Published on February 28, 2008
Non Pharmacological Treatment of Primary Insomnia: an evidence-based approachDr. Jean Grenier, C.Psych.Psychologist – CNFS / Hôpital MontfortAssociate Professor – Department of Family Medicine – U of O: Non Pharmacological Treatment of Primary Insomnia: an evidence-based approach Dr. Jean Grenier, C.Psych. Psychologist – CNFS / Hôpital Montfort Associate Professor – Department of Family Medicine – U of O Outline: Outline Presentation of a case 52 year old female Chronic insomnia since age 18 Treatment offered: 7 sessions (7 x 60 minutes/week) Treatment components Content of sessions Examples of how to explain things to patient What does the research say ? Questions / discussion The case: The case 52 year old female Lived with husband Has a 26 year old son and a grand child Worked in accounting Insomnia started at 18 years old 34 years of chronic insomnia ! Clinical assessment: Clinical assessment Should involve face-to-face, multi-focused clinical evaluation Detailed history of nature, duration, course, & severity of the sleep problem Presence of medical, psychological, behavioral, & environmental contributing factors History of problem: History of problem Insomnia began while 18 years old First job: bank teller Vulnerable to feeling stressed Started with difficulty initiating sleep which evolved, with years, into difficulties maintaining sleep Frustration++, would stay in bed hoping to fall asleep Started medication; sporadic success Insomnia persisted; waxing and waning through the years Never regained sense of control over her sleep History of problem: History of problem Previous treatments Benzodiazepines, tranquilizers, homeopathy, etc. Psychologist Insisted on treating stress Relaxation exercises Polysomnographic evaluation (5 years prior) Essentially normal Low proportions of deep sleep (stages 3-4) No apnea, no PLMs History of problem: History of problem She was told by a physician: « There is nothing else to do and you will probably be like this for the rest of your life » She told us: « I have tried everything …. I am here but at this point, I don’t believe anything can be done to help me… » Assessment : Assessment No problem initiating sleep (SOL = 15-20 min) Difficulty maintaining sleep Frequent awakenings Difficulty falling back asleep Early morning awakening (approx. 4:00am) Major sleep period Without medication: 10:00pm to 2:00am With medication: 10:00pm to 4:00pm Getting approx. 4-6 hours of sleep/night Assessment: Assessment When awake at 4:00am Stays in bed until 7:30am Sometimes falls asleep between 4:00am - 6:00am “Rests” in bed Uses this time to “think” Frustrated ++ when unable to sleep No excessive worries about her insomnia; more like learned helplessness Attention/awareness focused on checking if she is sleeping or not Assessment: Assessment Headaches if sleep period ≤ 4 hours Daytime fatigue: yes Daytime sleepiness: none or sometimes mild No naps Occasional sleepiness after supper Assessment: Assessment Environment Sleeps alone; husband snores too much Mattress: comfortable Temperature range: comfortable TV in room: no Disruptive sounds: no Other activities in bedroom: no Pets: no Assessment: Assessment Nighttime routine: Watches TV in living room Reads outside bedroom Bathroom rituals Seroquel 25mg before bedtime Bedtime at 10:00pm Quality of sleep better when away from home Assessment: Assessment Current medications Seroquel 25 mg HS (last 2 years) Antihypertensive Homeopathic remedy for acid reflux Assessment: Assessment Health Hypertension; well managed by meds Occasional reflux Cancer of the uterus 15 years ago Habits Alcohol: none Caffeine: none Tobacco: none Physical exercise: none Assessment: Assessment No symptoms of: Apnea PLM RLS Normal previous polysomnographic findings Assessment: Assessment Mental health Some elements of GAD (sub-clinical) Various worries (light to moderate) Vulnerability to stress Did not meet Dx criteria for any anxiety or mood disorder Working diagnosis: Working diagnosis Primary insomnia (DSM-IV) Difficulty initiating and/or maintaining sleep and/or non restorative sleep Clinically significant distress of impairment in daytime functioning Disturbance not related to: another sleep disorder a mental disorder (mood or anxiety) use of a substance * Data represents mean for the given week.: * Data represents mean for the given week. Cognitive-behavioral treatments of insomnia: Cognitive-behavioral treatments of insomnia Includes various methods/strategies: Sleep hygiene Stimulus control Sleep restriction Relaxation techniques Cognitive therapy Combination of these methods works best Typical cognitive-behavioral treatment(6-8 sessions): Typical cognitive-behavioral