Resiliency Training in the Recovery of OEF/OIF Soldiers with

1
Resiliency Training in the Recovery of OEF/OIF
Soldiers with PTSD

• J. Douglas Bremner, MD
• Atlanta VAMC
• Emory University,
• Atlanta, Georgia

www.dougbremner.com
2
Disclosures
Grant Support NIH R01 MH056120, T32 MH067547,
K24 MH076955, Veterans Administration Merit
Review, VET-HEAL Award National Alliance for
Research on Schizophrenia and Depression
(NARSAD), Independent Investigator Award American
Foundation for Suicide Prevention
(AFSP) GlaxoSmithKline Investigator Initiated
Medical Research Donations For Accutane
Research Mr. Liam Grant (80), lawyers involved
in Accutane litigation (20) Consulting
Novartis, Wyeth, GlaxoSmithKline,
Roundtable Expert Witness (current and past)
Accutane-psychiatric side effects
(Plaintiffs) Posttraumatic Stress Disorder
(Plaintiffs Defendants) Traumatic Brain Injury
(Defendants) Speakers Bureaus None Discussion
of Off Label Medication Use Phenytoin
3
Historical Timeline of the Development of
Concepts of Psychological Trauma
1830184018501860187018801890190019101920
19301940195019601970198019902000

• Description of Railway Injuries-UK
• Lancet-Railway injury without physical trauma
• DaCostas Syndrome (US)- Soldiers Heart,
  nervousness and startle, cardiovascular etiology
• Erichsen (UK) On Railway and Other Injuries of
  the Spine and Nervous System confusion,
  amnesia,back pain, paralysis (related to unseen
  cord trauma)
• Charcot (Fr) Traumatic hysteria
• H. Oppenheim (Ger) Traumatic neurosis
• Freud Studies in Hysteria developed seduction
  theory, then quickly abandoned it.
• Struggles over pension neurosis (Ger)
• Great War shell shock (UK) mental symptoms
  from impact of shells (ie, physical) war
  neurosis combat hysteria repressed wish to run
  from the battlefield (Freud) implied weakness of
  characterdefeat of traumatic neurosis in
  Europe compensation in US
• Rise of psychoanalysis in the US, emphasizes
  fantasy over reality (eg, trauma)
• WWII- Gross Stress Reaction in soldiers (US)
  (similar to hysteria)
• Rise of biological psychiatry in US lays
  foundation for viewing a physical role in the
  developmentof symptoms whose etiology is
  emotional trauma
• DSMIII PTSD central role of trauma emphasized
  (US) VN veterans only
• Biological research in PTSD, popular
  acknowledgement of both VN combat and child
  sexual trauma (US)
• Backlash of false memory movement
• Returning veterans from Operation Iraqi Freedom
  Lets do it better this time.

4
Stress and Psychopathology
Stress may lead to a range of outcomes that do
not have validity as discrete constructs These
trauma-related disorders have been termed Trauma
Spectrum Disorders From Bremner JD Does Stress
Damage the Brain? Understanding Trauma-related
Disorders from a Mind-Body Perspective. New
York W. W. Norton, 2002.
Foreshortened future (suicidality)
Alcohol/substance abuse (self destructiveness)
avoidance
Panic Somatization Eating Disorders
Decreased Concentration
Sleep disturbance
Feeling cut off (flat affect)
flashbacks (depersonalization, derealization)
Hyperarousal, hypervigilance (agitation)
startle
Intrusive memories (ruminations)
amnesia
nightmares
Feeling worse with reminders (Depressed mood)
Identity disturbance (dissociative identity d.o.)
Decreased interest
Genetics, prior stressors
Numbing (anhedonia)
Dissociative Disorders
PTSD
BPD
depression
Stress
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PTSD Impairs Function and Quality of Life
PTSD Non-PTSD
50
Percent
25
0
Not Working
PhysicalLimitation
ReducedWell-Being
Fair orPoorHealth
Violent BehaviorPast Year
Zatzick DF et al. Am J Psychiatry.
1997(Dec)154(12)1690-1695
7
Risk of Suicide Attempts Among Patients with
Anxiety Disorders
7
6
5
4
Odds Ratio
3
2
1
0
PTSD
GAD
Panic
Social
Any
Disorder
Anxiety
Anxiety
Disorder
Disorder
Kessler et al. Arch Gen Psychiatry. 199956617
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Mental Health Effects of OIF

