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PSYCHOLOGICAL EVALUATION OF INSOMNIA

Insomnia occurs mainly in the presence of certain antecedent stimuli (one hour of the night, the bed itself) that should be related precisely to the antagonistic behavior of sleep.
The ultimate goal of intervention is to replace, in the presence of such stimuli background, the pattern of sleep can not sleep the desired behavior. To do this, previously, you should evaluate the characteristics that define this behavior not sleep.
also must evaluate the physical and mental activity of the patient when trying to sleep without success. Also be evaluated quantitatively and qualitatively, the characteristics of sleep behavior when it occurs.
assessment behaviors can not sleep and sleep, is insufficient if not complemented by the detailed analysis of the links between antecedents, organization, response and consequences, in each case maintaining these behaviors, including those who are present when patients sleep during the day.
addition, the assessment should consider the real possibilities of intervention in each particular case.
The procedures used to assess insomnia can be grouped in three categories: psychophysiological, self-report measures and direct observation.

psychophysiological

psychophysiological records are made while the patient sleeps, using devices like the polygraph that allows variety of different physiological measures related to the conduct of not sleeping and sleeping.
Basically, we have taken into account indicators records and abandoned having reached different phases or stages of the owner, calculating the time to get sleep and / or each of its phases, the holding time in each of these phases, the number of awakenings, total sleep time at night and sleep efficiency.
In principle, psychophysiological recordings are the most valid and reliable procedure, but to depend on a complex instrumentation, poses difficult problems.
First is the lack of viability, are used, of course in basic research, but are less accessible to research the effectiveness of treatment and even less in everyday clinical practice.
The second problem is the questionable suitability. The assessment of sleep in the laboratory involves the observation of the behavior of not sleeping and sleeping in the presence of background stimuli than those normally present daily in the home environment.
These difficulties have led to this procedure is used only in a limited range of investigations.

self-report measures

Self-reports are the most common procedure, observing the distinction between global self-reports and diaries. The first provided that the patient considers his insomnia insomniac globally. The latter provide more precise information, by requiring the patient that day, observe and record information on their behavior.
Although daily self-reports, having to be the earliest, the next morning, carry some risk of error, greater reliability, coupled with the ease of use, support their use against global self-reports.
The dependent variables are often used for the evaluation of insomnia with daily self-reports are as follows:

• Sleep Latency Disruptions
• overnight
• Time that definitely woke
• Time that finally rose from bed sleep
• Efficiency is achieved by dividing the total sleep time from total time bed.
• frequency and duration of sleep behavior during the day.
• Quality of sleep during the night
• different subjective estimates, such as degree of difficulty falling asleep, level of tension in the bed or degree of fatigue during the day.
• Other measures such as the presence of interfering thoughts in bed or the dose of medication. Direct observation

observation can be a useful procedure in addition to self report, but its use is difficult. The observer may be the patient's spouse or anyone living with him. Its mission is to observe the subject insomniac to fall asleep, sleep latency recording.
To ensure adherence of observers to their task, the psychologist must decide how often to do so.
However, it is unnecessary to conduct direct observation every day or almost every day, but from time to time to refine, confirm or reject the data daily or more global self-reports.
To successfully apply this procedure, it is necessary to establish objective criteria that should guide the observers

Behavioral Analysis

Once defined the conduct of not sleeping and sleeping, it is necessary to observe the stimuli and background consequential damages are determined, and the states that make agencies more or less likely.

a) Incentives history
First, consider the stimuli in whose presence should occur normal sleep onset: the place that the patient is sleeping (your room, your bed) and time of day you wish to do so.
In many cases, these stimuli in the presence of background, the insomniac patient has become used to perform other behaviors incompatible with sleep, such as reading, working, eating, thinking or just lie in bed awake. Some researchers have observed that, while trying to sleep, patients have a mental activity that interferes with sleep to be incompatible with it.
The presence of behaviors that interfere with sleep, linked to background stimuli outlined, bed and sleep time, contributes to the development of a harmful association between them and them.
Also, the fact that the patient to sleep, fitfully, in other place and / or times of day, can contribute to sleep behavior is not associated with the place and when deemed appropriate.
also must be delimited by other environmental conditions such as noise, light, temperature, bed type, and the behavior of the couple.

b) State agency
sleep behavior implies that the body is relaxed. Excessive activation favoring insomnia can be caused by circumstances such as:

