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  • Predisposing Precipitating Predisposing (See Sleep-interfering and Sleep-interpreting process)
  • What is the interfering? Why? What is the trigger? If answer is not to get up to use the bathroom, do you know what is waking you up? Internal or external trigger? Insomnia as a symptom
  • From:
  • Genetic Biological Psychological Social
  • From:
  • Mammalian circadian rhythms are generated within the neurons of the SCN of the hypothalmus SCN are 2 clusters of about 10,000 neurons Each SCN neuron keeps its own time – circadian rhythmicity is inherent in the biochemistry of the clock's most basic building blocks – the SCN's neurons Regulates a variety of circadian rhythms including melatonin, corticosterone, and core body temperature Intrinsic rhythm of the clock is slightly longer than 24 hours (circa = about; dian = day)‏ Circadian clock modulates the timing of sleep and wakefulness through direct effects on sleep tendency (sleepiness/alertness) and on the neurophysiologic processes governing sleep state expression Demonstrated by lesion studies in rodents and squirrel monkeys and one case study of a human with lesions in this area Maintaining normal entrainment is a dynamic process that depends on regular adjustments of the circadian pacemaker via exposure to the relevant environmental time cues (zeitgebers)‏ Melatonin is produced by the pineal gland. SCN control the timing of melatonin release. Light evokes an immediate decrease in melatonin secretion levels. Melatonin is able to cause a change in the phase of the circadian oscillator – a phase advance when administered late in the day and phase delay when administered in the morning (opposite of light). Melatonin sharpens the SCN waveform, and may potentiate sleep onset over a relatively narrow phase. Light is the most powerful entrainment factor for the circadian clock
  • Non-rod, non-cone photoreceptors have been identified in the retina as especially important for the entraining effects of light Most sensitive to blue wavelength light Light exposure in the morning resets the pacemaker to an earlier time Light exposure in the evening resets the pacemaker to a later time Time cues not related to light, such as schedule and activity, may have some influence on circadian timing, but their potency, compared to the solar light/dark schedule, remains to be defined and appears to be weak. For example, If I have a delayed sleep phase and so want to wake up earlier, exposure to bright light as soon as I wake up will shift the circadian clock. If I have an advanced sleep phase and want to stay up later, I can shift my clock by exposing myself to bright light up until bedtime.
  • Insomnia presentation

    1. 1. AWP 2010, Portland, OR Conceptualization of Insomnia A Holistic Approach to Insomnia Sovann Pen, MA, Counseling Kaiser Insomnia Clinic
    2. 2. The Importance of Sleep • Sleep is vital to our health and well being. • National Sleep Foundation reveal that 60 percent of adults report having sleep problems a few nights a week or more. • In addition, more than 40 percent of adults experience daytime sleepiness severe enough to interfere with their daily activities at least a few days each month - with 20 percent reporting problem sleepiness a few days a week or more. • At least 40 million Americans suffer from sleep disorders, yet more than 60 percent of adults have never been asked about the quality of their sleep by a physician and fewer than 20 percent ever initiated a discussion. • Poor sleep has a price. • Millions of individuals struggle to stay alert at home, in school, on the job - and on the road. Tragically, fatigue contributes to more than 100,000 police-reported highway crashes, causing 71,000 injuries and 1,500 deaths each year in the United States alone.
    3. 3. Insomnia 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 results in impairment in daytime function.
    4. 4. Epworth Sleepiness Scale • Use the following scale to choose the most appropriate number for each situation: 0 = no chance of dozing • 1 = slight chance of dozing • 2 = moderate chance of dozing • 3 = high chance of dozing • Sitting and reading____________ • Watching TV____________ • Sitting inactive in a public place (e.g a theater or a meeting)____________ • As a passenger in a car for an hour without a break____________ • Lying down to rest in the afternoon when circumstances permit____________ • Sitting and talking to someone____________ • Sitting quietly after a lunch without alcohol____________ • In a car, while stopped for a few minutes in traffic____________
    5. 5. Insomnia is MessyInsomnia is MessyInsomnia is MessyInsomnia is Messy
    6. 6. Cognitive Behavioral Therapy
    7. 7. Chicken or the Egg?
    8. 8. Sleep-interfering process
    9. 9. Spielman Model
    10. 10. Insomnia over time • Premorbid • Acute • Short-term • Chronic • How long? • What triggered/started the problem?