• 150,000 soldiers are currently deployed in Iraq
  as part of Operation Iraqi Freedom (OIF).
• We know from prior wars, such as in Vietnam, that
  many of the returning soldiers will be afflicted
  with a wide range of physical and mental health
  complaints, including posttraumatic stress
  disorder (PTSD), depression, substance abuse, and
  physical problems such as increased risk for
  heart disease.

Hoge et al (2004). Combat duty in Iraq and
Afghanistan, mental health problems, and barriers
to care. New England Journal of Medicine 351,
13-22.
9
Mental Health Effects of OIF

• 15 of Vietnam combat veterans developed chronic
  PTSD.
• Thus of the 2,594,000 veterans who served in
  Vietnam, 389,100 developed chronic PTSD.
• A recent survey of OIF veterans showed rates of
  PTSD of 12
• less than 40 of these veterans spontaneously
  sought treatment for their disorders.
• Veterans with PTSD suffer from loss of work
  productivity, but also use more health care
  resources and have higher rates of disease.

Hoge et al (2004). Combat duty in Iraq and
Afghanistan, mental health problems, and barriers
to care. New England Journal of Medicine 351,
13-22.
10
Sertraline (Zoloft) Treatment Results in
Reduction in PTSD Symptoms
Adjusted Mean Change
Visit Week
P ? .05 sertraline vs placebo. Brady K et al.
JAMA. 20002831837-1894.
11
Paroxetine Fixed-Dose PTSD Study
Mean Change in CAPS-2 Total Score
0
Paroxetine 40 mg
-5
Paroxetine 20 mg
-10
Placebo
-15
-20
Adjusted Mean Change in CAPS-2 Total Score
-25

-30


-35


-40

-45
4
8
12
Week
LOCF dataset plt0.001 vs placebo Marshall et
al. Am J Psychiatry. (2001)
12
Effects of Psychological Debriefing (PD) on MVA
Victimswith High and Low Initial Impact of Event
Scale (IES)
Randomized
Controlled Trial
IES
Mayou et al. Br J Psychiatry. 2001178182-183
13
CBT Prevention Program for Acute PTSD

• Four to five weekly sessions
• Typically within 2-5 weeks post-trauma
• Delivered in individual setting
• Intervention Includes
• Discussions of normal reactions to assault
• Breathing retraining
• Deep muscle relaxation
• Recounting the assault imaginal exposure
• Cognitive restructuring
• Exposure in vivo assignments

14
Prolonged Exposure, Stress Inoculation Training
and Supportive Counseling for Acute Stress
Disorder
Motor Vehicle Accident/Assault Victims with Acute
Stress Disorder
Impact of Event Scale
Bryant RA, et al. Am J Psychiatry.
19991561780-1786.
15
Cognitive-Behavioral Treatments for Chronic PTSD

• Exposure therapy
• Helps person to confront situations, people,
  emotions associated with the stressor
• Imaginal exposure
• In vivo exposure
• More empirical evidence for this technique with
  PTSD than any other intervention 21 positive
  RCTs
• Cognitive therapy
• Corrects irrational beliefs and thoughts
• Promotes rational behavioral changes

16
What is Resilience?

• Capacity to avoid adverse mental and physical
  outcomes following exposure to extreme stress
• 70 of individuals free of major psychiatric
  outcome following exposure to traumatic event
• Traumatic event threat to life of self or others
  or threat to physical integrity associated with
  intense fear, horror or helplessness)

17
What Promotes Resilience?

• More education
• Older age
• Social support
• Specific training
• Absence of early life trauma
• Genetics
• Looking at glass half full

18
Factors of Resilience

• Seeking support
• Seeking purpose in life
• Belief in ability of self to overcome adversity
  and to influence events and outcomes
• Belief one can learn from and grow from
  experience
• Self enhancement
• Repressive coping
• Positive emotion
• laughter

