Download - Insomnia presentation

Transcript
Page 1: Insomnia presentation

AWP 2010, Portland, OR

Conceptualization of Insomnia

A Holistic Approach to Insomnia

Sovann Pen,

MA, Counseling

Kaiser Insomnia Clinic

Page 2: Insomnia presentation

The Importance of Sleep• Sleep is vital to our health and well being. • National Sleep Foundation reveal that 60 percent of adults report

having sleep problems a few nights a week or more. • In addition, more than 40 percent of adults experience daytime

sleepiness severe enough to interfere with their daily activities at least a few days each month - with 20 percent reporting problem sleepiness a few days a week or more.

• At least 40 million Americans suffer from sleep disorders, yet more than 60 percent of adults have never been asked about the quality of their sleep by a physician and fewer than 20 percent ever initiated a discussion.

• Poor sleep has a price. • Millions of individuals struggle to stay alert at home, in school, on the

job - and on the road. Tragically, fatigue contributes to more than 100,000 police-reported highway crashes, causing 71,000 injuries and 1,500 deaths each year in the United States alone.

Page 3: Insomnia presentation

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 results in impairment in daytime function.

Page 4: Insomnia presentation

Epworth Sleepiness Scale• Use the following scale to choose the most appropriate number for each

situation: 0 = no chance of dozing

• 1 = slight chance of dozing• 2 = moderate chance of dozing• 3 = high chance of dozing

• Sitting and reading____________• Watching TV____________• Sitting inactive in a public place (e.g a theater 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 traffic____________

Page 5: Insomnia presentation

Insomnia is MessyInsomnia is MessyInsomnia is MessyInsomnia is Messy

Page 6: Insomnia presentation

Cognitive Behavioral Therapy

Page 7: Insomnia presentation

Chicken or the Egg?

Page 8: Insomnia presentation

Sleep-interfering process

Page 9: Insomnia presentation

Spielman Model

Page 10: Insomnia presentation

Insomnia over time

• Premorbid• Acute• Short-term • Chronic

• How long?• What triggered/started the problem?

Page 11: Insomnia presentation

Predisposing Factors

• Genetic• Biological • Psychological• Social

Page 12: Insomnia presentation

Genetic Factors

• Co-morbidities• Medical• Sleep Disorders• Mood Disorders

Page 13: Insomnia presentation

Biological

• Hyperarousal• Hyperactivity (ADD/ADHD)• Startle• Physical tension

Page 14: Insomnia presentation

Psychological

• Personality: Worry, rumination• Type-A; driven, determined• Cognitive style: analytical, problem-

solver

Page 15: Insomnia presentation

Psychological cont.

• Compassionate, co-dependent, sympathetic/empathetic

• Creatives• Perfectionism

Page 16: Insomnia presentation

Social

• Living situation• Significant other• Family of Origin

Page 17: Insomnia presentation

Precipitating Factors

• Medical• Life Stressors• Negative changes • Positive changes• Women • Men• Shiftwork

Page 18: Insomnia presentation

Negative changes

• Illness• Conflict• Job stress• Financial• Unemployment• Abuse• Divorce

Page 19: Insomnia presentation

Positive changes

• Retirement• Marriage• Moving• Work• Vacation• Travel

Page 20: Insomnia presentation

Spielman Model

Page 21: Insomnia presentation

Perpetuating Factors

• Compensatory strategy• Counter Fatigue measures/ Stimulants• Rituals and Strategies• Self-medication

Page 22: Insomnia presentation
Page 23: Insomnia presentation

• Pain and Sleep• Stress and Pain• Stress and Sleep• Sleep and Mood• Mood and motivation• Mood and activity• Activity and weight• Caffeine and Sleep

Page 24: Insomnia presentation
Page 25: Insomnia presentation

Compensatory strategy

• Go to bed early “Give myself more of a chance to get

some sleep”• Sleep in (wake up later) “Catch up” “Only chance I have to sleep”• Napping

• Cons: Deprimes sleep homeostat. Dysregulation of circadian rhythm

Page 26: Insomnia presentation

Erratic sleeping patterns

• Your bedtime varies greatly depending on your mood, favorite television program, or the day of the week.

• This sends confusing messages to the sleep-regulating centers of your brain—a guarantee for all kinds of problems with sleep.

