Buysse, D. J., & Bootzin, R. R. (1999). Nonpharmacologic
treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep, 22, 1134–1156.
Murphy, M., & Donovan, S. (1999). The physical and psychological effects of meditation: A review of contemporary
research with a comprehensive bibliography 1931–1996 (2nd ed.). Sausalito, CA: The Institute of Noetic
Sciences.
Murtagh, D. R., & Greenwood, K. M. (1995). Identifying effective psychological treatments for insomnia: A
meta-analysis. Journal of Consulting and Clinical Psychology, 63, 79–89.
Patel, C. (1993). Yoga-based therapy. In P. M. Lehrer & R. L. Woolfolk (Eds.), Principles and practice of stress
management (2nd ed., pp. 89–137). New York: Guilford Press.
Raub, J. A. (2002). Psychophysiologic effects of Hatha Yoga on musculoskeletal and cardiopulmonary function:
A literature review. Journal of Alternative and Complementary Medicine, 8, 797–812.
Saper, R. B., Eisenberg, D. M., Davis, R. B., Culpepper, L., & Phillips, R. S. (2004). Prevalence and patterns
of adult yoga use in the United States: Results of a national survey. Alternative Therapies in Health and
Medicine, 10, 44–49.
Schoicket, S. L., Bertelson, A. D., & Lacks, P. (1988). Is sleep hygiene a sufficient treatment for sleep-maintenance
insomnia? Behavior Therapy, 19, 183–190.
278 Khalsa
Sharma, I., & Singh, P. (1989). Treatment of neurotic illnesses by yogic techniques. Indian Journal of Medical
Sciences, 43, 76–79.
Verbeek, I., Schreuder, K., & Declerck, G. (1999). Evaluation of short-term nonpharmacological treatment of
insomnia in a clinical setting. Journal of Psychosomatic Research, 47, 369–383.
Vgontzas, A. N., Tsigos, C., Bixler, E. O., Stratakis, C. A., Zachman, K., Kales, A., et al. (1998). Chronic insomnia
and activity of the stress system: A preliminary study. Journal of Psychosomatic Research, 45, 21–31.
Woolfolk, R. L., Carr-Kaffashan, L., & McNulty, T. F. (1976). Meditation training as a treatment for insomnia.
Behavior Therapy, 7, 359–365.
... Both these interventions can be very easily improvised into a person's daily life without any side effects. Yoga being a proven non-pharmacological intervention for insomnia [11] , via this study pharmacological add on is intended since Ksheerabala taila has direct indication on Vatananatmaja vikaras. Hence this study considers Pratimarsha nasya with Ksheerabala taila (14 aavartita) over selected Yoga techniques in insomnia. ...
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The word "yoga" is commonly used to refer specifically to Hatha yoga stretching postures or generally to Hatha yoga programs that also include certain relaxation,breathing and meditation practices. Such programs, however, represent only certain aspects of the comprehensive system that comprises the physical, psychological,philosophical, and spiritual components of yoga. In the generic sense, yoga means the practical aspect of a philosophy, — its methods and application. More specifically, it refers to the philosophical view of the world and the individual described in the Yoga Sutras of Patanjali and related texts.
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This paper reviews the evidence regarding the efficacy of nonpharmacological treatments for primary chronic insomnia. It is based on a review of 48 clinical trials and two meta-analyses conducted by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on non-drug therapies for the clinical management of insomnia. The findings indicate that nonpharmacological therapies produce reliable and durable changes in several sleep parameters of chronic insomnia sufferers. The data indicate that between 70% and 80% of patients treated with nonpharmacological interventions benefit from treatment. For the typical patient with persistent primary insomnia, treatment is likely to reduce the main target symptoms of sleep onset latency and/or wake time after sleep onset below or near the 30-min criterion initially used to define insomnia severity. Sleep duration is also increased by a modest 30 minutes and sleep quality and patient's satisfaction with sleep patterns are significantly enhanced. Sleep improvements achieved with these behavioral interventions are sustained for at least 6 months after treatment completion. However, there is no clear evidence that improved sleep leads to meaningful changes in daytime well-being or performance. Three treatments meet the American Psychological Association (APA) criteria for empirically-supported psychological treatments for insomnia: Stimulus control, progressive muscle relaxation, and paradoxical intention; and three additional treatments meet APA criteria for probably efficacious treatments: Sleep restriction, biofeedback, and multifaceted cognitive-behavior therapy. Additional outcome research is needed to examine the effectiveness of treatment when it is implemented in clinical settings (primary care, family practice), by non-sleep specialists, and with insomnia patients presenting medical or psychiatric comorbidity.
