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1 A Little CBT I With My Tea Please: Cognitive Behavioural Therapy for insomnia (CBT I) and Its Use In the Treatment of Sleeplessness W. Jerome Alonso, MD Medical Director, Canadian Sleep Consultants Clinical Associate Professor, Faculty of Medicine, University of Calgary March 2, 2018 Faculty/Presenter Disclosure Faculty/Presenter: Dr. Jerome Alonso Relationships with commercial interests: Grants/Research Support: Not Applicable Speakers Bureau/Honoraria: Not Applicable Consulting Fees: Not applicable Other: This presentation has received support from the Alberta College of Family Physicians in the form of a speaker fee and/or expenses. 1

2 ACFP 63 rd ASA Disclosure of Commercial Support This program has received financial support in the form of sponsorship from: Potential for conflict(s) of interest: Those speakers/faculty who have made COI disclosure are noted in the 63rd ASA Program and on the Salon A/B slide scroll. Mitigating Potential Bias ACFP: The ACFP s Sponsorship Guidelines apply to ASA Sponsorship. The ACFP abides by the College of Family Physicians of Canada s Understanding Mainpro+ Certification Guidelines, the Canadian Medical Association s Policy Guidelines for Physicians in Interactions With Industry and the Innovative Medicines Canada Code of Ethical Practices (2016). As a non profit organization, the ACFP complies with Canada Revenue Agency regulations. When deliberating acceptance of sponsorship, the ACFP considers and accepts sponsorship only from those whose products, services, policies, and values align with the ACFP vision, values, goals, and strategies priorities. ASA Planning Committee: Consideration was given by the 63 rd ASA Planning Committee to identify when Planning Committee members and speakers personal or professional interests may compete with or have actual, potential, or apparent influence over program content. Material/Learning Objectives and/or session description were developed and reviewed by a Planning Committee composed of experts/family physicians responsible for overseeing the program s needs assessment and subsequent content development to ensure accuracy and fair balance. The 63 rd ASA Planning Committee reviewed Sponsorship Agreements to identify any actual, potential or apparent influence over the program. Information/recommendations in the program are evidence and/or guidelines based, and opinions of the independent speakers will be identified as such. 2

3 Learning Objectives To determine the role of cognitive behavioural therapy for insomnia (CBT I) in light of current evidence, guidelines and practice in Alberta. To understand the basic components of CBT I and their use in primary care and specialty settings. To be able understand the use of CBT I to assist in medication taper protocols for insomnia. Role of Cognitive Behavioural Therapy Used primarily for psychophysiologic insomnia or adjustment insomnias May allow improvement in the context of other sleep disorders, but may not allow for complete resolution of symptomatology May be used either alone or in conjunction with currently prescribed sedative hypnotics. 3

4 Role of Cognitive Behavioural Therapy Psychological and behavioral interventions are effective and recommended in the treatment of chronic primary and comorbid (secondary) insomnia. (Standard) AASM (2008) Although all patients with chronic insomnia should adhere to rules of good sleep hygiene, there is insufficient evidence to indicate that sleep hygiene alone is effective in the treatment of chronic insomnia. It should be used in combination with other therapies. (Consensus) AASM (2008) Role of Cognitive Behavioural Therapy Combined therapy shows no consistent advantage or disadvantage over CBT I alone. AASM (2008) Manage chronic insomnia with CBT I (TOP 2015) If no CBT I programs are available, use CBT I strategies (TOP 2015) Emphasize synergistic effect for those on sedative/hypnotic medications (TOP 2015) 4

5 Mechanisms of Insomnia and their Presentations Sx of insomnia = up to 48 %; DSM=4 6% (Ohayon 2002) Hyperarousal > initiation & maintenance Circadian misalignment > initiation insomnia Condition of repetitive arousal > maintenance insomnia or early awakening Change in sleep architecture > maintenance insomnia or early awakening Behavioural fragmentation > initiation and maintenance Initiation Insomnia Lichstein, KL (2004) = 22.8% Adjustment/Psychophysiologic/Insomnia secondary to mental disorder 7.6% with primary insomnia; 8.1% depression; 8.7% anxiety (Ohayon 1998) Circadian rhythm disorder, delayed type % of px seen in a sleep clinic Inadequate sleep hygiene 5

