Beyond Sleep Hygiene: Behavioral Approaches to Insomnia

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1 Beyond Sleep Hygiene: Behavioral Approaches to Insomnia Rocky Garrison, PhD, CBSM Damon Michael Williams, RN, PMHNP-BC In House Counseling Laughing Heart LLC SE Main St. 12 SE 14 th Ave. Suite 10 Suite Insomnia is highly prevalent as an independent disorder and as a co-occurring disorder, and there is strong empirical support for cognitive-behavioral treatments for these difficulties initiating sleep, sustaining sleep, and/or nonrestorative sleep. One component of CBT-I is prescribing a sleep schedule based on the biology of sleep and designed to improve sleep efficiency. Sleep compression is a sleep scheduling strategy that is generally presented to the patient as a behavioral experiment, trying out several different sleep schedules and evaluating quality of sleep associated with each schedule. Objectives 1. Able to explain the two process model of sleep 2. Able to conceptualize patient insomnia in a bio-behavioral model 3. Able to formulate a sleep compression schedule based on patient data 4. Able to engage the patient in a behavioral experiment regarding their insomnia 5. Able to evaluate the effectiveness of the sleep scheduling intervention What Is Sleep? Brain Activity Stages Functions 2 Process Model

2 What is Insomnia? (3 months = chronic) Difficulty Falling Asleep and/or Difficulty Staying Asleep and/or Early Awakenings and/or Nonrestorative Sleep Adequate Opportunity and Circumstance Daytime Impairments Daytime Impairments (X3 / week) Fatigue/malaise Attention, concentration, or memory impairment Impaired social, family, occupational, or academic performance Mood disturbance/irritability Daytime sleepiness Hyperactivity, impulsivity, aggression Reduced motivation and initiative Proneness for errors or accidents Concerns about or dissatisfaction with sleep Prevalence and Course Chronic = 10%; transient = 30% to 35% More common o Women o Medical/psychiatric/substance abuse disorders o Lower SES o Older adults Onset: insidious or acute Course: situational, recurrent, or persistent Complaint may vary over time What is Not Insomnia? Sleep Disordered Breathing Restless Legs Syndrome Periodic Limb Movements of Sleep Circadian Rhythm Sleep Disorders Hypersomnia Healthy Sleep Habits Exercise Comfortable Sleep Environment Use Bed for Sleep Treat Medical Problems Moderation Decrease Worry

3 Perpetuating Factors Extending Sleep Opportunity Go to bed early: Deprimes sleep homeostat leading to insomnia and shallow sleep and possible circadian disregulation sleep in (wake up later): Deprimes sleep homeostat. Possible circadian disregulation Napping: Deprimes sleep homeostat Counter Fatigue Measures Increased use or inappropriately timed use of stimulants: Sleep-interfering arousal Avoid or decrease physical activity: May deprime "sleep homeostat. Can lead to conditioned arousal if increased time is spent in bed or bedroom Rituals and Strategies Increase in non-sleep behaviors to kill time : Promotes a lack of stimulus control Sleep somewhere other than the bedroom: Promotes a lack of stimulus control Engage in "rituals which are thought to promote sleep ( herbs, teas, etc.) > Promotes a dependence on the behaviors. Anticipatory anxiety when not available. Avoidance of behaviors thought to inhibit sleep: Promotes anticipatory anxiety when behaviors occur (e.g., sex, going outdoors near bedtime, etc.) Self-Medication Strategies alcohol hs: REM suppression and rebound sleep fragmentation; Early morning awakenings; Decreased sleep-related self-efficacy Marijuana use: Effects on sleep are poorly understood; Discontinuation may exacerbate insomnia; Decreased sleep related self-efficacy OTC sedatives (antihistamines): Increased dependence on medication to sleep; Decreased sleep related selfefficacy; Morning hangover Melatonin as a hypnotic: Circadian phase shifts: may promote insomnia; Increased dependence on substance to sleep; Decreased sleep related self-efficacy; May have a within or across night withdrawal; Lack of FDA regulation Two Factor Model Factor C: Circadian Clock Factor S: Sleep Drive Setting the Circadian Clock (Zeitgebers) First Light