19
Factors of Resilience

• Altruism
• Bonding
• Cooperation
• Optimism
• Contingency planning
• Reframing
• Revisiting

20
START

• S. is for Safety. Seek Safety and Support.
• T. Talk about your trauma. tell people about how
  you feel. Translate feelings into words.
• A. is for Action. Take Action, move beyond your
  restricted sphere. Use Altruism as a way to move
  beyond your trauma.
• R. is for Re-write history. Re-visit the scene of
  the trauma. Re-live it with new eyes.
• T. is for transform. Transform yourself from
  victim into survivor. Transform society to make
  it a better place (MADD, Megan's law) etc.

21
Mental Health Effects of OIF

• Intervening soon after the trauma is critical for
  long-term outcomes
• With time traumatic memories become indelible and
  resistant to treatment.
• Diminished efficacy of treatment over time is
  shown by the fact that trials of Vietnam veterans
  have shown less efficacy over the years.

22
Mental Health Effects of OIF

• Animal studies show that pretreatment before
  stress with antidepressants reduces chronic
  behavioral deficits related to stress.
• However, treatment is not indicated for all
  individuals (some early interventions negative).
• Therefore identifying people who need an
  intervention and those who would be better off
  left alone will be critical to developing new
  treatments
• Can neurobiologic and genetic factors identify
  those at risk?

23
Resiliency Training for PTSD Prevention

• Mindfulness Based Stress Reduction (MBSR)
  represents a possible method of PTSD prevention
  that has many inherent advantages.
• MBSR is manualized program involving 8 weekly
  classes and a single 6 hour silent retreat
  session during the 6th week.
• The program is based on a systematic procedure to
  develop enhanced non-reactive awareness of the
  moment-to-moment experience of perceptible mental
  processes.

24
Resiliency Training for PTSD Prevention

• Clinical trials have shown MBSR to be highly
  effective for patients with pain, anxiety,
  depression, and other complaints.
• Current study to perform brain imaging, randomize
  to MBSR or supportive group therapy, and repeat
  brain imaging after treatment.
• Incorporation of MBSR into resiliency training
  programs for promotion of mental health in OIF
  military personnel

25
Assess Interventions for Returning OIF Soldiers

• Studies show efficacy for paroxetine in chronic
  PTSD
• Interventions performed years after the war in
  Vietnam
• No studies of interventions early after return
  from combat theater
• Lifestyle interventions (exercise program, diet)
  equal to medication for depression no studies in
  PTSD

26
Functional Neuroanatomy of Traumatic Stress
Stress
Parietal Cortex
Cerebral Cortex
Long-term storage of traumatic memories
Amygdala
Prefrontal Cortex
Conditioned fear
Hippocampus
Orbitofrontal Cortex
Glutamate
CRF
Extinction to fear through amygdala inhibition
Hypothalamus
NE
Attention and vigilance-fear behavior Dose
response effect on metabolism
Pituitary
ACTH
Locus Coeruleus
Output to cardiovascular system
Adrenal
Cortisol
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Non-Stressed
Stressed
Stress results in decreased dendritic branching
of neurons in the CA3 region of the hippocampus
(Woolley et al. 1990)
29
Stress Results in DecreasedHippocampal
Neurogenesis

Number of BrdU-Labeled Cells
Gould et al, 2002.
30
Antidepressant Treatments Promote Hippocampal
Neurogenesis




BrdU Labeled Cells/DG
Duman et al, 2002.
31
Deficits in Verbal Memory inCombat-Related PTSD
plt.05


32
Decreased Right Hippocampal Volumein
Combat-Related PTSD
plt.05
Hippocampal Volume (mm3)

33
Hippocampal Volume Reduction in PTSD

• NORMAL PTSD
• MRI scan of the hippocampus in a normal control
  and patient with PTSD secondary to childhood
  abuse. The hippocampus, outlined in red, is
  visibly smaller in PTSD. Overall there was a 12
  reduction in volume in PTSD.