6 Pschophysiologic insomnia Thought Rumination Conditioned Activation Agitation related to sleep Clock watching Fatigue versus Sleepiness Psychophysiologic insomnia typically will not typically have sleepiness when in the pure form Sleepiness is more likely with sleep deprivation states (DSPS), poor sleep quality issue (OSA) or subjective sleepiness in mood disorders. EDS is an indication for sleep testing if not behavioural consider objective testing Be careful about giving a sedatives to a patient with EDS 6

7 Cognitive behavioral therapy for insomnia Stimulus control Sleep consolidations / Sleep restrictions Relaxation based Interventions Cognitive Therapy Mindfulness based interventions Sleep Hygiene 7

8 Hyperarousal From Psychophysiologic insomnia Adapted from: Borbély A.A., A Two Process Model of Sleep Regulation, Human Neurobiol (1982) 1: Stimulus control Wait for sleepiness not fatigue 8

9 Hyperarousal From Psychophysiologic insomnia Adapted from: Borbély A.A., A Two Process Model of Sleep Regulation, Human Neurobiol (1982) 1: Stimulus control Wait for sleepiness not fatigue Become mindful of the sensation of sleepiness prior to getting into bed If you cannot fall asleep in minutes, there is no need to practice being awake. Get up and out of bed. Return to bed once your sleepy. 9

10 Sleep consolidations / Sleep restrictions Use of the homeostatic drive or Wake drive Consolidating fragments of sleep accumulated during the day Limiting time in bed to perceived sleep with an additional 30 minutes. Do not limit to less than 5 ½ hours. Add minutes to time in bed every 7 days if sleep efficiency is 80 85% Cognitive restructuring Sleep is not about amount, it is about quality Why stay in bed if your awake anyways? There is no need to train to be a better insomniac You are an experienced insomniac, so you know how you ll feel the next day I am not removing sleep, I am removing wake 10

11 Sleep hygiene Avoid stimulants (e.g., caffeine, nicotine) for several hours before bedtime. Avoid alcohol around bedtime because it fragments sleep. Exercise regularly (especially in late afternoon or early evening). Allow at least a 1 hour period to unwind before bedtime. Keep the bedroom environment quiet, dark, and comfortable. Maintain a regular sleep schedule. Remove electronic devices from the bedroom. Relaxation and Meditation Progressive relaxation Guided imagery Mindfulness Meditation 11

12 Case Discussion 59 yo female with initiation and maintenance insomnia Started with menopause with awakenings because of hot flashes. Now has troubles falling asleep because of thought rumination and anxiety about ability to perform at work. In bed at 9:00pm, falling asleep after 2 hours. Wakes up 4 6 time frequently lying awake Out of bed at 7AM. Sleeps only 4 5 hours Same schedule on weekends Epworth 14/24 12

13 Initiation insomnia Hyperarousal? Yes Anxiety or psychophysiogic Circadian rhythm component? Sleep hygiene issue? Yes Worrier; anxiety without affectation None Maintenance insomnia Mood issue? Denies depression or anhedonia Other cause of awakenings? Maybe Sleep hygiene? Yes Sleepiness Yes Deprivation or sleep disorder? Sleep Disorder history of snoring Preliminary Dx & Tx Psychophysiologic insomnia CBTI and/or medications Inadequate sleep hygiene Eradicate napping and start sleep consolidation Obstructive sleep apnea suspect Either ambulatory sleep study after CBT or in lab sleep study 13

14 CBT I Prescription? Stimulus control Sleep consolidation How long? 5 ½ hours Cognitive restructuring Mediation and Relaxation techniques Hand out for Sleep Hygiene Fast forward.. Sleep efficiency up to 80%, but fragmented. OSA diagnosed and treated with CPAP and CBT I to associated sleepiness with CPAP interface Bedtime: 12 am Latency: 20 minutes Sleeping through with OSA treated. Out of bed: 7 am (Daytime functioning good) On zopiclone 7.5 mg qhs at bedtime. Wants off meds. 14

15 Medication taper protocol Do not initiate till they are falling asleep, staying asleep and having restorative sleep. Re enforce stimulus control techniques Taper medications by ¼ dosage per week Do not allow re escalations. Push back bedtime by 30 minutes and repeat as necessary to improve latency if needed. Either regain lost sleep or cut dosage once with normal latency. 15