Need Sleep? Session 1

5/11/2015
Need Sleep?
A Five Week Intervention
DRUCILLA BRETHWAITE, MSW, LCSW, OSW-C
[email protected]
703.698.2538
DARAH W CURRAN, MSW, LCSW
[email protected]
703-776-8798
Behavioral Sleep Medicine Program
 Michael Perlis, PhD, Director Behavioral Sleep Medicine
Program at University of Pennsylvania
 CBT-I workshop
 Advanced CBT-I workshop
 http://www.med.upenn.edu/bsm/cbt.html
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Assessments
 BSI-18
 Epworth Sleepiness Scale
 Dysfunctional Beliefs and Attitudes
about Sleep
 Insomnia Severity Index
 Pittsburg Sleep Quality Index
 MD Anderson Symptom Inventory
Technology
 Measurement of sleep amount and quality
 FitBit
 Jawbone – Up24
 Applications
 Insomniafix
 Veterans Administration – CBT-I Coach
http://www.ptsd.va.gov/professional/materials/apps/cbticoach_app_pro.asp
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Cognitive Behavioral Therapy for Insomnia
 Stimulus control
 Sleep restriction
 Education
 Thoughts about sleep
 Relaxation techniques
 Sleep hygiene
 Improvements in 4-6 weeks
 No tolerance or dependency risks
 Effective for 80% of patients
 Slows brain waves by curbing mental activity
 Strengthens the sleep system
Session I
 Assessments
 Introductions
 Education
 Stimulus control
 Sleep Diary (sleep restriction)
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Is Indicated for:
 Trouble falling asleep (SL- sleep latency)
 Trouble staying asleep (WASO- wake after
sleep onset)
 Non-Restorative sleep ?
 Early morning awakenings ?
Focus will be:
 Trouble falling asleep
 Trouble staying asleep
 Early morning awakenings
Not…
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Sleep apnea
Restless leg
Circadian rhythm disorders (Parkinson’s, shift work)
Poor quality (usually sleep disorders)
GERD, COPD, fibromyalgia
Hyperinsomnia (10+ hours)
Untreated major depression
PTSD
Substance abuse
Psychosis
Nightmares
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Insomnia
 Falling asleep > 30 minutes
 Staying asleep > 30 minutes
 Non-restorative sleep
 Occurs at least 3 nights per week
 Causes significant impairment in daytime functioning or distress
 Acute (directly connected to a stressor…abates)
 Chronic (learned association, negative thoughts, “I’m never going to fall
asleep.”
What it Looks like
 1/3 Americans complain of episode at least once
year
 May change over time
 Most common complaint after pain and
headaches
 More frequent in women and older adults
 “I’ll take it where ever I can get it.”
Consequences
 Decreased reflexes (accidents)
 Low, irritable/anxious mood
 Depression
 Decreased pain tolerance
 Decreased cognition, memory
 Reduced seizure threshold
 Increase cortisol
 Impairs glucose tolerance
 Affects NK cells
 Increases cytokines (inflammation)
 Gene activity
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Nat Geographic Channel
Sleepless in America trailer
Sleep and Mortality
 6-8 hours per night optimal for health (ACS 7 hrs
optimal)
 National Sleep Foundation 7-9
 Long Sleepers: >9 hours possible undiagnosed
co-morbidity, additional marker of ill-health
 Short Sleepers: <5 hours, higher risk factor for
co-morbidity, may trigger biological mechanisms
contributing to the deterioration of health status
 Is it a cause or marker for ill-health?
Insomnia and Cancer
 3 times more likely to have sleep disturbances when compared to
control group
 May peak at diagnosis, chemo, XRT, end-stage
 Succession of stressors
 Greater difficulty with sleep onset and sleep maintenance
 Sleep medication most commonly prescribed medication after those for
nausea
 Possible impact on immune function
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Medication
Medications Indicated for Insomnia
Generic
Brand
Dose (mg)
Drug Class
Negatives
Flurazapam
Dalmane
15-30
BZD
suppress SW/REM,
rebound insom
Temazepam
Restoril
15-30
BZD
same
Triazolam
Halcion
o.125-0.25
BZD
same
Zolpidem
Ambien
5-10
non-BZD
not curative
Zaleplon
Sonata
5-20
non-BZD
same
Eszopiclone
Lunesta
1-3
non-BZD
same
Ramelteon
Roserem
8
MT agonist
not melatonin,
efficacy?
Trazodone
Desyrel/Deprax
antidepressant
not curative
herb
? fatigue
Valerian
450mg
Melatonin
 Hormone secreted by the pineal gland
 Controls sleep/wake cycles
 Levels rise late evening and drop in early morning
 Light (artificial can also) affects production
 Melatonin levels drop with age
 Side affects: sleepiness, grogginess in morning, decrease temperature,
decrease BP, vivid dreams
 Inconclusive research for insomnia
 Supplements not regulated
 Talk with your doctor!