Page 27: Insomnia presentation

Counter Fatigue measures/ Stimulants

• Increased use • Inappropriately-timed • Avoid or decrease physical activity

• Cons: arousal, mood, conditioning

Page 28: Insomnia presentation

Rituals and Strategies

• Increase in non-sleep in bedroom and bed

• Sleep in other places• “Rituals” for sleep• Avoidance of behaviors thought to

inhibit sleep

• Cons: lack of stimulus control, dependence, anticipatory anxiety

Page 29: Insomnia presentation

Dysfunctional Beliefs

• Rewards and reinforcement• Forcing the issue• Catastrophic thinking• Rigid expectations

Page 30: Insomnia presentation

• I think, therefore I …

Page 31: Insomnia presentation
Page 32: Insomnia presentation

Cognitive vs Somatic Lichstein & Rosenthal 1980

• Cognitive arousal 10x more likely to be cited as major cause than somatic arousal

Page 33: Insomnia presentation
Page 34: Insomnia presentation

Unwanted intrusive thoughts

• Worry or Cognitive arousal• Most Common - Racing thoughts• “I am unable to empty my mind”• “I can’t turn off my mind”• “My mind keeps turning things over”

Page 35: Insomnia presentation

Pre-sleep stress/cognitive activity

• Hall, et al 1996 • Wicklow & Espie 2000

• Good sleepers threatened with making a speech

• Increased sleep latency

Page 36: Insomnia presentation

WHAT ARE YOU THINKING?Watts, Coyle, East 1994

• Mental activity and rehearsal• Thoughts about sleep• Family and long-term concerns• Positive plans and concerns• Somatic preoccupations• Work and recent concerns

Page 37: Insomnia presentation

Affect-laden thoughts

Page 38: Insomnia presentation
Page 39: Insomnia presentation

Vicious cycle (again)

AnticipationPerformance AnxietyArousal

Similar to Panic Disorder

Start to dread, avoid bed and bedtime

Page 40: Insomnia presentation

Perception of sleep (memory)

• Subjective vs Objective Measures

• Overestimate sleep latency• Underestimate Total Sleep Time (TST)• Underestimate number of awakenings

Page 41: Insomnia presentation

Neitzer, Semler and Harvey

• Positive and Negative Feedback study

• Negative feedback increased: negative thoughts, sleepiness, monitoring sleep-threat and safety behaviors the next day.

Page 42: Insomnia presentation

Mendelson 1990

• Another key study applying to use of benzodiazepines

• Objectively: benzos decrease SWS

• Subjectively: report better sleep with benzos

Page 43: Insomnia presentation

Attention

Insomniacs more aware of: • body sensations• environment• clock• needing to use the bathroom• mood• performance: attention, memory,

concentration failing

Page 44: Insomnia presentation

Worry about negative consequences of poor sleep

• Catastrophizing / awfulizing• Negative prediction

Similar to Cognitive Distortions from standard CBT –

“All-or-nothing” “Black-and-white” thinking

Page 45: Insomnia presentation

Unhelpful beliefs in Maintenance of insomnia

• Morin 1993

• Less Realistic about sleep required

• Strongly endorse – negative consequences of insomnia

• More likely to attribute insomnia to external and stable causes

Page 46: Insomnia presentation

Rewards and reinforcement

• By rewarding yourself with your favorite foods, beverages, or drug of choice when you can’t sleep, you ensure future nights of insomnia. The pleasure centers of your brain have great recall for this type of behavior. They will continue to awaken you to receive more of the same—night after night, after night, after night.

Page 47: Insomnia presentation

Forcing the issue

• When unable to fall asleep, you try to force sleep to happen with statements such as, “I must get to sleep right now,” or “If I can't get to sleep, I'll just have to force myself to stay in bed until I get to sleep.”

• Creating this negative association with sleep will lead only to frustration.

Page 48: Insomnia presentation

Harvey 2003b

• Attempts to stop, modify, suppress cognitive arousal may be counter productive

• Other options (discuss cognitive restructuring later)

• Suppress, distract (math problem study, TV, sheep), neutralizing, appraisal, punishment and worry

Page 49: Insomnia presentation

Catastrophic thinking

• Being unable to sleep, you predict that tomorrow will be a disaster.

• You tell yourself things such as, “I won't be able to function at all tomorrow if I don't get to sleep.”

• This type of thinking creates so much anxiety that you will most likely not be able to return to sleep.

Page 50: Insomnia presentation

Rigid expectations

• You believe that sleep is dependent on rigidly imposed expectations. You create a flexible work schedule that permits you to sleep in, expect a 100-percent quiet sleep environment, and strive for a stress-free life.

• If for some reason you cannot meet these conditions, you begin to worry that you will not be able to sleep.

