Behavioral Medicine Approaches to Sleep Disorders

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Introduction

• Sleep problems are common in the population (20-30%)

• Sleep problems are associated with medical and psychiatric conditions and alterations in normal behavior

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Waking Behaviors of People with Insomnia

Impaired concentration

Poorer memory

Irritability

More accident prone

Over-eat

More pain sensitive

Micro-sleeps

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Sleep/Wake Cycle

Circadian clock in the brain

Regulatory genes and feedback

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Body ClocksThe internal body clock is located in the part of the

brain called the suprachiasmatic nucleus (SCN).

Light sets the main clock in the SCN, there are other oscillators -- peripheral clocks in other cells and tissues in the body.

(Hamet, & Tremblay, 2006).

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Sleep Patterns Owls and Larks; Long and Short Sleepers

• Patterns and number of hours are partially inherited

• Natural long (8-9) and short sleepers (5-6) function normally

• Learning through conditioning and social learning modifies the inherited patterns

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SLEEP RHYTHM

• The natural body clock follows a 24 hr cycle; rhythm develops during the first 2 years.

• Many biological rhythms like temperature, are linked to the sleep cycle:

– Lowest body temperature occurs early morning and the highest early evening.

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Links to other Rhythms Appetite and satiety are controlled by neuronal

centers in the hypothalamus, linked to the internal time-keeping clocks (Froy, 2010).

Leptin, a neurochemical that decreases appetite, is suppressed during short sleep and other hormones that stimulate the desire to eat

are increased.

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Sleep and Metabolism

Healthy individuals -- sleep disrupted ----elevated blood glucose and insulin after the sixth consecutive night of disruption.

After a big meal, the increase in glucose levels in the blood turns off the neurons that produce orexin, making people feel sleepy and tired. (Froy, 2010)

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The stress-sleep link

The hypothalamic-pituitary adrenal (HPA) axis is involved in both the stress response and the sleep/wake cycle

These two physiological cycles interact within a multidimensional framework

(Buckley, & Schatzberg, 2005).

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Sleep and HPA Axis

• Excess activity of the hypothalamic-pituitary-adrenal activity has multiple negative effects. (Buckley & Schatzberg, 2005).

• Slow-wave sleep decreases, cortisol levels increase at inappropriate times

• The vicious cycle of broken sleep, increased arousal and insomnia continues, since sleep deprivation is associated with further activation of the HPA axis.

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Sleep and Mood• Misalignment between the sleep-wake cycle

and the circadian rhythm oscillators in the brain contribute to psychopathology (Kripke, Nievergelt, Joo, Shekhtman, & Kelsoe, 2009).

• Depressed patients : early morning awakenings (terminal insomnia)

• Bipolar disorder has been most strongly linked to mistiming of the brain clocks in bipolar disorder and dementia (Hamet, & Tremblay, 2006; Lamont et al., 2007).

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Sleep Disruption in Generalized Anxiety Disorder

• decreased sleep efficiency

• decreased total sleep time

• non-restorative sleep

• increased sleep latency

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Sleep and Pain

• Poor sleep quality, fewer hours of sleep, are related to worsening pain (Hamilton, et al., 2007).

• In healthy normal sleepers, four hours of sleep deficit produced hyperalgesia (Roehrs, Hyde, Blaisdell, Greenwald, & Roth, 2006).

• Fibromyalgia patients who achieve continuous, high quality sleep suffer less pain and cope more effectively with negative life events (Hamilton et al., 2008)

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Chronic Pain and Sleep A bi-directional relationship

• Effects of experienced pain on sleep– Non restorative sleep– Decreased deep sleep– Fragmented, broken sleep

• Effect of sleep deprivation on pain– Increased pain sensitivity– Increases spontaneous pain

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Assessment of people with disturbed sleep

• Sleep diary

• Sleep history

• Related rhythms

• Mood and anxiety

• Physical problems

• Daily habits

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Epworth Sleepiness ScaleHow likely are you to fall asleep?

