Cognitive Behavioral Therapy for Insomnia (CBT-I )

1. Cognitive Behavioral Therapy for Insomnia (CBT-I) Melissa E. Milanak, Ph.D. Sleep & Anxiety Treatment & Research Program (SATRP) Department of Psychiatry & Behavioral Sciences Medical University of South Carolina (MUSC)

2. Sleep Disorders • Insomnia • Narcolepsy • Sleep Apnea (Obstructive & Central) • Sleep Paralysis • Nightmares (REM) & Night Terrors (NREM) • Sleepwalking • REM Behavior Disorder • Restless Leg Syndrome • Periodic Limb Movement Disorder

3. The Insomnia Patient • Dissatisfaction with Sleep Quantity and/or Quality • Difficulty falling asleep • Difficulty staying asleep • Early morning awakening with inability to return to sleep • Daytime Fatigue • Inability to “shut off” the Mind/Racing Thoughts • Significant Distress and/or Impairment in Daytime Functioning

4. ASSESSMENT

5. Self-report Measures • Pittsburgh Sleep Quality Index (PSQI) • PSQI-A (Addendum specifically targeting PTSD Sleep Disturbance) • Epworth Sleepiness Scale (ESS) • Insomnia Severity Index (ISI) • SATED • S’atisfaction with sleep • ‘A’lertness during waking hours • ‘T’iming of sleep • Sleep ‘E’fficiency (proportion of time in bed spent asleep) • Sleep ‘D’uration

6. Pittsburgh Sleep Quality Index (PSQI) Instructions: The following questions relate to your sleep habits during the past month only. Your answer should indicate the most accurate reply for .the majority of days and nights in the past month. Please answer all the questions. 1. During the past month, when have you usually gone to bed at night? 2. During the past month, how long (in minutes) has it usually take you to fall asleep each night? 3. During the past month, when have you usually gotten up in the morning? 4. During the past month, how many hours of actual sleep did you get at night? 5. During the past month, how often have you had trouble sleeping because you ..... (a) Cannot get to sleep within 30 minutes (b) Wake up in the middle of the night or early morning (c) Have to get up to use the bathroom (d) Cannot breathe comfortably (e) Cough or snore loudly (f) Feel too cold (g) Feel too hot (h) Had bad dreams (i) Have pain (j) Other reason(s), please describe 6. During the past month, how often would you rate your sleep quality overall? 7. During the past month, how often have you taken medicine (prescribed or "over the counter") to help you sleep? 8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity? 9. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done? 10. Do you have a bed partner or roommate?

7. Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven't done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Situation Sitting and reading Watching TV Sitting, inactive in a public place (e.g. a theatre or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in the traffic

8. SATED & ISI

9. Sleep Diary

10. Actigraphy • Wrist-worn device • Monitors movement/activity • Used to compute sleep/wake • Movement infers wake • No movement infers sleep

11. Polysomnography (PSG) • Gold Standard of Sleep Measurement • Provides a moment-by-moment view of brain, motor, and eye movement activity • Basic Sleep Staging uses three measures: • Electroencephalograpy (EEG; Scalp) • Electromyography (EMG; Muscles) • Electroocculography (EOG; Eyes)

12. Treatment

13. CBT-I Treatment Efficacy • Highly Efficacious/Effective • Both for Primary and Comorbid Insomnia Symptom Improvements Include: • Sleep onset latency (SOL) • Number of awakenings (NA) • Duration of awakenings (DA) • Total sleep time (TST) • Sleep quality ratings (SQ)

14. CBT-I Treatment Efficacy • Well Standardized • Multiple treatment manuals now in print • CBTi vs./& Pharmacotherapy • Equal to medication in short-term • More durable long-term • No side-effects or drug interactions • Cost-effective • Consistently following procedures is key

15. Components of CBT-I • Sleep Education • Sleep Restriction (& Titration) • Stimulus Control • Sleep Hygiene • Relaxation • Cognitive Restructuring (& Worry Time) • Relapse Prevention

16. Sleep Education* *Images in this presentation, unless otherwise noted, have been reproduced from Perlis, M. L., & Lichstein, K. L. (Eds.). (2003). Treating sleep disorders: Principles and practice of behavioral sleep medicine. Hoboken, NJ, US: John Wiley & Sons Inc.