4 Temperature Exercise Eating & Drinking Sleep Efficiency Total Sleep Time Sleep Opportunity Percentage of time in bed that is sleep Goal is 85% or better Sleep Efficiency Research 29 couples tracked nightly SE, positive, and negative partner interactions For men, higher sleep efficiency predicted less negative partner interaction the following day. For women, less negative partner interaction during the day predicted higher sleep efficiency the following night. If women reported more positive and less negative interaction during the day this also predicted higher sleep efficiency for their male partners that night. Designing the Sleep Experiment Have patient estimate Total Sleep Time / night Use Sleep Efficiency Table to determine target Time in Bed Consistent First Exposure to Light Create weekly sleep schedule which decreases TIB by 30 min / week Outcome Measures Sleep Diary Inquiry (Carney, et al., 2012) o Arise Time o Sleep Efficiency o Unusual Nights

5 PROMIS Insomnia Questionnaire (lower = improved) Restorative Sleep Questionnaire (higher = improved)

6

7 Sleep Diary Instructions What is a sleep diary? A sleep diary is designed to gather information about your daily sleep pattern. How often and when do I fill out the sleep diary? It is necessary for you to complete your sleep diary every day. If possible, the sleep diary should be completed within one hour of getting out of bed. What should I do if I miss a day? If you forget to fill in the diary or are unable to finish it, leave the diary blank for that day. What if something unusual affects my sleep or how I feel in the daytime? If your sleep or daytime functioning is affected by some unusual event (such as illness, or an emergency) you may make brief notes on your diary. What do the words bed and day mean in the diary? This diary can be used for people who are awake or asleep at unusual times. In the sleep diary, the word day is the time when you choose or are required to be awake. The term bed means the place where you usually sleep. Will answering these questions about my sleep keep me awake? This is not usually a problem. You should not worry about giving exact times, and you should not watch the clock. Just give your best estimate. Item Instructions Use the guide below to clarify what is being asked for each item in the sleep diary. Date: Write the date of the morning you are filling out the diary. 1. What time did you get into bed? Write the time that you got into bed. This may not be the time that you began trying to fall asleep. 2. What time did you try to go to sleep? Record the time that you began trying to fall asleep. 3. How long did it take you to fall asleep? Beginning at the time you wrote in question 2, how long did it take you to fall asleep? 4. How many times did you wake up, not counting your final awakening? How many times did you wake up between the time you first fell asleep and your final awakening? 5. In total, how long did these awakenings last? What was the total tine you were awake between the time you first fell asleep and your final awakening? For example, if you woke 3 times for 20 minutes, 35 minutes and 15 minutes, add them all up ( = 70 min or 1 hr 10 min). 6. What time was your final awakening? Record the last time you woke up in the morning. 7. What time did you get out of bed for the day? What time did you get out of bed with no further attempt at sleeping? This may be different from your final awakening time (e.g. You may have woken up at 6:35 AM but did not get out of bed to start your day until 7:20 AM. 8. How would you rate the quality of your sleep? Sleep Quality is your sense of whether your sleep was good or poor. 9. Comments. If you have anything that you would like to say that is relevant to your sleep feel free to write it here.

8 PROMIS SRI Short Form (Patient Reported Outcomes Measurement Information System [PROMIS] Sleep Disturbance Questionnaire) During the past 7 days Not At All A Little Bit Somewhat Quite a Bit Very Much 1. I had a hard time concentrating because of poor sleep I had problems during the day because of poor sleep I had a hard time getting things done because of poor sleep I felt irritable because of poor sleep I felt tired I was sleepy during the daytime I had trouble staying awake during the day I felt alert when I woke up Percentiles 21 = 52% 22 = 56% 23 = 63% 24 = 68% 25 = 71% 26 = 72% 27 = 76% 28 = 81% 29 = 83% 30 = 85% 31 = 87% 32 = 89% 33 = 92% 34 = 93% 35 = 95% 36 = 96% 37 = 97% 38 = 98% 39 = 99% 40 = 99%

9 Restorative Sleep Questionnaire (J Clin Sleep Med 2014; 10(7): ) In the past 7 days to what extent did you feel Not at All A Little Bit Some Very Much 1. tired? sleepy? in a good mood? rested? refreshed or restored? ready to start the day? energetic? mentally alert? grouchy Often (Average score across completed items 1) * 25 = total score normal sleepers mean 87.9 SD 2.3 poor sleepers mean SD 2.55

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