Behavioral Treatment for Insomnia in Primary Care CHARLES M. MORIN, PH.D.

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1 SleepMedicine ALERT PUBLISHED BY THE NATIONAL SLEEP FOUNDATION Behavioral Treatment for Insomnia in Primary Care CHARLES M. MORIN, PH.D. Professor, Department of Psychology and Director, Sleep Disorders Center Université Laval, Québec, Canada INTRODUCTION Insomnia Series VOLUME 9.4, 2004 Insomnia is among the most common health complaints brought to the attention of primary care physicians. While population-based estimates indicate that 10% of adults reports persistent insomnia, this rate increases to 20% for patients seen in primary care medicine. Insomnia can produce an important burden for the individual and for society, as evidenced by reduced quality of life, increased absenteeism and reduced productivity at work, and higher health-care costs. Persistent insomnia is also associated with increased risks of depression and, among older adults with cognitive impairments, it may hasten placement in nursing home facilities. Treatment options for insomnia include pharmacotherapy, behavioral and psychological interventions, and a variety of complementary and alternative therapies. Although medication is the most readily available and most frequently used therapy in primary care, psychological and behavioral interventions are important insomnia management tools. Also, as no single treatment is effective for all forms of insomnia or an acceptable option to all patients, it is important to consider all treatment options. This paper describes behavioral therapies for insomnia and addresses practical issues related to their implementation in primary care medicine. DIAGNOSIS OF INSOMNIA AS A HETEROGENEOUS CONDITION Insomnia is a heterogeneous condition involving inadequate sleep quality or duration. It may involve difficulty falling asleep at bedtime (initial insomnia), waking up in the middle of the night and having difficulty going back to sleep (middle insomnia), and/or waking up too early in the morning and being unable to return to sleep (late insomnia). It may also involve a subjective complaint of non-restorative sleep. In addition, daytime fatigue and decreased energy, problems with cognitive functions (attention, memory), and mood disturbances (dysphoria) are extremely frequent and often the main concerns prompting patients to seek treatment. Insomnia may be a situational problem resulting from stressful life events or changes in sleep schedules and environment, or it may be a symptom of a medical, psychiatric, or even another sleep disorder (restless legs syndrome). It may also be a disorder in itself, as in primary insomnia, which is the result of psychophysiological and conditioning factors. The diagnosis of insomnia is based on a clinical sleep history, including the nature of the sleep complaint, its onset, duration, and course; the patient s sleep-wake schedule; medical and psychiatric contributing factors;

