The Behavioral Treatment of Insomnia

Andrew Berger, PhD

San Francisco and Dallas Mental Health Specialist

How much do you know?

Video #1 & #2

If You Have Insomnia You Are Not Alone

75% of Adults Had One Symptom of Sleep Disorder

30-40 Percent of US Population Occasionally Suffers from Insomnia

Partners Affected

Americans Average 6.9 Hours of Sleep

Consequences of Poor Sleep

Poor Health

Higher Death Rates

Physical Ailments

More Consequences of Poor Sleep

Hormone and Metabolism Changes

Sleep Debt Is Cumulative

Sleep Deprivation and Driving

Catastrophes

Cost to Americans

Benefits of Sleep

Alertness/Performance

Memory/Concentration/Creativity

Better Health

Many Types of Sleep Disorders

Primary Insomnia

Primary Hyperinsomnia

Narcolepsy

Breathing Related Disorders

Circadian Rhythm Sleep Disorder

Nightmare Disorder

Many Types of Sleep Disorders

Sleep Terror Disorder

Sleep Walking Disorder

Substance Induced Sleep Disorder

Sleep Disorder Due To Medical Condition

DSM4-TR Insomnia Essential Features

Onset and Intermittent Insomnia

Non-Restorative Sleep

Preoccupation and Distress

Better Sleeping Away From Home

Decreased Well-Being and Concentration

DSM4-TR Primary Insomnia

The predominant symptom is difficulty initiating or maintaining sleep or non-restorative sleep for at least one month

The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or para-somnia

DSM4-TR Continued

The disturbance does not occur exclusively during the course of another mental disorder (e.g., major depressive disorder, generalized anxiety disorder, a delirium).

The disturbance is not due to the direct physiological effects of a substance (e.g., drug abuse, medication) or a general medical condition.

Primary Insomnia

Occurs Independently

Not Due To An Obvious Cause

Rarely From Infancy

Learned

Predisposed Due To Overactive Nervous System

People With Insomnia Have:

Higher Metabolic Rates

Higher Levels of Stress Hormones

Associate Bedroom with Anxiety

Poor Coping

What Is Secondary Insomnia?

Results From Another Cause

Sleep Disorder

Non-Sleep Condition

Substances

Disorders That Can Disrupt Sleep

Angina

Diabetes

Hyperthyroidism

Parkinson’s Disease

Epilepsy

Alzheimer’s

Headaches

More Disorders Affecting Sleep

Strokes/Tumors

Asthma

Chronic Obstructive Pulmonary Disease (COPD)

Anxiety

Depression

More Disorders Affecting Sleep

Bipolar Disorder

Schizophrenia

Gastro esophageal Reflux Disease (GERD)

Kidney Disease

Arthritis

Medications That Can Disturb Sleep

Alpha blockers

Anti-arrhythmic

Beta blockers

Diuretics

Antidepressants

More Medications Affecting Sleep

Beta Agonists

Corticosteroids

Nicotine Patches

Stimulants

Theophylline

Thyroid Replacement Drugs

Types of Sleepers

Standard Sleepers

Larks

Owls

Adolescent and Young Adult Sleep Patterns

Teens

Young Adults

Dr Lawrence Epstein’s Six Step Plan To A Good Night’s Sleep

Recognizing the importance of sleep

Adopting a healthy lifestyle

Maintaining good sleep habits

Creating the optimal sleep environment

Seeking help for persistent sleep problems

Recognize The Importance of Sleep

Adopt A Healthy Lifestyle

Exercise Regularly

Maintain A Healthy Diet

Don’t Drink to Excess or Smoke

Maintain Good Sleep Habits

Keep A Regular Sleep/Wake Cycle

Develop A Pre-Sleep Routine

Reserve Bedroom for Sleep and Intimacy

Avoid Naps

If You Can’t Sleep Get Out of Bed

Create An Optimal Sleep Environment

Control Bedroom Noise

Block Out Light

Keep It Cool and Well Ventilated

Hide The Clock

Make Your Bed Comfortable

Sleep Saboteurs

Limit Caffeine

Use Alcohol Cautiously

Stop Smoking or Chewing Tobacco

Find Right Balance of Fluids

Avoid Heartburn Food

Seek Help For Persistent Sleep Problems

Behavioral Treatments ofInsomnia

Reconditioning/Stimulus Control

Sleep Restriction

Relaxation Techniques

Reconditioning/Stimulus Control

Go To Bed Only When Sleepy

Use Bed Only For Sleep or Sex

Get Up After 20 Minutes of No Sleep

Repeat Step 3 As Needed

Get Up At Same Time Every Morning

No Naps

Sleep Restriction

Less Time In Bed Promotes More Efficient Sleep

Estimate Sleep and Subtract From Wake Up Time

Continue Adding 15 to 30 Min

Less Than 5 Hours Not Recommended—Consult MD

Relaxation Techniques

Progressive Muscle Relaxation

Deep Breathing

Meditation

Visualization

Biofeedback

Cognitive Therapy

Misattributions

Hopelessness

Unrealistic Expectations

Exaggerating Consequences

Performance Anxiety

Cognitive Behavioral Therapy

Often Provided with Behavioral Therapy—Cognitive Behavioral Therapy (CBT)

CBT More Effective Than Any Behavioral Therapy Alone

More Effective Than Sleeping Pills

Largest Obstacle Lack of Patient Commitment

Sleeping Pills

10 Percent Adults Use Prescription or OTC Sleep Meds

Short-Term Solution Causes Long Term Problem

Do Not Help People Become Normal Sleepers

Fail To Treat Causes of Insomnia

Herbal Supplements

Valerian

Lavender

Chamomile

Passionflower

Melatonin

Bibliography

(1) Ohayon MM. Epidemiology of Insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002:;6:97-111

(2) National Sleep Foundation. Summary of Findings: 2005 Sleep in America Poll. March 2005. http://www.sleepfoundation.org

(3) Alattar M, Harrington JJ, Mitchell CM, et al. Sleep problems in primary care: a North Carolina Family Practice Research Network study. J Am Board Faro Med. 2007;20:365-374

Bibliography Continued

(4) NIH State-of-the-Science Conference Statement on manifestations and management of chronic insomnia in adults. NIH Consens State Sci Statements. 2005; 22:1-30

(5) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, Text Revision (DSM-IV-TR). Washington, De: American Psychiatric Association; 2000:597-663

(6) Sateia MJ, Pigeon WR. Identification and management of insomnia. Med Clin North Am. 2004;88:567-596

Bibliography Continued

(7) American Academy of Sleep Medicine. International Classification of Sleep Disorders, revised: Diagnostic and Coding Manual. Chicago, IL,: American Academy of Sleep Medicine; 2001

(8) Insomnia in the primary care practice. Journal of Family Practice, April, 2008

(9) Gregg D Jacobs, PhD Say Good Night To Insomnia, Henry Hold and Company, LLC 115 West 18th Street, New York, New York 10011

Bibliography Continued

(10) Lawrence J. Epstein, MD The Harvard Medical School Guide To A Good Night’s Sleep, McGraw Hill, 2007

(11) William C Dement, MD, PhD and Christopher Vaughan The Promise of Sleep, 1999, Dell Publishing, A division of Random House, Inc, 1540 Broadway, New York, New York 10036