Behavioral Treatment for Sleep Disorders - PowerPoint by shimeiyan


									Behavioral Treatment for
   Sleep Disorders

         Dr. Kala K. Davis
         October 4, 2006
Behavioral Medicine & Sleep
• Behavioral treatment approaches to
  sleep disorders began in the 1930s
• Now considered a sub-specialty within
  sleep medicine
• Cognitive behavioral therapy (CBT) is
  an established and very effective
  modality in the management of chronic
• 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 result in
  impairment in daytime function.
• Prevalence rates for chronic insomnia
  are higher in women and generally
  increase with age.
• Has been associated with reduced
  quality of life, mood disorders and
  increased health service utilization
• Represents a significant economic
  burden in the US, with estimated direct
  costs of $13.9 billion annually.
• There are many treatments options
  for insomnia including: behavioral
  therapy, non-pharmacological
  interventions such as relaxation
  therapy, biofeedback, exercise,
  dietary changes and medications
Behavioral Model of Insomnia
• Insomnia occurs acutely in relation to
  both predisposing and precipitating
• The chronic form of the disorder is
  maintained by maladaptive coping
• Behavioral therapy focuses on
  eliminating the “perpetuating factors”
  that lead to the development of chronic
Behavioral Model of Insomnia
• A state of “conditioned arousal” may
  develop in which situations associated
  with sleep become alerting rather than
  relaxing- further impairing sleep.
     Cycle of Persistent Insomnia
               •Mood Disturbances      •Excessive time in bed
                           •Fatigue    •Irregular sleep schedule
        •Performance impairments       •Daytime napping
                 •Social Discomfort    •Sleep- incompatible activities

        •Worrying over sleep loss      •Emotional
   •Ruminating over consequences       •Cognitive
        •Unrealistic Expectations     •Physiologic
   Cognitive Behavioral Therapy
       (CBT) for Insomnia

• CBT seeks to change poor sleep
  habits and faulty beliefs about sleep
  and promote good sleep hygiene.
• CBT principles include sleep
  restriction, stimulus control, relaxation
  techniques, education and sleep
  Cognitive Behavioral Therapy
      (CBT) for Insomnia

• CBT is as successful as medications in
  the acute treatment (4-8 weeks) of
• It is more effective than medications in
  the long term
• Average of 50-60% improvement
  Cognitive Behavioral Therapy
      (CBT) for Insomnia
• Long term studies reveal a sustained
  improvement in sleep quality and
• Patients continued to experience
  improvement over follow-up periods of
Cognitive Behavioral Therapy for
   • Stimulus Control Therapy
   • Sleep Restriction Therapy
   • Sleep Hygiene Education
   • Cognitive Therapy
   • Relaxation Training
   • Phototherapy
   Stimulus Control Therapy
• Recommended for sleep initiation and
  sleep maintenance problems
• Considered a first-line behavioral
  treatment for chronic insomnia by
• Principle: to re-associate bed, bedtime
  and the bedroom with sleepiness and
Stimulus Control Therapy: Rules
• Lie down to go to sleep only when
• Avoid any behavior in bed or the
  bedroom besides sleep or sex
• Leave the bedroom if awake for more
  than 15 minutes
• Keep a fixed wake up time, 7 days a
  week no matter how poorly you sleep
    Stimulus Control Therapy:
• Stimulus control therapy is generally
  well tolerated
• Maybe contraindicated in patients with
  mania, epilepsy, parasomnias or at high
  risk for falls
  Sleep Restriction Therapy
• Recommended for sleep initiation and
  sleep maintenance problems
• Requires the patient to:
    • limit his/her time in bed to an amount
      that equals their total sleep time
    • Time restriction determined by clinician
      and patient using sleep diaries and
      balancing the patient’s lifestyle
    • Establish a fixed wake up time
    • Delay bed time
   Sleep Restriction Therapy
• As sleep efficiency increases, patients
  are gradually allowed to spend more
  time in bed- increased in 15 minute
• Over the course of therapy, patients will
  begin to find it difficult to stay up until
  the prescribed hour- sleep initiation is
   Sleep Restriction Therapy
• Sleep restriction works for several
   • It prevents insomniacs from coping by
     extending sleep opportunity-
     produces a sleep that is shallow and
   • Initial sleep loss early in SRT
     increases the homeostatic drive for
     sleep, producing a condensed, quality
     sleep with shorter awake times
    Sleep Restriction Therapy:
• Maybe contraindicated in patients with
  history of mania, obstructive sleep
  apnea, seizure disorder, parasomnias
  or those at significant risk for falls.
   Sleep Hygiene Education
• Sleep only as long as you need to feel fresh
  the following day
• Get out of bed at approximately the same
  time every day
• Exercise regularly
• Make sure the bedroom is comfortable- free
  from light, noise and temperature extremes.
• Eat regular meals and do not go to bed
Sleep Hygiene Education
•   Avoid drinking too much in the evenings
•   Cut down on all caffeinated products
•   Avoid alcohol, especially in the evenings
•   Smoking may disturb sleep
•   Don’t take your problems to bed
•   Do NOT try and fall asleep
•   Turn your clock around
•   Avoid naps
        Cognitive Therapy
• Most suitable for patients who are
  preoccupied with the potential
  consequences of their insomnia or for
  patients who complain of unwanted
  intrusive ideation or worry.
• Serves to deconstruct patient’s negative
  thoughts and beliefs about their
• This is thought to decrease the anxiety
  and arousal associated with insomnia.
         Relaxation Training
•   Progressive Muscle Relaxation
•   Diaphragmatic Breathing
•   Autogenic Training
•   Imagery Training
•   Mindfulness-based stress reduction
•   Prayer
    Mindfulness-based stress
• Mindfulness meditation and stress
  regulation helps us explore alternative
  ways to emotionally regulate ourselves,
  providing a sense of awareness and
  control that comes from inner calmness,
  acceptance and openness.
Circadian Rhythm Disorders
• Cause insomnia because of a lack of
  synchronization between an individual’s
  internal clock and the external schedule
• Treatment is best accomplished with
  chronotherapy and/ or phototherapy
 Phototherapy- Light Therapy
• Light is a powerful trigger in allowing us to
  reset our internal biological clock each day
• Indicated when circadian factors appear to be
  a significantly contributing factor to insomnia
• Light Intensity: 10,000 lux
• Duration 30 - 60 min
• Timing of light exposure is very important
• Caution: may trigger mania in persons with
  bipolar disorder, chronic headaches, eye
  conditions, photosensitivity, seizure disorder
 Phototherapy- Light Therapy
• For DSPS- The patient sits in front of 10,000
  lux light for 30 to 40 minutes upon
  awakening; in addition, room lighting has to
  be markedly reduced in the evening to
  achieve the desired results.
• Response is generally evident after a two to
  three week period, but frequently requires
  indefinite treatment to maintain
• In patients with ASPS, bright light exposure in
  the evening has been successful in delaying
  sleep onset.
• Refers to the intentional delay of sleep
  onset by 2-3 hours on successive days
  until the desired bedtime is achieved
• Has a high degree of success in
  patients’ with delayed sleep phase
• Tendency over time to lapse back into
  old sleep habits