treatment (6-8 sessions) Educational component (1) Behavioral component (2-3) Stimulus control Sleep restriction Cognitive component (4-5-6) Sleep hygiene (7) Consolidation of therapeutic gains Relaxation methods Relapse prevention (8) Session 1: Education: Session 1: Education Why work with a sleep diary ? Pre-post treatment data Observe variations within a given week Observe improvement/deterioration Calculate sleep efficiency Subjective perception: quantity and quality Scientific attitude (being a manager as opposed to being a victim) Session 1: Education: Session 1: Education 5 stages of sleep: I, II, III, IV, REM Session 1: Education: Session 1: Education Cyclical and organized nature of sleep Stage I - Lying down, eyes closed - Slow eye movements - Brief/transitory phase Stage II - Loss of consciousness and light sleep thereafter Session 1: Education: Session 1: Education Stages III, IV - Deep or slow wave sleep - Breathing rate slows down - Heart rate slows down - Minimal cerebral activity - Minimal ability to recall a dream - Preponderance: first third of the night Session 1: Education: Session 1: Education REM sleep or Paradoxical sleep - Muscle atony / paralysis - Brain waves similar to waking state - Breathing + cardiac rhythm are irregular - Irregular blood pressure - Core body temperature is irregular - Erection / ↑ blood flow in vagina - Dream recall is very high - Preponderance: last third of night Slide26: Typical EEG for each sleep stage Session 1: Education: Session 1: Education Functions of deep/slow wave sleep (stages III, IV) Rest, recuperation of physical energy, reparation of bodily or organic tissues Selective deprivation of deep sleep leads to complaints of sleepiness, fatigue, muscular aches and pains Vigorous physical activity augments proportion of seep Necessary to feel rested Functions of REM sleep Treatment of newly learned information & consolidation of memory Important role in learning Selective deprivation leads to memory problems Session 1: Education: Session 1: Education Typical nightly proportions Babies ≈ 50% = REM ≈ 50% = stages I, II, III, IV Adults ≈ 25% = REM ≈ 25% = stages III, IV ≈ 50% = stages I, II Older adults ≈ 25% = REM ≈ 5-10% = stages III, IV ≈ 65-70% = stages 1, II Session 1: Education: Session 1: Education Gradual & constant reduction in deep sleep starting at age 40 Sleep deprivation and deep sleep Randy Gardner (1964): Total sleep deprivation for 264 hours (11 days) Recuperated with approximately 14 hours of sleep Selective increase in stages III – IV following a period of sleep deprivation Deep sleep: role in recuperation/feeling rested Therefore, the more I am sleep deprived, the more I will have access to deep sleep during the next major sleep period Session 1: Education: Session 1: Education Need for sleep varies… Short sleepers 4 to 6 hours Medium sleepers 7 to 8.5 hours Long sleepers 9 to 11 hours Distinction between fatigue versus sleepiness Session 1: Education: Session 1: Education Short and long sleepers essentially have the same amount of deep sleep; thus a minimum amount of deep sleep is needed no matter how long is the total sleep time; Partial and total sleep deprivation are followed by a prioritized increase in deep sleep. In fact, 100% of deep sleep is usually recuperated; Very normal to have several awakenings per night Session 1: Education: Session 1: Education Circadian factors Of all biological functions (ie., core body temperature (CBT), growth hormone, cortisol, melatonin), the CBT is one of the most pertinent to understanding insomnia Session 1: Education: Session 1: Education CBT is at its minimum early in the morning, increases as the day progresses, reaches its maximum during the evening and starts to decline at approx. 11:00pm Reduction in CBT = sleepiness and reduction in mental vigilance Increase in CBT = awakening and increase in mental vigilance Implications for various types of sleep problems Session 1: Education: Session 1: Education Everyone suffers from occasional bouts of insomnia ! How does insomnia become a chronic problem? Model of chronic insomnia Predisposing factors – vulnerabilities in terms of physiological arousal, genetic predisposition, personality style, etc. Precipitating factors – situational stressor, grief, etc. Perpetuating factors – compensatory strategies that the person utilizes to manage the insomnia; naps, excessive amount of time awake in bed, sleeping late, irregular sleep/wake cycle; develops performance anxiety about sleep Sessions 2-3: Behavioral component: Sessions 2-3: Behavioral component Stimulus control Limit amount of time spent awake in bed Break the conditioning phenomenon that exists between the bed/bedroom/sleep rituals and the