Introduction v Insomnia is very prevalent in acute (30-50%) and chronic forms (10-15%). v Insomnia is often ignored as a symptom of other disorders. v Insomnia is a risk factor for psychiatric and medical morbidity. v CBT for insomnia has moderate to large effect sizes which are equivalent to medical interventions for insomnia. 1
Definition of Insomnia v World Health Organization - problem initiating/maintaining sleep or non-refreshing sleep that occurs three nights/week and is associated with daytime distress or impairment. v DSM-IV calls it primary insomnia if the difficulty sleeping is not associated with any medical or psychiatric disorders. v ICSD calls it psychopysiological insomnia - a disorder of somatized tension and learned sleep preventing associations that result in insomnia and decreased functioning during the day. 2
Duration of Illness v Acute - less than one month - usually associated with clearly defined precipitants (stress, pain, substance abuse). v Chronic - symptoms persist for > one month, more typically > six months. v Transition from acute to chronic occurs when patient stops causally linking original precipitant to insomnia 3
Severity of Illness v Intensity - greater than 30 minutes to fall asleep or wakefulness during the night is usually considered the threshold between normal and abnormal sleep. v Total sleep time of less than 6 to 6.5 hours. TST threshold is not clearly established due to individual variation in sleep need. Also, sleep need may be met even though insomnia is present. v Frequency- usually symptom occurance of 3 or more nights per week. 4
Diagnostic Process v Two step process for diagnosing primary insomnia. v First rule out psychiatric disorders. This can be difficult due to significant overlap of symptoms of insomnia and depression and anxiety. Inadequately treated psychaitric disorders must be considered. v Second, rule out and other primary sleep disorders which cause insomnia symptoms for example circadian rhythm disorders or PLMD. 5
Common Medical/Psychiatric Rule Outs v Medical disorders which may cause insomnia - chronic pain, chronic obstructive pulmonary disease, gastroesophageal reflux disease, renal disease, hyperthyroidism, dementia. v Psychiatric disorders which cause insomnia - primarily major depression, bipolar depression, and anxiety disorders (generalized anxiety disorder, PTSD, panic disorder). 6
Common Sleep Disorder Rule Outs v Sleep Apnea (particularly central sleep apnea), narcolepsy, restless legss syndrome, periodic limb movement disorder. v It is important to disguish between fatigue and sleepiness sleepiness. v Fatigue - physical or mental weariness, feeling worn out. v Sleepiness - may or may not include fatigue, but patient indicates that they are struggling to stay awake. 7
Common Sleep Disorder Rule Outs - cont. v Most commonly, patients with insomnia report difficulty with fatigue, but less commonly sleepiness. v Sleepiness is more commonly associated with sleep apnea, narcolepsy, PLMD and RLS. v Circadian rhythm disorders, such as delayed sleep phase (sleep onset difficulty) or advanced sleep phase (early morning awakening), may present as insomnia. 8
Common Sleep Disorder Rule Outs - cont. v External factors may also cause or exacerbate insomnia. v These include, most commonly, insomnia associated with medication, drug or alcohol use. v Insomnia may be a side effect of some medications and should be considered. Timing and dosage should be considered for necessary medications. v Common problem is rebound insomnia after discontinuation of hypnotic medication. 9
Evaluation of Insomnia v Sleep is the outcome of a complex set of physiological and psychological processes o Assessment is not haphazard o Researchers have identified factors that commonly are associated with poor sleep o A comprehensive evaluation considers these factors o Idiosyncratic patient perceptions and meanings assigned to symptoms are also considered 10
Evaluation of Insomnia v A few insomnia complaints are associated with many diagnoses v Trouble falling asleep may be due to: o delayed sleep phase o learned sleep preventing associations o major depression, generalized anxiety Factors may vary from one night to the next in a patient 11
Evaluation - cont. v Evaluation begins before the first visit o Materials are sent to the patient prior to coming to the clinic o This serves to inform the patient that the evaluation will be comprehensive o Also allows the clinician to be efficient when the patient is being evaluated in the clinic 12
Depression Depression is commonly found in patients with insomnia and needs to be thoroughly evaluated o Depression inventories such as the Beck can be used in the initial evaluation o Depression can cause insomnia,, but insomnia can also cause mood disturbance,, so it is important to keep this issue open during treatment 13
Anxiety Anxiety disorders are common in insomnia Anxiety may manifest as either somatic or cognitive arousal that will interfere with the process of winding down before bed. Brief scales are available with which anxiety can be measured (e.g. state-trait anxiety inventory) Anxiety may be sub-clinical in many cases 14
Cognitive beliefs The beliefs that the patient hold regarding the functions sleep and the consequences of sleeplessness affect the course of the insomnia and the response to treatment. Scales are available which can be administered prior to treatment to assess dysfunctional beliefs and attitudes. 15
Sleep hygiene Assessment of basic sleep hygiene practices are sometimes overlooked as explanations for sleep difficulty. Assessment of basic sleep hygiene practices such as caffeine use, tobacco use, exercise patterns, eating habits should be included in the evaluation 16
