Assessment & Models of Insomnia Flashcards
ICSD-3 insomnia criteria
A. Difficulty initiating sleep, difficulty maintainning sleep and/or early morning awakening
B. 1-item daytime impairment/dissatisfaction with sleep
C. Despite adequate opportunity for sleep
D. > 3x/week
E. > 3 months
F. Not better explained another sleep disorder
Ways to assess insomnia
Clinical interview
Sleep diaries
Questionnaires
Actigraphy
Polysomnography
Clinical interview
1 on 1 interview
Ask questions to determine which criteria they fit
e.g. “what does your typical night look like?” will determine DIS, DMS and EMA, “When did your sleep problem start?”
Consensus sleep diary
Carney et al., 2012
Answer questions each day about their sleep that night to determine symptoms
Measures:
- sleep onset latency
- wake after sleep onset
- early morning awakening
- total sleep time
- time in bed
- sleep efficiency
Insomnia severity index
Morin, 1993
Questions about satisfaction, DIS, DMS, EMA…
0-4 likert scale
Sleep condition indicator
Espie et al., 2014
8 items asking about sleep over the past month
Answers score from 4 to 0
High scores indicate better sleep
Dysfunctional beliefs about sleep scale
Morin, 1993
0-10 likert scale, strongly disagree - strongly agree
assesses persons beliefs about sleep e.g. how much sleep they need to function well, what they believe will happen if they don’t get enough sleep
Insomnia questionnaires
Insomnia severity index (Morin, 1993)
Sleep condition indicator (Espie et al., 2014)
Dysfunctional beliefs about sleep scale (Morin, 1993)
Actigraphy
Not commonly used but can help to exclude possibilities of other sleep disorders related to the body clock
Worn like a watch
Accelerometer measures and records movement (black spikes on output) - lack of spikes on output = less movement = sleep? Could just be laying still in bed –> not a true measure of sleep
Also records light (yellow spikes on output)
Polysomnography
Used to measure wakefulness, REM sleep and NREM sleep
EEG measures cortical activity
EOG measures eye activity
EMG measures muscle tone
Measure respiratory effort to rule out apnoea conditions
How do we measure NREM sleep?
Electroencephalography (EEG)
Electrodes on scalp measure cortical activity
10-20 system –> electrodes placed at 10% and 20% distances between facial landmarks e.g. nose, ears
How do we measure REM sleep?
EEG to measure cortical activity, EOG (electrooculography) to measure lateral eye movement and EMG (electromyography) to measure muscle tone
EOG electrodes placed above and right of right eye, below and left of left eye. Positive signal when eye looks toward the electrode so…
- Left looking left = positive signal
- Left looking right = negative signal
- Right looking right = positive signal
- Right looking left = negative signal
EMG electrodes placed on and under chin
- chin EMG is relatively reduced during REM sleep
Misperception of total sleep time and hypertension in insomniacs
Vgontzas et al., 2009
Measure sleep objectively with PSG
- Insomniacs who underestimate TST have greater risk of hypertension
- 5x higher risk if they also have short sleep time
Insomnia and depression
Insomnia is a common feature of major depression
Insomnia predicts development of depression (Riemann et al., 2003)
Treatment of insomnia enhances effects of treatment for comorbid depression (Fava et al., 2006)
CBT-I enhances depression outcome in patients with comorbid major depressive disorder and insomnia (Manber et al., 2008)
What is the 3-P model?
3-P model:
- Spielman & Glovinsky, 1991
- Based on stress-diathesis model
- Predisposing factors (increase risk of insomnia)
- Precipitating factors (push over insomnia threshold)
- Perpetuating factors (behaviours that maintain insomnia)
3-P model Evidence
- Miller et al. (2014) - meta-analysis of 1344 studies
- Stand-alone SRT effectively treats chronic insomnia
3-P model limitations
- Doesn’t address development of insomnia from acute to chronic
Stimulus control model
Bootzin and Nicassion, 1978
- Based on operant conditioning - behaviour is present when stimulus is present
- Good sleepers: bedroom is condusive to sleep, don’t do other activities there - good stimulus control
- Insomnia: bedroom is also condusive to many other activities e.g. work, watching TV, playing video games - poor stimulus control
Stimulus control model limitations
Doesn’t take into account effects of classical conditioning - pairing of environment and behaviour. Bedroom is where person performs waking activities - automatic behaviour of arousal
Lack of evidence
Cognitive model of insomnia
Harvey
- Based on sympathetic responses
- Negative beliefs about sleep trigger arousal (stress)
- selectively attend info which supports their beliefs (e.g. mistakes at work)
- safety behaviours (e.g. take on less intensive work)
- feedback loop bc beliefs about sleep are affecting their life
Cognitive model evidence
Morini, 1993 - insomnia patients hold dysfunctional beliefs about sleep
Edinger et al., 2001 - cognitive treatment reduces negative beliefs about sleep
Semler & Harvey, 2004 - Insomnia patients monitor and attend to sleep-related stimuli
Harvey, 2002 - insomnia patients engage in safety behaviours
- interfering with regularity of sleep cycle e.g. naps, going to bed early
- interference with getting to sleep e.g. drinking coffee, watching TV/reading in bed, planning the next day
- paradoxical fuelling of thoughts e.g. telling self to stop worrying, telling self to go to sleep
- exacerbation of daytime sleepingess e.g. skipping exercise, cancelling appointments
Cognitive model limitations
Cause and effect - do the cognitions cause the insomnia or does the insomnia cause the cognitions?
Interacting component approaches
- Morin, 1993 – integrative model of insomnia
- Dysfunctional cognitions
- Maladaptive behaviour
- Psychological arousal
- Physical consequences
- Espie et al., 1991 – interacting systems model
- Arousal caused by psychological, cognitive and behavioural factors
- CBT-I addresses behavioural and cognitive theories of insomnia
Neurocognitive model of insomnia
Perlis et al., 1997
Adds on the 3-P model
- Classical conditioning
- Pairs bed to wakefulness – conditioned arousal
- Cognitive alterations
- Perception of time before sleep – attend to sensory processing
- Increased STM and LTM
- Perceived wakefulness
