Asst. Prof. Tantawan Awirutworakul

Department of Psychiatry

Faculty of Medicine

Ramathibodi Hospital

Non-Pharmacological Treatment of

Insomnia

DSM-IV ICSD-2 DSM-V (Proposed)

Diagnosis for primary

insomniaPrimary insomnia (307.42)

Psychophysiological insomnia

(307.42)Insomnia disorder

Paradoxical insomnia (307.42)

idiopathic insomnia (307.42)

Comorbid insomnia disorder

Sleep disorder due to general

medical condition, insomnia type

(327.01)

Insomnia due to medical condition

(327.01)

No separate category; includes

specifier to clarify comorbid

physical or mental illness

Insomnia related to another

mental disorder (327.02)

Insomnia due to mental disorder

(327.02)

Duration

Difficulty initiating or maintaining

sleep, or nonrestorative sleep for

at least 1 month

Not specified

Sleep difficulty occurs at least 3

nights per week, for at least

3 months

Other subtypes of insomnia Substance-induced insomnia

Adjustment insomnia, inadequate

sleep hygiene, insomnia due to

drug or substance, insomnia

unspecified and physiological

insomnia

Not yet specified

Summary of insomnia diagnoses across classification systems

Precipitating and Perpetuating Factors Contribute to Insomnia Over

TimeIN

SOM

NIA

SEV

ERIT

Y

TIME

THRESHOLD

Spielman AJ et al. Assessment techniques in Insomnia. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. Philadelphia, PA: Elsevier Saunders, 2005: Ch 119.

Precipitating Factors

Perpetuating Factors

Predisposing Factors

Insomnia

Hyper-arousal disorder not

related to another condition

Due to any of the following

• Psychiatric illness

• Medical illness/ medications

• Other sleep disorders

– Obstructive Sleep Apnea– Circadian rhythm disorders– Narcolepsy– Restless Leg Syndrome

Primary

Co-morbid (secondary)Insomnia

Determinants of SleepTwo-process Model of Sleep Regulation

Sleep propensity increases as waking accumulates and dissipates with sleep (Process S)

Sleep propensity oscillates with a daily (circadian) variation (Process C)

Social/External Factors

Intrinsic Illness

Borbély AA, Achermann P. 2000

Arousal Systems in Insomnia Subjects That

Do Not Deactivate From Waking to Sleep

ARASARAS

Thalamus

Mesial

temporal

cortex

Hypothalamus

Cingulate

Mesial

temporal

cortex

Hypothalamus

ARAS

Insular

cortex

ARAS, ascending reticular system.Nofzinger EA et al. Am J Psychiatry. 2004;161(11):2126-2128.

Core Temperature

Heart Rate

Plasma Melatonin

Plasma Cortisol

Happiness

N=11 insomniacs and N=13 controls

BMI (25) and age (29 yrs) matched

24-hour blood sampling every 30 min.

Significant 24-hour increase; significant daytime (730-2230); significant sleep (2300-630) increase

HPA Hyperactivity in Insomnia: Cortisol

BMI = Body Mass Index.

Vgontzas AN et al. J Clin Endocrinol Metab. 2001;86:3787-3794.

0

50

100

150

200

250

300

350

400

450

500

550

08:0

0

10:0

0

12:0

0

14:0

0

16:0

0

18:0

0

20:0

0

22:0

0

00:0

0

02:0

0

04:0

0

06:0

0

Cor

tiso

l (n

mol

/L

)

Time (Clock Hours)

Insomniacs Normals

Catecholamines in

Primary Insomnia

NE (µg/24 h) Epi (µg/24 h)

0

10

20

30

40

50

60

70

80

Uri

nar

y E

xc

reti

on

(µ

g/

24 h

)

Normal (n=7)

Insomnia (n=10)

1. Richardson GS, Poe GR, Seymore A, Roth T: Objective and subjective sleep disruptionfollowing dietary salt restriction in normal subjects. Sleep. 2001;24(abstract suppl):A114.