17. Basics of Sleep • Why do we need it? • Body restoration • Memory consolidation • Metabolism and immune system • Daytime alertness and concentration • Ability to respond to challenges

18. Sleep Stages (healthy young adult)

19. Typical Night of Sleep in Older Adults

20. Different Stages of Human Sleep In a typical night of young adult sleep: • Sleep time ranges from 7-8 hours. • Wakefulness = <5% • Stage N1 = 2-5% • Stage N2 = 45-55% • Stage N3 =(slow wave sleep) 15-25% • REM sleep = 20-25% • Cycles last 90-110 minutes • Early cycles have more stage 3 SWS. • Later cycles have more REM sleep.

21. Physiology Changes Across Stages Perlis, M. L., & Lichstein, K. L. (Eds.). (2003). Treating sleep disorders: Principles and practice of behavioral sleep medicine. Hoboken, NJ, US: John Wiley & Sons Inc.

22. Two Process Model:Working Together Edgar, DM, Dement, WC, and Fuller, CA. Effect of SCN lesions on sleep in squirrel monkeys: evidence for opponent processes in sleep-wake regulation. J Neurosci 1993;13:1065-79.

23. When sleep goes wrong: • Process S: If you haven't accumulated enough sleep debt, you can’t achieve sustained sleep. • Process C: Light exposure shifts your Circadian Rhythm. • Light at night • Negative Associations: Too much time awake in bed Light in the morning Images created by Greg Sahlem, MD.

24. SleepRestriction

25. Sleep Restriction Therapy Figure reproduced with permission from Michael Smith, PhD per Daniel Taylor, PhD

26. Too Little Pizza Dough Total Sleep Time (TST)/Time in Bed (TIB) = Sleep Efficiency (SE)

27. Sleep Restriction • Three basic steps: • Establish a fixed wake time • Decrease time in bed to average total sleep time • Increase time in bed when sleep efficiency >90% • SE = (TST/TIB)/100 Upward Titration • Sleep Efficiency (SE) > 90% • Increase time in bed by 15 minutes • Can be bedtime or wake time • Prefer bedtime • SE is between 85% and 90% • No change • SE < 85% • Decrease time in bed by 15 minutes • SE < 70% • Start over

28. Stimulus Control

29. Rationale for Patient • People with insomnia often associate their bed and bedroom with insomnia • They go into the room at night anticipating insomnia • Makes them anxious, agitated, or frustrated • Not very conducive to sleep • Longer they stay in bed awake • More wound up they get • Less likely they are to fall asleep • Stimulus Control • Designed to break theses associations

30. An Example of Poor Stimulus Control

31. Stimulus Control Therapy • Get out of bed if awake > 15 minutes • Increases association between bed and rapid sleep onset • Don’t watch the clock, estimate • If they start to wonder if 15 min has passed, it probably has... • Give them the list of things they can do • Return to bed only when sleepy • Repeat as often as necessary during night

32. Sleep Hygiene

33. Behavioral Perspective on Insomnia • Predisposing: • Personality • Neuroticism • Circadian type • Hyperarousal • Emotional • Cognitive • Physiologic • Genetic predisposition Spielman, Saskin, & Thorpy, (1987). Sleep, 10, 45-56.

34. Behavioral Perspective on Insomnia • Precipitating : • Situational stress • Acute injury • Illness • Bereavement • Deployment • College • New Job • Children • New Puppy Spielman, Saskin, & Thorpy, (1987). Sleep, 10, 45-56.

35. Behavioral Perspective on Insomnia • Perpetuating: • Extending Time in Bed • Variable schedule • Napping • Sleep-incompatible activities • Conditioned Arousal • Increased Caffeine intake Spielman, Saskin, & Thorpy, (1987). Sleep, 10, 45-56.

36. Sleep Hygiene – Sleep Drive: • Keep a consistent sleep schedule 7 days a week – especially wake time • Exercise each day, but not too close to bedtime • Avoid Naps • Naps can affect your circadian rhythm • They also fill some of your nightly sleep need, so can cause you to get less sleep at night.

