Can’t Sleep”€¦ · · 2016-02-29“I Can’t Sleep ” • • • • • ... Salvadore...
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2/29/2016 1 Janet E.Tatman, PhD, PA Diplomate American Board of Sleep Medicine Certified in Behavioral Sleep Medicine Why Behavioral Treatments? “I Can’t Sleep” • • • • • • International Classification of Sleep Disorders, 3 rd Ed Chronic Insomnia = 10% of population Short term = 30‐35% in any given year
Transcript of Can’t Sleep”€¦ · · 2016-02-29“I Can’t Sleep ” • • • • • ... Salvadore...
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Janet E. Tatman, PhD, PADiplomate American Board of Sleep MedicineCertified in Behavioral Sleep Medicine
Why Behavioral Treatments?
“I Can’t Sleep”
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International Classification of Sleep Disorders, 3rd Ed
Chronic Insomnia = 10% of populationShort term = 30‐35% in any given year
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Drugs vs. Behavioral Treatment
Cognitive Behavioral Therapy for Insomnia(CBT‐I)
?Morin et al JAMA 1999McClusky et al Am J Psychiatry 1991
CBT‐I vs. Pharmacotherapy
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CBT Both Zolpidem Placebo
MidtreatmentAfter Treatment
% C
han
ge
in S
leep
Lat
ency
Jacobs, G et al Archives of Int Med 2004Data are from sleep diaries
N 15/group
An 8‐week study
N = 18
CBT‐I vs. Pharmacotherapy
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CBT Both Zolpidem Placebo
Mid Treatment
After Treatment
% C
han
ge
in S
leep
Eff
icie
ncy
Jacobs, G et al Archives of Int Med 2004Data are from sleep diaries
N 15/group
An 8‐week study
N = 18
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CBT‐I vs. Pharmacotherapy• 80 subjects got CBT‐I alone X 6 wks, then either
• 80 subjects got CBT‐I + zolpidem 10 mg X 6 weeks, then either
o Remission rate for CBT‐I group continued to increase; but decreased for group getting CBT‐I + zolpidem prn
Morin, C et al. JAMA 2009
A 1‐year+ study
A Cautionary Note
Predictable Factors In Insomnia
• Predisposing
• Precipitating
• Perpetuating
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Spielman & Glovinsky, 1991
Factors In Insomnia
Predisposing
Precipitating
Perpetuating Factors
• Behavioral
• Cognitive
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Getting Enough Sleep
American Academy of Sleep Medicine and Sleep Research Society
7 or more hours
SLEEP, Vol 38, No 6, 2015
Respect Individual Differences
Normal Variants
•Short sleeper
•Long sleeperand
•Older sleepers
Salvadore Dali 1931
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80 y.o. patient; A. Spielman, in Case Studies in Insomnia, p. 57, P. Hauri (Ed), 1991
Sleep Physiology 101
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Circadian Rhythms
anticipate
sleep / wake appetite propensity for exercise
immune function hormones drug metabolism
level of alertness independent of prior sleep
Zeitgeberssunlightsleep-wake cycle
noise
social cues
food
temperature
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Homeostatic Forces
Homeostasis = the tendency of an organism to maintain internal equilibrium by adjusting its physiological processes
Circadian & Homeostatic Influences
A Shorter Rhythm
Ultradian rhythm
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Slow Wave Sleep
Basic Rest‐Activity Cycle
Developmental Changes
o total sleep time / consolidation of sleep
o distribution of sleep stages
o circadian rhythmicity and timing
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Sleep History
Timing Is Everything
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Sleep ScheduleUsual Earliest Latest
Bedtime
Lights out
Time it takes to get to sleep?
Wake time
Get up time
How many times do you wake up on an average night? How long does it take you to get back to sleep after waking up? How many naps do you take each day, and how long do they last?
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Analyzing the Sleep Schedule
• Understand that subjective estimates are often inaccurate —but they are actually quite valid as indicators of change over time
Sleep ScheduleUsual Earliest Latest
Bedtime 10:30 PM 8 PM 1:30 AM
Lights out 11 PM 8 PM 2 AM
Time it takes to get to sleep?