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Meditation—that great and mysterious subject which in the past has always conjured up the image of the solitary Asian ascetic sitting in deep trance—is fast appearing in unexpected places throughout modern American culture. Secretaries are doing it as part of their daily noon yoga classes. Preadolescent teenagers dropped off at the YMCA by their mothers on a Saturday morning are learning it as part of their karate training. Truck drivers and housewives in the Stress Reduction Program at the University of Massachusetts Medical Center are practicing a combination of Hindu yoga and Buddhist insight meditation to control hypertension. Star athletes prepare themselves for a demanding basketball game with centering techniques they learned in Zen. [1] Dhyana is the generic Sanskrit term for meditation, which in the Yoga Sutras refers to both the act of inward contemplation in the broadest sense and more technically to the intermediate state between mere attention to an object (dharana) and complete absorption in it (samadhi). [2] The earliest known reference to such practice on the Indian subcontinent occurs on one of the seals, a figure seated in the lotus posture, found in the ruins of the pre-Aryan civilizations at Harappa and Mohenjodaro which existed prior to 1500 BCE. Most of the orthodox Hindu schools of philosophy derive their meditation techniques from yoga, but superimpose their own theoretical understanding of consciousness onto the results of the practice. [3] Meditation is also referred to as a spiritual practice in China. Chinese forms of meditation have their origins in the early roots of popular Taoism which existed long before the codification of Taoism as a formal philosophy during the seventh century, B.C.. However, there is no concrete evidence to prove that meditation first arose in Hindu culture and then spread elsewhere. Thus, for the time being the original meditative traditions in China and India should be considered as separate and indigenous. To further complicate the issue, analogies between meditative states and trance consciousness suggest that even earlier precursors to the Asian meditative arts can be found in shamanic cultures such as those in Siberia and Africa. [4] As for modern developments, in trying to formulate a definition of meditation, a useful rule of thumb is to consider all meditative techniques to be culturally embedded. This means that any specific technique cannot be understood unless it is considered in the context of some particular spiritual tradition, situated in a specific historical time period, or codified in a specific text according to the philosophy of some particular individual. [5] Thus, to refer to Hindu meditation or Buddhist meditation is not enough, since the cultural traditions from which a particular kind of meditation comes are quite different and even within a single tradition differ in complex ways. The specific name of a school of thought or a teacher or the title of a specific text is often quite important for identifying a particular type of meditation. Vipassana, or insight meditation, for instance, as practiced in the United States is derived from the Theravada tradition of Buddhism, and is usually associated with the teachings of the Burmese monk Mahasi Sayadaw; Transcendental Meditation is associated exclusively with the teachings of Maharishi Mahesh Yogi, whose tradition is Vedantic Hinduism; and so on.
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This study compared the effectiveness of meditation, stimulus control, and sleep hygiene treatments for sleep-maintenance insomnia. Subjects were 65 adults who participated in a four-week treatment program. Subjective estimates of wake time after sleep onset (WASO) were obtained at pretest, posttest, and at six-weeks follow-up. Results demonstrated that all three treatments produced comparable reductions in WASO as well as in number and duration of arousals. Despite comparable rates of improvement, subjects in the sleep hygiene condition rated treatment less favorably and, at follow-up, were more likely to consider themselves still insomniac in comparison to subjects in the stimulus control and meditation treatments.
