insomnia presentation

AWP 2010, Portland, OR

Conceptualization of Insomnia

A Holistic Approach to Insomnia

Sovann Pen,

MA, Counseling

Kaiser Insomnia Clinic

The Importance of Sleep• Sleep is vital to our health and well being. • National Sleep Foundation reveal that 60 percent of adults report

having sleep problems a few nights a week or more. • In addition, more than 40 percent of adults experience daytime

sleepiness severe enough to interfere with their daily activities at least a few days each month - with 20 percent reporting problem sleepiness a few days a week or more.

• At least 40 million Americans suffer from sleep disorders, yet more than 60 percent of adults have never been asked about the quality of their sleep by a physician and fewer than 20 percent ever initiated a discussion.

• Poor sleep has a price. • Millions of individuals struggle to stay alert at home, in school, on the

job - and on the road. Tragically, fatigue contributes to more than 100,000 police-reported highway crashes, causing 71,000 injuries and 1,500 deaths each year in the United States alone.

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 results in impairment in daytime function.

Epworth Sleepiness Scale• Use the following scale to choose the most appropriate number for each

situation: 0 = no chance of dozing

• 1 = slight chance of dozing• 2 = moderate chance of dozing• 3 = high chance of dozing

• Sitting and reading____________• Watching TV____________• Sitting inactive in a public place (e.g a theater or a meeting)____________• As a passenger in a car for an hour without a break____________• Lying down to rest in the afternoon when circumstances permit____________• Sitting and talking to someone____________• Sitting quietly after a lunch without alcohol____________• In a car, while stopped for a few minutes in traffic____________

Insomnia is MessyInsomnia is MessyInsomnia is MessyInsomnia is Messy

Cognitive Behavioral Therapy

Chicken or the Egg?

Sleep-interfering process

Spielman Model

Insomnia over time

• Premorbid• Acute• Short-term • Chronic

• How long?• What triggered/started the problem?

Predisposing Factors

• Genetic• Biological • Psychological• Social

Genetic Factors

• Co-morbidities• Medical• Sleep Disorders• Mood Disorders

Biological

• Hyperarousal• Hyperactivity (ADD/ADHD)• Startle• Physical tension

Psychological

• Personality: Worry, rumination• Type-A; driven, determined• Cognitive style: analytical, problem-

solver

Psychological cont.

• Compassionate, co-dependent, sympathetic/empathetic

• Creatives• Perfectionism

Social

• Living situation• Significant other• Family of Origin

Precipitating Factors

• Medical• Life Stressors• Negative changes • Positive changes• Women • Men• Shiftwork

Negative changes

• Illness• Conflict• Job stress• Financial• Unemployment• Abuse• Divorce

Positive changes

• Retirement• Marriage• Moving• Work• Vacation• Travel

Spielman Model

Perpetuating Factors

• Compensatory strategy• Counter Fatigue measures/ Stimulants• Rituals and Strategies• Self-medication

• Pain and Sleep• Stress and Pain• Stress and Sleep• Sleep and Mood• Mood and motivation• Mood and activity• Activity and weight• Caffeine and Sleep

Compensatory strategy

• Go to bed early “Give myself more of a chance to get

some sleep”• Sleep in (wake up later) “Catch up” “Only chance I have to sleep”• Napping

• Cons: Deprimes sleep homeostat. Dysregulation of circadian rhythm

Erratic sleeping patterns

• Your bedtime varies greatly depending on your mood, favorite television program, or the day of the week.

• This sends confusing messages to the sleep-regulating centers of your brain—a guarantee for all kinds of problems with sleep.

Counter Fatigue measures/ Stimulants

• Increased use • Inappropriately-timed • Avoid or decrease physical activity

• Cons: arousal, mood, conditioning

Rituals and Strategies

• Increase in non-sleep in bedroom and bed

• Sleep in other places• “Rituals” for sleep• Avoidance of behaviors thought to

inhibit sleep

• Cons: lack of stimulus control, dependence, anticipatory anxiety

Dysfunctional Beliefs

• Rewards and reinforcement• Forcing the issue• Catastrophic thinking• Rigid expectations

• I think, therefore I …

Cognitive vs Somatic Lichstein & Rosenthal 1980

• Cognitive arousal 10x more likely to be cited as major cause than somatic arousal

Unwanted intrusive thoughts

• Worry or Cognitive arousal• Most Common - Racing thoughts• “I am unable to empty my mind”• “I can’t turn off my mind”• “My mind keeps turning things over”

Pre-sleep stress/cognitive activity

• Hall, et al 1996 • Wicklow & Espie 2000

• Good sleepers threatened with making a speech

• Increased sleep latency

WHAT ARE YOU THINKING?Watts, Coyle, East 1994

• Mental activity and rehearsal• Thoughts about sleep• Family and long-term concerns• Positive plans and concerns• Somatic preoccupations• Work and recent concerns

Affect-laden thoughts

Vicious cycle (again)

AnticipationPerformance AnxietyArousal

Similar to Panic Disorder

Start to dread, avoid bed and bedtime

Perception of sleep (memory)

• Subjective vs Objective Measures

• Overestimate sleep latency• Underestimate Total Sleep Time (TST)• Underestimate number of awakenings

Neitzer, Semler and Harvey

• Positive and Negative Feedback study

• Negative feedback increased: negative thoughts, sleepiness, monitoring sleep-threat and safety behaviors the next day.

