Transcript Insomnia: Concepts and Cognitive-Behavioral Treatment Joseph K. Neumann, Ph.D. Roth Neuropsychology and Behavioral Health Associates.

Insomnia: Concepts and
Cognitive-Behavioral Treatment
Joseph K. Neumann, Ph.D.
Roth Neuropsychology and
Behavioral Health Associates
Insomnia: How Defined
• World Health Organization – problem
initiating/maintaining sleep, at least 3 X week
with daytime sleep impairment.
• ICD – Disorder of Initiating/Maintaining Sleep
a. 307.41-transient – associated with acute
emotional distress.
b. 307.42 – chronic – associated with
anxiety, depressive disorders, psychosis --?
Evidence Against Insomnia as Only
Symptom Rather Than Co-morbid Dx
• Insomnia and Major Depression do not
necessarily co-occur
a. 40% of MDD patients – no insomnia
b. 40% of Insomnia pts. – no depression or
other major psychiatric disorder
• Insomnia is risk factor for development of
depression
Evidence (cont.)
• Severity of Insomnia increases prior to reoccurrence of Depression
• Successful Depression tx does not necessarily
eliminate Insomnia
• Primary Insomnia – Depression have different
neurobiological profiles (nocturnal NE, brain
activity, REM sleep patterns)
• Pigeon & Perlis (2007) Int. J. Sleep Disorders
Psychophysiological Insomnia (PI)
• International Classification of Sleep Disorders
• A disorder of somatized tension and learned
sleep-preventing associations that results in a
complaint of insomnia and associated
decreased daytime functioning/wakefulness
• r/o sleep apnea, restless leg syndrome, COPD,
pain conditions, PTSD, etc.
Signs of PI
• Excessive focus/worry concerning sleep
• Sleep occurs better in novel places
• Mental arousal reported as intrusive
thoughts/involuntary ruminations
• Somatic arousal, i.e., feels “wound up”
• Sleep extension strategies used (naps, longer
time in bed in AM)
Sleep Disorders:
Main Types
• Disorders of Initiating or Maintaining Sleep
(DIMS) – (fatigue, sleep unlikely) – circadian
rhythm, sleep phase syndromes, jet lag,
insomnias
• Disorders of Excessive Sleepiness (DOES) –
(sleepiness, sleep likely) – obstructive/central
sleep apnea, narcolepsy, periodic leg move.
• Parasomnias – REM Behavior D/O, Nightmare
D/O, Sleep Terror D/O, Sleep Eating D/O
Parameters of PI
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Severity – greater than 30 minutes
Frequency – 3 days/week
Types – initial, middle, terminal
Chronicity – acute-less than 4 weeks
chronic-more than 4
• Cognitive-Behavioral Treatment of Insomnia
(CBT-I) – focus on chronic insomnia
Problem Significance
• 10 – 15 % - Point prevalence of chronic ins.,
30-35 % of point prevalence of acute insomnia
• Only 6% obtain tx after waiting a year
• USA costs; accidents – 3.7 billion, work place
productivity – 150 billion
• Three mile island meltdown (1979),
Grounding of Exxon Valdez (1989), Air Traffic
Controllers falling asleep (2011)
Drugs – Cause of Sleep Problems-?
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Alcohol/caffeine
Beta blockers
Bronchodilators
Calcium channel blockers
Older antidepressants
Certain antibiotics (? – ampicillin,
aminoglycosides)
Conceptual 3-P Model
• Present to patients – Spielman (1987)
• P1 – Predisposing Factors – genetic (higher
arousal), tendency to worry due to family
modeling, spouse with incompatible sleep
schedule, etc.
• P2 – Precipitating Factors – acute medical
illness, grief reactions, life changes-babies
Model (cont.)
• P3 – Perpetuating Factors – focus of CBT-I,
maladaptive strategies to initiate/maintain
sleep, e.g., watching TV in bed to relax, naps
during day, sleeping later to “catch up”, extra
coffee during day to compensate, extra time in
bed, ETOH use to relax
• Sleep homeostasis concept
CBT-I Treatment Components
• Primary – Stimulus Control Therapy, Sleep
Restriction Therapy, Sleep Hygiene Education
• Secondary – Cognitive Therapy, Phototherapy
(light therapy), Sleep Compression,
Neurofeedback
CBT-I Side Effects/Problems
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Sleepiness during day for 1 to 3 weeks
Safety Issues, e.g., falling, driving
Worsening conditions such as mania, epilepsy
Sleep loss could increase parasomnias
Requires substantial compliance (30 % drop
out)
• Requires some therapist expertise
CBT-I Benefits
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Good short-/long-term efficacy
Not alter sleep architecture (sleep stages)
No abuse potential
Positively effects 50% of patients, perhaps less
in the elderly
• Takes 3 – 8 weeks to work
• Enables self-maintenance after treatment
Stimulus Control Therapy (SCT)
• Limit amount of time in bed when not asleep,
thus classical conditioning of bedroom stimuli to
sleep
• Instructions: a. lie down intending to go to sleep
only when sleepy, b. avoid lengthy behaviors in
bed/bedroom other than sleep/sex, c. leave
bedroom if awake more than 20 minutes, d.