2 Name: Week: to SLEEP DIARY 1. Yesterday, I napped from to 1:50 to (Note the times of all naps) 2:30 pm 2. Yesterday, I took mg of medication Ambien and/or oz. of alcohol as sleep aid 5 mg 3. Last night, I went to bed and turned the lights off at o clock 11:15 4. After turning the lights off, I fell asleep in minutes 40 min. 5. My sleep was interrupted times (Specify number of nighttime awakenings) 6. My sleep was interrupted for minutes (Specify duration of each awakening) 7. This morning, I woke up at o clock (Note time of last awakening) 8. This morning, I got out of bed at o clock (Specify the time) 9. When I got up this morning, I felt (1=Exhausted 5=Refreshed) 10. Overall, my sleep last night was Figure 1. Sleep Diary (1=Very Restless 5=Very Sound) EXAMPLE MON TUE WED THU FRI SAT SUN 3 10, 5, 45 6:15 6: pre-bedtime routines, alleviating and exacerbating factors, etc. A sleep laboratory evaluation (polysomnography) is usually not indicated, unless there is evidence of excessive daytime sleepiness or of symptoms of other disorders such as sleep apnea or periodic limb movements. The sleep diary is a very useful tool to complement the initial evaluation in establishing baseline and also to monitor treatment progress (see Figure 1). A typical diary includes entries for monitoring bedtime, arising time, and estimates of time to fall asleep, number and duration of awakenings, sleep time, and sleep quality. The patient is instructed to complete this diary on a daily basis, typically upon arising in the morning, for baseline evaluation and throughout treatment. It is important to emphasize the need to complete the diary on a daily basis, rather than rely on the absolute accuracy of the sleep-wake estimates. A CONCEPTUAL MODEL OF INSOMNIA It is helpful to distinguish between three types of contributing factors to insomnia which take on a different role at different times during the course of insomnia. Predisposing factors are those factors that make an individual at greater risk for insomnia. These include age, gender (female), hyperarousability, family/personal history of insomnia, medical, and psychiatric illnesses. Precipitating factors that are commonly associated with the onset of insomnia include major stressors (e.g., separation, hospitalization, death of a loved one), less severe but more chronic daily hassles (e.g., occupational stress, family conflicts), or other life events (e.g., birth of a child, menopause). While most individuals resume normal sleep after the initial triggering event has faded away, people who are initially more vulnerable to insomnia may continue to experience sleep difficulties. For these individuals, insomnia develops a life of its own fed by several perpetuating factors. A vicious cycle often develops in which poor sleep habits, irregular sleep scheduling, and the fear of not sleeping feed into the insomnia problem (see Figure 2). A person may spend excessive amounts of time in bed or nap during the day in a misguided effort to compensate for poor nocturnal sleep. Apprehensions about not sleeping and excessive worrying about the possible consequences of insomnia will further interfere with sleep. Although some of these strategies may be adaptive to cope with insomnia initially, they become part of the problem in the long run. To short-circuit this pattern, treatment must focus on poor sleep habits and faulty beliefs and attitudes about sleep. Hypnotic medication is useful for breaking the cycle of insomnia initially, but behavioral therapies are essential for many patients to alter the conditions that perpetuate it. Sleep Medicine Alert is a publication of the National Sleep Foundation. Comments, suggestions and letters to the editor are welcome. Please write to: National Sleep Foundation 1522 K Street, NW, Suite 500, Washington, DC Editor: James K.Walsh, PhD St. John s/st. Luke s Hospitals and St. Louis University Managing Editor: Pat Britz, M.Ed., M.P.M National Sleep Foundation Sleep Medicine Alert 2 VOLUME 9.4, 2004

3 A MICROANALYSIS OF CHRONIC INSOMNIA Arousal Emotional Cognitive Physiologic Dysfunctional Cognitions Worry Over Sleep Loss Rumination Over Consequences Unrealistic Expectations Misattributions/Amplifications INSOMNIA Consequences Mood Disturbances Fatigue Performance Impairments Social Discomfort Maladaptive Habits Excessive Time in Bed Irregular Sleep Schedule Daytime Napping Sleep Incompatible Activities Morin, CM. Insomnia: Psychological Assessment and Management, New York: Guilford Press, Figure 2. Conceptual Model of Insomnia BEHAVIORAL TREATMENTS: GOALS AND DESCRIPTION Behavioral and psychological approaches include sleep restriction, stimulus control, relaxation, cognitive strategies, and sleep hygiene education. Their main objectives are to target those factors that perpetuate or exacerbate sleep disturbances; and teach patients self-management skills to improve their sleep and to cope more adaptively with residual sleep disturbances that may persist even after therapy. Sleep restriction. Sleep restriction consists of curtailing the amount of time spent in bed to the actual amount of time asleep. This window of time in bed is subsequently adjusted based on sleep efficiency (SE; ratio of total sleep/time in bed X 100%) for a given period of time (usually the preceding week). For example, if a person reports sleeping an average of 6 hours per night out of 8 hours spent in bed, the initial prescribed sleep window (i.e., from initial bedtime to final arising time) would be 6 hours. The subsequent allowable time in bed is increased by about minutes for a given week when SE exceeds 85%, decreased by the same amount of time when SE is lower than 80%, and kept stable when SE falls between 80% and 85%. Adjustments are made periodically (weekly) until optimal sleep duration is achieved. Changes to the prescribed sleep window can be made at the beginning of the night (i.e., postponing bedtime), at the end of the sleep period (i.e., advancing rising time), or at both ends. This clinical procedure improves sleep continuity through a mild sleep deprivation and a reduction of sleep anticipatory anxiety. To prevent excessive daytime sleepiness, time in bed should not be reduced to less than 5 hours per night, regardless of sleep efficiency. Because some daytime drowsiness is expected in the first week or two of treatment, allowances must be made for those whose jobs require operation of motor vehicles or heavy machinery, or other duties in which drowsiness may be a danger to the patient or to others. Stimulus control. Stimulus control therapy consists of a set of behavioral instructions designed to reassociate temporal (bedtime) and environmental (bed and bedroom) stimuli with sleep and to establish a regular sleep-wake rhythm. These instructions involve going to bed only when sleepy, getting out of bed when unable to sleep, curtailing all sleep-incompatible activities, arising at a regular time every morning, and avoiding daytime napping (see Table 1). Repeated and unsuccessful sleep attempts eventually lead to a negative association between the pre-sleep rituals and the bedroom environment. With this conditioning process, the patient comes to associate the usual pre-sleep rituals with apprehension and arousal rather than with relaxation and sleep. In addition, many insomniacs display poor sleep habits that initially may emerge as a means of coping with sleep disturbances. For example, poor sleep at night may lead to daytime napping or sleeping late on weekends in efforts to catch-up on lost sleep. Although stimulus control prescriptions may appear quite simple on paper, the challenge is to foster strict compliance with all of the instructions for a few weeks. Also, there may be no need to follow some of those instructions (e.g., getting out of bed when unable to sleep) during the initial compression of time spent in bed; however, as time in bed is gradu- Table 1 BEHAVIORAL AND SLEEP SCHEDULING INSTRUCTIONS Restrict the amount of time spent in bed as close as possible to the actual sleep time Go to bed only when sleepy, not just fatigued, but sleepy If unable to sleep (e.g., within 20 min), get out of bed and go to another room and return to bed only when sleep is imminent Use the bed and bedroom for sleep (and sex) only; no eating, TV watching, radio listening, planning or problem solving in bed Maintain a regular sleep schedule, particularly a strict arising time every morning regardless of the amount of sleep the night before Avoid daytime napping Sleep Medicine Alert 3 VOLUME 9.4, 2004

