I Can t Sleep. Why Behavioral Treatments? 2/29/2016
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1 Janet E. Tatman, PhD, PA Diplomate American Board of Sleep Medicine Certified in Behavioral Sleep Medicine Why Behavioral Treatments? I Can t Sleep Chronic Insomnia = 10% of population Short term = 30 35% in any given year International Classification of Sleep Disorders, 3 rd Ed 1
2 Drugs vs. Behavioral Treatment Cognitive Behavioral Therapy for Insomnia (CBT I)? Morin et al JAMA 1999 McClusky et al Am J Psychiatry 1991 CBT I vs. Pharmacotherapy 60 An 8 week study % Change in Sleep Latency CBT Both Zolpidem Placebo N = 18 Midtreatment After Treatment N 15/group Data are from sleep diaries Jacobs, G et al Archives of Int Med 2004 CBT Ivs. Pharmacotherapy % Change in Sleep Efficiency CBT Both Zolpidem Placebo N = 18 An 8 week study Mid Treatment After Treatment N 15/group Data are from sleep diaries Jacobs, G et al Archives of Int Med
3 CBT I vs. Pharmacotherapy 80 subjects got CBT I alone X 6 wks, then either A 1 year+ study 80 subjects got CBT I + zolpidem 10 mg X 6 weeks, then either o Remission rate for CBT I group continued to increase; but decreased for group getting CBT I + zolpidem prn Morin, C et al. JAMA 2009 A Cautionary Note Predictable Factors In Insomnia Predisposing Precipitating Perpetuating 3
4 Spielman & Glovinsky, 1991 Factors In Insomnia Predisposing Precipitating Perpetuating Factors Behavioral Cognitive 4
5 Getting Enough Sleep American Academy of Sleep Medicine and Sleep Research Society 7 or more hours SLEEP, Vol 38, No 6, 2015 Respect Individual Differences Normal Variants Short sleeper Long sleeper and Older sleepers Salvadore Dali
6 80 y.o. patient; A. Spielman, in Case Studies in Insomnia, p. 57, P. Hauri (Ed), 1991 Sleep Physiology 101 6
7 Circadian Rhythms anticipate sleep / wake appetite propensity for exercise immune function hormones drug metabolism level of alertness independent of prior sleep Zeitgebers sunlight sleep-wake cycle noise social cues food temperature 7
8 Homeostatic Forces Homeostasis = the tendency of an organism to maintain internal equilibrium by adjusting its physiological processes Circadian & Homeostatic Influences A Shorter Rhythm Ultradian rhythm 8
9 Slow Wave Sleep Basic Rest Activity Cycle Developmental Changes o o o total sleep time / consolidation of sleep distribution of sleep stages circadian rhythmicity and timing 9
10 Sleep History Timing Is Everything Bedtime Lights out Time it takes to get to sleep? Wake time Get up time Sleep Schedule Usual Earliest Latest How many times do you wake up on an average night? How long does it take you to get back to sleep after waking up? How many naps do you take each day, and how long do they last? 10
11 Analyzing the Sleep Schedule Understand that subjective estimates are often inaccurate but they are actually quite valid as indicators of change over time Sleep Schedule Usual Earliest Latest Bedtime 10:30 PM 8 PM 1:30 AM Lights out 11 PM 8 PM 2 AM Time it takes to get to sleep? 1 hr 30 min 2.5 hrs Wake time 5:30 AM 5:30 AM Noon Get up time 6 AM 5:45 AM Noon How many times do you wake up on an average night? 3 How long does it take you to get back to sleep after waking up? 30 min 1 hr How many naps do you take each day, and how long do they last? 0-1, 30 min Sleep Schedule Usual Earliest Latest Bedtime 9 PM 8 PM 10 PM Lights out 10 PM 8:15 PM 10 PM Time it takes to get to sleep? 1 hr 30 min 10 min Wake time 7 AM 6:30 AM 9:30 AM Get up time 7:30-8 AM 6:35 AM 10:30 AM How many times do you wake up on an average night? 3+ How long does it take you to get back to sleep after waking up? 20 min to 1 hr How many naps do you take each day, and how long do they last? 0-1, 20 min 11
12 COGNITIVE BEHAVIORAL THERAPY Relaxation Training Stimulus Control Sleep Restriction Therapy Timed Bright Light Exposure Education in Realistic Expectations used singly or in combination Relaxation Techniques physical and mental relaxation o relaxed breathing and body awareness o pleasant mental imagery self-hypnosis, meditation biofeedback music Sleep Restriction Therapy used for fragmented, interrupted sleep (problems with sleep maintenance) especially when coupled w/ excessive time in bed ACCEPTS mild daytime sleepiness as a temporary side effect might take 6-8 weeks, often less probably retrains circadian/ultradian rhythms 12
13 Procedure for SRT Chose a realistic, restricted time in bed Establish wake-up time, then calculate bedtime Plan activities thoughtfully Expect temporary difficulties Log sleep If TIB is aggressively restricted, extend time in bed gradually in 15 min increments when sleep efficiency > 90% Get the clock out of sight! Individualize! Sleep Restriction Therapy: Pre and Post Spielman et al 1987 Calculate average Time in Bed, average Total Sleep Time use these to choose new restricted Time in Bed 13
14 Contraindications to SRT ANY other primary disorder of sleep until treated (e.g., sleep apnea) Major depression or other acute or severe psychiatric disorder, until treated Circadian Rhythm Disorder Shift Work Sleep Disorder Timed Bright Light Exposure resets circadian clock establishes new circadian phase time of exposure critical must be daily initially 14