inability to fall asleep Re-associate the bed/bedroom/bedtime with the ability to fall asleep Typical procedures: Keep stable awakening time 7 days/week Go to bed only when sleepy Reserve the bed only for sleep and sexual activities Sleep only in the bed/bedroom Never stay awake in bed for more than 20-30 minutes; if awake, get up and go relax into another room Return to bed only when sleepy Sessions 2-3: Behavioral component: Sessions 2-3: Behavioral component Sleep restriction Limit time in bed to time actually sleeping Consolidate sleep architecture on a shorter sleep period Establish a “sleep window” (minimum of 5 hours: for example, 1:00am à 6:00am) Determine the regular time for awakening and get up at that same time no matter how much sleep was obtained during the night Do not recuperate any sleep during the day (no naps!) In evening, go to bed at the specified time only if sleepy Sessions 2-3: Behavioral component: Sessions 2-3: Behavioral component Sleep restriction (…) Increase sleep window by 30 minute increments (ie., go to bed 30 minutes earlier) each time an average weekly sleep efficiency of 90% is obtained Maintain same “sleep window” if average weekly sleep efficiency is between 80-89% Reduce the “sleep window” by 30 minutes if average weekly sleep efficiency is below 80% Sessions 2-3: Behavioral component: Sessions 2-3: Behavioral component Important to explain… Procedures will initially cause sleep deprivation This sleep deprivation will be your best ally and will increase stages III-IV Give yourself permission to tolerate the initial discomfort in order to gain longer term control over sleep Importance of understanding the underlying biological and psychological mechanisms to the procedures It is OK to rest if you can’t sleep…. But rest outside your bedroom ! Associate your bed with sleeping….not resting. Sessions 4-5-6: Cognitive component: Sessions 4-5-6: Cognitive component Cognitive perspective: Beliefs and attitudes about sleep Insomniacs have unrealistic expectations about what constitutes normal sleep & tendency to catastrophize the consequences of insomnia « I should sleep within 5 minutes » « It is not normal to wake up a few time per night » « If I don’t sleep, I should at least rest in bed » « Because I have insomnia, I should go to bed earlier » Cognitive processes such as intrusive thoughts and worries Insomniacs take advantage of bedtime to think / worry about problems or even positive things Can happen at bedtime or during nocturnal awakenings Sessions 4-5-6: Cognitive component: Sessions 4-5-6: Cognitive component Performance anxiety Apprehension about bedtime and sleep Starts thinking about sleep in the afternoon Fear (sometimes very subtle) of not being able to sleep Constant attention focused on checking if awake or falling asleep or sleeping Inordinate amount of attention and importance given to sleep All difficulties, malaises or discomforts are linked as consequences of the insomnia Sessions 4-5-6: Cognitive component: Sessions 4-5-6: Cognitive component Cognitive therapy Aimed at identifying and modifying these problematic beliefs and attitudes about sleep to reduce performance anxiety and exaggerated arousal associated with sleep Cognitive restructuring: change the way the person thinks about sleep Worry time: schedule 30 minutes/day to worry and ruminate…. outside the bedroom Beliefs and Attitudes about Sleep Questionnaire (Morin, 1993) Tool to identify faulty expectations about sleep Session7 : Sleep hygiene and relaxation: Session7 : Sleep hygiene and relaxation Sleep hygiene Avoid caffeine 5 hours before bedtime Avoid smoking before sleep and at night (stimulant and decreases deep sleep) Avoid alcohol before bedtime (fragments sleep and reduces deep sleep) Avoid heavy/spicy meal before bedtime Exercise regularly but preferably not during evening Minimize noise, light, extreme temperatures Sleep hygiene by itself is insufficient Tx Session7 : Sleep hygiene and relaxation: Session7 : Sleep hygiene and relaxation Relaxation Progressive muscle relaxation, visualization, diaphragmatic breathing Aims to reduce physiological/cognitive arousal May be preferable to practice outside bedroom Relaxation by itself is insufficient Tx Session 8:Consolidation of therapeutic gains and relapse prevention: Session 8: Consolidation of therapeutic gains and relapse prevention Maintain gains Review all that has been learned in treatment Client must be able to explain in own words the mechanics and rationale behind the behavioral techniques Ask questions Present hypothetical situations and ask « From now on, how will you mange this situation ? » and « why is it preferable to do that ? » Motivation and engagement Maintain