Behavioral Treatment for Sleep Disorders

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Behavioral Treatment for Sleep Disorders

• Dr. Kala K. Davis
• October 4, 2006

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Behavioral Medicine Sleep

• Behavioral treatment approaches to sleep
  disorders began in the 1930s
• Now considered a sub-specialty within sleep
  medicine
• Cognitive behavioral therapy (CBT) is an
  established and very effective modality in the
  management of chronic insomnia

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Insomnia

• Insomnia is defined as difficulty initiating
  sleep, maintaining sleep, final awakenings that
  occur much earlier than desired or sleep that is
  non-restorative and of poor quality and result in
  impairment in daytime function.

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Insomnia

• Prevalence rates for chronic insomnia are higher
  in women and generally increase with age.
• Has been associated with reduced quality of life,
  mood disorders and increased health service
  utilization
• Represents a significant economic burden in the
  US, with estimated direct costs of 13.9 billion
  annually.

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Insomnia

• There are many treatments options for insomnia
  including behavioral therapy, non-pharmacological
  interventions such as relaxation therapy,
  biofeedback, exercise, dietary changes and
  medications

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Behavioral Model of Insomnia

• Insomnia occurs acutely in relation to both
  predisposing and precipitating factors
• The chronic form of the disorder is maintained by
  maladaptive coping behaviors.
• Behavioral therapy focuses on eliminating the
  perpetuating factors that lead to the
  development of chronic insomnia.

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Behavioral Model of Insomnia

• A state of conditioned arousal may develop in
  which situations associated with sleep become
  alerting rather than relaxing- further impairing
  sleep.

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Cycle of Persistent Insomnia
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Cognitive Behavioral Therapy (CBT) for Insomnia

• CBT seeks to change poor sleep habits and faulty
  beliefs about sleep and promote good sleep
  hygiene.
• CBT principles include sleep restriction,
  stimulus control, relaxation techniques,
  education and sleep hygiene.

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Cognitive Behavioral Therapy (CBT) for Insomnia

• CBT is as successful as medications in the acute
  treatment (4-8 weeks) of insomnia
• It is more effective than medications in the long
  term
• Average of 50-60 improvement

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Cognitive Behavioral Therapy (CBT) for Insomnia

• Long term studies reveal a sustained improvement
  in sleep quality and duration.
• Patients continued to experience improvement
  over follow-up periods of 1year

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Cognitive Behavioral Therapy for Insomnia

• Stimulus Control Therapy
• Sleep Restriction Therapy
• Sleep Hygiene Education
• Cognitive Therapy
• Relaxation Training
• Phototherapy

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Stimulus Control Therapy

• Recommended for sleep initiation and sleep
  maintenance problems
• Considered a first-line behavioral treatment for
  chronic insomnia by AASM
• Principle to re-associate bed, bedtime and the
  bedroom with sleepiness and sleep

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Stimulus Control Therapy Rules

• Lie down to go to sleep only when sleepy
• Avoid any behavior in bed or the bedroom besides
  sleep or sex
• Leave the bedroom if awake for more than 15
  minutes
• Keep a fixed wake up time, 7 days a week no
  matter how poorly you sleep

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Stimulus Control Therapy Caution!

• Stimulus control therapy is generally well
  tolerated
• Maybe contraindicated in patients with mania,
  epilepsy, parasomnias or at high risk for falls

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Sleep Restriction Therapy

• Recommended for sleep initiation and sleep
  maintenance problems
• Requires the patient to
• limit his/her time in bed to an amount that
  equals their total sleep time
• Time restriction determined by clinician and
  patient using sleep diaries and balancing the
  patients lifestyle
• Establish a fixed wake up time
• Delay bed time

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Sleep Restriction Therapy

• As sleep efficiency increases, patients are
  gradually allowed to spend more time in bed-
  increased in 15 minute increments.
• Over the course of therapy, patients will begin
  to find it difficult to stay up until the
  prescribed hour- sleep initiation is easier

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Sleep Restriction Therapy

• Sleep restriction works for several reasons
• It prevents insomniacs from coping by extending
  sleep opportunity- produces a sleep that is
  shallow and fragmented
• Initial sleep loss early in SRT increases the
  homeostatic drive for sleep, producing a
  condensed, quality sleep with shorter awake times

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Sleep Restriction Therapy Cautions!

• Maybe contraindicated in patients with history of
  mania, obstructive sleep apnea, seizure disorder,
  parasomnias or those at significant risk for
  falls.

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Sleep Hygiene Education

• Sleep only as long as you need to feel fresh the
  following day
• Get out of bed at approximately the same time
  every day
• Exercise regularly
• Make sure the bedroom is comfortable- free from
  light, noise and temperature extremes.
• Eat regular meals and do not go to bed hungry

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Sleep Hygiene Education

• Avoid drinking too much in the evenings
• Cut down on all caffeinated products
• Avoid alcohol, especially in the evenings
• Smoking may disturb sleep
• Dont take your problems to bed
• Do NOT try and fall asleep
• Turn your clock around
• Avoid naps

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Cognitive Therapy

• Most suitable for patients who are preoccupied
  with the potential consequences of their insomnia
  or for patients who complain of unwanted
  intrusive ideation or worry.
• Serves to deconstruct patients negative thoughts
  and beliefs about their condition
• This is thought to decrease the anxiety and
  arousal associated with insomnia.