15 Timed Bright Light Exposure Be outdoors as early as possible after waking up in the morning for 30 min. The activity does not matter and you can be in the shade. Just getting your eyes exposed to ambient outdoor light is all that s needed. Start with 7 days a week. You may be able to cut back when things are stable to maybe 4-5 times / wk. 15
16 Thoughts About Insomnia It s a chemical imbalance I can t control it I can t function the next day I must get 8 hours every night A bad night predicts more bad nights I ll get really sick When I don t sleep, I need to stay in bed more Rapid Resolution of Chronic Insomnia Mr. I.B. DIMS Perpetuating Factors 16
17 Mr. Dims Sleep Schedule Usual Earliest Latest Bedtime 9 PM 8:45 PM 11:30 PM Lights out 9 PM 8:45 PM 11:30 PM How long to get to sleep? 45 min 30 min 1 hr Wake time 6 AM 6:30 AM 8 AM Get up time 7 AM 6:30 AM 8:30 AM How many times do you wake up on an average night? 1 How long does it take you to get back to sleep after waking up? 2-3 hrs How many naps do you take each day, and how long do they last? 0-1, min The Problem? My experience? This is by far the most common perpetuating factor in insomnia. Mr. Dim s Treatment Plan Bedtime 9 pm w/lo. SOL = minutes. Sleeps thru til 6 am 30% of time (wakes 1 h before alarm). Usually wakes 2:30 3:30 w/2 3 hrs. to get back to sleep. Alarm at 7 am. No naps (except weekends). 17
18 Mr. DIMS Rx 9 pm 7 am 11 pm 6:30 am Mr. DIMS Follow up Type A, Anxiety & Night Owl Tendencies 18
19 Mr. Nat A. Bideal Mr. Bideal s Past History Mr. Bideal s Sleep Schedule Usual Earliest Latest Bedtime 10:30 PM 9:30 PM 1 AM Lights out 10:45 PM 9:30 PM 1:30 AM How long to get to sleep? 1 hr 30 min 2 hrs Wake time 5:30 AM 5:30 AM 10 AM Get up time 5:55 AM 5:35 AM 11 AM How many times do you wake up on an average night? 1-3 How long does it take you to get back to sleep after waking up? 30 min 1 hr How many naps do you take each day, and how long do they last? 1-2, min 19
20 Circadian Rhythm Disorders Delayed Sleep Phase Syndrome o o Advanced Sleep Phase Syndrome o from Principles and Practice of Sleep Medicine, 2 nd Ed. 1994, p
21 Xanax 2 mg at 10 PM, in bed 10:30, 1 hr to get to sleep, wakes 1 2 times/ night w/ 30 minutes to get back to sleep. Alarm at 5:30, snoozes it 3X, gets up tired. 20 min. nap after work. Weekends bedtime is midnight, wakes once w/quicker return, sleeps in until 9 AM ish. Mr. Bideal s Treatment Plan Habituation tolerance dependence? How do people get off these drugs? Chronic Use of Sleep Meds 21
22 Ms. Nita Pillé Ms. Pillé s Failures More Ms. Pillé History 22
23 Getting Off Sleep Meds Ms. Pillé s Sleep Schedule Usual Earliest Latest Bedtime? 8:30 PM 11 PM Lights out Same Same Same How long to get to sleep? 5 min 1 min 1 hr Wake time 6:30 AM 6:30 AM 7 AM Get up time 6:35 AM 6:30 AM 8 AM How many times do you wake up on an average night? 0-1 How long does it take you to get back to sleep after waking up? 0-30 How many naps do you take each day, and how long do they last? 0 Takes Ambien 9 10 PM, in bed min. later. (Husband worries she gets confused before bed.) Asleep w/in 5 min. Occasionally up to bathroom & usually forgets to flush toilet, no recall in AM. Occasionally can t get back to sleep and takes another ½ pill. Alarm at 6:30 AM. Same routine on weekends, but no alarm, sleeps til 7 AM. Groggy for 30 minutes on waking. 23
24 Ms. Pillé s Treatment Plan Ms. Pillé s Progress Week 2 A Shorter Rhythm Ultradian rhythm 24
25 Ms. Pillé s Progress Week 6 Adolescent Night Owl Extraordinare Joe L. Darkmann 4 alarms middle of the night see Wilhelmsen Langeland et al Behav Sleep Med
26 Joe s History Joe s Sleep Schedule Usual Earliest Latest Bedtime 1 AM Midnight 7 AM Lights out 2 AM 1 AM? Time it takes to get to sleep? 1 hr 2 hrs few min Wake time 6:30 AM 6:30 AM 2 PM Get up time 10 AM 7:30 AM 2 PM How many times do you wake up on an average night? 0 How long does it take you to get back to sleep after waking up? n/a How many naps do you take each day, and how long do they last? 0-1 2/4 2/5 2/6 2/7 2/8 2/9 2/10 the Darkside 26
27 Ideas? Circadian Rhythm Disorders Delayed Sleep Phase Syndrome o o Advanced Sleep Phase Syndrome o from Principles and Practice of Sleep Medicine, 2 nd Ed. 1994, p
28 Timed Bright Light Exposure Be outdoors as early as possible after waking up in the morning for 30 min. The activity does not matter and you can be in the shade. Just getting your eyes exposed to ambient outdoor light is all that s needed. Start with 7 days a week. You may be able to cut back when things are stable to maybe 4-5 times / wk. Joe s Rx * *An enormous challenge treating him during the school year see West Saxvig, I et al. Chronobio Internat l 2014 & Dodson E & Zee, P Sleep Med Clin
29 Joe s Rx Additional Benefit? 1 Mundey, K. SLEEP 2005;28(10) Questions? Henry Ward Beecher 29
30 RECOMMENDED READING? *highly recommended REFERENCES 30
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