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Transcript

  • 1. Insomnia
    • Dr Nic Wilkinson
    • Clinical Psychologist
    • Medical Psychology
    • University Hospital of Leicester (UHL) NHS Trust
    • [email_address]
  • 2. Lecture plan
    • What is sleep ?
    • Sleep disorders
    • What is Insomnia ?
    • CBT for Insomnia (Espie, 1991)
    • CT for Insomnia (Harvey, 2002)
  • 3. A rhythmic world
    • Planets circle the sun
    • Night follows day
    • 4 seasons
    • tidal movement
    • birds migrate
    • flowers close at night & open during day
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. An night of sleep for a young adult
  • 8. 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
  • 9. 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
  • 10. 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 100,000…rare
    • Cause unknown but strong familial component
    • Prescribed stimulants can be effective
  • 11. 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
  • 12. Parasomnias - Nightmares
    • Prevalence rate – 5%
    • Most common in childhood but can last into adulthood
    • Occurs during 2 nd 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)
  • 13. 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
  • 14. 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
  • 15. 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
  • 16.
    • 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.
  • 17. 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?
  • 18.
    • 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
  • 19. Prevalence of Insomnia
    • Up to 9% adults
    • Up to 25% older adults
    • 15-25% individuals in sleep clinics
    • women > men
    • shift workers
    • Course: 50-75% of people with insomnia have symptoms > year
  • 20. Insomnia assessment
    • Medical assessment to rule out other sleep disorders/ medical problems
    • Clinical interview
    • Psychometric HADs SDQ BDI-II PSWQ
  • 21. Insomnia - drug therapy
    • Benzodiazepines (temazepam, diazepam)
    • Nonbenzodiazepine hypnotics (Zolpidem, Zopiclone, Zaleplon)
    • Side effects: changes in sleep architecture,drowsiness, tolerance, withdrawal effects
  • 22. Insomnia - CBT model (Espie,91)
  • 23. Insomnia - CBT
    • Stimulus control
    • Sleep hygiene
    • Sleep restriction
    • Relaxation
    • Thought stopping
    • Paradoxical intention
    • Cognitive restructuring
  • 24.
    • 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
  • 25.
    • 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
  • 26.
    • Insomnia
    • Sleep Restriction
      • Reducing time in bed to match sleep obtained
      • To increase sleep efficiency
      • Adherence is problematic
      • Probably effacious treatment
  • 27.
    • Insomnia
    • Relaxation
      • to deactivate arousal system
      • various types - muscular, imaging, hypnosis
      • well established treatment
  • 28.
    • Insomnia
    • Paradoxical Intervention
      • Engage in the feared outcome (not sleeping)
      • Break cycle of performance anxiety
      • Large variance in response
  • 29.
    • Insomnia
    • Cognitive Therapy
      • Identify thought processes to reduce anxiety
      • Includes self-talk, distraction, rationalisation
      • Helpful in altering dysfunctional sleep beliefs
      • Efficacious treatment
  • 30.
    • 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 < 1.0
  • 31. 2.5 2.2 Posttreatment Posttreatment Case series of CT (n = 91) RCT for CT Gillespie et al. (2002) Ehlers et al. (2002) Posttraumatic Stress Disorder 2.2 Posttreatment Meta-analysis of 28 studies of CT Dobson (1989) Depression 2.9 2.8 2.9 3.2 Posttreatment 12-month follow up Posttreatment 12-month follow up RCT for full CT (12-16 sessions) RCT for brief CT (7 sessions) Clark et al (1999) Panic Disorder Effect size Interval Type of study Authors Diagnosis
  • 32. 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 can’t get to sleep because of …. Uncontrollable worry Intrusive thoughts “Racing mind” (Geer & Katkin, 1966)
  • 33. Sleep Deficit
    • People with insomnia honestly and persistently describe that they don’t 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, n=14, 35 mins.)
    • Many people with insomnia overestimate sleep onset latency and underestimate total sleep time ( Adam et al., 1986; Bonnet, 1990)
  • 34. 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)
  • 35. ‘ 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
  • 36. 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)