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Dr David O’Regan PhD MRCPsych, ST5 Higher Trainee Insomnia Clinic, Royal London Hospital for Integrated Medicine

Brief Behavioural Interventions for Insomnia

RCPsych International Congress, London 2014

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Goals

  To promote a practical understanding of insomnia.

  To demonstrate how to incorporate brief behavioural interventions for insomnia into our everyday practice.

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What is insomnia?

  Difficulty in initiating or maintaining sleep, or having sleep of subjectively poor quality which leads to daytime symptoms.

  Short sleep in the absence of daytime symptoms is not insomnia.

  Not getting enough sleep due to reduced sleep opportunity is not insomnia.

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“How tablets and phones before bed could lead to a stroke: Insomnia sufferers have higher risk than those who sleep

soundly – 18 to 34 year olds most effected” April 2014

“How insomnia can triple your risk of heart failure” March 2013

“Insomnia can double the risk of prostate cancer in men” May 2013

“Why insomnia can trigger arthritis” November 2012

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Making the diagnosis

  Comprehensive sleep history.

  Use of rating scales i.e. Insomnia Severity Index and the Epworth Sleepiness Scale.

  Consideration of investigations e.g. blood investigations, actigraphy or PSG.

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Duration of symptoms

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Duration of symptoms

Diagnostic Manual Duration ICD -10

(F51.0 – Non Organic Insomnia) 1 month

(Symptoms at least 3 times per week)

DSM V 1 month

ICSD3 3 months (Chronic Insomnia)

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The numbers

  UK – prevalence of 1 in 10 adults.

  Prevalence estimates vary between 10-48%.

  2010 cost of sleep disorders in the UK was 5,630 million €.

  Insomnia costs the US $63 billion/year.

References 1-3

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How does insomnia develop?

10   The 3P Model of Insomnia adapted from reference 4

Predisposing

Precipitating

Perpetuating

Inso

mni

a Se

verit

y

Insomnia Threshold

No Insomnia Acute Insomnia Chronic Insomnia

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Mental illness and insomnia

  Moving away from “primary” &“secondary” insomnia.

  The vast majority of insomnia exists in a co-morbid state.

  Insomnia is a powerful risk factor for psychiatric illness.

  Patients with insomnia have worse clinical outcomes than those without.

  Independent treatment of insomnia can also improve the co-morbid psychiatric condition.

e.g. References 5-11 12

% R

emis

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in M

DD

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som

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CBTI Sham

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CBTI Sham

SLEEP 2008;31(4):489-495

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How do we treat this?

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Historically

15 February 1933 16

Cognitive Behavioural Therapy for Insomnia

  Effective in about 80% patients.

  This includes insomnia comorbid with physical and psychiatric illnesses.

  Cheap – groups of 5-6 over 5 sessions with 1 therapist.

  Reduces the amount of hypnotics needed leading to savings later on.

  Reduces the burden of insomnia on society.

References 12-13

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Evidence for brief behavioural interventions?

Self-help e.g. internet

Telephone

2 x Session

1-day workshop

Group

Individual

Delivery methods for CBTI

Inc

reas

ing

inte

nsity

e.g. References 14-18 18

Components of CBT-I

Psycho-education

Stimulus Control

Sleep Scheduling

Sleep Hygiene

Relaxation

Cognitive Therapy

Behavioural Therapies

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Stimulus Control

  TV/Radio   Computer   Talking on phone   Texting   Exercise   Eating   Ironing   Studying   Paying bills   Reading!!   Meditating   Arguing   Etc, etc, etc

Sleep

Intimacy

Getting Dressed

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Stimulus Control Video

Goodnight Britain, clips from episodes 2&7, BBC 2013.

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Sleep Scheduling – an example

  Mr B goes to bed at 10pm sharp every night. He lies awake until 12am before falling asleep. He then drifts in and out of un-refreshing sleep for the rest of the night, before reluctantly dragging himself out of bed at 7am to go to work. In total he thinks he gets about 6 hours of sleep.

  In an attempt to get more sleep he starts going to bed at 9pm.

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Now he lies awake for 3 hours instead of 2!!!!

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Sleep Scheduling

  This strengthens the association between the bed and wakefulness.

  It confirms his inability to sleep.

  Or worse he may have little micro-sleeps which reduce his chance of getting good, consolidated sleep.

So,

  If Mr B only sleeps 6 hours he should not be in bed for more than 6 hours.

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Sleep Scheduling

We therefore advise him to:

  Get up at the same time seven days a week. This anchors his circadian rhythm and allows him to accumulate adequate fatigue through the day.

  He should not go to bed earlier than 6 hours before his rising time. Only once he has reached this “threshold time” AND he is sleepy should he go to bed.

  Once he is falling asleep quickly and his sleep fills up at least 90% of his time in bed, he can then move his threshold time backwards or his waking time later by 15 minutes.

