Insomnia

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Insomnia

• Dr Nic Wilkinson
• Clinical Psychologist
• Medical Psychology
• University Hospital of Leicester (UHL) NHS Trust
• nicolas.wilkinson_at_uhl-tr.nhs.uk

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Lecture plan

• What is sleep ?
• Sleep disorders
• What is Insomnia ?
• CBT for Insomnia (Espie, 1991)
• CT for Insomnia (Harvey, 2002)

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A rhythmic world

• Planets circle the sun
• Night follows day
• 4 seasons
• tidal movement
• birds migrate
• flowers close at night open during day

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Biorhythms

• Circadian - approx 24 hr cycle
  e.g sleep/wake cycle
• Ultradian - cycles within a day
  e.g. sleep stages
• Infradian - cycles more than a day
  e.g. menstrual

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Human sleep

• A period a substantial neurological
  physiological activity
• car engine running but with the clutch depressed
  so the car is resting (Espie,1991)
• different types of sleep sleep stages/
  architecture
• exact functions of sleep remain unclear

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How much sleep?

• Amount changes with age lifestyle
• Myth of 8 hours
• Adult Range 3 10hrs sleep
• 6 hours is probably enough (Horne, 1988)
• Less than 2/3 may have detrimental effect

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An night of sleep for a young adult
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Sleep Disorders - Sleep Apnoea

• Transient closure of the upper airway during
  sleep
• Symptoms - Snoring headaches/shortness of breath
  on waking daytime fatigue
• Prevalence rate 3-8
• Risk factors male, obese, small jaw, thick
  neck, alcohol
• Increased risk of accident, cardiovascular
  disease
• CPAP mask often effective

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SD - Restless Legs Syndrome

• Feeling of discomfort in deep tissues between
  knee and ankles, occurs when resting
• Appears in Stage 2 sleep
• Prevalence rate 2-5 - increases with age
• Associated with anaemia and heart failure
• Medication very effective

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SD - Narcolepsy

• Irresistible attacks of refreshing sleep occur
  daily for at least 6 months
• REM sleep disorder
• Cataplexy (sudden loss of muscle tone) and/or
  intrusions from REM stage (often described as
  hallucinations)
• Prevalence rare 5 per 100,000rare
• Cause unknown but strong familial component
• Prescribed stimulants can be effective

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Jet Lag and Shift Work

• Desynchronicity of internal body clock
• Sleepiness at wrong times of the day
• Light box treatment can be effective
• Melatonin resets circadian rhythm

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Parasomnias - Nightmares

• Prevalence rate 5
• Most common in childhood but can last into
  adulthood
• Occurs during 2nd part of the night
• Dreams involve threat to survival, security or
  self-esteem
• If no paralysis, may cause injury to self and
  others
• Often a feature of Post Traumatic Stress Disorder
  (PTSD)

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Parasomnias Night Terrors

• Abrupt waking associated with features of terror
• Symptoms rapid heart rate, sweating and
  confusion
• Occurs in Stage 3 and 4 sleep
• Most common in children
• Often related to emotional distress

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Parasomnias Sleep Walking

• Person engaged in activity whilst asleep
• May undertake simple or complex tasks
• Usually unaware of behaviour
• Occurs during Stage 3 and 4 sleep
• Strong familial component

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Insomnia - DSM IV criteria

• difficulty initiating or maintaining sleep, or
  non-restorative sleep, for at least 1 month.
• b) clinically significant distress or impairment
  in social/occupational functioning
• c) not exclusively due to another sleep disorder
• d) not exclusively due to another mental disorder
• e) not due to the physiological effects of a
  substance or a medical disorder

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• Features of Insomnia
• Problems initiating sleep (greater than 30
  minutes)
• Frequent and/or prolonged nocturnal awakenings
• Early morning awakenings with an inability to
  return to sleep
• Poor sleep quality and sleep efficiency
• Cognitive arousal typically reported
• Severity is judged along several dimensions,
  including frequency, intensity and duration of
  sleep difficulties. Also impact on daytime
  functioning, mood and quality of life.

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Screen for other disorders

• Depression and GAD common co-morbid problems
• Eg.s other problems PTSD/Acute stress
  drug/alcohol dependence, low self esteem
• Use psychometrics BDI II/PSWQ etc
• Interview
• Which problem started first?
• Which is most distressing?
• Which causes most interference with functioning?

