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current topics 2 > L6: insomnia > Flashcards

L6: insomnia Flashcards

1
Q

what is insomnia according to the dsm? (5)

A
  1. difficulty initating sleeping, maintaining sleep or early morning awakening (for min. 30 mins per night)
  2. for min. 3 nights a week for min. 3m
  3. causes sig distress or impairment in functioning (daytime complaints)
  4. not explained by another condition
  5. occurs despite adequate opporutnity for sleep
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2
Q

what are some of the daytime complaints associated w insomnia? (6)

A
  • difficulty concentrating or slowed thinking
  • fatigue
  • delayed reflexes
  • difficulty remembering things
  • mood disruptions, anxiety, especially irritability
  • disruptions in work or social routines
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3
Q

what is the prevalence of insomnia? (6)

A
  • most common sleep disorder
  • symptoms of insmonia: 30% of adult pop
  • insomnia diagnosis: 10% of adult pop
  • more prevalent in women (3:2)
  • more insomnia symptoms in psychiatric samples (50-90%)
  • more insomnia symptoms w age
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4
Q

what are the risks associated w insomnia? (6)

A
  • psych: emotional distress, depression, anxiety suicidal behaviuor
  • physical: diabetes, cardiovascular disease / hypertension
  • falling & accidents
  • reduced quality of life
  • reduced social & occupational functioning
    -> insomnia is a personal, societal, and economic burden (costing 150billino a year)
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5
Q

how are insomnia & depression related? (4)

A

-ppl w depression (60-80% have sleep complaints)
- ppl w insomnia: 40% have a clinical depression & 3x more likely to dev a depression & depression treatment is less succesful

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6
Q

can you treat insomnia to improve depression? (1)

A

yes, treating insomnia can indirectly improve mood complaints

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7
Q

how does insomnia develop? (3p model & how it relates to every type of insomnia) (7)

A

3P model: predisposing factors (aka vulnerabilities), precipitating facotrs (aka triggers), perpetuating factors (aka maintaining)
types of insomnia:
pre morbid: predisposing factor
acute: predisposing + precipitating
early: predisposing + precipitating + perpetuating
chronic: predisposing + little precipitating + lots of perpetuating

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8
Q

what are the predisposing factors of insomnia? (3)

A
  • genetic factors (incl brain areas associated w emotion reguation)
  • personality traits (neuroticism, perfectionism)
  • sensitivity to stress
  • being a woman at menopause age
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9
Q

what are the precipitating factors of insomnia? (5)

A
  • stressful situations or life events
  • depression
  • chronic pain
  • noise disturbance
  • substance or medication use
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10
Q

what are perpetuating factors of insomnia? (3)

A
  • poor sleep habits (like going to bed too early, sleeping in, irregular sleep schedule, napping, safety behaviours)
  • worrying &negative beliefs about sleep & its impact
  • substance use
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11
Q

what are the main models used to explain how insomnia arises? (3)

A
  • 3P model: precipitating, perpetuating, predisposing factors
  • cognitive behavioural model
  • attention-intention-effort pathway
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12
Q

what is the role of REM sleep instability? (3)

A

maintains hyperarousal & emotional distress which could make u more vulnerable to insomnia & other mental disorders

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13
Q

how does arousal & hyperarousal interact w insomnia? (4)

A

can be emotional, cognitive, physio
in insomniacs: hyperarousal usually higher during day & night

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14
Q

what are the physio indicators of hyperarousal in insomnia (8)

A
  • increased body temp
  • increased metabolic rate
  • increased heart rate & variability
  • inrease HPA axis activity
  • increased EEG fast frequencies during sleep
  • increased nr of arousals during rem sleep
  • increased daytime sleep-onset latency
  • short sleep duration
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15
Q

how does the attention-intention-effort pathway explain the how insomnia arises? (5)

A

if u cant sleep for nights on end, then u:
- start focusing on the sleep problem (what could be the cause? ATTENTION)
- try to control your sleep (INTENTION) cause if not…
- doing everything you can to improve your sleep!! (EFFORT)
problem here is that sleep is an automatic process, efforts to control sleep can inhibit its natural expression

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16
Q

what does psychotherapy for insomnia focus on? (1)

A

changing maintaining factors (like maladatpvie sleep habits, safety behaviour, dysfunctional cognitions, hyperarousal, efforts to control sleep)