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Sleep Hygiene

  NOT effective as a mono-therapy.

  Many tenants are not tested.

  Best tailored to the individual.

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Do not chase sleep

“Sleep (is like) a dove which has landed near one’s hand and stays there as long as one does not

pay any attention to it; if one attempts to grab it, it quickly flies away”

Viktor E. Frankl, 1965

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Discourage napping

  If fatigue is the fuel that drives sleep, then every nap is like stealing some of that sleep fuel from the night.

  It is better to push through the sleepy periods during the day and save that fatigue for the night.

  Once their sleep improves it will be easier to avoid napping.

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A final few words of advice for your patients with insomnia

  Wake up at the same time EVERY day.

  Yes, even on weekends. Yes, even if you’ve slept badly.

  Sticking to a constant bed time can be a very bad idea. Go to bed when, and only when, you feel sleepy tired.

  If you are not asleep in 15-20 minutes get out of bed and out of the bedroom.

  Use the extra time out of bed to do something relaxing and enjoyable.

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Teach the mantra

“I am not doing this to sleep better tonight. I may actually sleep worse tonight.

I am doing this to sleep better in a month.”

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Thank you

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References 1.  Morphy H; Dunn KM; Lewis M et al. Epidemiology of Insomnia: a Longitudinal Study in a UK

Population. SLEEP 2007;30(3):274-280. 2.  Fineberg N; Haddad PM; Carpenter L et al. The size, burden and cost of disorders of the

brain in the UK Journal of Psychopharmacology 2013; 27(9): 761–770 . 3.  Kessler RC; Berglund PA; Coulouvrat C et al. Insomnia and the performance of US workers:

results from the America Insomnia Survey. SLEEP 2011;34(9):1161-1171. 4.  Spielman AJ;Caruso LS; Glovinsky PB. A behavioural perspective on insomnia treatment.

Psychiatr Clin North Am 1987;10(4): 541-53. 5.  Taylor DJ, Mallory LJ, Lichstein KL, et al. Co-morbidity of chronic insomnia with medical

problems. Sleep 2007;30(2):213-8. 6.  Ford DE; Kamerow DB. Epidemiological study of sleep disturbances and psychiatric

disorders. J. Am. Med. Assoc. 1989; 262, 1479–1484. 7.  Dew MA, Reynolds CF, Houck PR, et al. Temporal profiles of the course of depression

during treatment. Predictors of path-ways toward recovery in the elderly. Arch Gen Psychiatry 1997;54:1016-24.

8.  Thase ME, Buysse DJ, Frank E, et al. Which depressed patients will respond to interpersonal psychotherapy? The role of abnor-mal EEG sleep profiles. Am J Psychiatry 1997;154:502-9.

9.  Fava M; McCall WV; Krystal A, et al. Eszopiclone co-adminis-tered with fluoxetine in patients with insomnia coexisting with major depressive disorder. Biol Psychiatry 2006;59:1052-60.

10.  Manber R, Bernert RA, Suh S, et al. CBT for insomnia in patient with high and low depressive symptoms severity: adherence and clinical outcomes. J Clin Sleep Med. 2011;7(6):645-52.

References II 11.  Watanabe N, Furukawa TA, Shimodera S, et al. Brief behavioral therapy for refractory

insomnia in residual depression: an assessor-blind, randomized controlled trial. J Clin Psychiatry. 2011;72:1651–8.

12.  Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and behavioural treatment of insomnia: update of the recent evidence (1998-2004). Sleep. 2006;29(11):1398-414.

13.  Morin CM, Hauri PJ, Espie CA et al. Nonpharmacologic treatment of chronic insomnia. Sleep. 1999; 22: 1134-56.

14.  Mimeault V, Morin CM. Self-help treatment for insomnia: bibliotherapy with and without professional guidance. J Consult Clin Psychol. 1999; 67: 511-19.

15.  Ritterband LM, Thorndike FP, Gonder-Frederick LA, et al. Efficacy of an internet-based behavioral intervention for adults with insomnia. Arch Gen Psychiatry. 2009; 66: 692-98.

16.  Currie SR, Clark S, Hodgins DC, et al: Randomized controlled trial of brief cognitive-behavioural interventions for insomnia in recovering alcoholics. Addiction. 2004; 99: 1121-32.

17.  Bastien CH, Morin CM, Ouellet MC, et al. Cognitive-behavioral therapy for insomnia: comparison of individual therapy, group therapy, and telephone consultations. J Consult Clin Psychol. 2004; 72: 653-59.

18.  Swift N, Stewart R, Andiappan M, et al. The effectiveness of community day-long CBT-I workshops for participants with insomnia symptoms: a randomized controlled trial. J Sleep Res. 2012;21:270-80.

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