Rate on 0-3 scale; 0=never; 2 = sometimes; 3=very likely

Reading ____

Watching TV ____

As a passenger in a car ____

Lying down to rest ____

Talking to someone ____

In a car, as the driver, stopped in traffic ____» National Sleep Foundation Wash. DC 2000

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What is your score on the Epworth scale?

0-5

6-9

10-

12

13-

15, b

ut 0 o

n last

item

13-

15, 2

or 3

on la

st it

em

0% 0% 0%0%0%

1. 0-5

2. 6-9

3. 10-12

4. 13-15, but 0 on last item

5. 13-15, 2 or 3 on last item

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Interventions for Sleep Disorders

• Sleep hygiene

• Relaxation

• Biofeedback

• CBT

• Medication

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Practice Parameters

• Standard: “generally accepted patient-care strategy, which reflects a high degree of clinical certainty”

• Guideline: “patient care strategy, which reflects a moderate degree of clinical certainty”

Morgenthaler (2006) Pg. 1416.

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Relaxation Therapy - Standard

• Premise: patient’s sleep disorder is due to excessive muscle tension

• Goal: reduce tension to decrease onset insomnia

• Procedure: teach relaxation procedure and encourage daily practice; use at bedtime

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Sleep Hygiene (inconclusive)

• Arise at the same time every day

• Discontinue stimulants: caffeine

• Avoid daytime naps

• Use hot baths near bedtime

• Avoid large meals

or exercise near bedtime

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Stimulus Control - Standard

• Premise: insomnia is a conditioned response to (bed) time and (bedroom) environmental cues that are usually associated with sleep.

• Goal: retrain the patient to associate the bed and bedroom with rapid sleep onset

• Procedure: – go to bed only when sleepy– use the bed only for sleep and sex– get out of bed when can’t sleep– no naps

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Cognitive Behavioral Therapy Standard

• Premise: people with insomnia have faulty beliefs, expectations, attitudes about sleep

• Goal: replace the vicious cycle of insomnia, distress, dysfunctional cognitions….

• Procedure:– Identify negative thoughts and replace– Lessen catastrophic thinking– Hypothesis testing

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Case Description of Jake

Jake is a 22 year old law student who comes to you complaining of onset and terminal insomnia. For the past month, it is taking him between one and two hours to fall asleep several times a week. He is “exhausted”. He is worried about completing his class requirements at the law school and thinks that maybe he chose the wrong profession.

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Jake cont’d• It’s a struggle to stay awake in class. He

drinks 4-6 cups of coffee/day and has been for 8 months. He has mild to moderate body aches, weekly headaches and he thinks he may have “the flu”. He is on no medication and has no medical diagnoses.

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Sleep history

• Long history of sleep difficulties; he was a hard child to get to sleep and then he woke up

every night until he was 3.

During his teenage years, Jake stayed up until midnight on school nights and had great difficulty getting up in the morning (DSPS).

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Etiology• Partially genetic in origin, later influenced by social

learning and modified by current stressors.

• Onset insomnia and early awakenings short-circuited his restorative, slow wave sleep and led to fatigue during the day.

• Extreme fatigue and anxiety negatively affected his views of law, law school and his own

performance.

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Intervention

• Education about the natural need for sleep, the relationship among disrupted sleep patterns and other circadian rhythms, such as appetite/satiety, temperature regulation and mood.

• Jake understood why he was sleepy when he should be alert and sometimes very hungry at 2 am.

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Intervention

• Mindful breathing – practice and more practice; then use at bedtime. Self soothing -- listening to repetitive sounds, such as music with a repeating pattern or ocean waves.

• Sleep hygiene

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Interventions

• Progressive relaxation: Jake had excessive muscle tension. Daily practice recommended

• Sleep control therapy: Re-organize the bedroom in order to re-condition the bed and bedroom with the onset of sleep, instead of with stimulating activities

(Giardino, McGrady, & Andrasik, 2007).