•   General Principle: Phase Shifting
Normal Sleep Pattern
Advanced Sleep-Phase Disorder
Delayed Sleep-Phase Disorder
Shift Work Disorder
Irregular Sleep-Wake Rhythm
Advanced Sleep-Phase Disorder
Delayed Sleep-Phase Disorder
Jet Lag Disorder
          Jet Lag Disorder
• Use activities (eating, exercise, sightseeing)
  and exposure to light to try to synchronize
  body rhythms with those of the environment
• Adult travelers crossing five or more time
  zones are likely to benefit from melatonin
• Melatonin 3 mg about 30 minutes before
  bedtime on the day of travel and for up to four
  days after arrival is appropriate
• A dose of 0.5 mg has less effect on sleep, but
  otherwise helps adaptation similarly
    Obstructive Sleep Apnea
• Unlike people with insomnia, OSA is a
  structural/ anatomical problem with
  physiological consequences
• Treatment of OSA with CPAP/ Bi-level, oral
  appliance or surgery is needed before one
  can completely treat co-existing sleep
• Sleep maintenance insomnia, sleep walking,
  PLM are all improved with treatment of OSA
    Obstructive Sleep Apnea
• CBT and desensitization are useful in
  improving CPAP/ Bi-level compliance
• Weight Loss
• Avoid alcohol and other substances known to
  make apnea worse
• Restriction of body position during sleep
• Avoidance of upper airway mucosal irritants
• Possibly avoidance of altitude
Restless Legs Syndrome (RLS)
• In contrast to patients with insomnia,
  patients with RLS frequently require
  long term pharmacological therapies.
• Non-pharmacological strategies:
     • Avoid caffeine, nicotine and alcohol
     • Avoid medications which may aggravate
     • Iron replacement therapy
     • Mental alerting activities
     • Regular moderate exercise and stretching
     • Warm baths or cold packs
• Sleep disorders characterized by abnormal
  behavioral or physiological events which
  occur during sleep or during sleep-wake
• Parasomnias typically do not cause insomnia
  or excessive sleepiness
• Avoid sleep deprivation- schedule naps/
• Avoid alcohol, drugs and stimulants
• Stress Reduction
• Treat OSA if present
• Secure the home and safety of the bed
• Licensed Sleep Psychologist in Northern
     •   Kathleen L. Benson, Ph.D. Palo Alto, CA
     •   Richard M. Coleman, Ph.D. Ross, CA
     •   Sharon A. Keenan, Ph.D. Palo Alto, CA
     •   Tracy F. Kuo, Ph.D. Stanford, CA
     •   Derek H. Loewy, Ph.D. Belmont, CA
     •   Karen H. Naifeh, Ph.D. San Francisco, CA
     •   Rachel Manber, Ph.D. Stanford, CA
• Stanford Sleep Disorders Clinic offers
     • Group therapy- insomnia workshop,
       night owls workshop and CPAP
     • Individual therapy
     • (650) 723-6601
• Full Catastrophe Living
  by Jon Kabat-Zinn

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