• The accumulation of activation along day, which will be greater if the subject has been exposed to stressful situations.
• The presence of activities and / or intense emotional states, close to when trying to sleep.
• Excess quantitative and / or qualitative cognitive and motor activity when in bed.
• ingestion of drugs or other substances.
• subject's reactions in relation to their own inability to sleep.

many insomnia patients have higher levels of physiological arousal to others, may be that this excess favors the maintenance of insomnia.
However, not all cases of insomnia are related to high activation, proposing a distinction between tense and subject relaxed subjects to discriminate insomnia patients who might benefit from intervention strategies aimed at reducing the activation.
As noted, excessive activation of insomnia patients may be affected by the use of stimulants such as caffeine. Raich suggests that insomnia patients take coffee immediately before sleep, have a greater tendency to sleep disruptions during the night, while you take in the afternoon, will be more prone to insomnia initiation.
It has been observed in smokers, greater sleep latency with subjects who did not smoke. On alcohol, even in moderate doses may have, in principle, short-term positive effects, often negatively affect the quality and duranción it.
Accordingly, it seems that the dream is harmed when people change their usual diet at dinner. Foods that are rich in tryptophan (those that contain lots of protein), vitamin B and minerals like calcium, magnesium, zinc, copper and iron, tend to benefit the dream.
Another aspect to assess is the level of overall activity, because people who are physically and mentally active tend to be more prone to sleep. However, it is not suitable physical exercise just before trying to sleep, since short-term exercise can have an activating effect.
Finally, consider the problem of people who, for their job or family obligations, can not maintain a regular rhythm of sleep (people traveling, working in shifts) because these are cases of high risk suffering from insomnia.

c) Incentives
consequential in this category must be taken into account, firstly, the own remedies that people seek to alleviate the problem, such as turning to alcohol or certain drugs, developing eventually a state of tolerance requiring increased doses and a state of physiological and psychological dependence requiring the patient to continue in this direction. The immediate gratification of being able to sleep after ingesting alcohol or drugs, is a very reinforcing consequence that may contribute to consolidating the behavior of taking these substances, especially if the patient fails attempts carried out without taking them.
can also be reinforcing to the insomniac patient, and contribute to the maintenance of insomnia, the care you receive from others when he complains about his problem and is a good excuse for poor job performance or neglect of family and social obligations, allowing the patient to avoid or escape undesirable situations.
may occur also, that the patient enjoys without sleep when others sleep, enjoying doing things he likes, etc. in which case the behavior will not sleep again, strongly reinforced.

PSYCHOLOGICAL TREATMENT OF INSOMNIA

Psychological techniques have been used traditionally:

• relaxation training.
• Various forms of biofeedback and control stimuli

However, the first two have decreased significantly, consolidating the third next to:

• restriction of sleep time.
• cognitive strategies
• sleep hygiene programs.

These strategies can be used separately or together within a single intervention program.

relaxation training

Relaxation training can help change the dysfunctional response patterns presented by patients through the following channels:

• Developing a self-priming ability to reduce activation during wakefulness and, more specifically, reduce the overactivation when trying to sleep. Providing an alternative
• thoughts cognitive interference that can occur in the bed.
• giving patients an alternative form of behavior that can help increase the perception of control and self-efficacy.

Several studies support the effectiveness of relaxation training. These techniques have proved superior to placebo and control conditions, without any differences found between them and other relaxation procedures.
However, the improvement observed in insomniac patients under the relaxation training should be considered limited, as evidenced by facts such as the mean time to sleep that has been reduced, rarely reaches 50% of the lag time before the intervention and, when you've worked with seriously ill patients to achieved despite a marked decrease, the latency is still high at the end of treatment.
addition, in some studies, relaxation was less effective than stimulus control technique, suggesting that it may be right, when high activation predominates, and almost always in combination with other strategies.