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• Effects of Insomnia
• BIOLOGICAL
• Increased surveillance of immune system
• Reduced mortality rate but increase if take
  sleeping tablets
• COGNITIVE AND BEHAVIOURAL
• Flexible thinking and other pre-frontal cortex
  functions mildly affected
• Increased risk of accidents
• More likely to report lack of concentration and
  motivation
• Reduced productivity, work absenteeism
• Increased use of medical services
• PSYCHOLOGICAL
• Insomnia at first assessment increases risk of
  developing first onset depression, anxiety or
  alcohol problems
• Risk factor in suicide

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Prevalence of Insomnia

• Up to 9 adults
• Up to 25 older adults
• 15-25 individuals in sleep clinics
• women gt men
• shift workers
• Course 50-75 of people with insomnia have
  symptoms gt year

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Insomnia assessment

• Medical assessment to rule out other sleep
  disorders/ medical problems
• Clinical interview
• Psychometric HADs SDQ BDI-II PSWQ
  

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Insomnia - drug therapy

• Benzodiazepines (temazepam, diazepam)
• Nonbenzodiazepine hypnotics (Zolpidem,
  Zopiclone, Zaleplon)
• Side effects changes in sleep architecture,drowsi
  ness, tolerance, withdrawal effects

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Insomnia - CBT model (Espie,91)
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Insomnia - CBT

• Stimulus control
• Sleep hygiene
• Sleep restriction
• Relaxation
• Thought stopping
• Paradoxical intention
• Cognitive restructuring

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• Insomnia
• Stimulus Control
• Insomnia is a conditioned response to temporal
  and
• environmental cues
• Promote consistent sleep / wake cycle
• Re-associate the bedroom with sleeping
• Well established treatment

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• Insomnia
• Sleep Hygiene Education
• Factors that affect sleep, e.g caffeine,
  alcohol etc
• Not primary cause of insomnia but can maintain
  problem
• Limited benefits if used alone

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• Insomnia
• Sleep Restriction
• Reducing time in bed to match sleep obtained
• To increase sleep efficiency
• Adherence is problematic
• Probably effacious treatment

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• Insomnia
• Relaxation
• to deactivate arousal system
• various types - muscular, imaging, hypnosis
• well established treatment

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• Insomnia
• Paradoxical Intervention
• Engage in the feared outcome (not sleeping)
• Break cycle of performance anxiety
• Large variance in response

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• Insomnia
• Cognitive Therapy
• Identify thought processes to reduce anxiety
• Includes self-talk, distraction,
  rationalisation
• Helpful in altering dysfunctional sleep beliefs
• Efficacious treatment

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• Insomnia - Efficacy of CBT
• Two meta analyses (Morin et al., 1994 Murtagh
  Greenwood, 1995)
• - Significantly more effective than no treatment
• Review by the AASM (Chesson ET al., 1999 Morin
  et al ., 1999)
• However
• 19-26 fail to respond
• overall average improvement is 50-60
• effect sizes for pre to post treatment/
  follow-up lt 1.0

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A cognitive approach?

• The cognitive approach has lead to advances in
  theory and treatment for several psychological
  disorders ...minimally applied to insomnia
• The majority of people with insomnia report that
  they cant get to sleep because of .
  Uncontrollable worry
  Intrusive
  thoughts
  Racing mind (Geer Katkin, 1966)

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Sleep Deficit

• People with insomnia honestly and persistently
  describe that they dont get enough sleep
• The difference in sleep duration between good
  sleepers and individuals with insomnia is not
  enough to account for the severity of the
  complaints (Chambers Keller, 1993, n14, 35
  mins.)
• Many people with insomnia overestimate sleep
  onset latency and underestimate total sleep time
  (Adam et al., 1986 Bonnet, 1990)

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Daytime Deficit

• People with insomnia honestly and persistently
  describe wide-ranging daytime deficits
• Not detected by majority of studies using MSLT,
  pupillometry, and neuropsychological testing (see
  Riedel Lichstein, 2000 for review)

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Distortions of reality (Beck, 1976)

• Anorexia nervosa People think they are fat when
  they actually thin
• Hypochondriasis People think they are suffering
  from a grave illness when actually they are well
• Panic disorder People think they are going to
  have a heart attack when actually they are
  experiencing the symptoms of anxiety

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No. of cues utilised in any situation tends to
become smaller with an increase in emotion
(Easterbrook, 1959) Anxiety is associated with an
attentional bias toward threat (Dalgleish
Watts, 1990)
Harvey - Behaviour Research Therapy (2002)