Mendelson 1990

• Another key study applying to use of benzodiazepines

• Objectively: benzos decrease SWS

• Subjectively: report better sleep with benzos

Attention

Insomniacs more aware of: • body sensations• environment• clock• needing to use the bathroom• mood• performance: attention, memory,

concentration failing

Worry about negative consequences of poor sleep

• Catastrophizing / awfulizing• Negative prediction

Similar to Cognitive Distortions from standard CBT –

“All-or-nothing” “Black-and-white” thinking

Unhelpful beliefs in Maintenance of insomnia

• Morin 1993

• Less Realistic about sleep required

• Strongly endorse – negative consequences of insomnia

• More likely to attribute insomnia to external and stable causes

Rewards and reinforcement

• By rewarding yourself with your favorite foods, beverages, or drug of choice when you can’t sleep, you ensure future nights of insomnia. The pleasure centers of your brain have great recall for this type of behavior. They will continue to awaken you to receive more of the same—night after night, after night, after night.

Forcing the issue

• When unable to fall asleep, you try to force sleep to happen with statements such as, “I must get to sleep right now,” or “If I can't get to sleep, I'll just have to force myself to stay in bed until I get to sleep.”

• Creating this negative association with sleep will lead only to frustration.

Harvey 2003b

• Attempts to stop, modify, suppress cognitive arousal may be counter productive

• Other options (discuss cognitive restructuring later)

• Suppress, distract (math problem study, TV, sheep), neutralizing, appraisal, punishment and worry

Catastrophic thinking

• Being unable to sleep, you predict that tomorrow will be a disaster.

• You tell yourself things such as, “I won't be able to function at all tomorrow if I don't get to sleep.”

• This type of thinking creates so much anxiety that you will most likely not be able to return to sleep.

Rigid expectations

• You believe that sleep is dependent on rigidly imposed expectations. You create a flexible work schedule that permits you to sleep in, expect a 100-percent quiet sleep environment, and strive for a stress-free life.

• If for some reason you cannot meet these conditions, you begin to worry that you will not be able to sleep.

Self-medication

• Alcohol• Marijuana• OCT – [Benadryl, Nyquil, Unisom,

Tylenol PM]• Melatonin as hypnotic

• Cons: REM-supression, fragmentation, withdrawal, rebound insomnia, dependence, circadian rhythm shift

Medication dependence

• You take a nightly sleeping pill “just in case”—without first determining whether you really need it.

• After a few weeks of this, you can lose confidence in your ability to sleep without the pill, creating the perfect set-up for a pattern of medication dependence.

Chronic, perpetual problems

• Pain, disability• Are you managing or coping as best as

you can?• Resources, trying new ways or

approaches, support group• Mood: Depression and Bipolar D/o

• Mental Disorders• Pain• Hormone: menopause,

hyperthyroidism• Medication• Neurological• Medical

Organic disorders

• Similar symptoms of primary or psychophysiologic insomnia

• Delayed Sleep Onset• Sleep maintenance, early awakening.• “Light” sleep• Frequent awakenings• Non-restorative sleep

Sleep-Disordered Breathing - SDB

• Obstructive Sleep Apnea• Central Sleep Apnea• Mixed Apnea• Upper Airway Resistance Syndrome• Hyponea• Obesity Hypoventilation Syndrome

Symptoms

• Snoring• Apnea: snort, gasp, choke, pause, puff• Dry throat/dry mouth• Heart racing• Shortness of breath• Headache• Numbness/tingling in limbs• Muscle pain/soreness• GERD

Risks

• Daytime impairment, sleepiness

• Heart Disease• Hypertension• Diabetes• Stroke

Limb movement Disorders

Restless Leg Syndrome

• Do you feel a strong desire to move your legs from time to time, often when they make you uncomfortable?

• Do those sensations in your legs occur or get stronger when you are inactive?

• Does moving around or stretching help ease those uncomfortable sensations in your legs?

• Do those uncomfortable sensations feel their worst at night?

Other RLS symptoms

• Burning• Creeping• Crawling• Aching• Tingling• Itching • Tugging

Periodic Limb Movement Syndrome

• PLMS• Prevalence of PLMS seems to increase with

age. • 45% elderly adults aged 65 years and older

had PLMS, compared to 5% to 6% of the younger adult population.

• 80% of those with RLS also had PLMS. • • Rule out SDB

Parasomnias

• Nightmare disorder • Sleep terror disorder • Sleepwalking disorder • Sleep talking• REM-Behavior disorder• Bruxism

Confusional arousals

• Arousals during REM

• Vs sleep talking

Narcolepsy

• Cataplexy: a sudden loss of muscle tone while in a conscious state

• Hallucination• Sleep paralysis

AWP 2010, Portland, OR

Hex of Insomnia

homeostat

arou

sal

life style

rhythm

associa

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ions

beliefs

Circadian Rhythm Biology

Normal Sleep Pattern

Monday Morning Blues

Delayed Sleep-Phase Disorder

DSPS

• “Night Owl”• Teens• Seasonal Affective Disorder

• Jet Lag/Shift Work

Advanced Sleep-Phase Disorder

Entrainment Zeitgerbers

• How to reset your body clock every day?

• Retrain your body:• Daytime• Nighttime

Light exposure

Light Box

Light and Sleep-Wake Rhythm

Physical Activity

Meal times

Wake Time