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17
Q

what is the diagnostic process of insomnia? (4)

A
  1. clinical intake
  2. sleep diary
  3. optional: questionnaire (Insomnia Severity Index)
  4. optional: physio sleep tests
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18
Q

what physio tests can u do to measure sleep? (2)

A
  • polysomnography (PSG): measures same parameters as a sleep diary, can identify range of sleep disorders
  • actigraphy (wristband): to identify irregular bedtime patterns
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19
Q

what is paradoxical insomnia? (3)

A

when patients believes they are not sleeping & write this down in sleep diary, while objectively and according to PSG they are asleep
but subjective complaints, according to dsm, is our focus, not the physio measures

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20
Q

how does the clinical intake of insomnia go? (4)

A
  • it provides insight into type & severity of sleep problem
  • by asking direct questions about sleep complaints
  • inquire about daytime consequences
  • be specific
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21
Q

what are some specific questions from the insomnia intake? (8)

A
  • what time do you go to bed
  • how long does it take u to fall asleep
  • how often do u wak up during the night
  • how long does that last
  • what do you do/think about during that time
  • what time do you wake up for the last time
  • what time do u get up
  • do you take naps during the day
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22
Q

what are you inquiring about with the insomnia intake interview? (7)

A
  • onset, course, frequency, 3P model
  • complaints also during vacations/weekends?
  • balance activity vs relaxation
  • worrying, anxiety, panic, mood
  • caffeine, alcohol, medication
  • nightmares
  • hormonal influences (menopause)
23
Q

what is the sleep diary? (3)

A
  • discussing how you slept last week
  • with wake up times, times you were in bed etc
  • use for diagnostics & treatment
24
Q

what is the current treatment situation for insomnia? (4)

A
  • far from optimal!
  • most insomniacs do not go to their GP
  • of those who go 50-75% get meds
  • only 1% of insomniacs get the recommended treatment
25
Q

what is the recommended insomnia treatment? (2)

A

CBT for insomnia (CBT-I) (for every age)
- meds only for short term use & as 2nd choice (if CBT I is ineffective or unavailable)

26
Q

what are the downsides of using meds for insomnia? (3)

A
  • addictiveness
  • short action duration
  • patients lose confidence in their own ability to sleep
27
Q

what are the most common sleep meds? (5)

A
  • benzodiazepines
  • benzodiazepine receptor agonists
  • antipsychotics
  • antidepressants
  • melatonin
28
Q

what are the specific downsides of benzos as a sleep medication? (3)

A
  • dependence
  • daytime drowsiness
  • disrupted REM sleep
29
Q

what are the specific downsides of antipsychotics & antidepressants as a sleep medication? (1)

A

limited knowledge about their effectiveness & long term pros and cons

30
Q

what are the risks of melatonin? (2)

A
  • only effective if u have a melatonin deficiency, which very little ppl have
  • incorrect timing can worsen sleep issues
31
Q

what are the 3 main elements of CBT I? (3)

A
  • psychoeducation & sleep hygiene
  • cognitive therapy
  • behavioural therapy
32
Q

what is the psychoeducation given in CBT I? (6)

A
  • function of sleep
  • sleep quality vs quantity
  • core sleep vs residual sleep
  • sleep quality reduces w age
  • sleep as a 24h phenomenon
  • 3P model & maintaining factors (sleep safety behaviour)
33
Q

what are the important sleep hygiene tips in CBT I? (9)

A
  • keep bedtimes consistent
  • create a wind-down period before bed
  • avoid screens 1-2h before bed
  • limit caffeine & nicotine
  • avoid large meals & alcohol before bed
  • create a cool, dark, quiet bedroom
  • use ur bed only for sleep or sex
  • avoid checking the clock during the night
  • get natural light and exercise during the day
34
Q

what does the cognitive therapy componenet of CBT I consist of? (5)

A
  • cognitive reappraisal
  • special attention to dysfunctional sleep-related thoughts (like “if i dont sleep i wont be able to get thru tomorrow)
  • plan in “worry time” during the day
  • thought blocking (ex: visualize stop sign at thoughts racing)
  • paradoxal intention (“stay awake as long as you can”)
35
Q

what does the behavioural therapy componenent of CBT I consist of? (6)

A
  • stimulus control
  • sleep restriction
  • relaxation exercises (less focus)

core strategies
- keep consistent bed & rise times (stimulus control)
- use bed only for sleeping (stimulus control)
- reduce time spent in bed (sleep restriction)

36
Q

what is the goal of stimulus control? (part of behavioural therapy which is part of CBT I)?