    11. 11. Predisposing Factors • Genetic • Biological • Psychological • Social
    12. 12. Genetic Factors • Co-morbidities • Medical • Sleep Disorders • Mood Disorders
    13. 13. Biological • Hyperarousal • Hyperactivity (ADD/ADHD) • Startle • Physical tension
    14. 14. Psychological • Personality: Worry, rumination • Type-A; driven, determined • Cognitive style: analytical, problem- solver
    15. 15. Psychological cont. • Compassionate, co-dependent, sympathetic/empathetic • Creatives • Perfectionism
    16. 16. Social • Living situation • Significant other • Family of Origin
    17. 17. Precipitating Factors • Medical • Life Stressors • Negative changes • Positive changes • Women • Men • Shiftwork
    18. 18. Negative changes • Illness • Conflict • Job stress • Financial • Unemployment • Abuse • Divorce
    19. 19. Positive changes • Retirement • Marriage • Moving • Work • Vacation • Travel
    20. 20. Spielman Model
    21. 21. Perpetuating Factors • Compensatory strategy • Counter Fatigue measures/ Stimulants • Rituals and Strategies • Self-medication
    22. 22. • Pain and Sleep • Stress and Pain • Stress and Sleep • Sleep and Mood • Mood and motivation • Mood and activity • Activity and weight • Caffeine and Sleep
    23. 23. Compensatory strategy • Go to bed early “Give myself more of a chance to get some sleep” • Sleep in (wake up later) “Catch up” “Only chance I have to sleep” • Napping • Cons: Deprimes sleep homeostat. Dysregulation of circadian rhythm
    24. 24. Erratic sleeping patterns • Your bedtime varies greatly depending on your mood, favorite television program, or the day of the week. • This sends confusing messages to the sleep-regulating centers of your brain —a guarantee for all kinds of problems with sleep.
    25. 25. Counter Fatigue measures/ Stimulants • Increased use • Inappropriately-timed • Avoid or decrease physical activity • Cons: arousal, mood, conditioning
    26. 26. Rituals and Strategies • Increase in non-sleep in bedroom and bed • Sleep in other places • “Rituals” for sleep • Avoidance of behaviors thought to inhibit sleep • Cons: lack of stimulus control, dependence, anticipatory anxiety
    27. 27. Dysfunctional Beliefs • Rewards and reinforcement • Forcing the issue • Catastrophic thinking • Rigid expectations
    28. 28. •I think, therefore I …
    29. 29. Cognitive vs Somatic Lichstein & Rosenthal 1980 • Cognitive arousal 10x more likely to be cited as major cause than somatic arousal
    30. 30. Unwanted intrusive thoughts • Worry or Cognitive arousal • Most Common - Racing thoughts • “I am unable to empty my mind” • “I can’t turn off my mind” • “My mind keeps turning things over”
    31. 31. Pre-sleep stress/cognitive activity • Hall, et al 1996 • Wicklow & Espie 2000 • Good sleepers threatened with making a speech • Increased sleep latency
    32. 32. WHAT ARE YOU THINKING? Watts, Coyle, East 1994 • Mental activity and rehearsal • Thoughts about sleep • Family and long-term concerns • Positive plans and concerns • Somatic preoccupations • Work and recent concerns
    33. 33. Affect-laden thoughts
    34. 34. Vicious cycle (again) Anticipation Performance Anxiety Arousal Similar to Panic Disorder Start to dread, avoid bed and bedtime
    35. 35. Perception of sleep (memory) • Subjective vs Objective Measures • Overestimate sleep latency • Underestimate Total Sleep Time (TST) • Underestimate number of awakenings
    36. 36. Neitzer, Semler and Harvey • Positive and Negative Feedback study • Negative feedback increased: negative thoughts, sleepiness, monitoring sleep-threat and safety behaviors the next day.
    37. 37. Mendelson 1990 • Another key study applying to use of benzodiazepines • Objectively: benzos decrease SWS • Subjectively: report better sleep with benzos
    38. 38. Attention Insomniacs more aware of: • body sensations • environment • clock • needing to use the bathroom • mood • performance: attention, memory, concentration failing
    39. 39. Worry about negative consequences of poor sleep • Catastrophizing / awfulizing • Negative prediction Similar to Cognitive Distortions from standard CBT – “All-or-nothing” “Black-and-white” thinking
    40. 40. Unhelpful beliefs in Maintenance of insomnia • Morin 1993 • Less Realistic about sleep required • Strongly endorse – negative consequences of insomnia • More likely to attribute insomnia to external and stable causes
    41. 41. Rewards and reinforcement • By rewarding yourself with your favorite foods, beverages, or drug of choice when you can’t sleep, you ensure future nights of insomnia. The pleasure centers of your brain have great recall for this type of behavior. They will continue to awaken you to receive more of the same—night after night, after night, after night.