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Alcohol
 Gets you to sleep
 Metabolizes during sleep
 Decreases REM early in night
 Increases sleep disruption later in night,
fragmentation
 Increases sympathetic arousal
 As dependency increases there is a decrease in total
sleep time
 Disruption of circadian rhythm
 Exacerbates snoring/sleep apnea
 Limit to 1 ounce at least 2 hrs before bedtime
Modafinil
 Stimulant
 Improves wakefulness
 Shift work
 Military
Stimulus Control
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Some people don’t sleep because
they have insomnia.
I can’t sleep because
I have internet connection.
Effects of Technology
 Artificial room light
 Technology use (television, computer, video games, cell phone, tablet)
 Blue blocking glasses
 Blue blocking program
 Bright light therapy
Gooley, Joshua J., et al. (2011). "Exposure to Room Light before Bedtime Suppresses Melatonin Onset and Shortens Melatonin Duration in Humans." Endocrine
Reviews 32(1): 155-56.
"Annual Sleep in America Poll Exploring Connections with Communications Technology Use and Sleep." 2011 Sleep in America Poll: Results. National Sleep
Foundation, 11 Mar. 2011. Web. 10 Apr. 2015.
Bromundt V., et al. (2015). Blue Blocker Glasses as a Countermeasure for Alerting Effects of Evening Light-Emitting Diode Screen Exposure in Male Teenagers. The
Journal of Adolescent Health.
Sleep Restriction
 Calculate actual time spent asleep
(sleep diary)
 Sleep ability matches sleep
opportunity
 Set wake time
 Count back to hour of bedtime
 Consistency
 Builds sleep compression
 No naps
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Sleep Diaries
 Time to bed and then put down…do not
fill in during the night
 Estimate time for awakenings, what did
it feel like, put clock under bed
 Fill out first thing in morning
 Diaries are necessary for this
intervention
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
Average for Week
Time to bed
Time out of bed
Total time in bed
Time to fall asleep
Time awake during
the night
Total time awake
Total time asleep
Session II
 Comments
 Review diaries
 Education
 Sleep restriction
 Sleep efficiency
 Handouts
 Homework
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Sleep Efficiency
Total Sleep Time (TST)
X
Total time in Bed (TTIB)
100
= SE
< 85% (Mismatch between sleep opportunity and sleep ability,
take away 15 minutes)
85%-90% (Hold)
>90% (Add 15 minutes
Match Sleep Ability with Sleep Effort
12
10
8
In Bed - Sleep Opportunity
6
Slept - Sleep Ability
4
2
0
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Sleep Compression
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Caution
 In treatment
 Sleepiness
To Stay Awake Until Bedtime…
 Stay off the Internet
 Call a friend
 Do some chores
 Turn on all the lights
 Read a book that is hard to put down
 Stand up and walk around
 Watch a comedy
 Listen to upbeat music
 Pay bills
U.S. Department of Veterans Affairs
Waking in the Middle of the Night
 “Give up.” and “Don’t fight it.”
 GET OUT OF BED
 Don’t eat or exercise
 No work
 Activities that do not result in arousal
 Journal
 Watch TV
 When sleepy…Go back to bed.
 Repeat as necessary
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How to Get Out of Bed at Wake Time
 Set two alarms
 Wiggle fingers and toes
 Stretch
 Positive thoughts about the day
 Get into the light
****If YOU ARE SLEEPY, DO NOT DRIVE. GET A RIDE. IF YOU FEEL
SLEEPY WHILE DRIVING, PULL OVER TO THE SIDE OF THE ROAD
AND TAKE A NAP.
