Behavioral Treatment for Sleep Disorders

1. Behavioral Treatment for Sleep Disorders Dr. Kala K. Davis October 4, 2006

3. Behavioral Medicine & Sleep • Behavioral treatment approaches to sleep disorders began in the 1930s • Now considered a sub-specialty within sleep medicine • Cognitive behavioral therapy (CBT) is an established and very effective modality in the management of chronic insomnia

4. Insomnia • Insomnia is defined as difficulty initiating sleep, maintaining sleep, final awakenings that occur much earlier than desired or sleep that is non-restorative and of poor quality and result in impairment in daytime function.

5. Insomnia • Prevalence rates for chronic insomnia are higher in women and generally increase with age. • Has been associated with reduced quality of life, mood disorders and increased health service utilization • Represents a significant economic burden in the US, with estimated direct costs of $13.9 billion annually.

6. Insomnia • There are many treatments options for insomnia including: behavioral therapy, non-pharmacological interventions such as relaxation therapy, biofeedback, exercise, dietary changes and medications

8. Behavioral Model of Insomnia • Insomnia occurs acutely in relation to both predisposing and precipitating factors • The chronic form of the disorder is maintained by maladaptive coping behaviors. • Behavioral therapy focuses on eliminating the “perpetuating factors” that lead to the development of chronic insomnia.

9. Behavioral Model of Insomnia • A state of “conditioned arousal” may develop in which situations associated with sleep become alerting rather than relaxing- further impairing sleep.

10. Cycle of Persistent Insomnia

11. Cognitive Behavioral Therapy (CBT) for Insomnia • CBT seeks to change poor sleep habits and faulty beliefs about sleep and promote good sleep hygiene. • CBT principles include sleep restriction, stimulus control, relaxation techniques, education and sleep hygiene.

12. Cognitive Behavioral Therapy (CBT) for Insomnia • CBT is as successful as medications in the acute treatment (4-8 weeks) of insomnia • It is more effective than medications in the long term • Average of 50-60% improvement

13. Cognitive Behavioral Therapy (CBT) for Insomnia • Long term studies reveal a sustained improvement in sleep quality and duration. • Patients continued to experience improvement over follow-up periods of >1year

14. Cognitive Behavioral Therapy for Insomnia • Stimulus Control Therapy • Sleep Restriction Therapy • Sleep Hygiene Education • Cognitive Therapy • Relaxation Training • Phototherapy

16. Stimulus Control Therapy • Recommended for sleep initiation and sleep maintenance problems • Considered a first-line behavioral treatment for chronic insomnia by AASM • Principle: to re-associate bed, bedtime and the bedroom with sleepiness and sleep

17. Stimulus Control Therapy: Rules • Lie down to go to sleep only when sleepy • Avoid any behavior in bed or the bedroom besides sleep or sex • Leave the bedroom if awake for more than 15 minutes • Keep a fixed wake up time, 7 days a week no matter how poorly you sleep

18. Stimulus Control Therapy: Caution! • Stimulus control therapy is generally well tolerated • Maybe contraindicated in patients with mania, epilepsy, parasomnias or at high risk for falls

19. Sleep Restriction Therapy • Recommended for sleep initiation and sleep maintenance problems • Requires the patient to: • limit his/her time in bed to an amount that equals their total sleep time • Time restriction determined by clinician and patient using sleep diaries and balancing the patient’s lifestyle • Establish a fixed wake up time • Delay bed time

20. Sleep Restriction Therapy • As sleep efficiency increases, patients are gradually allowed to spend more time in bed- increased in 15 minute increments. • Over the course of therapy, patients will begin to find it difficult to stay up until the prescribed hour- sleep initiation is easier

21. Sleep Restriction Therapy • Sleep restriction works for several reasons: • It prevents insomniacs from coping by extending sleep opportunity- produces a sleep that is shallow and fragmented • Initial sleep loss early in SRT increases the homeostatic drive for sleep, producing a condensed, quality sleep with shorter awake times

22. Sleep Restriction Therapy: Cautions! • Maybe contraindicated in patients with history of mania, obstructive sleep apnea, seizure disorder, parasomnias or those at significant risk for falls.

23. Sleep Hygiene Education • Sleep only as long as you need to feel fresh the following day • Get out of bed at approximately the same time every day • Exercise regularly • Make sure the bedroom is comfortable- free from light, noise and temperature extremes. • Eat regular meals and do not go to bed hungry

24. Sleep Hygiene Education • Avoid drinking too much in the evenings • Cut down on all caffeinated products • Avoid alcohol, especially in the evenings • Smoking may disturb sleep • Don’t take your problems to bed • Do NOT try and fall asleep • Turn your clock around • Avoid naps

25. Cognitive Therapy • Most suitable for patients who are preoccupied with the potential consequences of their insomnia or for patients who complain of unwanted intrusive ideation or worry. • Serves to deconstruct patient’s negative thoughts and beliefs about their condition • This is thought to decrease the anxiety and arousal associated with insomnia.

