Heidi Moawad, MD

Research shows that a combination of sleep knowledge and education about sleep can have a substantial impact on a person’s sleep habits. An often underrecognized fact is that healthy sleep habits are not intuitive, and attitudes about sleep vary widely. Inconsistent sleep schedules, sacrificing sleep, poorly timed naps, and use of electronics before sleep are all common habits among individuals of all ages, including those with and without sleep disorders. These habits can lead to consequences like behavioral and emotional issues, even among individuals who do not fit the criteria for a psychiatric diagnosis.

For example, a study assessing parental practices among parents whose children were enrolled in an early child education program showed that 81% of the parents surveyed believed that their children had healthy sleep habits, yet 50% and 33% of the children had unhealthy bedtime practices and insufficient sleep that were not recognized as such by their parents.

 These habits may lead to lifelong sleep problems if parents and children are not provided with the correct information about the importance of sleep and instructed about safe and effective ways to improve sleep quality and quantity.

Older adults often have sleep practices that can be detrimental to emotional and health as well. A large study that included 2312 participants aged 65 and older showed a high prevalence of insufficient sleep that was found to be associated with a sedentary lifestyle and an overall lack of physical activity.

Sleep knowledge and attitudes include several different components. One study conducted at the Department of Psychological Science at the University of North Carolina at Charlotte defined 3 separate components of sleep attitudes:

1) A cognitive component includes a person’s beliefs about the importance and necessity of adequate sleep.

2) An emotional component involves having a positive evaluation of the necessity of sleep.

3) A behavioral component involves taking action to make time for sleep in a person’s schedule.

The study found that participants who reported positive attitudes about sleep also experienced longer sleep duration, better sleep quality, and better sleep hygiene.

 Of these 3 interrelated components, it is the behavioral that has the most definitive impact, as it is a necessary factor in actually achieving adequate sleep. However, most individuals would not take the steps to incorporate the behavioral component in the absence of the cognitive and emotional components, so they are all key factors.

Another study used objective measures tracked by a Fitbit Flex accelerometer for 7 days to assess sleep among a group of 218 college students. Interestingly, while the study also showed that sleep attitudes were directly associated with longer sleep duration and better sleep quality, the researchers found that greater sleep knowledge did not correlate with these outcomes.

 These results suggest that a fundamental comprehension about the benefits of sleep and a baseline knowledge of the effective ways to attain good sleep are not enough to impact a person’s daily sleep habits and sleep outcomes. It appears that the attitudes a person has about sleep play a far greater role than pure knowledge when it comes to influencing behavior.

Of course, a positive attitude about sleep must be paired with accurate knowledge, as even the most well-intentioned patient can potentially attempt to use methods for sleep that are not beneficial. These can include drinking alcohol before bed, which many believe promotes healthy sleep, but can reduce the quality of a person’s sleep. For individuals who do not have sleep problems, interventions to improve sleep can include a variety of strategies, including stress management, relaxation, stimulus control, sleep hygiene, and exercise.

It is not uncommon for people to underestimate the importance of sleep and its impact on health. For instance, workaholism and competitive sleep deprivation are common among highly productive individuals—even health professionals. The outcomes can lead to interpersonal relationship difficulties, and in some instances, may lead to a referral for a psychiatric or psychological evaluation.

Physicians can help promote accurate sleep knowledge and healthy sleep attitudes for patients. Cognitive and behavioral interventions have been shown to have a positive impact on sleep,

 and these interventions can have lasting effects once patients experience an improved quality of life with less daytime fatigue, improved mood, and better productivity after adopting them.

; clinical assistant professor, Case Western Reserve University School of Medicine, Division of Medical Education; and editor in chief emeritus of 

Sleep health literacy in head start families and staff: exploratory study of knowledge, motivation, and competencies to promote healthy sleep

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Association of physical activity, sedentary behavior, and sleep with unhealthy aging: consistent results for device-measured and self-reported behaviors using isotemporal substitution models

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Direct and indirect associations of sleep knowledge and attitudes with objective and subjective sleep duration and quality via sleep hygiene

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A systematic review and meta-analysis of cognitive and behavioral interventions to improve sleep health in adults without sleep disorders

Articles

How can knowledge—and positive attitudes—about sleep improve quality of life for patients?