Article
The majority of individuals with insomnia treated with single behavioral interventions do not achieve normal sleep. In this study, individuals with chronic sleep-onset insomnia (n=12) were treated with a sequentially administered multifactor behavioral intervention consisting of sleep restriction, modified stimulus control, and relaxation training. They were compared to age- and sex-matched normal sleepers (n=14) prior to and following treatment using home-based polysomnography and power spectral analysis of pre-sleep EEG activity as dependent measures. Individuals with insomnia showed highly significant beneficial changes on EEG measures of insomnia, including a 75% reduction in sleep-onset latency, and did not differ from normal sleepers at posttreatment. Individuals with insomnia exhibited greater pre-sleep CNS arousal than normal sleepers at pretreatment and showed a significant reduction on this measure at posttreatment. Objective improvements in sleep were accompanied by significant improvements in self-report measures of sleep and mood. We conclude that a multifactor behavioral intervention consisting of sleep restriction, modified stimulus control, and relaxation response training is highly effective in moving individuals with chronic sleep-onset insomnia into the range of normal sleepers and may achieve its effect, in part, by reducing pre-sleep CNS arousal.
Article
A set of attention-focusing techniques derived from methods of meditation was compared with progressive relaxation and a waiting list as treatments for insomnia. Analysis of data from 24 insomniacs recruited from the community showed both meditation and progressive relaxation to be superior to no treatment in reducing latency of sleep onset. These treatments did not differ in effectiveness. At 6 months follow-up, both the meditation and progressive relaxation groups showed significant improvement over pretreatment levels on latency of sleep onset, while pretreatment and follow-up means for the control group did not differ.
Article
Of the 86 chronic insomnia patients we treated with nonpharmacological means, 74 improved considerably. The subjective improvement was confirmed by the outcome of the sleep logs registered after 4 weeks of treatment (decrease in sleep-onset latency, wake after sleep onset, and an increase of sleep efficiency). Of the 49 patients who had used hypnotics at intake, 18 discontinued their medication and 19 considerably reduced theirs after therapy. The investigated population was characterized by high scores for anxiety, depression, and somaticization; the depression and anxiety scores were significantly higher for the hypnotics users. The percentage of nonresponders (patients who were unaffected by the treatment) was highest for the group of homemakers and for the group of patients with a low level of education. Significantly less of the nonresponders had received cognitive therapy compared with responders. The value of nonpharmacological treatment lies in the fact that it leads to a subjective improvement of sleep and to increased control over the sleep problem that the patient was experiencing. Helping the patients to obtain control over their sleep problems was our main therapeutic goal.
Article
Insomnia is a widespread and debilitating disorder. Regardless of the initial cause, it may assume a chronic course perpetuated by psychological and behavioral factors. Although sedative-hypnotic medications are the most common treatment for insomnia, they pose certain risks such as adverse effects and dependence. Furthermore, medications target symptoms and fail to address the underlying perpetuating mechanisms. There are many nonpharmacologic treatment options for insomnia, including cognitive/behavioral methods, relaxation strategies, and complementary and alternative medicine (CAM) approaches. Most CAM therapies lack sufficient scientific evidence to recommend their use. Over the past 30 years, cognitive-behavioral therapies have emerged as the treatment of choice for chronic insomnia. These therapies target behavioral, cognitive, and conditioning factors underlying insomnia, thereby restoring normal sleep-wake functioning. The effectiveness of these therapies is well established. They compare favorably to pharmacologic approaches, with the added benefits of few or no adverse effects and no risk of abuse or dependence. Perhaps most importantly, behavioral insomnia therapies offer a potential cure for the insomnia, instead of the symptom-focused approach provided by medications. Despite the proven success of cognitive-behavioral therapies, they are not widely available to patients with insomnia because of a paucity of behavioral sleep specialists. Efforts are now being made to disseminate these treatments to meet the demand. Emerging therapies hold promise for further refinement and development of successful treatments.