Sleep Log A sleep log provides a systematic, subjective portrayal of key features of the sleep pattern (bed time, waketime, sleep onset latency, etc) o Patients should not use clock to record information as this might interfere more with sleep o Sometimes patients resist keeping a sleep log because believe the pattern is always the same or there is no rhyme or reason to the pattern o Patients are often surprised by the results of their log-they see that they are getting more sleep then they thought 17
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Sleep History v The evolution of the sleep problem helps the clinician better understand the current problem v Sleep history involves understanding the predisposing, precipitating and perpetuating factors in the sleep problem. v Treatment is usually focussed on treating the perpetuating factors,, such as the behavioral adaptations to poor sleep or changes in thinking v The sleep complaint points to the part of the night that is most troubling and how often the problem occurs 19
Sleep Wake Pattern v The pattern of sleep is usually obtained in the sleep log and involves the following information: o Type, dosage, frequency and timing of sleep medicine o Time and activities around bedtime o Time of lights out o Estimated sleep latency o Frequency, timing, duration, cause and consequences of nocturnal awakenings 20
Sleep Wake Pattern - cont. o Final wake-up and rise time (out of bed) o Quality of sleep o Frequency, timing, duration of naps o daytime consequences such as fatigue or cognitive alertness This list simplifies the nature of obtaining this information as sleep may follow a branching pattern such as with and without medication, good vs. bad nights.. An assessment may need to be done for each branch. 21
Sleep Related Cognitions v Worries, apprehension about not sleeping and cognitive hyperarousal may set off a self- fulfilling prophecy v Obsessional thinking will preclude sleep as the mind remains on alert rehearsing responses to crises v Sometimes no particular distressing thoughts can be described, but the patients mind flits from one mundane thought to another. 22
Sleep Related Cognitions - cont. v How does the insomnia appear to the insomniac? v What is the form of the cognitions? Obsessive fixture on one thought or unable to focus on one thought? v What is the emotional tone? Anger and agitation or resignation and detachment? 23
Social Determinants v Social intrusions prior to going to bed may effect sleep. Telephone may ring Nightly news headlines Internet chat rooms, instant messaging v People with chronic sleep difficulties vary in their approaches to dealing with social intrusions Some are very protective of their sleep Others may follow a night-owl pattern v Understanding the social context will be helpful in planning treatment 24
Physiological Hyperarousal v Heightened physiological arousal is present in individuals with sleeping problems and this arousal inhibits sleep. v Techniques are available to measure heart rate, body temperature and muscle tension,, but no levels are known above which insomnia is triggered. v There are no suitable assessment instruments for quantifying hyperarousal in the clinical setting 25
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Circadian Rhythms v The circadian system promotes sleep as well as wakefulness. v Knowing the phase position of the endogenous rhythm can help to explain a particular sleep problem. v No direct assessments are available for measurement of the circadian system. v Indirect measures include the Horne-Ostberg morningness-eveningness scale, preferred sleep time when no time constraints exist 27
Sleep Disorders v Restless Legs Syndrome can be diagnosed by patient report. Sleep onset insomnia is common with RLS v Periodic Limb Movement Disorder- - can be a subtle writhing of the foot to distinct rapid jerks.. These movements occur, by definition, during sleep, so the patient may not be aware of them. v PLMD can only be diagnosed with overnight PSG and may include difficulty maintaining sleep because of fragmented sleep due to arousals. 28
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Sleep Disorders - cont. v Respiratory disturbance during sleep may produce fragmented sleep and complaint of insomnia. v Daytime sleepiness is the far more common complaint in sleep disordered breathing. v Sleep apnea is part of the differential diagnosis for insomnia 31
Objective Tests for Insomnia v PSG is used if the clinician suspects that some other primary sleep disorder (besides insomnia) is causing insomnia.. Symptoms of RLS, PLMD or sleep apnea would be sufficient to require PSG testing. v If a patient is unresponsive to behavioral or pharmacological treatment, a PSG may be necessary. v PSG may be used to confirm a diagnosis of sleep state misperception 32
Objective Tests for Insomnia - cont. v Physical exam - several medical disorders may be responsible for insomnia, however most commonly, behavioral and psychological factors are responsible and there are few indications of any medical problem. v Actigraphy - Behavioral quiescence is a defining characteristic of sleep, and actigraphy which measures movement may be useful to assess sleep patterns. v When used in conjunction with sleep logs, actigraphy can detail the sleep pattern over many days or weeks. 33
Trial Treatment as Evaluation v If RLS or PLMD is suspected,, an overnight PSG is the only definitive way to diagnose the disorder. v However, dopaminergic agents are commonly used to treat these disorders and can be used on a trial basis. v If the patients symptoms are resolved,, with Mirapex or Sinemet,, then diagnostic certainty is high. 34