26. Relaxation Training • Progressive Muscle Relaxation • Diaphragmatic Breathing • Autogenic Training • Imagery Training • Mindfulness-based stress reduction • Prayer

27. Mindfulness-based stress reduction • Mindfulness meditation and stress regulation helps us explore alternative ways to emotionally regulate ourselves, providing a sense of awareness and control that comes from inner calmness, acceptance and openness. 

28. Circadian Rhythm Disorders • Cause insomnia because of a lack of synchronization between an individual’s internal clock and the external schedule • Treatment is best accomplished with chronotherapy and/ or phototherapy

31. Phototherapy- Light Therapy • Light is a powerful trigger in allowing us to reset our internal biological clock each day • Indicated when circadian factors appear to be a significantly contributing factor to insomnia • Light Intensity: 10,000 lux • Duration 30 - 60 min • Timing of light exposure is very important • Caution: may trigger mania in persons with bipolar disorder, chronic headaches, eye conditions, photosensitivity, seizure disorder

32. Phototherapy- Light Therapy • For DSPS- The patient sits in front of 10,000 lux light for 30 to 40 minutes upon awakening; in addition, room lighting has to be markedly reduced in the evening to achieve the desired results. • Response is generally evident after a two to three week period, but frequently requires indefinite treatment to maintain • In patients with ASPS, bright light exposure in the evening has been successful in delaying sleep onset.

33. Chronotherapy • Refers to the intentional delay of sleep onset by 2-3 hours on successive days until the desired bedtime is achieved • Has a high degree of success in patients’ with delayed sleep phase syndrome • Tendency over time to lapse back into old sleep habits

34. Chronotherapy • General Principle: Phase Shifting

35. Normal Sleep Pattern

36. Advanced Sleep-Phase Disorder

37. Delayed Sleep-Phase Disorder

38. Shift Work Disorder

39. Irregular Sleep-Wake Rhythm

40. Advanced Sleep-Phase Disorder

41. Delayed Sleep-Phase Disorder

42. Jet Lag Disorder

43. Jet Lag Disorder • Use activities (eating, exercise, sightseeing) and exposure to light to try to synchronize body rhythms with those of the environment • Adult travelers crossing five or more time zones are likely to benefit from melatonin • Melatonin 3 mg about 30 minutes before bedtime on the day of travel and for up to four days after arrival is appropriate • A dose of 0.5 mg has less effect on sleep, but otherwise helps adaptation similarly

45. Obstructive Sleep Apnea • Unlike people with insomnia, OSA is a structural/ anatomical problem with physiological consequences • Treatment of OSA with CPAP/ Bi-level, oral appliance or surgery is needed before one can completely treat co-existing sleep disorders • Sleep maintenance insomnia, sleep walking, PLM are all improved with treatment of OSA

46. Obstructive Sleep Apnea • CBT and desensitization are useful in improving CPAP/ Bi-level compliance • Weight Loss • Avoid alcohol and other substances known to make apnea worse • Restriction of body position during sleep • Avoidance of upper airway mucosal irritants • Possibly avoidance of altitude

47. Restless Legs Syndrome (RLS) • In contrast to patients with insomnia, patients with RLS frequently require long term pharmacological therapies. • Non-pharmacological strategies: • Avoid caffeine, nicotine and alcohol • Avoid medications which may aggravate symptoms • Iron replacement therapy • Mental alerting activities • Regular moderate exercise and stretching • Warm baths or cold packs

48. Parasomnias • Sleep disorders characterized by abnormal behavioral or physiological events which occur during sleep or during sleep-wake transitions. • Parasomnias typically do not cause insomnia or excessive sleepiness • Avoid sleep deprivation- schedule naps/ awakenings • Avoid alcohol, drugs and stimulants • Stress Reduction • Treat OSA if present • Secure the home and safety of the bed partner

50. Resources • Licensed Sleep Psychologist in Northern California: • Kathleen L. Benson, Ph.D. Palo Alto, CA • Richard M. Coleman, Ph.D. Ross, CA • Sharon A. Keenan, Ph.D. Palo Alto, CA • Tracy F. Kuo, Ph.D. Stanford, CA • Derek H. Loewy, Ph.D. Belmont, CA • Karen H. Naifeh, Ph.D. San Francisco, CA • Rachel Manber, Ph.D. Stanford, CA