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Insomnia

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CBT for Insomnia (Espie, 1991) CT for Insomnia (Harvey, 2002) A rhythmic world ... Cataplexy (sudden loss of muscle tone) and/or intrusions from REM stage (often ... – PowerPoint PPT presentation

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Title: Insomnia


1
Insomnia
  • Dr Nic Wilkinson
  • Clinical Psychologist
  • Medical Psychology
  • University Hospital of Leicester (UHL) NHS Trust
  • nicolas.wilkinson_at_uhl-tr.nhs.uk

2
Lecture plan
  • What is sleep ?
  • Sleep disorders
  • What is Insomnia ?
  • CBT for Insomnia (Espie, 1991)
  • CT for Insomnia (Harvey, 2002)

3
A rhythmic world
  • Planets circle the sun
  • Night follows day
  • 4 seasons
  • tidal movement
  • birds migrate
  • flowers close at night open during day

4
Biorhythms
  • Circadian - approx 24 hr cycle
    e.g sleep/wake cycle
  • Ultradian - cycles within a day
    e.g. sleep stages
  • Infradian - cycles more than a day
    e.g. menstrual

5
Human sleep
  • A period a substantial neurological
    physiological activity
  • car engine running but with the clutch depressed
    so the car is resting (Espie,1991)
  • different types of sleep sleep stages/
    architecture
  • exact functions of sleep remain unclear

6
How much sleep?
  • Amount changes with age lifestyle
  • Myth of 8 hours
  • Adult Range 3 10hrs sleep
  • 6 hours is probably enough (Horne, 1988)
  • Less than 2/3 may have detrimental effect

7
An night of sleep for a young adult
8
Sleep Disorders - Sleep Apnoea
  • Transient closure of the upper airway during
    sleep
  • Symptoms - Snoring headaches/shortness of breath
    on waking daytime fatigue
  • Prevalence rate 3-8
  • Risk factors male, obese, small jaw, thick
    neck, alcohol
  • Increased risk of accident, cardiovascular
    disease
  • CPAP mask often effective

9
SD - Restless Legs Syndrome
  • Feeling of discomfort in deep tissues between
    knee and ankles, occurs when resting
  • Appears in Stage 2 sleep
  • Prevalence rate 2-5 - increases with age
  • Associated with anaemia and heart failure
  • Medication very effective

10
SD - Narcolepsy
  • Irresistible attacks of refreshing sleep occur
    daily for at least 6 months
  • REM sleep disorder
  • Cataplexy (sudden loss of muscle tone) and/or
    intrusions from REM stage (often described as
    hallucinations)
  • Prevalence rare 5 per 100,000rare
  • Cause unknown but strong familial component
  • Prescribed stimulants can be effective

11
Jet Lag and Shift Work
  • Desynchronicity of internal body clock
  • Sleepiness at wrong times of the day
  • Light box treatment can be effective
  • Melatonin resets circadian rhythm

12
Parasomnias - Nightmares
  • Prevalence rate 5
  • Most common in childhood but can last into
    adulthood
  • Occurs during 2nd part of the night
  • Dreams involve threat to survival, security or
    self-esteem
  • If no paralysis, may cause injury to self and
    others
  • Often a feature of Post Traumatic Stress Disorder
    (PTSD)

13
Parasomnias Night Terrors
  • Abrupt waking associated with features of terror
  • Symptoms rapid heart rate, sweating and
    confusion
  • Occurs in Stage 3 and 4 sleep
  • Most common in children
  • Often related to emotional distress

14
Parasomnias Sleep Walking
  • Person engaged in activity whilst asleep
  • May undertake simple or complex tasks
  • Usually unaware of behaviour
  • Occurs during Stage 3 and 4 sleep
  • Strong familial component

15
Insomnia - DSM IV criteria
  • difficulty initiating or maintaining sleep, or
    non-restorative sleep, for at least 1 month.
  • b) clinically significant distress or impairment
    in social/occupational functioning
  • c) not exclusively due to another sleep disorder
  • d) not exclusively due to another mental disorder
  • e) not due to the physiological effects of a
    substance or a medical disorder

16
  • Features of Insomnia
  • Problems initiating sleep (greater than 30
    minutes)
  • Frequent and/or prolonged nocturnal awakenings
  • Early morning awakenings with an inability to
    return to sleep
  • Poor sleep quality and sleep efficiency
  • Cognitive arousal typically reported
  • Severity is judged along several dimensions,
    including frequency, intensity and duration of
    sleep difficulties. Also impact on daytime
    functioning, mood and quality of life.

17
Screen for other disorders
  • Depression and GAD common co-morbid problems
  • Eg.s other problems PTSD/Acute stress
    drug/alcohol dependence, low self esteem
  • Use psychometrics BDI II/PSWQ etc
  • Interview
  • Which problem started first?
  • Which is most distressing?
  • Which causes most interference with functioning?