Sleep Attitudes Influence Sleep More than Knowledge

Borderline personality disorder has many clinical features, including relatively unrecognized sleep disturbances. Generally, sleep problems are not considered a primary characteristic of this condition, but research is beginning to identify specific patterns of sleep disruptions that are associated with the disorder.

 is characterized by substantial emotional instability, relationship strains, behavioral problems, and difficulties with self-image. It is disruptive for the person who has the disorder, as well as for other individuals in their lives. There is no effective or recommended pharmacological treatment for this chronic disorder. The clinical management, which consists of behavioral and cognitive therapies, is challenging.

 differ from the criteria for diagnosis of bipolar disorder, there are some similarities, and it can be difficult at times to differentiate the 2 conditions.

 Bipolar disorder is a psychiatric disorder characterized by fluctuations in mood and energy levels, often with features of 

 and depression. Borderline personality disorder and bipolar disorder can both profoundly interfere with an affected patient’s quality of life, and they both often cause mood instability, hopelessness, and other overlapping symptoms. Unlike borderline personality disorder, 

 is often treated with prescription medication, along with counseling and behavioral therapy. A 

 of either of these disorders can delay proper referral to a psychiatrist or behavioral specialist and delay the timely implementation of appropriate therapy.

Several studies have shown that patients who have borderline personality disorder experience substantial variability in their sleep times from night to night when compared with the general population. These trends have been documented by clinical history and questionaries, and objectively with actigraphy and polysomnogram studies.

 is a disruptive condition that causes fluctuations in sleep rhythms, with phase delay and misaligned rest-activity pattens. Patients who have circadian rhythm sleep disturbance can experience irregular sleep patterns, with inconsistency and unpredictability from day to day. This causes a lack of adequate sleep, as well as low energy and concentration during the day. This sleep disturbance has been associated with borderline personality disorder.

Furthermore, the severity of certain symptoms of borderline personality disorder has been shown to correlate with certain actigraphy patterns that demonstrate daytime and nighttime abnormalities that are consistent with circadian sleep disturbance. In one study, patients who carried a diagnosis of borderline personality disorder and who had high levels of impulsivity and mood instability showed substantial phase delayed daytime activity patterns, low inter daily stability, weak amplitude, and greater fragmentation of rest activity states over a study duration of 28 days.

 These patterns were not noted in the study participants who had a diagnosis of 

 or in the controls. Another study showed that patients with borderline personality disorder had delayed phase of nighttime rest patterns, delayed daytime activity onset, as well as delayed temperature phase, while controls and patients who had bipolar disorder did not exhibit these features.

While there appears to be a correlation between the severity of symptoms of borderline personality disorder and circadian rhythm dysfunction, the clinical implications have not been established, nor has any specific cause-and-effect relationship. Whether the emotional and behavioral aspects of borderline personality disorder affect circadian rhythm regulation, or the circadian rhythm dysregulation affects symptoms of borderline personality disorder is not clear. The distinct differences in circadian rhythm disturbance patterns between patients with borderline personality disorder and patients with bipolar disorder that has been replicated in several studies is interesting, especially given the similarities between the 2 conditions.

Circadian rhythm disturbance is objectively quantifiable, but difficult to treat, and these observations do not clearly provide direction for the treatment of borderline personality disorder. However, awareness and treatment of sleep disturbances are important aspects of patient management. Screening tests, including interviews and actigraphy, can identify 

 that patients might not have otherwise reported if they did not know those problems were abnormal. Patients who would benefit from appropriate therapy for their sleep disorder may experience an improved quality of life if treatment is implemented. Furthermore, the diagnostic signs can potentially provide an adjunct in the diagnostic process for patients when borderline personality disorder is considered in the differential diagnosis. Because borderline personality disorder lacks objective criteria, it is possible that some patients may feel empowered, heard, and understood when they are made aware of an objective feature of their condition. This may potentially improve compliance with treatment for some patients.

Self-report screening instruments differentiate bipolar disorder and borderline personality disorder.

The emerging circadian phenotype of borderline personality disorder: mechanisms, opportunities and future directions.

3. McGowan NM, Goodwin GM, Bilderbeck AC, Saunders KEA. 

Actigraphic patterns, impulsivity and mood instability in bipolar disorder, borderline personality disorder and healthy controls.

4. McGowan NM, Goodwin GM, Bilderbeck AC, Saunders KEA. 

Circadian rest-activity patterns in bipolar disorder and borderline personality disorder.