Bremner et al., Am. J. Psychiatry 1995
152973-981 Bremner et al., Biol. Psychiatry
1997 4123-32
34
Effect Size Estimates for Hippocampal Volume in
Adults With Chronic PTSD vs Healthy Subjects
Pooled Meta-Analysis Demonstrates Smaller
Hippocampal Volume in PTSD
Gilbertson, 2002
Notestine, 2002
Gilbertson 02
Bremner, 1995
Bremner, 1997
Bremner, 2003
Notestine 02
Villareal, 2002
Gurvits, 1996
Bremner 95
Bremner 97
Bremner 03
Schuff, 2001
Villareal 02
Gurvits 96
Stein, 1997
Schuff 01
Stein 97
Overall
Overall
2
2
1
1
0
0
-1
-1
Effect Size
Effect Size
-2
-2
-3
-3
plt.05
-4
-4
plt.05
-5
-5
Left Hippocampus
Right Hippocampus
Effect size (black square) and 95 confidence
interval (red line) measured with Hedges GU.
35
Smaller Right Hippocampal Volume in PTSD Twins
Compared to their Brothers

• 11 smaller volume
• in PTSD
• 8 in MZ, 12 in DZ
• p0.001

Black squares MZ (N13) Red triangles DZ
(N21) Lines connect brothers
36
CRF and Stress

• CRF plays an important role in the stress
  response
• Stress exposure is associated with increases in
  CRF
• Central CRF administration is associated with
  fear related behaviors (decreased exploration,
  increased startle, decreased grooming)

37
Elevated CSF Concentrations Of Corticotropin
Releasing Factor In Combat-Related PTSD

Controls (N17)
PTSD (N11)
Plt.05.Bremner et al. Am J Psychiatry.
1997154624-629.
38
Fear Conditining and Extinction in PTSD

• Pairing of light and shock leads to fear
  responses to light alone (fear conditioning)this
  is mediated by the amygdala
• With exposure to light alone there is a gradual
  decrease in fear responding (extinction to
  fear)
• Reexposure to light-shock at later time point
  results in rapid return of fear responding
• Prefrontal Cortical inhibition of amygdala
  represents neural mechanism of extinction to fear
  responding
• Conditioning and extinction relevant to PTSD

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Medial Prefrontal Cortical Dysfunction with
Traumatic Memories in PTSD
Medial PFC (BA 25)
AC (BA32)
Decreased function in medial prefrontal cortical
areas Anterior Cingulate BA 25, BA 32 in veterans
with PTSD compared to Veterans without PTSD
during viewing of combat-related slides
sounds Z score gt3.00 plt.001
41
Neural Circuits in PTSD

• Decreased anterior cingulate/medial prefrontal
  cortex function replicated finding in PTSD
• Other areas decreased function in hippocampus,
  visual association and parietal cortex, parts of
  dorsolateral prefrontal cortex
• Role for amygdala in PTSD?

42
Increased Blood Flow with Fear Acquisition versus
Control in Abuse-related PTSD
Orbitofrontal Cortex
Superior Temporal Gyrus
Left Amygdala
Yellow areas represent areas of relatively
greater increase in blood flow with paired vs.
unpaired US-CS in PTSD women alone, zgt3.09
plt0.001
43
Normal
Stress
Antidepressants

• Glucocorticoids

Serotonin and NE
BDNF
BDNF
Glucocorticoids
Normal Survival and Growth
Atrophy/Deathof Neurons
Increased Survival and Growth

• Other neuronal insults
• Hypoxia-ischemia
• Hypoglycemia
• Neurotoxins
• Viruses

Genetic Factors
Modifed from Duman, Heninger, and Nestler. AGP.
199754(7)597-606.
44
Effects of Paroxetine on Hippocampal-Based Verbal
Declarative Memory in PTSD
Mean 35 improvement
Effects of 9-12 months of treatment with 10-40 mg
paroxetine. Vermetten et al. Biol Psychiatry.
2003.
45
Increased Hippocampal Volume With Paxil in PTSD
plt.05


Effects of 9-12 months of treatment with 10-40 mg
paroxetine. Vermetten et al. Biol Psychiatry.
2003.
46
Phenytoin and Stress

