Insomnia: Concepts and Cognitive-Behavioral Treatment

1. Insomnia: Concepts and Cognitive-Behavioral Treatment Joseph K. Neumann, Ph.D. Roth Neuropsychology and Behavioral Health Associates

2. Insomnia: How Defined • World Health Organization – problem initiating/maintaining sleep, at least 3 X week with daytime sleep impairment. • ICD – Disorder of Initiating/Maintaining Sleep a. 307.41-transient – associated with acute emotional distress. b. 307.42 – chronic – associated with anxiety, depressive disorders, psychosis --?

3. Evidence Against Insomnia as Only Symptom Rather Than Co-morbid Dx • Insomnia and Major Depression do not necessarily co-occur a. 40% of MDD patients – no insomnia b. 40% of Insomnia pts. – no depression or other major psychiatric disorder • Insomnia is risk factor for development of depression

4. Evidence (cont.) • Severity of Insomnia increases prior to re-occurrence of Depression • Successful Depression tx does not necessarily eliminate Insomnia • Primary Insomnia – Depression have different neurobiological profiles (nocturnal NE, brain activity, REM sleep patterns) • Pigeon & Perlis (2007) Int. J. Sleep Disorders

5. Psychophysiological Insomnia (PI) • International Classification of Sleep Disorders • A disorder of somatized tension and learned sleep-preventing associations that results in a complaint of insomnia and associated decreased daytime functioning/wakefulness • r/o sleep apnea, restless leg syndrome, COPD, pain conditions, PTSD, etc.

6. Signs of PI • Excessive focus/worry concerning sleep • Sleep occurs better in novel places • Mental arousal reported as intrusive thoughts/involuntary ruminations • Somatic arousal, i.e., feels “wound up” • Sleep extension strategies used (naps, longer time in bed in AM)

7. Sleep Disorders: Main Types • Disorders of Initiating or Maintaining Sleep (DIMS) – (fatigue, sleep unlikely) – circadian rhythm, sleep phase syndromes, jet lag, insomnias • Disorders of Excessive Sleepiness (DOES) – (sleepiness, sleep likely) – obstructive/central sleep apnea, narcolepsy, periodic leg move. • Parasomnias – REM Behavior D/O, Nightmare D/O, Sleep Terror D/O, Sleep Eating D/O

8. Parameters of PI • Severity – greater than 30 minutes • Frequency – 3 days/week • Types – initial, middle, terminal • Chronicity – acute-less than 4 weeks chronic-more than 4 • Cognitive-Behavioral Treatment of Insomnia (CBT-I) – focus on chronic insomnia

9. Problem Significance • 10 – 15 % - Point prevalence of chronic ins., 30-35 % of point prevalence of acute insomnia • Only 6% obtain tx after waiting a year • USA costs; accidents – 3.7 billion, work place productivity – 150 billion • Three mile island meltdown (1979), Grounding of Exxon Valdez (1989), Air Traffic Controllers falling asleep (2011)

10. Drugs – Cause of Sleep Problems-? • Alcohol/caffeine • Beta blockers • Bronchodilators • Calcium channel blockers • Older antidepressants • Certain antibiotics (? – ampicillin, aminoglycosides)

11. Conceptual 3-P Model • Present to patients – Spielman (1987) • P1 – Predisposing Factors – genetic (higher arousal), tendency to worry due to family modeling, spouse with incompatible sleep schedule, etc. • P2 – Precipitating Factors – acute medical illness, grief reactions, life changes-babies

12. Model (cont.) • P3 – Perpetuating Factors – focus of CBT-I, maladaptive strategies to initiate/maintain sleep, e.g., watching TV in bed to relax, naps during day, sleeping later to “catch up”, extra coffee during day to compensate, extra time in bed, ETOH use to relax • Sleep homeostasis concept

13. CBT-I Treatment Components • Primary – Stimulus Control Therapy, Sleep Restriction Therapy, Sleep Hygiene Education • Secondary – Cognitive Therapy, Phototherapy (light therapy), Sleep Compression, Neurofeedback

14. CBT-I Side Effects/Problems • Sleepiness during day for 1 to 3 weeks • Safety Issues, e.g., falling, driving • Worsening conditions such as mania, epilepsy • Sleep loss could increase parasomnias • Requires substantial compliance (30 % drop out) • Requires some therapist expertise

15. CBT-I Benefits • Good short-/long-term efficacy • Not alter sleep architecture (sleep stages) • No abuse potential • Positively effects 50% of patients, perhaps less in the elderly • Takes 3 – 8 weeks to work • Enables self-maintenance after treatment

16. Stimulus Control Therapy (SCT) • Limit amount of time in bed when not asleep, thus classical conditioning of bedroom stimuli to sleep • Instructions: a. lie down intending to go to sleep only when sleepy, b. avoid lengthy behaviors in bed/bedroom other than sleep/sex, c. leave bedroom if awake more than 20 minutes, d. return to bed only when sleepy, d. encourage patient to assume will be up, e. wake with alarm

17. Sleep Restriction Therapy (SRT) • SRT requires limiting amount of time in bed equal to average sleep time • Establish fixed wake time and decrease time in bed, i.e., less sleep but more consolidated • Adjusted during treatment based on sleep efficacy index • Minimum – 4 to 4.5 hours sleep/night