Cognitive-Behavioral Perspective on Insomnia v Behavioral perspective Predisposing factors - personality factors, physiologic arousal, genetic predisposition, etc. Precipitating factors - situational stress, acute injury, bereavement, etc. Perpetuating factors - any form of compensatory strategies a patient used to cope with insomnia - napping, spending too much time in bed, variable schedule 35
Cognitive-Behavioral Perspective on Insomnia v Cognitive perspective - two types of cognitive problems: Beliefs and attitudes toward sleep o Unrealistic views about what constitutes adequate sleep and catastrophic beliefs about the consequences of insomnia Cognitive processes like intrusive thoughts and worry. o Perseverative problem-solving about mundane daily activities or work or relationships. 36
Cognitive-Behavioral Perspective on Insomnia v Neurocognitive perspective - dysfunctional beliefs and worry are epiphenomena. v In chronic insomnia cognition occurs secondary to conditioned arousal. v Arousal is conditioned cortical arousal observed as high frequency EEG activity (14-45 Hz) at or around sleep onset and during non-rem sleep. v High frequency EEG activity allows for more sensory processing and memory formation and difficulty with perceiving sleep. 37
Cognitive-Behavioral Treatment of Insomnia v Most common cognitive-behavioral therapies (CBT) are: Sleep hygiene education Stimulus control Sleep restriction Relaxation therapy Cognitive therapy v Most behavioral sleep medicine clinicians use a multi-modal approach - combining the techniques above. 38
Cognitive-Behavioral Treatment of Insomnia v Therapeutic regimen - usually therapy requires 4-8 weeks of, in most cases, face-to-face meeting with the provider. Sessions last 30-90 minutes. v Stimulus control and sleep restriction are implemented during the first 2-3 sessions. Additional sessions are used to upwardly titrate sleep time v Adjunctive therapies such as cognitive therapy, relaxation training and relapse prevention occur during the balance of the sessions. 39
Stimulus Control Therapy v Stimulus control therapy limits the amount of time that patients spend awake in the bed. v They are designed to decondition pre-sleep arousal and re-associate the bed with rapid well consolidated sleep. v Typical instructions include: o o o o o Keep a fixed wake time 7 days a week avoid any behavior in the bed besides sleep sleep nowhere else except the bedroom leave the bedroom after being awake for longer than 15 minutes return to bed only when sleepy 40
Sleep Restriction Therapy v Recommended for both sleep initiation and maintenance problems. v Procedure entails three steps: Establish a fixed waketime. Decrease sleep opportunity to average total sleep time. Increase time in bed by 15 minutes per week as sleep efficiency (TST/TIB) increases. v May be contraindicated in patients with bipolar or seizure disorder. 41
Sleep Hygiene Education v Addresses a variety of behaviors that may influence the quality and quantity of sleep. v Common suggestions include: Exercise regularly, Make bedroom a comfortable temperature and free of noise and light, Cut down on caffeine and tobacco products Avoid alcohol, especially in the evening, Don t go to bed hungry 42
Cognitive Therapy v Based on the observation that people with insomnia have negative thoughts and beliefs about their condition and its consequences. v Challenging these beliefs can decrease anxiety and arousal associated with insomnia. v Cognitive restructuring focuses on catastrophic thinking and the belief that poor sleep will have devastating consequences. v These beliefs are challenged with evidence collected by the patient of how often these horrible consequences have occurred (not often). 43
Relaxation Training and Phototherapy v Relaxation training specifically targets the physiological arousal experienced by the patient. v Any technique (progressive muscle relaxation, deep breathing, autogenic training) with which the patient is comfortable can be used. It may need to be practiced out of bed because of performance anxiety. v Phototherapy,, although not a behavioral therapy, can be used in conjunction with CBT when a patients sleep difficulty has a circadian rhythm component. 44
Treatment Complinace v The single most important complicating factor in CBT is poor treatment compliance. v Patients expectations should be managed with a thoughtful rationale for each aspect of treatment to help increase compliance v Patients should be advised that sleep may get somewhat worse before improvement is appreciated 45
CBT and Sedative/Hypnotics v CBT may be combined with hypnotics to take advantage of the strengths of each: the rapid reduction in symptoms with medicine and the long lasting effects of CBT. v The best method of combining therapy has yet to be established. v For patients who are currently taking hypnotics, collaborating with their physician to withdraw them may be most useful. 46
Pharmacologic Treatment Options v Most common hypnotics are benzodiazepines (temazepam, flurazepam) ) and benzodiazepines receptor agonists (zolpidem, zaleplon). v These medicines have mostly been studied as short-term treatments.. Thus the effects of long- term use is undocumented. v Physicians often have some concern with tolerance, side-effects and rebound insomnia. v Daytime functioning is not improved with hypnotic medication. 47
Recettore GABAA 48
Pharmacologic Treatment Options - cont. v Sedating anti-depressant medications are often used to treat primary insomnia. v There exists a paucity of data on the use of sedating anti-depressants for insomnia. v These medicines are thought to have a low abuse profile and may be useful in treating occult depression and are considered a better long term treatment for primary insomnia by some physicians. 49
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