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Relaxation Training

• Progressive Muscle Relaxation
• Diaphragmatic Breathing
• Autogenic Training
• Imagery Training
• Mindfulness-based stress reduction
• Prayer

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Mindfulness-based stress reduction

• Mindfulness meditation and stress regulation
  helps us explore alternative ways to emotionally
  regulate ourselves, providing a sense of
  awareness and control that comes from inner
  calmness, acceptance and openness. 

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Circadian Rhythm Disorders

• Cause insomnia because of a lack of
  synchronization between an individuals internal
  clock and the external schedule
• Treatment is best accomplished with chronotherapy
  and/ or phototherapy

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Phototherapy- Light Therapy

• Light is a powerful trigger in allowing us to
  reset our internal biological clock each day
• Indicated when circadian factors appear to be a
  significantly contributing factor to insomnia
• Light Intensity 10,000 lux
• Duration 30 - 60 min
• Timing of light exposure is very important
• Caution may trigger mania in persons with
  bipolar disorder, chronic headaches, eye
  conditions, photosensitivity, seizure disorder

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Phototherapy- Light Therapy

• For DSPS- The patient sits in front of 10,000 lux
  light for 30 to 40 minutes upon awakening in
  addition, room lighting has to be markedly
  reduced in the evening to achieve the desired
  results.
• Response is generally evident after a two to
  three week period, but frequently requires
  indefinite treatment to maintain
• In patients with ASPS, bright light exposure in
  the evening has been successful in delaying sleep
  onset.

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Chronotherapy

• Refers to the intentional delay of sleep onset by
  2-3 hours on successive days until the desired
  bedtime is achieved
• Has a high degree of success in patients with
  delayed sleep phase syndrome
• Tendency over time to lapse back into old sleep
  habits

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Chronotherapy

• General Principle Phase Shifting

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Normal Sleep Pattern
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Advanced Sleep-Phase Disorder
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Delayed Sleep-Phase Disorder
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Shift Work Disorder
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Irregular Sleep-Wake Rhythm
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Advanced Sleep-Phase Disorder
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Delayed Sleep-Phase Disorder
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Jet Lag Disorder
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Jet Lag Disorder

• Use activities (eating, exercise, sightseeing)
  and exposure to light to try to synchronize body
  rhythms with those of the environment
• Adult travelers crossing five or more time zones
  are likely to benefit from melatonin
• Melatonin 3 mg about 30 minutes before bedtime on
  the day of travel and for up to four days after
  arrival is appropriate
• A dose of 0.5 mg has less effect on sleep, but
  otherwise helps adaptation similarly

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Obstructive Sleep Apnea

• Unlike people with insomnia, OSA is a structural/
  anatomical problem with physiological
  consequences
• Treatment of OSA with CPAP/ Bi-level, oral
  appliance or surgery is needed before one can
  completely treat co-existing sleep disorders
• Sleep maintenance insomnia, sleep walking, PLM
  are all improved with treatment of OSA

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Obstructive Sleep Apnea

• CBT and desensitization are useful in improving
  CPAP/ Bi-level compliance
• Weight Loss
• Avoid alcohol and other substances known to make
  apnea worse
• Restriction of body position during sleep
• Avoidance of upper airway mucosal irritants
• Possibly avoidance of altitude

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Restless Legs Syndrome (RLS)

• In contrast to patients with insomnia, patients
  with RLS frequently require long term
  pharmacological therapies.
• Non-pharmacological strategies
• Avoid caffeine, nicotine and alcohol
• Avoid medications which may aggravate symptoms
• Iron replacement therapy
• Mental alerting activities
• Regular moderate exercise and stretching
• Warm baths or cold packs

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Parasomnias

• Sleep disorders characterized by abnormal
  behavioral or physiological events which occur
  during sleep or during sleep-wake transitions.
• Parasomnias typically do not cause insomnia or
  excessive sleepiness
• Avoid sleep deprivation- schedule naps/
  awakenings
• Avoid alcohol, drugs and stimulants
• Stress Reduction
• Treat OSA if present
• Secure the home and safety of the bed partner

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Resources

• Licensed Sleep Psychologist in Northern
  California
• Kathleen L. Benson, Ph.D. Palo Alto, CA
• Richard M. Coleman, Ph.D. Ross, CA
• Sharon A. Keenan, Ph.D. Palo Alto, CA
• Tracy F. Kuo, Ph.D. Stanford, CA
• Derek H. Loewy, Ph.D. Belmont, CA
• Karen H. Naifeh, Ph.D. San Francisco, CA
• Rachel Manber, Ph.D. Stanford, CA

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Resources

• Stanford Sleep Disorders Clinic offers
• Group therapy- insomnia workshop, night owls
  workshop and CPAP workshop
• Individual therapy
• [phone]

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Resources

• Full Catastrophe Living by Jon Kabat-Zinn