A

associate bed w sleep & not w worry, anxiety, frustration, work, eating, netflix, lying awake …

37
Q

how does stimulus control (part of behavioural therapy which is part of CBT I) work? (5)

A
  • get out of bed after 20min of lying awake
  • if u go out of bed, do something that does not arouse you (like read)
  • go back to bed when feeling sleepy
  • go out of bed as often as needed, until you sleep, but keep a set rise time
  • dont nap during the day
38
Q

what is the philosophy behind sleep restriction (part of behavioural therapy which is part of CBT I)? (1)

A

less time in bed can improve sleep

39
Q

how does sleep restriction (part of behavioural therapy which is part of CBT I) work? (6)

A
  1. look at time in bed vs total sleep time
  2. total sleep time becomes the new time in bed (5h minimum)
  3. decide the rise & bedtimes together w patients
  4. patient keeps these bedtimes for 7 days, no napping
  5. prepare your client: start is tough, fatigue, concentration problems, careful with driving, machines etc
    from week 2 onwards
  6. review & adjust bedtimes weekly (for 4-6w) (look at sleep efficiency: if Se<85% reduce time in bed by 15min, if SE 85-90% keep similar, if SE>90% add 15min to time in bed
40
Q

what is the sleep efficiency (SE) equation? (1)

A

(time asleep / total time in bed ) *100

41
Q

what is the effectivity of CBT-1? (4)

A

2/3 patients improve
large effect on insomnia = 1.0
medium effect on depression .35-.68
so it also influences comorbidities & general quality of life

42
Q

what is the effectivity of standalone sleep restriction? (3)

A
  • also effective as stand alone insomnia treatment
  • large effect on insomnia .93
  • medium effect on depression .45
43
Q

what makes stand alone sleep restriction an appealing treatment? (4)

A
  • quite effective
  • straightforward protocol
  • telephone/remote
  • can be provided by basically anyone w some psych background
44
Q

how does ACT-I work for insomnia? (5)

A

acceptance & commitment thearpy for insomnia
- letting go of the struggle to control sleep
- by increasing psych felxibility skills
- these skills are theorized to change the influence of maintaining factors of insomnia, like sleep related arousal, safety behaviours, and dysfunctional cognitions

45
Q

what is the theory behind ACT I? (2)

A
  • attention intention effort pathway: controlling your sleep doesnt work
  • psych flexbility model:
46
Q

what are the 6 psych flexibility skills taught in ACT?

A
  • acceptance (be willing to experience difficult thoughts)
  • cognitive defusion (observing your thoughts without being ruled by them)
  • being present
  • self as context (notice your thought)
  • values (discover whats really important to u)
  • commitment (take action to pursue the important things in ur life)
47
Q

what is the goal of ACT I? (3)

A
  • decrease the controlling realtionship w sleep
  • increase valued living -> values & commited action
  • reduce suffering, react more effectively to difficult inner experiences related to insomnia, improve valued living -> mindfulness skills
48
Q

why is PSG (polysomnography) controloversial as a routine diagnostic tool? (1)

A

due to discrepancies between subjective sleep complaints and objective measures.

49
Q

what are the challenges in CBT I? (2)

A
  • not all patients respond to it (1/3 dont)
  • long term benefits can fade
50
Q

what does future research on insomnia need to look at? (2)

A
  • research into insomnia phenotypes - objective measurements (like eegs) need to be dev better
  • prevention strategies
51
Q

what are common comorbidities w insomnia? (3)

A
  • mental health issues (depression, anxiety, ptsd)
  • physical disorders (cvd, diabetes)
  • other sleep disordrs: obstructive sleep apnea, restless legs syndrome
52
Q

what is dCBT - I? how effective is it?

A

digital version of CBT I
shows similar efficacy as face to face CBT I

53
Q

what are good adjunct therapies to add while using CBT I? (3)

A
  • pharmacological interventions when CBT I alone is inefficient
  • light therapy
  • exercise

current topics 2 (6 decks)

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