2. Vgontzas AN, et al. J Psychosom Res. 1998; 45 (1 Spec No): 21-31).

rxy=.49 (P=.07)

Norepinephrine (µg/24 hr)W

ake

Tim

e A

fte

r Sl

ee

p O

nse

t (m

ins)

Sleep-Wake History

Daytime activities

& symptoms

Pre-sleep activities

&symptoms Events during sleep

Events on awakening

Sleep

12:00 Midday 0:00 midnight

Sleep-Wake History

Daytime activities

& symptoms

Pre-sleep activities

&symptoms Events during sleep

Events on awakening

Sleep

12:00 Midday 0:00 midnight

Relaxation therapy

Process or activity

: Helps a person to relax

: Increased calmness

: Reduce levels

- Anxiety

- Stress

- Anger

Relaxation

Stress management

program

Decrease muscle tension

Lower the blood pressure

Slow heart & breath rates

Other health benefits

Relaxation technique

Progressive Muscle Relaxation

Deep breathing

Meditation

Yoga

Deep breathing

- Expansion : Abdomen > Chest

“หายใจเข้าท้องป่อง หายใจออกท้องแฟบ”

Meditation

-Promote relaxation

-Build internal energy or life force

Example

- Breathing

- Wisdom words

- Movement

Usefulness:

Relaxation

Calm

Compassion

Love

Care

Clip : ))

Yoga

Progressive Muscle

Relaxation

- Learning

: Specific muscle group

Tense

- By Tensing

Letting it go

- Clip : )))

- Exercise

Recording and display

- Small changes in the physiological level

Visual

Auditory

Awareness of many physiological functions

Provide information on the activity

Biofeedback

Goal : manipulate them at will

Usefulness :

- Improve health, performance, and the physiological changes

- Changes to thoughts, emotions, and behavior

Feedback instrument

Electroencephalograph (EMG)

Electroencephalograph (EEG)

Electrocardiograph (ECG)

heart rate variability (HRV)

VDO

Biofeedback 1

Biofeedback 2

VDO

- Stress 1

- Stress 2

- Relax 1

- Relax 2

Bruxism

- EMG –masseter muscle

- High tone - muscle contract

- Low tone –muscle relax

Patients- learn to alter the tone

Relaxation

Sleep Feedback

: Sound Alarms

Not appear to be effective in reducing

nocturnal bruxing

"subjects learned to ignore the tone

and to maintain sleep."

Cognitive Behavioral Therapy vs Relaxation

Therapy for Primary Sleep-maintenance Insomnia

CBT = Cognitive Behavioral Therapy.

PMR = Progressive Muscle Relaxation.

PT = Placebo Therapy.

TST = Total Sleep Time.

MWASO = Middle Wake Time After Sleep Onset.

Edinger JD et al. JAMA. 2001;285:1856-1864.

72

74

76

78

80

82

84

86

CBT PMR PT

P<.002; CBT>PMR and PT

Mean Sleep Efficiency

(%)

0

10

20

30

40

50

CBT PMR PT

P=.004; CBT<PMR and PT

Mean MWASO

Min

utes

5.3

5.4

5.5

5.6

5.7

5.8

5.9

6.0

6.1

6.2

6.3

CBT PMR PT

P=.02; CBT>PT

Mean TST

Hou

rs

Mindfulness Training Results from the University of

Pennsylvania

MALADAPTIVE HABITS•Excessive time in bed

•Irregular sleep schedule

•Daytime napping

•Sleep- incompatible activities

AROUSAL•Emotional

•Cognitive

•Physiologic

DYSFUNCTIONAL COGNITIONS•Worrying over sleep loss

•Ruminating over consequences

•Unrealistic Expectations

CONSEQUENCES•Mood Disturbances

•Fatigue

•Performance impairments

•Social Discomfort

Cycle of Persistent Insomnia

Hope you all sleep well.