18
  • Effects of Insomnia
  • BIOLOGICAL
  • Increased surveillance of immune system
  • Reduced mortality rate but increase if take
    sleeping tablets
  • COGNITIVE AND BEHAVIOURAL
  • Flexible thinking and other pre-frontal cortex
    functions mildly affected
  • Increased risk of accidents
  • More likely to report lack of concentration and
    motivation
  • Reduced productivity, work absenteeism
  • Increased use of medical services
  • PSYCHOLOGICAL
  • Insomnia at first assessment increases risk of
    developing first onset depression, anxiety or
    alcohol problems
  • Risk factor in suicide

19
Prevalence of Insomnia
  • Up to 9 adults
  • Up to 25 older adults
  • 15-25 individuals in sleep clinics
  • women gt men
  • shift workers
  • Course 50-75 of people with insomnia have
    symptoms gt year

20
Insomnia assessment
  • Medical assessment to rule out other sleep
    disorders/ medical problems
  • Clinical interview
  • Psychometric HADs SDQ BDI-II PSWQ

21
Insomnia - drug therapy
  • Benzodiazepines (temazepam, diazepam)
  • Nonbenzodiazepine hypnotics (Zolpidem,
    Zopiclone, Zaleplon)
  • Side effects changes in sleep architecture,drowsi
    ness, tolerance, withdrawal effects

22
Insomnia - CBT model (Espie,91)
23
Insomnia - CBT
  • Stimulus control
  • Sleep hygiene
  • Sleep restriction
  • Relaxation
  • Thought stopping
  • Paradoxical intention
  • Cognitive restructuring

24
  • Insomnia
  • Stimulus Control
  • Insomnia is a conditioned response to temporal
    and
  • environmental cues
  • Promote consistent sleep / wake cycle
  • Re-associate the bedroom with sleeping
  • Well established treatment

25
  • Insomnia
  • Sleep Hygiene Education
  • Factors that affect sleep, e.g caffeine,
    alcohol etc
  • Not primary cause of insomnia but can maintain
    problem
  • Limited benefits if used alone

26
  • Insomnia
  • Sleep Restriction
  • Reducing time in bed to match sleep obtained
  • To increase sleep efficiency
  • Adherence is problematic
  • Probably effacious treatment

27
  • Insomnia
  • Relaxation
  • to deactivate arousal system
  • various types - muscular, imaging, hypnosis
  • well established treatment

28
  • Insomnia
  • Paradoxical Intervention
  • Engage in the feared outcome (not sleeping)
  • Break cycle of performance anxiety
  • Large variance in response

29
  • Insomnia
  • Cognitive Therapy
  • Identify thought processes to reduce anxiety
  • Includes self-talk, distraction,
    rationalisation
  • Helpful in altering dysfunctional sleep beliefs
  • Efficacious treatment

30
  • Insomnia - Efficacy of CBT
  • Two meta analyses (Morin et al., 1994 Murtagh
    Greenwood, 1995)
  • - Significantly more effective than no treatment
  • Review by the AASM (Chesson ET al., 1999 Morin
    et al ., 1999)
  • However
  • 19-26 fail to respond
  • overall average improvement is 50-60
  • effect sizes for pre to post treatment/
    follow-up lt 1.0

31
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32
A cognitive approach?
  • The cognitive approach has lead to advances in
    theory and treatment for several psychological
    disorders ...minimally applied to insomnia
  • The majority of people with insomnia report that
    they cant get to sleep because of .
    Uncontrollable worry
    Intrusive
    thoughts
    Racing mind (Geer Katkin, 1966)

33
Sleep Deficit
  • People with insomnia honestly and persistently
    describe that they dont get enough sleep
  • The difference in sleep duration between good
    sleepers and individuals with insomnia is not
    enough to account for the severity of the
    complaints (Chambers Keller, 1993, n14, 35
    mins.)
  • Many people with insomnia overestimate sleep
    onset latency and underestimate total sleep time
    (Adam et al., 1986 Bonnet, 1990)

34
Daytime Deficit
  • People with insomnia honestly and persistently
    describe wide-ranging daytime deficits
  • Not detected by majority of studies using MSLT,
    pupillometry, and neuropsychological testing (see
    Riedel Lichstein, 2000 for review)

35
Distortions of reality (Beck, 1976)
  • Anorexia nervosa People think they are fat when
    they actually thin
  • Hypochondriasis People think they are suffering
    from a grave illness when actually they are well
  • Panic disorder People think they are going to
    have a heart attack when actually they are
    experiencing the symptoms of anxiety

36
No. of cues utilised in any situation tends to
become smaller with an increase in emotion
(Easterbrook, 1959) Anxiety is associated with an
attentional bias toward threat (Dalgleish
Watts, 1990)
Harvey - Behaviour Research Therapy (2002)
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