Biofeedback

Biofeedback is a technique of self-control of physiological responses, consisting of constant proportional to patient information on a particular answer to learn to control voluntarily.
In the treatment of insomnia, the most common procedure was the frontal electromyographic biofeedback (EMG BF-front): the patient receives visual information and / or hearing on the level of frontal muscle tension, in order to get relax. This relaxation will be generalized to other parts of the body and, in this way, is to reduce the high activation that interferes with sleep, like when using relaxation training.
In general, the BF-EMG has been the most effective in mild cases of insomnia, which in severe chronic insomnia, but without providing benefits greater than relaxation training.
also has questioned the appropriateness of reducing frontal EMG activity for improving sleep behavior, citing the following arguments:

1. insomniac subjects do not differ from those that are not in their frontal EMG activity levels during wakefulness and sleep;
2. that relaxation is achieved through frontal EMG BF-not necessarily generalize to other muscles or other activity that may interfere with sleep;
3. that the decrease latency time is not related to the reduction of EMG activity.

However, it is possible that the BF-EMG is a suitable procedure for insomniac subjects with high frontal EMG activity. Hauri noted that the application of the BF-EMG showed only useful subset of subjects with insomnia who were classified as intense, but not to those classified as relaxed.
lesser extent, biofeedback has been used electrodermal activity, primarily on the level of skin conductance (BF-SCL), in order to reduce sympathetic activity of patients. Although there is no linear decrease electrodermal activity through the various stages of dream, it is considered a good predictor of the degree of surveillance of people, so it is assumed that its depletion may contribute to a relaxed state favoring sleep behavior. It was observed that the BF-SCL can encourage states of relaxation that contribute to increasing the total sleep time in patients insomniacs. It seems an interesting alternative for overactive subjects.
Also, in some cases next to the BF-EMG biofeedback was used electroencephalographic (EEG BF). Was used three types of EEG BF: BF

• theta rhythm associated with a transition state between wakefulness and sleep. BF
• alpha rhythm associated states of relaxation. BF
• sensorimotor rhythm, related to the inhibition of basic motor responses.

Simon et al have reported that the BF-alpha tries to provoke a state of relaxation that promotes sleep, but question its usefulness, though, could help patients decrease their activation, for its part, the BF-theta seems help the patients increase theta waves that promote sleep, but learning is difficult and not everybody get it, finally, and at the same address, the sensorimotor BF (BF-SMR) has been effective in insomnia patients who did not have high stress levels, suggesting the convenience consider the presence or absence of physiological overactivation before deciding what therapeutic strategy should be used.
In any event, research on the BF, and its application in everyday clinical practice are scarce.

stimulus Control

stimulus control is the monitoring by the patient in a series of instructions to pursue two basic goals:

1. weaken the association between antecedent stimuli present when trying to sleep and not sleep behavior or other behaviors that foster it.
2. strengthen the relationship between such stimuli and background desired sleep behavior.

The technique is based on the fact that in many cases, background stimuli, such as time of day, the bed or the room, have been associated with activities such as reading, watching television, etc. that may favor the waking state incompatible with sleep. The elimination of this type of behavior in this context, the association aims to weaken harmful "stimulus-response" and provide that in the presence of these stimuli background, to develop, again, the habit of sleeping.
Also, since patients tend to sleep in insomniacs presence of other antecedent stimuli (during the day in an armchair), it is considered that removing this partnership, the greater the likelihood of sleep before the appropriate stimuli.
To achieve these objectives, we propose the patient that day, must faithfully follow instructions as those designed by Bootzin (Table 5.1.). It is assumed that the repetition of these instructions will favor the weakening and strengthening of stimulus-response links, inappropriate or unwanted respectively.
Several studies have shown the effectiveness of this strategy and its superiority over other psychological techniques as relaxation training. However, in clinical practice its application can be difficult because of lack of patient adherence to rigorous monitoring of standards. To prevent or resolve this problem, Bootzin stresses the importance of the following measures:

1. Explain to the patient the rationale behind each of the instructions, instead of giving the instruction sheet and tell you to follow.
2. Periodically check how the patient is using the instructions. Hauri

stressed that the negative cognitive activity in bed (concerns, musings, etc.) Is usually present in most cases of insomnia. However, disagreeing Bootzin, points out that behavior such as reading or watching tv. in bed, in some cases may promote sleep, as a result of two effects: deactivator and a distractor, which can neutralize inteferente cognitive activity. In these cases Hauri encourages patients to read in bed .. Following the approach
Bootzin, et Buceta. to suggest that it also turned off or distracting activity takes place out of bed, at a place close to it. In this way it is reserving the bed only for sleeping. Once in bed, as a complementary measure, may use some form of self-instruction to decrease their activation and avoid interfering cognitive activity. Regarding
instructions to "get up on time regardless of time which has been asleep" and "not to sleep during the day" to facilitate their proper application may be desirable as programmed strategies essential activities early in the morning and in general, plan the day with activities that prevent sleep on time and high risk situations.
In general, stimulus control is a useful strategy when present the conditions outlined above, but unnecessary when dealing with patients in the dominated, especially high levels of activation, or in cases in which undetected associations targeted between relevant stimuli and responses.