1 hr 30 min 2.5 hrs
Wake time 5:30 AM 5:30 AM Noon
Get up time 6 AM 5:45 AM Noon
How many times do you wake up on an average night? 3How long does it take you to get back to sleep after waking up? 30 min – 1 hrHow many naps do you take each day, and how long do they last? 0-1, 30 min
Sleep ScheduleUsual Earliest Latest
Bedtime 9 PM 8 PM 10 PM
Lights out 10 PM 8:15 PM 10 PM
Time it takes to get to sleep?
1 hr 30 min 10 min
Wake time 7 AM 6:30 AM 9:30 AM
Get up time 7:30-8 AM 6:35 AM 10:30 AM
How many times do you wake up on an average night? 3+How long does it take you to get back to sleep after waking up? 20 min to 1 hrHow many naps do you take each day, and how long do they last? 0-1, 20 min
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COGNITIVE BEHAVIORAL THERAPY• Relaxation Training
• Stimulus Control
• Sleep Restriction Therapy
• Timed Bright Light Exposure
• Education in Realistic Expectations
‐used singly or in combination
Relaxation Techniques• physical and mental relaxation
o relaxed breathing and body awarenesso pleasant mental imagery
• self-hypnosis, meditation
• biofeedback
• music
Sleep Restriction Therapy• used for fragmented, interrupted sleep
(problems with sleep maintenance)…especially when coupled w/ excessive time in bed
• ACCEPTS mild daytime sleepiness as atemporary side effect
• might take 6-8 weeks, often less
• probably retrains circadian/ultradian rhythms
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Procedure for SRT Chose a realistic, restricted time in bed
Establish wake-up time, then calculate bedtime
Plan activities thoughtfully
Expect temporary difficulties
Log sleep
If TIB is aggressively restricted, extend time in bed gradually in 15 min increments when sleep efficiency > 90%
Get the clock out of sight! Individualize!
Spielman et al 1987
Sleep Restriction Therapy: Pre and Post
Calculate average Time in Bed, average Total Sleep Time use these to choose new restricted Time in Bed
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Contraindications to SRT• ANY other primary disorder of sleep until treated
(e.g., sleep apnea)
• Major depression or other acute or severe psychiatric disorder, until treated
• Circadian Rhythm Disorder
• Shift Work Sleep Disorder
Timed Bright Light Exposure• resets circadian clock
• establishes new circadian phase
• time of exposure critical
• must be daily initially
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Timed Bright Light Exposure
Be outdoors as early as possible after waking up in the morning for 30 min.
The activity does not matter and you can be in the shade. Just getting your eyes exposedto ambient outdoor light is all that’s needed.
Start with 7 days a week. You may be able to cut back when things are stable to maybe 4-5 times / wk.
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Thoughts About Insomnia It’s a chemical imbalance I can’t control it I can’t function the next day I must get 8 hours every night A bad night predicts more bad
nights I’ll get really sick When I don’t sleep, I need to
stay in bed more
Rapid Resolutionof Chronic Insomnia
Mr. I.B. DIMS
Perpetuating Factors
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Mr. Dims’ Sleep ScheduleUsual Earliest Latest
Bedtime 9 PM 8:45 PM 11:30 PM
Lights out 9 PM 8:45 PM 11:30 PM
How long to get to sleep?
45 min 30 min 1 hr
Wake time 6 AM 6:30 AM 8 AM
Get up time 7 AM 6:30 AM 8:30 AM
How many times do you wake up on an average night? 1How long does it take you to get back to sleep after waking up? 2-3 hrsHow many naps do you take each day, and how long do they last? 0-1, 15-20 min
The Problem?
My experience?This is by far the most common perpetuating factor in insomnia.
Mr. Dim’s Treatment PlanBedtime 9 pm w/LO. SOL = 45‐60 minutes. Sleeps thru ‘til 6 am “30% of time” (wakes 1 h before alarm). Usually wakes 2:30‐3:30 w/2‐3 hrs. to get back to sleep. Alarm at 7 am. No naps (except weekends).
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Mr. DIMS Rx
9 pm–7 am 11 pm–6:30 am
Mr. DIMS Follow‐up
Type A, Anxiety &Night Owl Tendencies
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Mr. Nat A. Bideal
Mr. Bideal’s Past History
Mr. Bideal’s Sleep ScheduleUsual Earliest Latest
Bedtime 10:30 PM 9:30 PM 1 AM
Lights out 10:45 PM 9:30 PM 1:30 AM
How long to get to sleep?