return to bed only when sleepy, d. encourage
patient to assume will be up, e. wake with alarm
Sleep Restriction Therapy (SRT)
• SRT requires limiting amount of time in bed
equal to average sleep time
• Establish fixed wake time and decrease time in
bed, i.e., less sleep but more consolidated
• Adjusted during treatment based on sleep
efficacy index
• Minimum – 4 to 4.5 hours sleep/night
Sleep Diary Data - SRT
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TTB – Time to Bed (also PTTB)
TOB – Time out of Bed (also PTOB)
SL – Sleep Latency, i.e., time to fall asleep
NOA – Number of Times Awakened
WASO – Amount of Time Awake
TST – Total Sleep Time
SE – Sleep Efficacy
Sleep Data Calculations
• TST = TIB – (SL + WASO)
• TIB = Difference between TOB
and TTB
• Sleep Efficacy (SE) = TST/TIB
In Treatment
• Obtain baseline data
• Fix prescribed time out of bed
• Calculate prescribed time to bed based on TST
obtained at baseline (i.e., PTTB)
• Calculate Sleep Efficacy: 90% or more- move
PTTB forward by 15 minutes (e.g., 1 AM to
12:45 AM), 85-89%- no change, 84% or lessmove backwards PTTD by 15 minutes (1 AM to
1:15 AM)
Sleep Hygiene Instructions
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Instructions related to habits and environment
Safe and comfortable environment
Limit stimulating liquids/activities before bed
Get up if not asleep, limit light exposure
Cognitively refocus before bed, develop
pattern, not clock watch or try to “force”
sleep
Additional Therapies
• Cognitive – monitor/change negative thinking
patterns such as catastrophizing, reframing,
cognitive self-talk
• Relaxation – imagery, progressive muscle
relaxation, autogenic, EMG biofeedback
• Phototherapy – bright light tx, usually in AM
for 20 – 30 minutes
Additional Therapies (cont.)
• Neurofeedback – EEG biofeedback
• Sleep Compression – slow Sleep Restriction
Therapy (SRT), divide TST – TIB by 5, change
PTTB over five-week period until Sleep Efficacy
goal of 85-90 % met
Case History
• A 50 y/o divorced WM physical therapist,
Greg, with a 3-yr. h/o chronic sleep onset
insomnia. Physician referral with no clear
physical reasons for insomnia. Childhood
marked by some verbal abuse with sense of
being slightly “hyper” for several decades.
Prior to divorce, he reported periodic sleep
problems, but no chronic problems. His
chronic insomnia started with job change/
Case History (cont.)
• /change in personal relationship. He first
found taking Lunesta, sleeping later, and
drinking a lot of coffee during the day helpful
but not now. Can you help????
• Predisposing Factors:
• Precipitating Factors:
• Perpetuating Factors:
Case – Session 1
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Clinical interview – rule outs, rapport
Sleep Tx – rationale, requirements
Sleep medication/other medical conditions
Explain 3-P model, sleep hemostat
Explain/start sleep diary
Handling objections (e.g., start now)
Give handouts
Case – Session 2
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Review data, confirm CBT-I interest
Review sleep hygiene issues
Start Stimulus Control procedures, Greg asks…
Calculate Prescribed Time To Bed/Time Awake
TST = TIB – (SL, 75 min.+WASO,120 min.)
TIB = 9 hours (540 min.)
Case – Session 2 (cont.)
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TST = 540 min.-195 min. = 345 min. (5.75 hrs.)
SE = TST/TIB = 345/540 = 64% (what range??)
Prescribed Time Out of Bed is 7 AM due/work
PTTB = 7:00 AM - 5.75 hours = 1:15 AM
Reviewing staying up procedures/safety
Case – Session 3
• Review data – titrate PTTB based on SE, GT 90
%, 85-90%, LT 85%
• Greg c/o difficulty staying awake-review
physical activity, cold compresses to neck,
brief bright light exposure, positioning, coffee
• Greg’s SE = 91%, PTTB now 1 AM, praise
• Review sleep hygiene/stimulus control
• Secure treatment commitment
Case – Session 4
• Review data – titrate PTTB , Greg’s SE=85%,
maintain
• Confirms adherence to stimulus control/sleep
hygiene procedures
• Discuss thinking patterns – fears concerning
new relationship, “all/none” thinking
concerning progress
• Review tx/commit to program
Case – Sessions 5, etc.
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Repeat steps
Review data, titrate
Review thinking pattern issues
Confirm adherence/handle problems
Fade sessions 1 X 2 weeks
Maintenance
Helpful Sayings
• Bad thing to be awake when reason sleeps
• If not tonight, then tomorrow night
• Sleep is like a bird in hand- bird will stay if you
do nothing – will leave if you try to grab it
• W.C. Fields – “The best cure for insomnia is to
get a lot of sleep.”
PCP Sleep Screening
• B – Do you have difficulty falling asleep? (Bedtime)
• E – Do you ever fall asleep during the day? (Excessive
Daytime Sleep)
• A – Do you awaken frequently or for long periods?
(Awake)
• R – What time do you go to bed? … get up?
(Regularity)
• S – Have you noticed/anybody said you snore?
(Snoring)
Publications
• Perlis, M.L. et al. Cognitive-behavioral
treatment of insomnia: A session-by-session
guide. New York: Springer.
• Edinger, J.D. et al. (2007). Dose-response
effects of cognitive-behavioral insomnia
therapy. Sleep, 30 (2), 203-212.
• Sivertsen, B. et. Al. (2006). Cognitive
behavioral tx vs. zopiclone for the tx of chronic
primary insomnia. JAMA, 295, 2851-2858.
For Further Contact:
• Address: Joseph K. Neumann, Ph.D.
Roth Neuropsychology and
Behavioral Health Associates
2333 Knob Creek Rd., St. 11
Johnson City, TN 37604
• Phone: 423-952-0500 , Fax: 952-0005
• E-mail:
[email protected]