Handouts
Homework
 VA Sleep
 SLEEP DIARY
 Retraining your Brain
 Sleep Environment
Questionnaire
 Sleep Hygiene
 Five thoughts I have about sleep
 Nutrition
Sleep Hygiene
 Exercise regularly
 Nighttime ritual
 Bedroom dark, cool, free from noise
 Do not go to bed hungry (light snack, carbohydrates)
 Avoid excessive liquids in the evening
 Decrease caffeinated beverages
 Avoid alcohol
 Turn the clock around
 Avoid naps
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Session III
 Comments
 Review diaries, sleep restriction, calculate sleep efficiency
 Review handouts
 Review homework (sleep environment, Five Thoughts I have about
Sleep)
 Education (arousal, sleep architecture)
 CBT
 Homework
1/3 of Your Life
Sleep
Sleep Cycle about 90 Minutes; 4-6 Times a Night
Stage 1
drowsy, slow rolling eye
movements,
daydreaming, theta
waves, few minutes
REM
dream, eyes move, can
awake, HR, BP,
respiration become
irregular, increase blood
flow to brain, muscles
paralyzed, memory, few
minutes to 1 hour
Stage 2
light sleep, more
relaxed, sleep spindles,
30-45 minutes
Stage 3/4
deep sleep, delta, slow
waves, respiration, HR,
BP all decrease,
difficult to wake,
restore tissue, 45
minutes
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Beta emitted when we are consciously alert, or we feel
agitated, tense, afraid
Alpha when we are in a state of physical and mental
relaxation, but still aware, meditation
Theta a state of somnolence with reduced consciousness,
stage 1
Delta when there is unconsciousness, deep sleep, stage
3/4
Increased Arousal at Bedtime
 Sympathetic arousal during sleep
 Are you awake because you are anxious
or are you anxious because you are
laying in bed awake due to insomnia
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Brain and Stress Response
Prefrontal
Cortex
Hippocampus
CBT-I
 Slows brain waves by curbing mental activity
 Strengthens the sleep system
Speilman Model
Poor
Sleep
Perpetuating Factors
Precipitating Factors
Predisposing Factors
Good
Sleep
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Cognitive Model
Behavior
Feeling
Thought
Situation
Language is Important
 All-or-Nothing Thinking: “If I don’t get to sleep, I’ll do terrible at
work tomorrow.”
 Overgeneralization: single event is seen as a pattern: “I haven’t slept
all week.”
 Mind Reading: you know what people think/feel
 Catastrophizing: worry about worse case scenario
 Personalizing: compare self, all about me
 Should Statements: inflexible rules
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Disrupted Sleep the Night before Work
Thoughts
How Certain
Up all night
Won’t be able to
function
Make mistakes
Lose job
95%
80%
# times actually
happened
0
10
# times it did not
happy
365
355
Chance it will NOT
happen
100%
97.%
100%
100%
15
0
350
365
95.8%
100%
Cognitive Therapy
 What’s the evidence?
 What makes the thought true or not completely true?
 What is the effect of continuing to have this thought?
 What could happen if I changed my thinking?
 What would I tell a friend in the same position?
 What should I do next?
1.
You have a thought
2. Repeat “It’s not likely to happen.”
3. Get out of bed.
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Positive Sleep Thoughts
 My performance will not suffer significantly if I get my core sleep.
 I’m probably getting more sleep than I think I am.
 Sleeping 7 hours is associated with the longest life expectancy
 In most cases, the worst thing that might happen is that my mood will
be impaired during the day.
 My sleep will improve as I learn these techniques.
 These techniques have worked for others, they will work for me.
 "I am having a thought. It is only a thought and probably not likely to
happen."
 "I'll be tired tomorrow but I have been tired before and managed OK."
 "If I practice these strategies my insomnia will get better."
 "If I don't sleep well tonight, I will probably sleep better tomorrow
night."
 "I'm probably getting more sleep than I think I am."
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Homework
 Diary
 Negative/positive sleep thoughts
 Affirmations
 Inspirational words
 VA CBT Mobile App
Session IV
 Sleep diaries
 Review homework
 Biodots
 Relaxation response review
 Relaxation strategies
 CD’s/DVD’s
 Hypnosis
 Review previous sessions
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Relaxation Strategies

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
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Breath
Meditation
Progressive muscle relaxation
Gravity body scan
Yoga poses
Yoga for Cancer Survivors
 Journal of Clinical Oncology
 Cancer survivors engaging in yoga:
 Slept better
 Less daytime exhaustion
 Better perceptions of how they slept
 Less frequent use of sleep medications
Mustian, K, Sprod, L, Janelsins, M, Peppone, L, Palesh, O, Chandwani, K, et al. Multicenter, randomized controlled trial of
yoga for sleep quality among cancer survivors. Journal of Clinical Oncology. 2013; 31 (26): 3233-3241
Mindfulness-Based Stress Reduction (MBSR)
 Journal of Clinical Oncology
 Results: Both increased total sleep time
 CBT-I more rapid improvement, MBSR more gradual
 Both improved mood and stress related symptoms
Garland, SN, Carlson, LE, Stephens AJ, et al: Mindfulness-based stress reduction compared with cognitive behavioral
therapy for the treatment of insomnia comorbid with cancer: A randomized, partially blinded, noninferiority
trial, Journal of Clinical Oncology. 2014; 32: (1-9)
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Read Hypnosis Script
Technical Aids/Apps
 Meditation Apps (iPhone and android)




The Mindfulness App
Simply Being
Mindfulness Meditation
Buddhist Meditation Trainer
Holland, Kimberly. "The Best Meditation IPhone & Android Apps of the Year." The 13 Best IPhone & Android Meditation Apps of 2014. Healthline, 19 May 2014. Web. 14 Apr. 2015.