1 hr 30 min 2 hrs
Wake time 5:30 AM 5:30 AM 10 AM
Get up time 5:55 AM 5:35 AM 11 AM
How many times do you wake up on an average night? 1-3How long does it take you to get back to sleep after waking up? 30 min – 1 hrHow many naps do you take each day, and how long do they last? 1-2, 20-45 min
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Circadian Rhythm Disorders
Delayed Sleep Phase Syndrome
o
o
Advanced Sleep Phase Syndrome
o
from P
rinciples and Practice of Sleep M
edicine, 2
ndEd. 19
94, p
. 478
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Xanax 2 mg at 10 PM, in bed 10:30, 1 hr to get to sleep, wakes 1‐2 times/ night w/ 30 minutes to get back to sleep. Alarm at 5:30, snoozes it 3X, gets up tired. 20 min. nap after work. Weekends bedtime is midnight, wakes once w/quicker return, sleeps in until 9 AM‐ish.
Mr. Bideal’s Treatment Plan
Chronic Use of Sleep Meds
Habituation…tolerance…dependence?How do people get off these drugs?
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Ms. Nita Pillé
Ms. Pillé’s Failures
More Ms. Pillé History
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Getting Off Sleep Meds
Ms. Pillé’s Sleep ScheduleUsual Earliest Latest
Bedtime ? 8:30 PM 11 PM
Lights out Same Same Same
How long to get to sleep?
5 min 1 min 1 hr
Wake time 6:30 AM 6:30 AM 7 AM
Get up time 6:35 AM 6:30 AM 8 AM
How many times do you wake up on an average night? 0-1How long does it take you to get back to sleep after waking up? 0-30How many naps do you take each day, and how long do they last? 0
Takes Ambien 9‐10 PM, in bed 30‐60 min. later. (Husband worries she gets “confused” before bed.) Asleep w/in 5 min. Occasionally up to bathroom & usually forgets to flush toilet, no recall in AM. Occasionally can’t get back to sleep and takes another ½ pill. Alarm at 6:30 AM. Same routine on weekends, but no alarm, sleeps ‘til 7 AM. Groggy for ≈ 30 minutes on waking.
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Ms. Pillé’sTreatment Plan
Ms. Pillé’s Progress –Week 2
A Shorter Rhythm
Ultradian rhythm
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Ms. Pillé’s Progress –Week 6
Adolescent Night OwlExtraordinare
Joe L. Darkmann
4 alarms
middle‐of‐the‐night
see Wilhelmsen‐Langeland et al Behav Sleep Med 2014
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Joe’s History
Joe’s Sleep ScheduleUsual Earliest Latest
Bedtime 1 AM Midnight 7 AM
Lights out 2 AM 1 AM ?
Time it takes to get to sleep?
1 hr 2 hrs few min
Wake time 6:30 AM 6:30 AM 2 PM
Get up time 10 AM 7:30 AM 2 PM
How many times do you wake up on an average night? 0How long does it take you to get back to sleep after waking up? n/aHow many naps do you take each day, and how long do they last? 0-1
…the Darkside
2/4
2/5
2/6
2/7
2/8
2/9
2/10
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Ideas?
Circadian Rhythm Disorders
Delayed Sleep Phase Syndrome
o
o
Advanced Sleep Phase Syndrome
o
from P
rinciples and Practice of Sleep M
edicine, 2
ndEd. 19
94, p
. 478
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Timed Bright Light Exposure
Be outdoors as early as possible after waking up in the morning for 30 min.
The activity does not matter and you can be in the shade. Just getting your eyes exposedto ambient outdoor light is all that’s needed.
Start with 7 days a week. You may be able to cut back when things are stable to maybe 4-5 times / wk.
Joe’s Rx*
*An enormous challenge treating him during the school year
see West Saxvig, I et al. Chronobio Internat’l 2014& Dodson E & Zee, P Sleep Med Clin 2010
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Joe’s Rx – Additional Benefit?
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1Mundey, K. SLEEP 2005;28(10)
Questions?
Henry Ward Beecher
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RECOMMENDED READING?
*highly recommended
REFERENCES
