Treatment of Insomnia Flashcards
Key components of CBT-I
Multi-modal
- Stimulus control therapy
- Sleep restriction therapy
- Cognitive therapy
- Relaxation therapy
Aim to change beliefs and attitudes about insomnia and behaviours which maintain it
Stimulus control therapy
CBT-I
Eliminate wakeful stimuli from the bedroom (eating, reading, TV, working, worrying
Reset bed-sleep relationship
- Only go to bed when tired
- get out of bed if not asleep after 15 mins & go to another room until feeling sleepy
- repeat as often as necessary through the night
Relaxation training
CBT-I
Reduce somatic tension or intrusive thoughts at bedtime that interfere with sleep
- progressive muscle relaxation (reduce skeletal muscle tension)
- diaphragmatic breathing (slower, deeper breathing)
- autogenic training (increase peripheral bloodflow by imagining that extremities feel warm)
- imagery training (engage relaxing image from multisensory perpective
Practice techniques during day in preparation for using them at night
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Sleep restriction therapy
CBT-I
Curtail amount of time in bed to actual amount of time spent sleeping –> create mild sleep deprivation
- Calculate total sleep time (TST) & set time in bed (TIB) to that
- Make adjustments according to sleep efficacy (15 mins extra until optimal window is reached, approx. 80-95%. 100% efficacy shows P needs longer in bed - falling asleep instantly bc very tired)
- Always set min 5hrs TIB
- Side effects (Kyle et al., 2011)
- sleep deprivation!! Worsened symtoms from insomnia
- Works via
- restricting time in bed,
- regularising timing of sleep & wake and consequently…
- re-conditioning sleep-bed association
The sleep-wake switch components
Neurotransmitters
- VLPO promote sleep by inhibiting wake-promoting neurons e.g. GABAergic neurons (inhibited when awake)
- Oxytocin & hypocretin promote wakefulness by inhibiting sleep-promoting neurons e.g. Acetylcholinergic neurons, dopaminergic neurons (inhibited when asleep)
Two-process model of sleep
- sleep homeostasis and circadian rhythm interaction
- sleep pressure increases the longer we are awake (sleep homeostasis) and melatonin moderates alertness (circadium rhythm).
- High sleep pressure and decreasing alertness at the end of the day encourage sleep
sleep homeostasis
reduced sleep –> greater drive for sleep –> fall asleep faster
Thakkar et al., 2008 – adenosine acts as a sleep promoter
- Gave rates adenosine agonist à stayed awake longer after being denied sleep
The circadian rhythm
External clock is 24hrs but internal clock is ~24.2hrs (Czeisler et al., 1999)
Synchronising the internal clock with the external clock
- Light inhibits melatonin production
- Melatonin released in evening darkness (dim-light melatonin onset, DLMO) by pineal gland in epithalamus causes drowsiness
- production decreases with age
- can be taken in tablet form
- DLMO is a marker of our “natural” sleep phase
Zeitgebers
External environmental cues that affect the sleep-wake cycle
- light - electrical light, especially blue light
- food and drink - caffeine, many foods contain melatonin
- social interaction
- pharmacoactive substances - recriational and prescribed drugs
Cognitive therapy
Thought restructuring
Behavioural experiments
Paradoxical intention
Cognitive therapy: Thought restructuring
- Change thought to a more accuracte one to reduce anxiety about lack of sleep & improve sleep onset
- e.g. “If I don’t sleep I will feel bad tomorrow” –> “I always manage to get a bit of sleep and manage to get through the day”
Cognitive therapy: Behavioural experiments
Harvey, 2011
- identify belief/thought/process to target
- collaborate with patient - brainstorm for experiment ideas
- write predictions about outcome & devise recording method
- anticipate problems, brainstorm solutions
- conduct experiment
Cognitive therapy: Paradoxical intention
Trying to do the opposite of what you want to happen reduces fear, desired behaviour occurs
- I can’t sleep (fear)
- I’ll try to stay awake instead (paradoxical intention)
- Falling asleep (content)
Eliminates perpetuating effort
Support for this is for sleep onset insomnia. May not generalise to maintenance or mixed insomnia.
What is the most effective long-term treatment for insomnia?
Morin 2009
- CBT-I & medication combination –> reduce medication –> just CBT-I
- Behavioural treatments = fast, short term effect
- Cognitive treatments = long-lasting effect
- Both together gives quick results so patients don’t drop out and maintains them by altering underlying cognitions
Evidence of CBT-I effectiveness
- Manber 2011 – good for comorbid depression-insomnia
- Garland 2014 – improves sleep of cancer patients
CBT-I delivery modes
Bastien et al., 2014
- Individual delivery had greater improvement than group or phone after 2 weeks, but little variance in 3 and 6 month follow-ups
Apps
- Shutti – Ritterband 2009
- Sleepio – Espie 2012
- RESTore – Lewycky 2009