Sleep disturbances in borderline personality disorder are relatively unrecognized. 

Sleep Patterns in Borderline Personality Disorder 

Patients can experience sleep dysfunction due to many different physical, psychiatric, and psychological causes. Being an adult victim of peer victimization is one of the causes that is becoming more recognized in the medical literature as a source of patient distress and health risks. The terminology to define this type of experience is inconsistent and vague, and it can be described as being a victim of bullying, intimidation, harassment, narcissist abuse, or being a part of frenemy relationships.

 Generally, the intensity is defined as mild to moderate, and it is seen as a recurrent behavior. There is not an established screening tool that is used to identify adult recipients of peer victimization, and some patients might not consciously consider it a cause of their health issues. In fact, some patients may not recognize 

sleep as the source of their health issues

 that can occur as a result of this type of experience may include various patterns of insomnia.

 This may lead to an increased need for sleep or can cause daytime symptoms of sleep deprivation, such as anxiety, irritability, and hunger. A large Scandinavian survey that included public and private sector employees specifically noted that participants who were defined as victims of bullying reported waking up during sleep and experiencing a lack of restful sleep.

Traditionally, patients and physicians consider bullying to be a childhood problem. Adult peer bullying can occur in the workplace, in social settings, and in family situations. It is loosely defined as a recurrent pattern in which 1 or more people demonstrates power through actions such as belittling, insulting, embarrassing, dividing work or compensation unfairly, and more. One particular type that has been described is the indirect experience in which a person becomes confused about whether someone is their friend or not due to inconsistent patterns of behavior.

 The effects of peer victimization can vary depending on many factors, including the recipient’s baseline coping mechanisms, the level of connection they had anticipated to have with their peers, the naturally expected duration of exposure, and the estimated future need for contact. Workplace bullying has been found to affect witnesses, people who personally experience the behavior frequently, and people who experience the behavior infrequently. Those who experience the behavior more frequently are more likely to experience disturbances outside of work, such as sleeping problems.

Interestingly, a unique study published in 

 noted that participants who were found to have the miR-146a GG genotype were more likely to experience associated distress and insomnia when they were exposed to negative social acts in the workplace. While the results were unique, the researchers suggested that the genetic variability of the participants could affect the response of the hypothalamus and functions of the autonomic nervous system that play a role in 

, distress, and sleep. They also noted that this gene mediates actions of the innate immune response.

 An interplay between the immune response and autonomic nervous system is noted in many medical conditions, which could have further implications.

Managing sleeping problems requires a comprehensive approach to diagnosis and intervention. The treatment of sleep impairment that is associated with adult bullying may be more effective if it is focused on the emotional and behavioral aspects, rather than pharmacologic therapies, such as 

, anxiolytics, or antidepressants. Certainly, adult peer victimization that has a substantial effect on a patient can pose complex challenges in terms of medical treatment.

The initial step of awareness and defining the problem can help direct the discussion so that patients can express their preference for which approaches they would like to consider for managing the problem. Physicians can directly offer reassurance that the patient’s experience is not uncommon, and that the experience is recognized as a cause of distress, even among health care professionals.

 Strategies for patient support and symptom management may include individual therapy and direction to consider participating in a support group. Goals can include learning ways to avoid the external cause of distress. Patients may also benefit from follow-up to monitor changes in sleep patterns and the cause of the sleep problems.

is associate editor, humanities in Neurology; clinical assistant professor, Case Western Reserve University School of Medicine, Division of Medical Education; and editor in chief emeritus of 

Frenemy: a new addition to the bullying circle.

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Associations between exposure to workplace bullying and insomnia: a cross-lagged prospective study of causal directions.

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Workplace bullying, sleep problems and leisure-time physical activity: a prospective cohort study.

4. Hansen AM, Hogh A, Garde AH, Persson R. 

Workplace bullying and sleep difficulties: a 2-year follow-up study

5. Rajalingam D, Jacobsen DP, Nielsen MB, et al. 

Exposure to workplace bullying, distress, and insomnia: the moderating role of the miR-146a genotype.

6. Alshawush K, Hallett N, Bradbury-Jones C. 

The impact of transition programmes on workplace bullying, violence, stress and resilience for students and new graduate nurses: a scoping review.

Peer victimization can cause patient distress and health risks, including issues with sleep. 