sleep time restriction

restriction of sleep time is to limit the time a patient spends in sleeping and lying in bed, in order of occurrence of sleep deprivation promotes sleep behavior in the restricted time available, increasing the time gradually to the extent that the patient get better sleep efficiency.
The implementation of this strategy assumes that the patient can not sleep during the day, or anywhere else other than your bed, having to get up, inevitably, at a predetermined time. Furthermore, it limits the time they can be in bed established, initially, a period less than they are usually sleeping.
This limitation should be kept for a period agreed with the patient, observed at that time it succeeded. After this period, if the patient has been able to sleep 90% of the time allotted, it will increase by 15 minutes for the next period and so on until a reasonable amount of sleep. Similarly, if the patient has not been able to sleep at least 80% of the scheduled time, it must be deducted in 15 minutes in the next period, and so achieve 90% from this time, the time will increase progressively in each period thereafter, provided the patient continues to achieve this percentage of sleep efficiency.
requires that the patient is willing to respect the rules during the agreed time. To do this, you should explain the rationale behind this measure. Furthermore, to achieve adequate levels of adherence may be useful measures as initially establish

• periods "test" short to reduce the likelihood of abandonment.
• Plan activities incompatible with the behavior of sleeping or going to bed to help control the times of greatest risk.
• Provide ongoing supportive care to the patient.

Likewise, the patient should know that will be sleepy and tired during the day, but if they follow the rules, this lack of sleep is that, sooner or later, will help you sleep at night.
restriction of sleep time has been effective in several studies, sometimes combined with sleep hygiene standards and instructions for stimulus control.

Sleep Hygiene

The aim is that patients acquire healthy habits that promote sleep. To do this, you are informed about these habits and helps you plan and weigh out the appropriate action. Some of these measures coincide with the directions of other strategies, for example, always getting the same thing in the morning regardless of the time it has fallen asleep, not sleeping during the day and not stay in bed longer than necessary to sleep.
Now, for the insomniac patients change their habits, it is important to explain the reasoning behind and also help plan and implement such measures.
Therefore, improving on sleep hygiene is not limited to providing a set of instructions, it covers wide patient education on issues that may harm or benefit the sleep behavior, ie, antecedent stimuli, state of the body , stimulus consistent and personal behaviors that can affect all these. Moreover, the implementation of this strategy must include the selection, planning and operation of the specific measures that are most appropriate in each particular case.
Sleep hygiene is a procedure that has proved effective in several studies and is very convenient in any treatment program as a complementary strategy. Favoring the acquisition of sleep habits is a measure beneficial to the treatment of insomnia and, after passing the problem to prevent relapses.

Cognitive Techniques

The application of cognitive techniques focusing on two main objectives: control of cognitive activity interfering at specific times, especially when the patient is in bed and can not sleep, or in the presence of background risk stimuli, and Furthermore, in changing beliefs, attitudes, expectations and / or harmful ratings on relevant aspects related to insomnia, such as sleep behaviors and not sleeping, the potential consequences of these behaviors, the use and effects of treatment, the control you have over the situation, etc.
Regarding the first objective, various strategies have been used with the intention of eliminating dysfunctional cognitive activity in bed, usually in addition to other procedures. Among them:

• The use of the imagination to divert attention from the dysfunctional thoughts that prevent sleep.
• concentration in a monotonous activity incompatible flattering sleep and interfering with cognitive activity.
• The self-statements and self-instructions that help you stay relaxed while trying to sleep, or help you remember what the specific objective pursued and what to do.
• The arrest of thought to drastically eliminate interfering thoughts. The aim is