4 ally increased, these procedures become more relevant and must be implemented systematically. Relaxation techniques. When stress and anxiety are contributing to sleep disturbances, relaxation can be a useful addition to other behavioral procedures. Some relaxation techniques (e.g., progressive-muscle relaxation, autogenic training) seek to reduce somatic arousal, whereas other attention-focusing procedures (e.g., imagery training, meditation) target mental arousal in the forms of worries and intrusive thoughts. While most relaxation procedures are equally effective for treating insomnia, they are not necessarily indicated for all individuals with insomnia. Some people may have a paradoxical response and become more anxious when trying to relax. The most critical issue is to ensure diligent and daily practice of the selected method for at least two to four weeks, and keep the focus on reducing arousal rather than on inducing sleep. Professional guidance is often necessary in the initial phase of training. Another helpful technique to reduce mental activity at bedtime is to set aside a time and a place (other than bedtime and the bedroom) to write down thoughts or worries of the day and plans for the next day (see Table 2). A more comprehensive stress management program may be necessary for patients under acute or severe occupational or family-related stress. identifying the dysfunctional thought patterns, the clinician offers alternative interpretation and then the patient can begin to think about his or her insomnia in a different way. Specific targets for intervention may include unrealistic expectations ( I must get my 8 hours of sleep every night ) and amplification of the consequences of insomnia ( Insomnia may have serious consequences on my health ). Given that patients often perceive themselves as victims of insomnia and as having few resources to cope with sleep difficulties and their daytime consequences, cognitive therapy is useful to teach them coping skills to prevent or minimize recurrence of sleep disturbances. A more didactic approach can be used to provide basic information about normal sleep, individual differences in sleep needs, and changes in sleep physiology over the course of the life span. This information is useful to help some patients distinguish clinical insomnia from short-sleep or from normal (age-related) sleep disturbances. Although formal cognitive therapy requires more time and training than other behavioral procedures, there are simple messages to communicate to patients about sleep expectations and perceptions of the causes and consequences of insomnia (see Table 3). COGNITIVE RESTRUCTURING THERAPY STRESS AND ANXIETY-REDUCTION METHODS Allow at least one hour to unwind before bedtime Set aside a time/place to write down worries and plans for the next day Never try to sleep as it will produce performance anxiety Cover the alarm clock and avoid clock watching Practice relaxation Table 2 Cognitive therapy. Insomnia is often exacerbated by excessive preoccupation with sleep and apprehensions of the next day consequences, which can heighten arousal and interfere with sleep. For example, when a person is unable to sleep at night and begins thinking about the possible consequences of sleep loss on the next day s performance, this can set off a spiral reaction and feed into the vicious cycle of insomnia, emotional distress, and more sleep disturbances. Cognitive therapy is designed to short-circuit the self-fulfilling nature of this vicious cycle. After Themes Keep realistic expectations Do not blame insomnia for all daytime impairments Do not catastrophize after a poor night s sleep Do not give too much importance to sleep Develop some tolerance to the effects of insomnia Table 3 Even good sleepers do not always get 8 hours of quality sleep; also, there are individual differences in sleep needs Consider alternative explanations that might contribute to those impairments Insomnia can be unpleasant, but it is not dangerous; the worst that can happen is that you will be more sleepy the next day, and sleep more soundly the next night Even if sleep occupies about one third of your life, do not make it the sole focus of your existence Rearrange your schedule but do not cancel planned activities Sleep Medicine Alert 4 VOLUME 9.4, 2004