Adult Bullying and Sleeping Problems

Most patients are well aware that anxious thoughts at bedtime can keep them up at night. Recent research also shows that it is not just nighttime thoughts that interfere with sleep—daytime thoughts can interfere with sleep as well. Additionally, anxious thoughts involve several distinct features. Worry and rumination are specific types of anxious thoughts. While they often coexist and have some similar features, worry and rumination are not the same, and they each independently impact 

Patients often do not seek professional help for managing anxious thoughts. However, many patients do seek help to get treatment for symptoms of fatigue, sleepiness, low energy, and other effects of sleep deprivation. While these issues can be caused by medical problems that should be ruled out, like anemia and heart disease, insufficient sleep due to insomnia is a common cause of daytime symptoms.

Daytime sleepiness caused by insomnia can manifest with difficulty concentrating, diminished ability to multitask, impaired emotional regulation, and falling asleep during activities such as meetings and driving. Objective sleep measures may also reflect shortened daytime sleep latency.

A research study involving 459 adults published in 

 considered worry and rumination as 2 separate constructs, a distinction that had been established in previous literature. Worry is thinking about future events that may have undesirable outcomes, particularly if there are factors that a person may not be able to control. Rumination involves recurrent negative thoughts and can include repeatedly thinking about problems or events (usually negative events), especially those that have happened in the past and cannot be changed. Using patient self-reports, the researchers found that each of these factors individually contributes to daytime sleep-related impairment. Furthermore, analysis specifically showed that worry was a predictor of sleep disturbance, and that rumination predicted sleep-related daytime impairment.

 This suggests that each of these may have a different impact on patients’ 

, and that each is important enough to be addressed independently.

 is thought to be associated with nighttime thoughts. However, daytime worry and rumination may affect sleep as well. A small research study involving 27 insomnia patients and 20 healthy controls published in 

 found a significant relationship between daytime levels of repetitive thought and participants’ sleep using objective sleep measures obtained by polysomnography. The researchers reported that heightened worry levels were related to an augmented wake after sleep onset and a diminished total sleep time, reduced sleep efficiency, and lower percentage of REM sleep. They also found that rumination was associated with an increase of sleep latency and a decrement of sleep efficiency.

The impact of daytime thoughts on nighttime sleep suggests that strategies for reducing worry and rumination at the time of sleep might not be enough to alleviate insomnia. To have a greater impact, strategies to reduce worry and rumination can also address the problems of anxious daytime thoughts. Several approaches are used to manage worry and rumination. Habits that help with problem solving and with providing a frequent sense of closure can reduce rumination and worry and may help alleviate anxious daytime thoughts. Additionally, rumination-focused cognitive behavioral therapy can be administered by a qualified therapist. This can relieve symptoms of rumination and has been used as a treatment for different age groups.

 Treatments using a mobile app may be effective for helping patients who have these problems as well.

In general, worry and rumination are not uncommon, and they can affect patients who do not have a psychiatric condition. Most patients recognize the effects of nighttime anxious thoughts on their sleep. But the impact of daytime 

 on sleep are not as well-known and are often ignored in the management of insomnia. For many patients, awareness of this interaction is a first step in alleviating the problem. The key component to resolving the issue is to provide patients with tools to help them manage their recurrent thoughts during both their waking hours and their sleeping hours. This often involves instruction and therapy, as it can be difficult for patients who are experiencing anxious thoughts to create solutions in the midst of anxiety-provoking circumstances, or when they are distracted by recurrent thoughts.

is associate editor, Humanities in Neurology; clinical assistant professor, Case Western Reserve University School of Medicine, Division of Medical Education; and editor in chief emeritus of 

Worry and rumination have distinct associations with nighttime versus daytime sleep symptomology.

2. Galbiati A, Giora E, Sarasso S, et al. 

Repetitive thought is associated with both subjectively and objectively recorded polysomnographic indices of disrupted sleep in insomnia disorder.

Guided, internet-based, rumination-focused cognitive behavioural therapy (i-RFCBT) versus a no-intervention control to prevent depression in high-ruminating young adults, along with an adjunct assessment of the feasibility of unguided i-RFCBT

, in the REducing Stress and Preventing Depression trial (RESPOND): study protocol for a phase III randomised controlled trial. 