help patients deal with at particular risk. These techniques are intended to replace harmful cognitive activity with a more healthy.
In the same vein as we noted in the case of other strategies, so that these procedures are effective, not enough to indicate what to do, but it is necessary to train the patient to master self-application of each strategy considered appropriate. You can try the strategy chosen by using simulated situations imagination or role-playing, completed the trial, patient and therapist should discuss the experience and draw conclusions relevant to refine the procedure, continuing the work in this direction until the patient is able to effectively self-administered real situation.
cognitive techniques can also be applied to monitor cognitive activity which can promote sleep behavior in the presence of "high-risk stimuli" unwanted, for example, when the patient is sleepy after eating. The patient should be adequately trained to implement strategies as appropriate, learning to control high-risk situations.
Regarding the second objective, certain beliefs, attitudes, expectations and dysfunctional appraisals may influence the patient's readiness to react detrimental when you are in bed, hence, detect and modify can be crucial to favorably alter the course of insomnia.
As noted Buceta, dysfunctional beliefs and attitudes, generally quite stable and can allow the emergence of erroneous and prejudicial expectations about what will happen, and ease the interpretation, too biased and dysfunctional, what happens, influencing, In both cases, the development and consolidation of insomnia. If a patient has well-established belief that "can not sleep if it does not take the medication," is very likely to develop a specific expectation on this line.
This type of prior expectations and subsequent measurement, often biased and misleading, usually present at the beginning of psychological treatment when the patient is still not well understood, nor the specific goal of therapeutic work, or what it can expect in the short and long term, nor take into account the immediate effects of cessation of medication or other relevant issues; also be maintained, in many cases, during surgery, preventing any other strategies and action leading sometimes to the neglect of treatment.
In many cases, changing beliefs and attitudes should be applied within the therapeutic program, interacting with the use of cognitive strategies of coping. In this regard, firstly, cognitive intervention may be addressed to undermine and replace harmful beliefs and attitudes that negatively affect the previous expectations, the ratings "in situ" and ultimately, the patient's behavior, on the other hand, the cognitive intervention can help patient to cope adequately with their own beliefs, attitudes, expectations and erroneous assessments in the time of highest risk and also the procedure of cognitive therapy, the experiences of coping with situations of risk, may be used to obtain empirical evidence that contributes to change dysfunctional beliefs and attitudes, establishing, thus, very beneficial interaction.
The effectiveness of cognitive coping strategies depends largely on its consistency with beliefs, attitudes and expectations relatively stable, and hence the importance of focusing the intervention on both fronts. In cases like this, previous work on beliefs, attitudes and expectations can pave the way for the cognitive and coping strategies, and these in turn, the other intervention strategies, helping all to the collection of valuable data that can be used later to continue the work to modify the beliefs, attitudes and expectations.

Paradoxical intention

The strategy used by Buceta, changing the order to "sleep" by "being comfortable in bed," suggests that in some cases, it is important to eliminate the anxiety associated with objective "having to sleep." In the same direction lies the art of paradoxical intention, although in this case the objective is that the patient "awake as long as possible."
The results to date have been mixed. However, it is likely to work in combination with other cognitive strategies. Thus, research Sanavio was effective "package" consisting of restructuring cognitive, paradoxical intention and thought stopping.
is important to remember that you can not establish a paradoxical goal without having prepared the patient for it, this generally involves prior work on changing their beliefs on issues such as "time to sleep" or " the consequences of poor sleep at night "and have provided a coping strategy to control potential interfering activity in bed and help patients remember and focus on your goal (stop, remember that your goal is to stay awake remember that for a few days no matter if you sleep fewer hours, focus on your goal, stay awake as long as possible).

Combined treatments

The combination of two or more strategies, with different specific objectives may be very appropriate in many cases, the alternative being that today is used more often.
An interesting example that illustrates the interaction between different techniques has been described by Jacobs, to test the combined effectiveness of three strategies: sleep hygiene, stimulus control and relaxation. All subjects underwent the first two strategies, then half of them continued this treatment and the other half were applied relaxation. At the end, both groups improved, but significantly further the group that used the relaxation.
combined treatments should be tailored to the needs of each patient, select strategies based on existing needs, rather than go to the "standardized packages." Each treatment, therefore, may be different, including two, three or more strategies. In summary, a combined intervention strategies could include the following:

Sleep hygiene
• relaxation (and / or EMG biofeedback)
• restriction of sleep time
• The stimulus control
• Changing beliefs, attitudes, expectations and assessments
dysfunctional self-statements and self-instruction
• The
• Paradoxical intention.

Similarly it is not necessary to apply all these strategies, it is not convenient to use at the same time from the first moment that in each case have been chosen, on the contrary, they should be introduced in stages, depending on the existing priorities.
In general, it is recommended that patients use fewer strategies but use them correctly, will cover a wide range of techniques at the expense of confusing and overloaded.