5 Sleep hygiene education. Sleep hygiene education is intended to provide information about lifestyle (diet, exercise, substance use) and environmental factors (light, noise, temperature) that may either interfere with or promote better sleep (see Table 4). Although inadequate sleep hygiene is rarely the primary cause of insomnia, it may potentiate sleep difficulties caused by other factors or interfere with treatment progress. In addition, even if patients with insomnia are often well informed about the detrimental impact of poor sleep hygiene, they do not necessarily maintain good sleep hygiene practices. Hence, there is a need to directly address these factors in therapy. Table 4 SLEEP HYGIENE GUIDELINES Avoid all stimulants (e.g., caffeine, nicotine) several hours before bedtime Do not drink alcohol around bedtime as it fragments sleep Exercise regularly (especially in late-afternoon or early evening) Finish eating at least 2-3 hours before your regular bedtime. Keep the bedroom environment quiet, dark, and comfortable. Sleep on a comfortable mattress and pillows INDICATIONS, BENEFITS, AND LIMITATIONS OF BEHAVIORAL TREATMENTS The efficacy of behavioral approaches is well documented for persistent primary insomnia. Between 70% and 80% of patients benefit from treatment. Although only about one third achieve full remission (i.e., resume normal sleep ), most patients reduce their symptoms by at least 50%, with a corresponding increase of about minutes in total sleep time. Such improvements are associated with greater sleep satisfaction and enhanced perception of control over sleep and, most importantly, they are well sustained over time. When insomnia is associated with a co-morbid medical or psychiatric condition, initial intervention should focus on those underlying conditions. However, successful treatment of those conditions does not always alleviate sleep disturbances. Thus, behavioral approaches may still be used as an augmentation therapy for patients treated for several medical (e.g. arthritis, cancer) and psychiatric conditions (e.g., depression, anxiety). Behavioral treatment can also be helpful to facilitate discontinuation of hypnotic medications if the patient desires. While there are no contraindications for using behavioral treatments for insomnia, some caution is warranted when using sleep restriction with patients presenting symptoms of excessive daytime sleepiness, patients with bipolar disorders, and those operating motor vehicles or heavy machinery in which drowsiness might compromise safety of patients or of others. Behavioral and drug therapies can be combined to take advantage of the more immediate relief with medication and the more sustained benefits with behavioral therapy. In view of the mediating role of psychological factors in chronic insomnia, behavioral and attitudinal changes appear essential to sustain improvements in sleep patterns. Ongoing research is currently examining the short-and long-term effects of combined therapies and mechanisms of changes mediating short- and long-term outcomes. IMPLEMENTATION ISSUES The success of behavioral and psychological approaches depends largely on the patient s motivation and willingness to carry out the recommended procedures. Although behavioral treatment is generally well accepted by patients, it is more time consuming and requires more efforts than drug therapy, both for clinicians and patients. Although direct consultation time in clinical trials averages 5 hours per patient, which is usually spread over 6-8 weekly consultations visits, most behavioral methods can be abbreviated to meet the reality of primary care medicine. Consultation time and number of follow up visits are likely to vary as a function of several factors (insomnia severity, comorbidity, patient s motivation and education). Milder forms of insomnia may require less time, but it would be unrealistic to expect to treat every patient with insomnia in a single session. To optimize outcome, it is necessary to schedule follow up visits after the initial evaluation to monitor progress, address compliance issues, and provide guidance and support to patients facing difficulties with the treatment regimen. The use of self-help materials (printed, audio/video) and nurse clinicians can facilitate treatment implementation. Sometimes, it is necessary to refer to a sleep medicine specialist or to a behavioral psychologist who deals with sleep disorders for more closely monitored treatment. Sleep Medicine Alert 5 VOLUME 9.4, 2004