• Phenytoin (dilantin) efficacious in the treatment
  of epilepsy
• Modulates glutamatergic function
• Blocks the effects of stress onthe hippocampus
• Conducted pilot in 9 PTSD subjects

47
Effect of Phenytoin onSymptoms of PTSD
plt.05

Nine patients with PTSD from mixed causes treated
for 3 months with Phenytoin 300 mg/day on an open
label basis.Bremner et al. 2005 J Clinical
Psychiatry
48
Effects of Phenytoin onBrain Structure in PTSD

plt.05

• Phenytoin resulted in a significant increase in
  right brain volume similar increases in
  hippocampal volume were seen but not significant
  after controlling for changes in whole brain
  volume
• Bremner et al 2005 J Psychopharmacology

49
Is there a pill that will make all of our
symptoms and problems go away that doesnt have
any side effects?
50
Are Medications the Answer?

• Are medications always going to be the answer for
  physical and mental health problems?
• What are the true relative risks and benefits of
  psychotropic medications?
• Are there alternatives to psychotropic drugs?
• What about changes in diet and lifestyle? Social
  changes?
• What about alternative treatments?

51
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52
Too Many Pills?

• More than half of US on prescription drugs
• 81 take some kind of pill
• Companies create new markets, new risks
• 100,000 deaths per year from medications

53
Only in America

• Direct to Consumer Ads
• Funding of Advocacy Groups
• Screening in the absence of evidence

Companies relentlessly seek to increase their
markets (e.g. recommendations that women without
heart disease should take statins based on
research in men).
54
What Will They Think of Next?
Denmark bans fortified cereals under new
fortification policy                            
                                                
                         
March 27, 2006 Bacon That's Good For You?
Researchers Create Pigs That Produce
Heart-healthy Omega-3 Fatty Acids Science Daily
Researchers report they have created pigs that
produce omega-3 fatty acids, which are known to
improve heart function and help reduce the risks
for heart disease
Now you can have your cake (bacon?) and eat it
too!
http//www.sciencedaily.com/releases/2006/03/06032
7084435.htm
12/08/2004 - Vitamin-enriched products made by
Kellogg, the world's biggest cereal maker, have
been blocked from entering the Danish market by a
new policy for assessing the safety of fortified
foods.
55
Efficacy of Antidepressants

• 80 of improvement with antidepressants come from
  the placebo response.
• Overall 2-point improvement on a 62 item scale
  (the 21 item Hamilton Depression Scale) above and
  beyond the placebo response.
• Placebos help, but we cant get away with giving
  them
• SSRIs not shown to work better than the older
  tricyclics.
• Loss of libido (SSRIs) preferable to dry mouth?
  (tricyclics)
• Dual reuptake inhibitors (e.g. venlafaxine
  (Effexor)) better efficacy for depression than
  SSRIs, but more suicidality

Kirsch et al, The Emperor's new drugs An
analysis of antidepressant medication data
submitted to the U.S. Food and Drug
Administration. Available at http//www.journals.
aoa.org/prevention/volume5/pre0050023a.html.
56
Antidepressants Suicide

• Doubling of risk of suicide attempt or attempted
  self harm on SSRIs
• Also risk with older tricyclics
• Greatest risk appears to be with Effexor

57
Placebo Controlled Trials of Alternative
Medicines for Depression
58
Exercise Works for the Treatment of Depression
Hamilton Depression Score
156 patients with major depression over age 50
who were randomly assigned to aerobic exercise,
antidepressants (sertraline) or a combination of
the two for 16 weeks. All patients showed an
improvement in symptoms of depression with an
essentially identical response between the
groups. Other studies show 3 ½ hours per week
required for benefit
Blumenthal et al, Effects of exercise training on
older patients with major depression. Archives of
Internal Medicine. 19991592349-2356
59
Antipsychotics

• Typical antipsychotic medications block the
  dopamine 2 receptor in the brain, which is felt
  to be involved in the symptoms of schizophrenia.
• Work as well as atypical antipsychotics
• Dropped off the map because of the potential for
  tardive dyskinesia (odd twitches)
• Massive weight gain and life threatening diabetes
  with the second generation drugs is calling into
  question the so-called inferiority of the old
  generation drugs.