Reducing worry and rumination in young adults via a mobile phone app: study protocol of the ECoWeB (Emotional Competence for Well-Being in Young Adults) randomised controlled trial focused on repetitive negative thinking.

Recent research shows that daytime thoughts can interfere with sleep just as much as nighttime thoughts. 

Daytime Negative Thoughts Have an Impact on Sleep 

, both chronic and acute, often interferes with sleep. Sleep interruptions and the side effects of pain medication are among the most commonly described disruptive interactions between pain and sleep. Bad dreams, which can be more difficult to study objectively than sleep disorders, are frequently associated with stress, anxiety, depression, and psychiatric and emotional disorders.

 Bad dreams are also associated with physical pain. The implications of this relationship are important, as bad dreams have been shown to have a substantial impact on sleep quality and restorative sleep. The disruptive effects of bad dreams can impact several important life issues, including mood, 

Recent research is beginning to shed a light on the complex relationships between pain and bad dreams. Postsurgical frightening dreams have been reported, especially among children.

 These dreams are thought to be short-lived, without a strong rate of recurrence, and are thought to be possibly associated with the effects of anesthesia, unfamiliar surroundings, and anxiety about surgery. Bad dreams during the perioperative timeframe are not thought to have a substantial impact on quality of life. Chronic pain, however, is also associated with bad dreams, and this can have more disruptive implications on day-to-day life.

Musculoskeletal pain, which is a particularly common type of pain, can develop as a result of serious injuries and associated 

 (PTSD), but it more often occurs in the absence of severe physical issues or associated psychological sequelae. A recent observational study published in 

 compared the frequency of self-reported bad dreams and nightmares between participants who had chronic musculoskeletal pain and a control group who did not have this type of pain. Over the course of a month, 44% of 191 participants with established pain reported bad dreams, compared to 7.3% of the 191 controls. The researchers also measured several other variables, including vitamin D and calcium levels, anxiety, and depression. Low vitamin D and calcium, as well as the presence of anxiety or depression, were all correlated with bad dreams and with musculoskeletal pain.

While the conclusions do not definitively point to a strong independent correlation between pain and pain bad dreams, these results do support the idea that there could be a possible connection.

Research has also examined the relationship between 

 and bad dreams. Migraines are widely considered to be complex experiences that include pain but are not limited to pain. Bad dreams are associated with 

, and the relationship seems to be bidirectional. Some small studies have suggested that bad dreams can occur during an ongoing migraine episode, and research also suggests that some people may have bad dreams prior to the onset of the painful portion of a migraine episode, possibly as part of a migraine prodrome.

The mechanism behind the relationship between pain and bad dreams is not fully established, but these types of 

 generally occur during the rapid eye movement (REM) sleep stage. Researchers suggest that the either the dream content is altered by pain experiences, or that the recollection or amount of REM sleep is altered by the physiological effects of pain on the brain.

 Understanding the mechanism can help guide treatment strategies. And, for some patients, their own awareness of the interactions between pain and their dreams can help encourage them to report their experiences and to seek treatment.

 and bad dreams have an impact on sleep quality, as well as on daytime sleepiness. Patients who experience chronic pain conditions, including migraine, often experience daytime fatigue and increased sleepiness around the time of the episodes. These symptoms are independent of sleep disturbance, but they can be exacerbated by sleep disturbances. Nightmares and bad dreams can further contribute to daytime sleepiness and diminished quality of life for people who are living with chronic pain. Patients who have bad dreams can experience anxiety about the dream content or may become concerned about whether the dreams are a reflection of their own mental health. These issues highlight the importance of adequate pain treatment for people who have pain conditions. Yet some medications can further interfere with sleep, making treatment less than straightforward.

Pain treatment can be intimidating for patients who are concerned about side effects and addiction. While these are valid concerns, there are many safe options for managing pain besides oral medication, including injections, patches, meditation, and cognitive behavioral therapy, among others. All of these can help alleviate the risk of bad dreams that can worsen sleep quality and quality of life for patients who have chronic pain.

is Associate Editor Humanities in Neurology, Clinical Assistant Professor Case Western Reserve University School of Medicine, Div. of Medical Education, and Editor in Chief Emeritus of 

1. Vanek J, Prasko J, Ociskova M, et al. 

Nightmares affect the experience of sleep quality but not sleep architecture: an ambulatory polysomnographic study.