scientific attitude towards one’s sleep problems Weaning off sleep medication: Weaning off sleep medication Insomniacs are typically afraid of stopping !! Performance anxiety increases when we try to wean off medication Belief that one will not sleep adequately without meds Wean off VERY gradually even if not pharmacologically indicated… do it for psychological reasons more so than biological reasons… Weaning off sleep medication:Procedures for the patient: Weaning off sleep medication: Procedures for the patient Choose a date when to start weaning off Wean off one medication at a time Reduce the original dose by a maximum of 10-25% per week, until you reach the most minimal dose possible If on a given week you are not confident about reducing further, continue taking the same dose for another week…but once you have committed to reducing, you cannot come back on your commitment Once you have attained the most minimal dose possible, start introducing « sleep medication vacations » until you stop completely Give yourself permission to tolerate some discomfort or withdrawal symptoms Cognitive-behavior therapy and use of hypnotics/sedatives: Cognitive-behavior therapy and use of hypnotics/sedatives Medication for sleep should be used on short term/occasional basis CBT may be combined with medication to take advantage of the two: rapid reduction in symptoms with medication and durable changes brought on by CBT For patients who already taking medication, assess if appropriate to wean off Cognitive-behavior therapy:Conclusions: Cognitive-behavior therapy: Conclusions Individual or group Tx works well No contraindications If another sleep disorder is suspected, refer to a sleep lab If insomnia is secondary to a medical or psychiatric condition, treat that condition first However, patients with chronic pain, anxiety or depression can benefit with more modest results Efficacious with geriatric poipulation Cognitive-behavior therapy:Conclusions: Cognitive-behavior therapy: Conclusions Produces durable results 70-80% of patients benefit and 30% become “good sleepers” Satisfaction with sleep increases Sense of control over one’s sleep increases Reduction in use of sleep medication generally follow Occasional bouts of insomnia return but with less fear and apprehension The 5 minute intervention: The 5 minute intervention Stimulus control procedures Of all methods, the one that works best on its own is stimulus control If the patient follows this religiously, there are good chances the insomnia will improve However, patients who do not fully understand and appreciate why it is important to follow these procedures (or the mechanics behind) typically abandon after one night… This is why the educational component is so important…but this necessitates 30-45 minutes. My 7 new sleeping habits: My 7 new sleeping habits 1) I give myself at least 1 hour to relax before bedtime. 2) I go to bed only when I feel sleepy. 3) If I am unable to fall asleep within 20-30 minutes, I get out of bed and do something else in another room. I go back to bed only when I feel sleepy again. If I do not fall back to sleep quickly, I repeat this instruction as often as necessary throughout the night. 4) I use an alarm clock to get out of bed at the same time each morning regardless of how much I have slept. 5) I use my bed only for sleeping and sexual activities. I do not eat, read, watch television or work in my bedroom. 6) I do not nap during the day. 7) I limit my time spent in bed. I will not go to bed earlier than _________ (but later if I do not feel sleepy). I will get up at exactly __________, regardless of the night’s sleep I have had. References: References Billiard, M., (2003). Sleep: Physiology, Investigations and Medicine. New York: Kluwer Academic Publishers. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision) (2000) by American Psychiatric Association Grenier, J. (2003). A Decision Tree Approach to the Differential Diagnosis of Insomnia. In Sleep: Physiology, Investigations and Medicine. Edited by Michel Billiard . New York: Kluwer Academic Publishers. Références: Références Morin, C.M. (1996). Insomnia: Psychological Assessment and Management. New York: Guilford Press. Morin, C.M., & Espie, C.A. (2003). Insomnia: A clinical guide to assessment and treatment. New York: Kluwer Academic/Plenum Publishers. Perlis, M., Lichstein, K. (2003). Treating Sleep Disorders: Principles and Practice of Behavioral Sleep Medicine. New Jersey: Wiley & Sons. Références: Références ICSD - International classification of sleep disorders: Diagnostic and coding manual. Diagnostic Classification Steering Committee, Thorpy MJ, Chairman. Rochester, Minnesota: American Sleep Disorders Association, 1990.