Page 51: Insomnia presentation

Self-medication

• Alcohol• Marijuana• OCT – [Benadryl, Nyquil, Unisom,

Tylenol PM]• Melatonin as hypnotic

• Cons: REM-supression, fragmentation, withdrawal, rebound insomnia, dependence, circadian rhythm shift

Page 52: Insomnia presentation

Medication dependence

• You take a nightly sleeping pill “just in case”—without first determining whether you really need it.

• After a few weeks of this, you can lose confidence in your ability to sleep without the pill, creating the perfect set-up for a pattern of medication dependence.

Page 53: Insomnia presentation

Chronic, perpetual problems

• Pain, disability• Are you managing or coping as best as

you can?• Resources, trying new ways or

approaches, support group• Mood: Depression and Bipolar D/o

Page 54: Insomnia presentation

• Mental Disorders• Pain• Hormone: menopause,

hyperthyroidism• Medication• Neurological• Medical

Page 55: Insomnia presentation

Organic disorders

• Similar symptoms of primary or psychophysiologic insomnia

• Delayed Sleep Onset• Sleep maintenance, early awakening.• “Light” sleep• Frequent awakenings• Non-restorative sleep

Page 56: Insomnia presentation

Sleep-Disordered Breathing - SDB

• Obstructive Sleep Apnea• Central Sleep Apnea• Mixed Apnea• Upper Airway Resistance Syndrome• Hyponea• Obesity Hypoventilation Syndrome

Page 57: Insomnia presentation
Page 58: Insomnia presentation
Page 59: Insomnia presentation
Page 60: Insomnia presentation

Symptoms

• Snoring• Apnea: snort, gasp, choke, pause, puff• Dry throat/dry mouth• Heart racing• Shortness of breath• Headache• Numbness/tingling in limbs• Muscle pain/soreness• GERD

Page 61: Insomnia presentation

Risks

• Daytime impairment, sleepiness

• Heart Disease• Hypertension• Diabetes• Stroke

Page 62: Insomnia presentation

Limb movement Disorders

Page 63: Insomnia presentation

Restless Leg Syndrome

• Do you feel a strong desire to move your legs from time to time, often when they make you uncomfortable?

• Do those sensations in your legs occur or get stronger when you are inactive?

• Does moving around or stretching help ease those uncomfortable sensations in your legs?

• Do those uncomfortable sensations feel their worst at night?

Page 64: Insomnia presentation

Other RLS symptoms

• Burning• Creeping• Crawling• Aching• Tingling• Itching • Tugging

Page 65: Insomnia presentation

Periodic Limb Movement Syndrome

• PLMS• Prevalence of PLMS seems to increase with

age. • 45% elderly adults aged 65 years and older

had PLMS, compared to 5% to 6% of the younger adult population.

• 80% of those with RLS also had PLMS. • • Rule out SDB

Page 66: Insomnia presentation

Parasomnias

• Nightmare disorder • Sleep terror disorder • Sleepwalking disorder • Sleep talking• REM-Behavior disorder• Bruxism

Page 67: Insomnia presentation

Confusional arousals

• Arousals during REM

• Vs sleep talking

Page 68: Insomnia presentation

Narcolepsy

• Cataplexy: a sudden loss of muscle tone while in a conscious state

• Hallucination• Sleep paralysis

Page 69: Insomnia presentation

AWP 2010, Portland, OR

Hex of Insomnia

homeostat

arou

sal

life style

rhythm

associa

t

ions

beliefs

Page 70: Insomnia presentation
Page 71: Insomnia presentation

Circadian Rhythm Biology

Page 72: Insomnia presentation

Normal Sleep Pattern

Page 73: Insomnia presentation

Monday Morning Blues

Page 74: Insomnia presentation

Delayed Sleep-Phase Disorder

Page 75: Insomnia presentation

DSPS

• “Night Owl”• Teens• Seasonal Affective Disorder

• Jet Lag/Shift Work

Page 76: Insomnia presentation
Page 77: Insomnia presentation

Advanced Sleep-Phase Disorder

Page 78: Insomnia presentation

Entrainment Zeitgerbers

• How to reset your body clock every day?

• Retrain your body:• Daytime• Nighttime

Page 79: Insomnia presentation

Light exposure

Page 80: Insomnia presentation

Light Box

Page 81: Insomnia presentation

Light and Sleep-Wake Rhythm

Page 82: Insomnia presentation

Physical Activity

Page 83: Insomnia presentation

Meal times

Page 84: Insomnia presentation

Wake Time