3. Eriksson M, Nilsson U, Bramhagen AC, et al. 

Self-reported postoperative recovery in children after tonsillectomy compared to tonsillotomy.

Nightmares and bad dreams among individuals with musculoskeletal pain: a link to vitamin D and calcium.

Nightmares in migraine: a focused review.

Pain can have a substantial impact on sleep quality and quality of life. 

Pain on the Brain: The Relationship Between Bad Dreams and Chronic Pain

Controlled breathing exercises can be a solution or an adjunctive treatment for some people who have primary insomnia. 

 is a common problem, affecting most adults at some point in their lives. Chronic insomnia and temporary bouts of insomnia can both affect total sleep time, restorative sleep, mood, and daytime sleepiness. These issues can also lead to disrupted sleep schedules—with unwanted daytime naps, 

, decreased productivity, and a feeling of being unrested.

Many patients who cannot fall asleep or stay asleep will report their symptoms to their primary care doctor, and those who have idiopathic 

 may be referred to a psychiatrist or a sleep specialist when first line and second line therapies are ineffective. As more patients are learning about the harms of chronic use of various sleeping pills, some are asking for nonpharmacological therapies to aid in the treatment of insomnia or will agree to try a nonpharmacological management approach when it is suggested by their doctor. While dysregulated breathing is a key component of obstructive sleep apnea and central sleep apnea, breathing irregularities have not been widely considered a significant component of 

 to help patients with insomnia is based on several underlying issues: the role that the autonomic nervous system plays in sleep and the relationship between insomnia and depression or anxiety. Breathing exercises are considered an adjunct in management anxiety and depression, which are common comorbidities of insomnia. Researchers have proposed that hyperarousal and chronic sympathetic hyperactivation and/or parasympathetic hypoactivation could disrupt a number of sleep features, such as normal sleep onset latency, sleep quality, and sleep duration.

 A large review study noted that people who had insomnia were found to have a range of different alterations in their autonomic activity.

 This subclinical autonomic dysfunction is one of the potential explanations for why breathing exercises may have a beneficial impact on insomnia.

A few studies have examined the effects of controlled breathing on insomnia. One study, for example, assessed the effects of presleep breathing exercises on a small group of participants who had self-reported insomnia. During the study, the participants learned how to do slow paced breathing exercises for 20 minutes before going to sleep. After implementing the exercises, participants experienced a number of positive outcomes.

 Sleep onset latency, number of awakenings, and awakening time during sleep were decreased, and sleep efficiency was increased. Based on these observations, the researchers proposed that people who have insomnia may have disordered autonomic function, suggesting that deliberate control of breathing could help regulate autonomic function in patients who have insomnia, and that this could have potentially played a role in the observed symptom improvement.

Another experiment assessed the effect of a yoga breathing technique on healthcare professionals during the 

. Participants initially rated their sleep through a series of questionaries before learning breathing techniques that are part of a specific type of yoga practice.

 After using the breathing techniques on a regular basis, the participants experienced improvements in self-reported sleep and quality of life measures.

While these and other similar studies are generally small, a variety of different types of breathing exercises with varying schedules (during the day or right before sleep) seem to have a positive impact on sleep, without side effects. Controlled breathing and deep breathing may help to promote sleep initiation.

 The effect on sleep initiation would not, however, explain the benefits of 

 that are done during the day. There seems to be a positive effect of breathing exercises on insomnia that reaches beyond sleep initiation. Sympathetic hyperactivation is generally associated with rapid, shallow breathing, while the parasympathetic state is associated with slower, deeper breathing, and the interplay between these aspects of the autonomic nervous system is generally expected to have effects that last several hours.

Breathing exercises can be a safe and useful adjunct in the treatment of insomnia. People can learn to use controlled breathing on a regular basis or can add these techniques to a more comprehensive sleep regimen as a way to help manage bouts of insomnia. For patients who want to gain a sense of personal control over their sleep, such exercises may provide a good way to take part in their own management. Patients can learn breathing techniques by working with a therapist or by using videos or apps recommended by their doctor. Because deep breathing techniques have also been shown to help alleviate anxiety, which is both a cause and an effect of insomnia, these types of exercises can reduce insomnia and its effects with a multipronged approach.

Self-regulation of breathing as an adjunctive treatment of insomnia.

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New research suggests deliberate control of breathing could help regulate autonomic function in patients who have insomnia.