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CBT (Jansson, & Linton, 2005; Jacobs, Pace-Schott, Stickgold, & Otto, 2004)

• Negative thoughts about sleep were identified, countered, and finally replaced with more positive thoughts about the ability to get to sleep.

• Jake’s statement: “when I sleep badly, I cannot do any studying” was challenged. “Hypothesis testing,” was successful since on that particular day, Jake had already completed one class assignment. He felt sleepy during the day, but he could accomplish some studying.

• Jake’s negative views of his future profession were explored and countered with rational thinking.

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Case of Jamela

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History• Jamela was a 40 year old divorced mother of a 10

year old girl.• Jamela had trouble falling asleep for more than one

month, and awakened between 4:00 and 5:00 AM• Jamela had been divorced for two years and had

joint custody of her daughter with her ex-husband. Their daughter, Rachel, spent alternate weeks with Jamela and her father. He had already remarried, and was seemingly very happy in his new relationship with his wife and his wife’s two daughters by her first marriage.

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History

• During the weeks that Rachel was with her father, Jamela felt sad and lonely. But when mother and daughter were together Rachel frequently complained that the house was too quiet and that there was not enough going on. Rachel said that at her dad’s house there was always something happening and her step-siblings were fun.

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Work History There was downsizing at her insurance company.

Jamela retained her job but the workload increased. Her two close friends were let go, leaving her as the only worker in a three person office, surrounded by empty desks and idle computers.

The major problem was isolation and lack of communication with other workers.

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Comparison

• Is Jamela’s case similar to Jake’s?

• Do they both have a primary sleep disorder?

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Etiology - Jamela• Family history of depression,

• Difficult break up of marriage

• Inflexible coping style, minimal coping skills. She lacked assertiveness and clear communication skills.

• Social isolation leads to poor sleep quality whereas social engagement during the day facilitates better slow wave, deep sleep (Cacioppo et al., 2002). Loneliness and isolation bring on feelings of threat, making it difficult to go to sleep and increasing nighttime awakenings.

• Sleeping in a perceived safe environment promotes restorative sleep (Cacioppo, & Hawkley, 2009).

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Interventions

• Moving followed by physical exercise (Ferris, Williams, & Shen , 2007; Ruscheweyh et al., 2009).

• Progressive relaxation – to direct her attention to the experiences of tension and relaxation (McGuigan, & Lehrer, 2007).

• Antidepressant medicine (Zoloft)

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Imagery for Sleep

There are several different types of imagery ranging from simple imagery that is used for relaxation to complicated visualization for problem solving or healing. We will be focusing on relaxation to ease into sleep.

Remember a pleasant experience that involved people whom you love and sharing food, perhaps during a holiday or special family event. Write down what you remember on the lines below.

 Who was there?______________________________________________________________ Can you smell the food? If yes, what foods?______________________________________________________________

CBT

CBT explored Jamela’s many negative cognitions about her social interactions, work performance, mothering skills and chances of finding a suitable partner

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Biofeedback - HRV• Slow diaphragmatic breathing created larger

regular oscillations in heart rate, and increased overall heart rate variability.

• ** HRV is more pronounced during slow wave sleep than during REM sleep, and is elevated during all sleep phases compared to wakefulness (Ebben, Kurbatov, & Pollak, 2009).

• 6 sessions of HRV biofeedback helped Jamela establish a pattern of slow breathing that she utilized each evening at bedtime.

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Summary of Cases

• Jake: primary sleep disorder,• Jamela’s sleep problems were linked to major

depression .• Jake : soothing, mindful breathing, sleep hygiene,

progressive relaxation and CBT. • Jamela: movement and communication,

progressive relaxation and physical exercise, CBT, biofeedback and anti-depressant medication.

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Summary

• Insomnia can be categorized as primary, when the sleep problem is neither part of an emotional or physical illness nor associated with the use of stimulants or as a secondary sleep disorder. Both mood and anxiety disorders have sleep dysfunction and non restorative sleep as a component of the diagnosis.

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