18. Sleep Diary Data - SRT • TTB – Time to Bed (also PTTB) • TOB – Time out of Bed (also PTOB) • SL – Sleep Latency, i.e., time to fall asleep • NOA – Number of Times Awakened • WASO – Amount of Time Awake • TST – Total Sleep Time • SE – Sleep Efficacy

19. Sleep Data Calculations • TST = TIB – (SL + WASO) • TIB = Difference between TOB and TTB • Sleep Efficacy (SE) = TST/TIB

20. In Treatment • Obtain baseline data • Fix prescribed time out of bed • Calculate prescribed time to bed based on TST obtained at baseline (i.e., PTTB) • Calculate Sleep Efficacy: 90% or more- move PTTB forward by 15 minutes (e.g., 1 AM to 12:45 AM), 85-89%- no change, 84% or less- move backwards PTTD by 15 minutes (1 AM to 1:15 AM)

21. Sleep Hygiene Instructions • Instructions related to habits and environment • Safe and comfortable environment • Limit stimulating liquids/activities before bed • Get up if not asleep, limit light exposure • Cognitively refocus before bed, develop pattern, not clock watch or try to “force” sleep

22. Additional Therapies • Cognitive – monitor/change negative thinking patterns such as catastrophizing, reframing, cognitive self-talk • Relaxation – imagery, progressive muscle relaxation, autogenic, EMG biofeedback • Phototherapy – bright light tx, usually in AM for 20 – 30 minutes

23. Additional Therapies (cont.) • Neurofeedback – EEG biofeedback • Sleep Compression – slow Sleep Restriction Therapy (SRT), divide TST – TIB by 5, change PTTB over five-week period until Sleep Efficacy goal of 85-90 % met

24. Case History • A 50 y/o divorced WM physical therapist, Greg, with a 3-yr. h/o chronic sleep onset insomnia. Physician referral with no clear physical reasons for insomnia. Childhood marked by some verbal abuse with sense of being slightly “hyper” for several decades. Prior to divorce, he reported periodic sleep problems, but no chronic problems. His chronic insomnia started with job change/

25. Case History (cont.) • /change in personal relationship. He first found taking Lunesta, sleeping later, and drinking a lot of coffee during the day helpful but not now. Can you help???? • Predisposing Factors: • Precipitating Factors: • Perpetuating Factors:

26. Case – Session 1 • Clinical interview – rule outs, rapport • Sleep Tx – rationale, requirements • Sleep medication/other medical conditions • Explain 3-P model, sleep hemostat • Explain/start sleep diary • Handling objections (e.g., start now) • Give handouts

27. Case – Session 2 • Review data, confirm CBT-I interest • Review sleep hygiene issues • Start Stimulus Control procedures, Greg asks… • Calculate Prescribed Time To Bed/Time Awake • TST = TIB – (SL, 75 min.+WASO,120 min.) • TIB = 9 hours (540 min.)

28. Case – Session 2 (cont.) • TST = 540 min.-195 min. = 345 min. (5.75 hrs.) • SE = TST/TIB = 345/540 = 64% (what range??) • Prescribed Time Out of Bed is 7 AM due/work • PTTB = 7:00 AM - 5.75 hours = 1:15 AM • Reviewing staying up procedures/safety

29. Case – Session 3 • Review data – titrate PTTB based on SE, GT 90 %, 85-90%, LT 85% • Greg c/o difficulty staying awake-review physical activity, cold compresses to neck, brief bright light exposure, positioning, coffee • Greg’s SE = 91%, PTTB now 1 AM, praise • Review sleep hygiene/stimulus control • Secure treatment commitment

30. Case – Session 4 • Review data – titrate PTTB , Greg’s SE=85%, maintain • Confirms adherence to stimulus control/sleep hygiene procedures • Discuss thinking patterns – fears concerning new relationship, “all/none” thinking concerning progress • Review tx/commit to program

31. Case – Sessions 5, etc. • Repeat steps • Review data, titrate • Review thinking pattern issues • Confirm adherence/handle problems • Fade sessions 1 X 2 weeks • Maintenance

32. Helpful Sayings • Bad thing to be awake when reason sleeps • If not tonight, then tomorrow night • Sleep is like a bird in hand- bird will stay if you do nothing – will leave if you try to grab it • W.C. Fields – “The best cure for insomnia is to get a lot of sleep.”

33. PCP Sleep Screening • B – Do you have difficulty falling asleep? (Bedtime) • E – Do you ever fall asleep during the day? (Excessive Daytime Sleep) • A – Do you awaken frequently or for long periods? (Awake) • R – What time do you go to bed? … get up? (Regularity) • S – Have you noticed/anybody said you snore? (Snoring)

34. Publications • Perlis, M.L. et al. Cognitive-behavioral treatment of insomnia: A session-by-session guide. New York: Springer. • Edinger, J.D. et al. (2007). Dose-response effects of cognitive-behavioral insomnia therapy. Sleep, 30 (2), 203-212. • Sivertsen, B. et. Al. (2006). Cognitive behavioral tx vs. zopiclone for the tx of chronic primary insomnia. JAMA, 295, 2851-2858.

35. For Further Contact: • Address: Joseph K. Neumann, Ph.D. Roth Neuropsychology and Behavioral Health Associates 2333 Knob Creek Rd., St. 11 Johnson City, TN 37604 • Phone: 423-952-0500 , Fax: 952-0005 • E-mail: drjosephneumann@rothneuropsychology.com