37. Sleep Hygiene - Sleep Environment: Your sleep environment should: Be very dark (During the day your room should be pitch dark) (new window treatments?) Be cool enough that you need a cover (60-70 degrees if possible) Be quiet (a white noise generator or ear plugs and eye shades may help) Your bed should be comfortable

38. Sleep Hygiene – Circadian/Light: • Limit bright light exposure if you get up at night • Avoid TV and computer 1 hour before bedtime • Aim to get exposure to sunlight within 30 min of waking up

39. Sleep Hygiene - Substances: • Do not smoke after 7 pm (Try not to smoke at all!) • Limit caffeine use to no more than three cups of coffee before 10 am (2pm at the very latest) • If using alcohol, practice light to moderate use of alcoholic beverages (especially in the evening)

40. Sleep Hygiene – Arousal in Sleep Setting: • Avoid strenuous exercise after 6 pm • Don’t watch TV or use a computer in the bedroom • Keep the clock face turned away, and do not look at the time when you wake up at night • Don’t eat or drink heavily for 3 h before bedtime. A light bedtime snack may help. Do not retire too hungry or too full. • Reading before bedtime may be helpful if it is not arousing

41. Deep Diaphragmatic Breathing • Progressive Muscle Relaxation Relaxation

42. Cognitive Therapy & Worry Control

43. Cognitive Triangle #3 Interpretations/Beliefs/Perceptions Context Thoughts #2 Self-fulfilling Prophecy Feelings Behaviors #1

44. Disordered Beliefs About Sleep (DBAS)Strongly, S., & Agree, D. (1994). Dysfunctional Beliefs and Attitudes about Sleep (DBAS). I need 8 hours of sleep to feel refreshed and function well during the day. When I don't get the proper amount of sleep on a given night, I need to catch up on the next day by napping or on the next night by sleeping longer. I am concerned that chronic insomnia may have serious consequences on my physical health. I am worried that I may lose control over my ability to sleep. After a poor nights sleep, I know that it will interfere with my daily activities on the next day. In order to be alert and function well during the day, I am better off taking a sleeping pill rather than having a poor night's sleep. When I feel irritated, depressed, or anxious during the day, it is mostly because I did not sleep well the night before. When I sleep poorly on one night, I know it will disturb my sleep schedule for the whole week. Without an adequate night's sleep, I can hardly function the next day. I can't ever predict whether I'll have a good night's sleep. I have little ability to manage the negative consequences of disturbed sleep. When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before. I believe insomnia is essentially the result of a chemical imbalance. I feel insomnia is ruining my ability to enjoy life and prevents me from doing what I want. A “nightcap” before bedtime is a good solution to sleeplessness. It usually shows in my physical appearance when I haven't slept well.

45. Problem Solving • People with insomnia often find themselves making to do lists in bed in the dark. • Recommend a scheduled worry time • 10-15 to make a to do list

46. Worry Time Don’t take your troubles to sleep with you Have worry time in advance of bedtime, and write down one sentence solutions to any problems. Don’t problem solve at night or in bed. Don’t actively try to fall asleep. It is ok to not sleep!

47. Relapse Prevention • Review • Behavioral model of insomnia • Have them identify their own predisposing, precipitating, and perpetuating factors. • Cognitive Model • Have them identify some thoughts they still need to work on. • “What To Do If Insomnia Returns” • Never stay in bed awake for more than 15-20 minutes. • Never compensate for a bad night. • Do not turn in early, stay in bed later, or nap. • Remember the Mantra: “If not tonight, then tomorrow night.” • Resume sleep restriction if the insomnia persists • Identify risk factors recurrence • Discuss steps to reduce their risk

48. Addictions & Sleep Using to Sleep Using to Stay Awake Sleep as Scapegoat Sleep as Creative Avoidance Reduction in relapse (e.g., Arnedt et al. 2007; Friedmann et al., 2003)

49. GABA & Glutamate 5 5 GABA Glutamate +5 Drinks

50. + 5 Drinks Glutamate GABA + 5 to Balance