Behav Trtmt Sleep Disorders

Behavioral Treatment for Sleep Disorders: 

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

Behavioral Medicine & Sleep: 

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

Insomnia: 

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.

Insomnia: 

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.

Insomnia: 

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

Behavioral Model of Insomnia: 

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.

Behavioral Model of Insomnia: 

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.

Cycle of Persistent Insomnia: 

Cycle of Persistent Insomnia

Cognitive Behavioral Therapy (CBT) for Insomnia: 

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.

Cognitive Behavioral Therapy (CBT) for Insomnia: 

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

Cognitive Behavioral Therapy (CBT) for Insomnia: 

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

Cognitive Behavioral Therapy for Insomnia: 

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

Stimulus Control Therapy: 

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

Stimulus Control Therapy: Rules: 

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

Stimulus Control Therapy: Caution!: 

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

Sleep Restriction Therapy: 

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

Sleep Restriction Therapy: 

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

Sleep Restriction Therapy: 

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

Sleep Restriction Therapy: Cautions!: 

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.

Sleep Hygiene Education: 

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

Sleep Hygiene Education: 

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

Cognitive Therapy: 

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.

Relaxation Training: 

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

Mindfulness-based stress reduction: 

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. 

Circadian Rhythm Disorders: 

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

Phototherapy- Light Therapy: 

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

Phototherapy- Light Therapy: 

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.

Chronotherapy: 

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

Chronotherapy : 

Chronotherapy General Principle: Phase Shifting

Normal Sleep Pattern: 

Normal Sleep Pattern

Advanced Sleep-Phase Disorder: 

Advanced Sleep-Phase Disorder

Delayed Sleep-Phase Disorder: 

Delayed Sleep-Phase Disorder

Shift Work Disorder: 

Shift Work Disorder

Irregular Sleep-Wake Rhythm: 

Irregular Sleep-Wake Rhythm

Advanced Sleep-Phase Disorder: 

Advanced Sleep-Phase Disorder

Delayed Sleep-Phase Disorder: 

Delayed Sleep-Phase Disorder

Jet Lag Disorder: 

Jet Lag Disorder

Jet Lag Disorder: 

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

Obstructive Sleep Apnea: 

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

Obstructive Sleep Apnea: 

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

Restless Legs Syndrome (RLS): 

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

Parasomnias: 

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

Resources: 

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

Resources: 

Resources Stanford Sleep Disorders Clinic offers Group therapy- insomnia workshop, night owls workshop and CPAP workshop Individual therapy (650) 723-6601

Resources: 

Resources Full Catastrophe Living by Jon Kabat-Zinn