Insomnia presentation
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This document summarizes a presentation on insomnia given at the AWP 2010 conference in Portland, OR. The presentation provided an overview of insomnia, discussing its definition, prevalence, and impacts. It also reviewed biological, psychological, social, and environmental factors that can predispose, precipitate, or perpetuate insomnia. Common sleep disorders that can cause insomnia symptoms, such as sleep apnea, restless leg syndrome, and circadian rhythm disorders were also outlined. The presentation emphasized a biopsychosocial model for conceptualizing insomnia and highlighted cognitive behavioral therapy as an effective treatment approach.
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Insomnia presentation
- 1. AWP 2010, Portland, OR Conceptualization of Insomnia A Holistic Approach to Insomnia Sovann Pen, MA, Counseling Kaiser Insomnia Clinic
- 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. 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. 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. Insomnia is MessyInsomnia is MessyInsomnia is MessyInsomnia is Messy
- 7. Chicken or the Egg?
- 10. Insomnia over time • Premorbid • Acute • Short-term • Chronic • How long? • What triggered/started the problem?
- 11. Predisposing Factors • Genetic • Biological • Psychological • Social
- 12. Genetic Factors • Co-morbidities • Medical • Sleep Disorders • Mood Disorders
- 13. Biological • Hyperarousal • Hyperactivity (ADD/ADHD) • Startle • Physical tension
- 14. Psychological • Personality: Worry, rumination • Type-A; driven, determined • Cognitive style: analytical, problem- solver
- 15. Psychological cont. • Compassionate, co-dependent, sympathetic/empathetic • Creatives • Perfectionism
- 16. Social • Living situation • Significant other • Family of Origin
- 17. Precipitating Factors • Medical • Life Stressors • Negative changes • Positive changes • Women • Men • Shiftwork
- 18. Negative changes • Illness • Conflict • Job stress • Financial • Unemployment • Abuse • Divorce
- 19. Positive changes • Retirement • Marriage • Moving • Work • Vacation • Travel
- 20. Spielman Model
- 21. Perpetuating Factors • Compensatory strategy • Counter Fatigue measures/ Stimulants • Rituals and Strategies • Self-medication
- 23. • Pain and Sleep • Stress and Pain • Stress and Sleep • Sleep and Mood • Mood and motivation • Mood and activity • Activity and weight • Caffeine and Sleep
- 25. 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
- 26. 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.
- 27. Counter Fatigue measures/ Stimulants • Increased use • Inappropriately-timed • Avoid or decrease physical activity • Cons: arousal, mood, conditioning
- 28. 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
- 29. Dysfunctional Beliefs • Rewards and reinforcement • Forcing the issue • Catastrophic thinking • Rigid expectations
- 30. •I think, therefore I …
- 32. Cognitive vs Somatic Lichstein & Rosenthal 1980 • Cognitive arousal 10x more likely to be cited as major cause than somatic arousal
- 34. 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”
- 35. Pre-sleep stress/cognitive activity • Hall, et al 1996 • Wicklow & Espie 2000 • Good sleepers threatened with making a speech • Increased sleep latency
- 36. 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
- 39. Vicious cycle (again) Anticipation Performance Anxiety Arousal Similar to Panic Disorder Start to dread, avoid bed and bedtime
- 40. Perception of sleep (memory) • Subjective vs Objective Measures • Overestimate sleep latency • Underestimate Total Sleep Time (TST) • Underestimate number of awakenings
- 41. Neitzer, Semler and Harvey • Positive and Negative Feedback study • Negative feedback increased: negative thoughts, sleepiness, monitoring sleep-threat and safety behaviors the next day.
- 42. Mendelson 1990 • Another key study applying to use of benzodiazepines • Objectively: benzos decrease SWS • Subjectively: report better sleep with benzos
- 43. Attention Insomniacs more aware of: • body sensations • environment • clock • needing to use the bathroom • mood • performance: attention, memory, concentration failing
- 44. 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
- 45. 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
- 46. 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.
- 47. 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.
- 48. 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
- 49. 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.
- 50. 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.
- 51. Self-medication • Alcohol • Marijuana • OCT – [Benadryl, Nyquil, Unisom, Tylenol PM] • Melatonin as hypnotic • Cons: REM-supression, fragmentation, withdrawal, rebound insomnia, dependence, circadian rhythm shift
- 52. 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.
- 53. 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
- 54. • Mental Disorders • Pain • Hormone: menopause, hyperthyroidism • Medication • Neurological • Medical
- 55. Organic disorders • Similar symptoms of primary or psychophysiologic insomnia • Delayed Sleep Onset • Sleep maintenance, early awakening. • “Light” sleep • Frequent awakenings • Non-restorative sleep
- 56. Sleep-Disordered Breathing - SDB • Obstructive Sleep Apnea • Central Sleep Apnea • Mixed Apnea • Upper Airway Resistance Syndrome • Hyponea • Obesity Hypoventilation Syndrome
- 60. 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
- 61. Risks • Daytime impairment, sleepiness • Heart Disease • Hypertension • Diabetes • Stroke
- 63. 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?
- 64. Other RLS symptoms • Burning • Creeping • Crawling • Aching • Tingling • Itching • Tugging
- 65. 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
- 66. Parasomnias • Nightmare disorder • Sleep terror disorder • Sleepwalking disorder • Sleep talking • REM-Behavior disorder • Bruxism
- 67. Confusional arousals • Arousals during REM • Vs sleep talking
- 68. Narcolepsy • Cataplexy: a sudden loss of muscle tone while in a conscious state • Hallucination • Sleep paralysis
- 69. AWP 2010, Portland, OR Hex of Insomnia homeostat arousallife style rhythm associations beliefs
- 75. DSPS • “Night Owl” • Teens • Seasonal Affective Disorder • Jet Lag/Shift Work
- 78. Entrainment Zeitgerbers • How to reset your body clock every day? • Retrain your body: • Daytime • Nighttime
- 79. Light exposure
- 80. Light Box
- 83. Meal times
- 84. Wake Time
Editor's Notes
- 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: http://www.scholarpedia.org/article/Insomnia
- Genetic Biological Psychological Social
- From: http://www.scholarpedia.org/article/Insomnia
- 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.