60
Time to Discontinuation for Any Cause in
Schizophrenia CATIE Phase 1 Study
Cost 520/mo for olanzapine v 60/mo for
perphenazine withdrawal for EPSthat for weight
gain
Lieberman JA, et al. N Engl J Med
2005353(12)1209-1223.
61
Atypical Antipsychotics Increase Risk of Diabetes
Gain of 22 pounds in 30 of patients on
olanzepine also risk with clozepine
Sernyak et al, AJP 2002159(4)561-566.
62
International Pilot Study of Schizophrenia

• 2/3 patients recovered from schizophrenia in
  India v 1/3 in the US.
• old cheap medications (chlorpromazine) used in
  India atypical antipsychotics in US (cost
  thousands of dollars per year)
• Consistent with studies (CATIE) showing no
  advantage of new drugs
• Doses used in US are way above required for
  receptor occupancy extra doses?side effects
• India used very low doses, increases only with
  flair-up of symptoms
• More family involvement in India US patients in
  institutions/homeless.
• Indians not as focused on productivity, gave
  small jobs to the patients
• Families paid the employer to retain them, so
  that the patient would have a sense of
  independence and their own discretionary money
• Results completely ignored by the American
  psychiatric community

Leffet al, The International Pilot Study of
Schizophrenia five-year follow-up findings.
Psychological Medicine. Feb 199222(1)131-145
63
Donepezil Treatment of Dementia

• 431 patients with AD were randomized to one year
  of donepezil (Aricept) or placebo.
• Donepezil was shown to delay the decline of
  cognitive function in AD patients by five months
  compared to placebo.
• However that was mostly due to a delay in the
  onset of changes in symptoms.
• After one year MMSE score not statistically
  significant

Mohs et al. A 1-year, placebo-controlled
preservation of function survival of donepezil in
AD patients. Neurology. 200157481-488.
64
Drug Treatment of Dementia

• Studies show about a 5-point change on the
  ADAS-Cog, or a 7 change in cognition (i.e. not
  much).
• That means that if I asked you to buy 10 items at
  the grocery store, you would remember seven with
  the drug, and six without it.
• The rate of change is not stopped.
• because of flawed methods and small clinical
  benefits, the scientific basis for
  recommendations of cholinesterase inhibitors for
  the treatment of Alzheimers Disease is
  questionable.
• Kaduszkiewicz et al, British Medical Journal.
  2005331321-327

--memory?
--time?
65
Psychotropic Medications in the Elderly

• ¼ in nursing homes prescribed antipsychotic
  medications. In spite of guidelines to the
  contrary, only one quarter of elderly patients on
  antipsychotics actually have a psychotic
• Use of atypical antipsychotics doubles the risk
  of death in the elderly.
• Antipsychotic drugs developed for schizophrenia
  are actually used just as much or more in elderly
  patients with dementia.

66
Psychotropic Medications in the Elderly

• Anticholinergic side effects of the tricyclics
  are especially bad for patients with dementia and
  the elderly, since they are more susceptible to
  the memory impairing effects
• Recommended that tricyclics amitriptyline and
  doxepin not be prescribed to the elderly.
• In spite of this these two medications make up
  the most commonly inappropriately prescribed
  medications for the elderly, making up 23 of all
  such medications (21 of medications prescribed
  for the elderly are felt to be inappropriate).

67
Sleeping Pills

• Insomnia affects 10-15 of people
• 100 increase in use of sleeping pills last five
  years.
• "Doctors are handing out these drugs like Pez,"
  NYT, 3/8/06
• Drug companies spend 298 million a year on ads
  for the drugs, a four-fold increase over the last
  five years.
• Between 5-33 of individuals over the age of 60
  are prescribed a sleeping pill in the form of a z
  drug or a benzodiazepine.
• For gt60, 5-fold in cognitive dysfunction, and a
  four fold increase in daytime fatigue with
  sleeping pills

68
Benzodiazepines Cause Car Accidents

• Decrease time it takes to fall asleep by 4
  minutes, 1 hr more sleep
• 80 more daytime drowsiness, dizziness, and
  light-headedness.
• 25 increase in mortality
• 14 of hip fractures related to a sleeping pill
  or other psychotropic
• Older adults with cognitive impairment, 11 was
  related to a drug, 46 of those sleeper.
• 60 increase in road traffic accidents with
  benzos (also zopiclone).