6 National Sleep Foundation 1522 K Street, NW Suite 500 Washington, DC FOUNDATION OFFICERS AND BOARD OF DIRECTORS Officers James K. Walsh, PhD, Chairman Martha U. Gillette, PhD, Vice Chairman Meir H. Kryger, MD, Vice Chairman Christopher A. Hart, Esq., Secretary Jeffrey C. Potts, Treasurer Directors Gregory Belenky, MD William C. Dement, MD, PhD John C. Dowd, SC Ian R. Ferrier, MD, PhD Orville John Hoag, Jr. Ronald L. Krall, MD Emmanuel Mignot, MD, PhD Jodi A. Mindell, PhD Robert Y. Moore, MD, PhD William C. Orr, PhD John S. Palmer Francisco Perez-Guerra, MD Barbara A. Phillips, MD, MSPH David M. Raynal Mark R. Rosekind, PhD Dermott F.X. Ryan Frank J. Steinberg, DO Fred W. Turek, PhD Phyllis C. Zee, MD, PhD Richard L. Gelula, MSW, Chief Executive Officer Honorary Directors David A. Hamburg, MD Honorable Mark O. Hatfield Honorable Michael M. Honda Honorable Zoe Lofgren Carol C. Westbrook Philip R. Westbrook, MD CONCLUSION Insomnia is a prevalent health condition associated with significant morbidity. The primary care physician plays an important role in recognizing and treating this condition. Behavioral approaches can be used, alone or in combination with hypnotic medication, to treat successfully the large majority of patients with insomnia seen in the context of primary care medicine. SMA SUGGESTED READINGS/REFERENCES 1. Edinger JD, Wohlgemuth WK, Radtke RA, Marsh GR, Quillian E. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. JAMA. 2001;285: Espie CA, Inglis SJ, Tessier S, Harvey L. The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in general medical practice. Behav Res Ther. 2001;39: Morin CM, Espie CA Insomnia: A clinical guide to assessment and treatment. New York: Kluwer Academics/Plenum Publishers, Morin C M, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life insomnia : A placebo-controlled randomized clinical trial. JAMA 1999; 281: Morin CM, Hauri PJ, Espie CA, Spielman AJ, Buysse DJ, Bootzin, RR. Nonpharmacologic treatment of chronic insomnia. Sleep 1999; 22: Perlis M, Lichstein KL. Treating Sleep Disorders: Principles and Practice of Behavioral Sleep Medicine. New York, Wiley, Simon G, VonKorff M. Prevalence, burden, and treatment of insomnia in primary care. Am J Psychiatry. 1997;154: Spielman AJ, Glovinsky PB. The varied nature of insomnia. In: Hauri P, editor. Case Studies in Insomnia. New York (NY): Plenum Press; 1991:1-15. For more information, visit the National Sleepoundation Web site: Sleep Medicine Alert 6 VOLUME 9.4, 2004

7 Sleep Restriction Schedule (SAMPLE) BASED ON PATIENT SLEEP DIARY CLINICIAN S RECOMMENDATION Week Time spent Time spent Sleep Recommended Bedtime Arising time in bed (hrs) asleep (hrs) Efficiency (%) sleep window (hrs) for following week 1 (baseline) 8:00 6:00 75% 10:30 6:30 6:00 12:00 6:00 2 6:00 5:45 96% 6:15 11:45 6:00 3 6:15 6:00 96% 6:30 11:45 6:15 4 7:00 6:30 93% 6:45 11:30 6:15 5 7:45 6:15 81% 6:30 11:30 6:00 6 6:30 6:15 96% 6:45 11:15 6:00 7 7:00 6:30 93% 7:00 11:00 6:00 8 7:30 7:00 93% 7:15 10:45 6:00

Cognitive-Behavioral Therapy for Insomnia

Cognitive-Behavioral Therapy for Insomnia Wisconsin Department of Health Services Wisconsin Public Psychiatry Network Teleconference (WPPNT) This teleconference is brought to you by the Wisconsin Department of Health Services (DHS) Bureau of Prevention,