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.
AWP 2010, Portland, OR
Conceptualization of Insomnia
A Holistic Approach
Kaiser Insomnia Clinic
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.
Insomnia is defined as
difficulty initiating sleep,
final awakenings that occur much earlier
or sleep that is non-restorative and of poor
results in impairment in daytime function.
Epworth Sleepiness Scale
• Use the following scale to choose the most appropriate number for each
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____________
Insomnia is MessyInsomnia is MessyInsomnia is MessyInsomnia is Messy
• Pain and Sleep
• Stress and Pain
• Stress and Sleep
• Sleep and Mood
• Mood and motivation
• Mood and activity
• Activity and weight
• Caffeine and Sleep
• Go to bed early
“Give myself more of a chance to get
• Sleep in (wake up later)
“Catch up” “Only chance I have to sleep”
• Cons: Deprimes sleep homeostat.
Dysregulation of circadian rhythm
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
Rituals and Strategies
• Increase in non-sleep in bedroom and
• Sleep in other places
• “Rituals” for sleep
• Avoidance of behaviors thought to
• Cons: lack of stimulus control,
dependence, anticipatory anxiety
• Rewards and reinforcement
• Forcing the issue
• Catastrophic thinking
• Rigid expectations
Cognitive vs Somatic
Lichstein & Rosenthal 1980
• Cognitive arousal 10x more likely
to be cited as major cause than
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”
• Hall, et al 1996
• Wicklow & Espie 2000
• Good sleepers threatened with making
• Increased sleep latency
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
Vicious cycle (again)
Similar to Panic Disorder
Start to dread, avoid bed and bedtime
Perception of sleep (memory)
• Subjective vs Objective Measures
• Overestimate sleep latency
• Underestimate Total Sleep Time (TST)
• Underestimate number of awakenings
Neitzer, Semler and Harvey
• Positive and Negative Feedback study
• Negative feedback increased: negative
thoughts, sleepiness, monitoring
sleep-threat and safety behaviors the
• Another key study applying to
use of benzodiazepines
• Objectively: benzos decrease
• Subjectively: report better
sleep with benzos
Insomniacs more aware of:
• body sensations
• needing to use the bathroom
• performance: attention, memory,
Worry about negative
consequences of poor sleep
• Catastrophizing / awfulizing
• Negative prediction
Similar to Cognitive Distortions from
standard CBT –
Unhelpful beliefs in
Maintenance of insomnia
• Morin 1993
• Less Realistic about sleep
• Strongly endorse – negative
consequences of insomnia
• More likely to attribute insomnia to
external and stable causes
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.
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.
• Attempts to stop, modify, suppress
cognitive arousal may be counter
• Other options (discuss cognitive
• Suppress, distract (math problem
study, TV, sheep), neutralizing,
appraisal, punishment and worry
• 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.
• 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.
• 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
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
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?
Periodic Limb Movement
• Prevalence of PLMS seems to increase with
• 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