 CD’s


Healthful Sleep Meditations - Belleruth Naparstek
Sleep: Guided Relaxation & Instrumental Harmonies – Dr. James Rouse (GAIAM)
 DVD

Mayo Clinic Wellness Solutions for Insomnia – (GAIAM)
Session V
 Review
 My Sleep Tools
 Sleep Plan
 Sleep Diaries
 Assessments
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Sleep Tools Activity
What has helped you over these last four
weeks?
1. _______________________
2. _______________________
3. _______________________
4. _______________________
Sleep Plan
Red Flags
Strategies
 Awake for > 30 min
 I have learned skills
 Difficulty functioning
 Review sleep tools
 Increased worries
 Restrict time in bed
 Preoccupation about sleeping
 Avoid arousing activities
 Sleep efficiency < 85%
 Challenge negative thoughts
 Stress management
 Restart sleep diary
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It appears that every man's insomnia is as different from
his neighbour's as are their daytime hopes and aspirations.
~F. Scott Fitzgerald
Insomnia References
 Barton, D.L., et al. (2011) The use of Valerian in improving sleep in patients
who are undergoing treatment for cancer: A phase III randomized, placebocontrolled, double-blind study (NCCTG Trial, N01C5). J Support Oncology,
9(1), 24-31.
 Beck, S. L., et al. (2009). Sleep quality after initial chemotherapy for breast
cancer. Support Care Cancer, 18, 679-689.
 Berger, A.M. (2009). Update on the state of the science: Sleep-wake
disturbances in adult patients with cancer. Oncology Nursing Forum, 36(4),
165-177.
 Cappuccio, F. et al., (2010). Sleep duration and all-cause mortality: A
systematic review and meta-analysis of prospective studies. Sleep, 33(5), 585592.
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Insomnia References
 Cheng, K.K. (2011). Effects of pain, fatigue, insomnia, and mood disturbance
on functional status and quality of life of elderly patients with cancer. Crit
Rev Oncology Hematology, 78(2), 127-137.
 Coleman, E.A., et al. (2011). Fatigue, sleep, pain, mood, and performance
status in patients with multiple myeloma. Cancer Nursing, 34(3), 219-227.
 Edinger, J.D., et al. (2001). Cognitive behavioral therapy for treatment of
chronic primary insomnia: A randomized controlled trial. Journal of the
American Medical Association, 285(14), 1856-1864.
 Enderlin, C.A. et al., (2011). Subjective sleep quality, objective sleep
characteristics, insomnia symptom severity, and daytime sleepiness in
women aged 50 and older with non-metastatic breast cancer. Oncology
Nursing Forum, 38(4), 314-325.
Insomnia References
 Fiorentino, L., (2007). Sleep dysfunction in patients with cancer. Curr Treatment Options
Neurology, 9(5), 337-346.
 Fleming, L., et al. (2010 ). The development and impact of insomnia on cancer survivors: a
qualitative analysis. Psycho-Oncology, 19(9), 991-996.
 Garland, S.N. (2011). I-can sleep: Rationale and design of a non-inferiority RCT of mindfulness-
based stress reduction and cognitive behavioral therapy for the treatment of insomnia in cancer
survivors. Contemp Clin Trials, 32(5), 747-754.
 Jim, H.S., et al., (2011). Fatigue, depression, sleep, and activity during chemotherapy: daily and
intraday variation and relationships among symptom changes. Ann Behav Med 42(3), 321-333.
 Khalsa, S.B. (2004). Treatment of chronic insomnia with yoga: A preliminary study with sleepwake diaries. Appl Psychophysiol Biofeedback, 29(4). 269-278.
Insomnia References
 Krystal, A.D. (2010). Sleep EEG predictors and correlates of the response to
cognitive behavioral therapy for insomnia. Sleep, 33(5), 669-677.
 Moore, T.A., et al. (2011). Sleep aid use during and following breast cancer
adjuvant chemotherapy. Psycho-Oncology, 20(3), 321-325.
 Morin, C. M., (2009). Cognitive behavioral therapy, singly and combined
with medication, for persistent insomnia: A randomized controlled trial.
Journal of American Medical Association, 301(19), 2005-2015.
 Savard, J. et al., (2011). Natural course of insomnia co-morbid with cancer:
An 18 month longitudinal study. J. Clin Oncology, 29(26), 3580-3586.
Insomnia frequent and enduring problem, early intervention strategies such
as CBT can prevent from becoming more severe and chronic.
 Woodward, S.C. (2011). Cognitive-behavioral therapy for insomnia in
patients with cancer. Clin J. Oncology Nurs, 15(4), 42-52.
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