Relative Risk of Car Accident
--increasing sleeping pill dose?
Barbone et al, Association of road-traffic
accidents with benzodiazepine use. Lancet.
1998352(9137)1331-1336.
69
Z Drugs for Zzzzzzzz

• Act on subsets of the GABA receptor.
• Use of non-benzodiazepine misleading, since
  they bind to the GABA-benzodiazepine receptor
  complex
• Difference is that they bind to a different part
  of the same receptor complex.
• No Z drug better or safer than another
• Lunesta is a variant of zopiclone, developed
  because of bad publicity about driving
• Have not been shown to work better or be safer
  than benzodiazepines

zaleplon (Sonata), zolpidem (Ambien), eszopiclone
(Lunesta), zopiclone (Imovane)
70
Sleepwalking on Sleeping Pills

• Cases of people getting up, walking around the
  house, cooking, driving, even having sex,
  reported.
• Driving and getting into car accidents, with
  absolutely no memory of what happened.
• One man became the incredible hulk after
  drinking two glasses of wine with Ambien during a
  trans-Atlantic flight. He tore off his clothes
  and threatened to kill himself and others. The
  plane had to make an emergency landing. He had no
  memory of the incident.
• Any amount of alcohol, even a glass, is forbidden

71
Cognitive Therapy for Insomnia

• Sleep hygiene minimizing or avoiding all
  together caffeine, alcohol, stimulants, and heavy
  or extremely spicy meals 4-6 hours before going
  to bed exercise
• Sleep restriction maintaining a regular sleep
  schedule, eliminating daytime naps, use the
  bedroom only for sleep
• Stimulus control Dont work in bed
• Cognitive therapy Replace negative thoughts (I
  cant sleep without medications) with more
  positive ones (If I take the time to relax, I
  can get to sleep without help from pills.).
• Progressive relaxation progressive muscle
  relaxation often help (alternately contracting
  individual muscles and relaxing with exhalation
  the individual goes progressively through the
  body one-muscle group at a time)

72
Cognitive Behavioral Therapy Better (and Safer)
than Sleeping Pills for Insomnia

• 46 patients with insomnia were randomized to
  receive CBT, zopiclone, or placebo medication
  each night for six weeks.
• CBT was better than zopiclone for sleep
  efficiency, with an increase from 81 to 90
  compared to zopiclone which stayed at 82 before
  and after treatment.
• Six months after the end of treatment CBT
  resulted in better sleep efficiency using
  polysomnography than placebo or zopiclone.

Sivertsen et al, Cognitive behavioral therapy vs
zopiclone for treatment of chronic primary
insomnia in older adults a randomized controlled
trial. Journal of the American Medical
Association. Jun 28 2006295(24)2851-2858.
73
Insomnia in Context

• Average person sleeps 7 hours a night, and has
  the best health outcomes.
• No need for 8 hours of sleep, gt8 hours associated
  with worse health outcomes.
• -Kripke et al, Mortality associated with sleep
  duration and insomnia. Archives of General
  Psychiatry. 200259131-136
• Increased mortality does not occur until sleep is
  in range of 4-5 hours
• Insomniacs sleep 6 hours a night based on
  objective monitoring.
• It is not abnormal to wake up in the middle of
  the night

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Insomnia in Context

• With removal from artificial light, you fall
  asleep when it gets dark, sleep 3-4 hours, wake
  up, lie awake for 2-3 hours, then fall asleep
  again for 3-4 hours
• Primitive hunter-gatherer societies sleep in the
  same way.
• May has adaptive value, since if someone is
  always awake they are more likely to detect
  predators and wake up the rest of the clan.
• Artificial to stay up until 11 pm with artificial
  lights, then sleep 8 hours straight
• If you wake up in the middle of the night, you
  should not reach for sleeping pills

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