Patients with medication

many insomnia patients are undergoing therapy. In these cases, one of the objectives you should consider psychological treatment is the patient leaves the medication, with the consent and medical guidelines.
In a study by Hauri, 26 subjects with insomnia were treated with relaxation and standards to improve sleep hygiene. Half of them left the medication when you start treatment, while the other half continued to use drugs when considered appropriate. Upon completion, all subjects improved in latency and sleep efficiency, but ten months later, those who discontinued the study medication showed better sleep patterns than those who continued taking it. It is suggested that reliance on medication, reduces the medium term, the potential benefits of psychological techniques, suggesting that one of the objectives of the intervention should be precisely to help patients to stop taking their medication.
The timing of the treatment that the patient should try to sleep without the aid of drugs will depend, first, the doctor's advice and, secondly, that you are psychologically prepared. To this end, the psychologist must focus in:

• Change the beliefs, attitudes and expectations of patients regarding the effects, problems and the convenience / inconvenience of the medication.
• Training the patient to master the relevant skills and strengthen their confidence, so you can try to effectively abandon the medication and face the inevitable negative effects
• Using his skill as a therapist to detect the appropriate time in which the patient should seek the abandonment of the medication successfully.

In many cases, the time to stop taking their medication is a dreaded situation for patients. This fear can be neutralized programming "Trial days" collecting information on experiences. These "trial days" should not be scheduled until the patient is prepared to cope with success, in general, this moment will come when the following conditions are present:

1. That, regarding the treatment, the subject has developed a operating style characterized by personal commitment and self-control of the process that has
2. skills to try to sleep without medication and
3. their beliefs, attitudes and expectations are favorable for the attempt.

When the therapist believes that it is now, should raise the patient the convenience of, say, a couple of days of testing during the next week, explaining the reasons for and benefits of doing it and anticipating their possible consequences. Subsequently, should involve the patient in the therapeutic decision and plan with him, the plan followed in those days.
During the day following each night of testing is advisable that the patient can see briefly, or call, the therapist, to tell the main impact of the test and it can be reinforced by the attempt and make some suggestions for next test.

treatment of insomnia in children and adolescents

In particular, this population may be useful operant techniques applied by parents of patients, such as the phasing out of quota attention to insomnia, and positive reinforcement contingent on appropriate behavior of bed . They can be applied along with others, depending on the age of the children, may also be of interest, but must be amended, as appropriate, the instructions or how to apply.
An interesting alternative in this area are prevention programs.

Treatment of insomnia in the elderly

Pallesen et al conducted a meta-analysis of thirteen studies that showed that psychological intervention had significant improvements on measures such as sleep latency, number of awakenings at night and total sleep time.
The most recent study of Morin showed that both psychological treatment and the medication can be effective in the short term, but only the former maintains this positive effect in the medium to long term.
In another review, Morin noted that the techniques of stimulus control and sleep restriction of time are most beneficial for patients older with insomnia, while relaxation to reduce the level of activation, more limited positive effects. The main conclusion of this paper is that psychological techniques help to improve the efficiency and continuity of sleep in these patients and reduce the consumption of sleeping pills.
The research suggests that psychological techniques can be used effectively with older patients, suggesting that it should not be unattended treatment of these patients, mistakenly thinking that because of your age, insomnia and has no solution

Treatment applied to other populations

behavioral intervention may also help relieve chronic insomnia patients, medical and psychiatric, in which the problem may be secondary to the primary disorder, or have been caused by the effects of medication.
strategies such as relaxation, sleep hygiene, stimulus control and sleep restriction of time, have proved useful in patients with cancer and psychiatric disorders.

effectiveness of psychological treatment

Comparing behavioral intervention with drug therapy, the study McClusky controlled has shown that while drugs get better results with a faster, behavioral intervention, it is higher in the medium to long term.
Morin et al. reviewed 48 studies and 2 meta-analysis of behavioral treatment of insomnia. It was noted that three psychological strategies meet the requirements of the APA to be considered empirically supported psychological treatments: stimulus control, progressive muscle relaxation and paradoxical intention, and three other techniques to meet the criterion of treatments likely to be effective: the restriction sleep, biofeedback and cognitive behavioral therapy.

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