Insomnia Flashcards
INSOMNIA: IS IT A PROBLEM?
Who has slept poorly at least once?
Who sleeps poorly regularly?
Who has a sleeping problem?
Who has slept poorly at least once? 95% of the population
Who sleeps poorly regularly? 30% of the population
Who has a sleeping problem? 10% of the population
WHY DO WE NEED SLEEP?
We still don’t really know
We know what happens if you don’t sleep:
> Physical: Inflammation processes are disturbed
> Cognitive: Poor memory
> Emotional: Mood swings + irritable
> Ultimately: death
HOW MUCH SLEEP DO WE NEED?
WHAT IS SLEEP?
5 fases = 1 cycle = about 1,5 hr Every night: 4 a 5 cycles
Start of the night: most of the deep sleep
the phases are: awake, REM-sleep, snooze, light sleep, moderate deep sleep and deep sleep
WHAT MAKES US SLEEP?
2 mechanisms
- Circadian rhythm (C)
- Regulates hormones in our body (e.g. melatonine)
- Normally slightly longer than 24hrs
- Regulated by cues = “zeitgebers” e.g. light
- Also regulates appetite, core body temperature etc.
- Homeostatic sleep process (S)
- Accumulation of sleep inducing substances in the brain during waking hours
- The longer you are awake à the more tired
- During sleep you break down the substances
WHY DO WE NOT SLEEP? (hyperarousal)
Hyperarousal
Impossible to ‘switch of’
During acute stress periods
Or chronic stressors:
- Too busy during the day
- Ruminating too much
- Then: Ruminating about sleep
- Develop bad sleep habits: Circle!
Likelihood of sleep disturbance (types of insomnia)
WHY DO WE NOT SLEEP?
- individual vulnerability
- precipitating factors
- perpetuating factors
In summary:
Individual vulnerability > Biological, personality
Precipitating factors > Stress and life events
Perpetuating factors > Dysfunctional sleep habits: going to bed early (or very late), to lie in in the morning, take a nap etc
INSOMNIA: WHEN IS IT A DISORDER?
DSM-IV: sleep disorder
DSM-5: sleep- wake disorder
DSM-5: Insomnia Disorder:
- Difficulty initiating or maintaining sleep (at least 30 minutes per night)
- At least 3 nights a week
- At least 3 months
- Causes clinically significant distress or impairment in daytime functioning
Other sleep disorders:
- Sleepapnea = breathing stops §
- Restless legs
- Circadian rhythm disorders=sleep at the wrong moment §
- Parasomnia = nightmares
- Hypersomnolence=excessive sleepiness (during day)
How (with what) do you measure sleep/insomnia?
Objective:
- Polysomnography: gold standard
- Actigraphy: NB not Fitbit etc
Subjective:
- sleepdiary
Various sleep estimates:
- Sleep Onset Latency – time to fall asleep
- Totale Sleep Time
- Sleep Efficiency - % asleep of total time in bed
- Wake After Sleep Onset
INSOMNIA: HOW DO YOU MEASURE IT?
(Objective v. subjective)
Objective ≠ subjective
Good sleepers: overestimate hours of sleep
Poor sleepers: underestimate hours of sleep
INSOMNIA: HOW DO YOU MEASURE IT? (Questionnaire)
Questionnaire: Insomnia Severity Index
INSOMNIA: CONSEQUENCES
- Tired
- Mood swings
- Poor concentration
- Absence school / work
- More use of health care
- Higher risk on other disorders > Depression > Anxiety > Cardiovascular > Mortality
TREATMENT: MEDICATION
Sleep medication (called hypnotics): OK, if it is every now and then
- If long-term: > dependent > Not alert > Chance on accidents
Antidepressants
- More and more used
- Currently trials in NL (amitryptiline)
Melatonine
- Only effective in jetlag
- Might enhance insomnia
TREATMENT: MANY APPS AVAILABLE
Mostly based on:
- Relaxing music or noise
- Relaxation exercices
- Measuring sleep (phases)
However: No proof at all that this is effective
TREATMENT: PSYCHOLOGICAL
CBTi
- Psycho-education
- Sleephygiene
- Stimulus control
- Sleeprestriction
- Cognitive therapy
- Relaxation exercices
§ Psycho-education
Psycho-education:
Information about sleep & sleep disorders
- e.g. sleep phases, number of hours
Sleephygiene
Behavior that can promote sleep:
Behavior that can promote sleep:
- No coffee
- No alcohol
- Relaxation during the day
- Bedroom (noise, light)
- Not looking at alarm clock etc
Stimulus control
- “Conditioning’ on sleep
- Slowing down the day
- bedroom only for sleep (and sex)
- Create 24 hours rhythm
- Fixed times to go to bed
- Fixed times to get up
- No sleep during the day
Sleeprestriction
- Restrict number of hours in bed (to average hours of sleep)
- When sleeping through: slowly increase hours
Rationale: In bed for many hours -> many hours awake
Less hours in bed
- Building sleep ‘sleep debt’
- Increases chance on sleeping through
- People feel much better
Cognitive therapy:
Usually aimed at:
- Disfunctional thoughts about sleep
E.g.: “I need 8 hours of sleep to function well”
“I avoid commitments (social, family) after a bad night”
Relaxation exercises (TREATMENT: PSYCHOLOGICAL)
Audio fragments or book
Is a skill you need to practice!
Practice during the day
Effectiveness
CBTI: meta-analyses
(Van Straten et al. Cognitive and behavioral therapies in the treatment of insomnia: a meta-analysis. Sleep Medicine Reviews. 2017. 87 randomised controlled trials; ca. 6.000 patients § Effects of (elements of) CBTi compared to no treatment / waitlist)
Effects:
- Not: sleeping more hours
- But less wakenings
- With circadian rhythm
- Feeling more rested
- More in control of sleep problem
- Less anxious and depressed
ONLINE TREATMENT
- Consensus about treatment components
- Relatively easy to translate to online (e.g. iSleep)
ONLINE TREATMENT (iSleep)
5 lessons:
- Sleep and habits
- Improving sleep pattern
- Less ruminating, more relaxation
- Changing disfunctional beliefs
- The future
Every lesson:
- Sleepdiary
- explanation
- Video clips expert & patient
- Homework
Online feedback after every lesson by coach
I-SLEEP effectiveness
Internet CBT voor insomnie is effectief
TAKE HOME MESSAGE VANDAAG
Insomnie = volksgezondheidprobleem Goed te behandelen met CGT Ook online
treatment: many apps available
Cognitive therapy (How to stop ruminating)
Stop rumination
Alternative thoughts
Without emotional content
e.g.
- Rehearsing capitals
- Telefone alphabet
- Counting sheep!