    42. 42. Forcing the issue • When unable to fall asleep, you try to force sleep to happen with statements such as, “I must get to sleep right now,” or “If I can't get to sleep, I'll just have to force myself to stay in bed until I get to sleep.” • Creating this negative association with sleep will lead only to frustration.
    43. 43. Harvey 2003b • Attempts to stop, modify, suppress cognitive arousal may be counter productive • Other options (discuss cognitive restructuring later) • Suppress, distract (math problem study, TV, sheep), neutralizing, appraisal, punishment and worry
    44. 44. Catastrophic thinking • Being unable to sleep, you predict that tomorrow will be a disaster. • You tell yourself things such as, “I won't be able to function at all tomorrow if I don't get to sleep.” • This type of thinking creates so much anxiety that you will most likely not be able to return to sleep.
    45. 45. Rigid expectations • You believe that sleep is dependent on rigidly imposed expectations. You create a flexible work schedule that permits you to sleep in, expect a 100- percent quiet sleep environment, and strive for a stress-free life. • If for some reason you cannot meet these conditions, you begin to worry that you will not be able to sleep.
    46. 46. Self-medication • Alcohol • Marijuana • OCT – [Benadryl, Nyquil, Unisom, Tylenol PM] • Melatonin as hypnotic • Cons: REM-supression, fragmentation, withdrawal, rebound insomnia, dependence, circadian rhythm shift
    47. 47. Medication dependence • You take a nightly sleeping pill “just in case”—without first determining whether you really need it. • After a few weeks of this, you can lose confidence in your ability to sleep without the pill, creating the perfect set-up for a pattern of medication dependence.
    48. 48. Chronic, perpetual problems • Pain, disability • Are you managing or coping as best as you can? • Resources, trying new ways or approaches, support group • Mood: Depression and Bipolar D/o
    49. 49. • Mental Disorders • Pain • Hormone: menopause, hyperthyroidism • Medication • Neurological • Medical
    50. 50. Organic disorders • Similar symptoms of primary or psychophysiologic insomnia • Delayed Sleep Onset • Sleep maintenance, early awakening. • “Light” sleep • Frequent awakenings • Non-restorative sleep
    51. 51. Sleep-Disordered Breathing - SDB • Obstructive Sleep Apnea • Central Sleep Apnea • Mixed Apnea • Upper Airway Resistance Syndrome • Hyponea • Obesity Hypoventilation Syndrome
    52. 52. Symptoms • Snoring • Apnea: snort, gasp, choke, pause, puff • Dry throat/dry mouth • Heart racing • Shortness of breath • Headache • Numbness/tingling in limbs • Muscle pain/soreness • GERD
    53. 53. Risks • Daytime impairment, sleepiness • Heart Disease • Hypertension • Diabetes • Stroke
    54. 54. Limb movement Disorders
    55. 55. Restless Leg Syndrome • Do you feel a strong desire to move your legs from time to time, often when they make you uncomfortable? • Do those sensations in your legs occur or get stronger when you are inactive? • Does moving around or stretching help ease those uncomfortable sensations in your legs? • Do those uncomfortable sensations feel their worst at night?
    56. 56. Other RLS symptoms • Burning • Creeping • Crawling • Aching • Tingling • Itching • Tugging
    57. 57. Periodic Limb Movement Syndrome • PLMS • Prevalence of PLMS seems to increase with age. • 45% elderly adults aged 65 years and older had PLMS, compared to 5% to 6% of the younger adult population. • 80% of those with RLS also had PLMS. • • Rule out SDB
    58. 58. Parasomnias • Nightmare disorder • Sleep terror disorder • Sleepwalking disorder • Sleep talking • REM-Behavior disorder • Bruxism
    59. 59. Confusional arousals • Arousals during REM • Vs sleep talking
    60. 60. Narcolepsy • Cataplexy: a sudden loss of muscle tone while in a conscious state • Hallucination • Sleep paralysis
    61. 61. AWP 2010, Portland, OR Hex of Insomnia homeostat arousallife style rhythm associations beliefs
    62. 62. Circadian Rhythm Biology
    63. 63. Normal Sleep Pattern
    64. 64. Monday Morning Blues
    65. 65. Delayed Sleep-Phase Disorder
    66. 66. DSPS • “Night Owl” • Teens • Seasonal Affective Disorder • Jet Lag/Shift Work
    67. 67. Advanced Sleep-Phase Disorder
    68. 68. Entrainment Zeitgerbers • How to reset your body clock every day? • Retrain your body: • Daytime • Nighttime
    69. 69. Light exposure
    70. 70. Light Box
    71. 71. Light and Sleep-Wake Rhythm
    72. 72. Physical Activity
    73. 73. Meal times
    74. 74. Wake Time