Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
AWP 2010, Portland, OR
Conceptualization of Insomnia
A Holistic Approach
to Insomnia
Sovann Pen,
MA, Counseling
Kaiser Ins...
The Importance of Sleep
• Sleep is vital to our health and well being.
• National Sleep Foundation reveal that 60 percent ...
Insomnia
Insomnia is defined as
difficulty initiating sleep,
maintaining sleep,
final awakenings that occur much earlier
t...
Epworth Sleepiness Scale
• Use the following scale to choose the most appropriate number for each
situation:
0 = no chance...
Insomnia is MessyInsomnia is MessyInsomnia is MessyInsomnia is Messy
Cognitive Behavioral Therapy
Chicken or the Egg?
Sleep-interfering process
Spielman Model
Insomnia over time
• Premorbid
• Acute
• Short-term
• Chronic
• How long?
• What triggered/started the problem?
Predisposing Factors
• Genetic
• Biological
• Psychological
• Social
Genetic Factors
• Co-morbidities
• Medical
• Sleep Disorders
• Mood Disorders
Biological
• Hyperarousal
• Hyperactivity (ADD/ADHD)
• Startle
• Physical tension
Psychological
• Personality: Worry, rumination
• Type-A; driven, determined
• Cognitive style: analytical, problem-
solver
Psychological cont.
• Compassionate, co-dependent,
sympathetic/empathetic
• Creatives
• Perfectionism
Social
• Living situation
• Significant other
• Family of Origin
Precipitating Factors
• Medical
• Life Stressors
• Negative changes
• Positive changes
• Women
• Men
• Shiftwork
Negative changes
• Illness
• Conflict
• Job stress
• Financial
• Unemployment
• Abuse
• Divorce
Positive changes
• Retirement
• Marriage
• Moving
• Work
• Vacation
• Travel
Spielman Model
Perpetuating Factors
• Compensatory strategy
• Counter Fatigue measures/ Stimulants
• Rituals and Strategies
• Self-medica...
• Pain and Sleep
• Stress and Pain
• Stress and Sleep
• Sleep and Mood
• Mood and motivation
• Mood and activity
• Activit...
Compensatory strategy
• Go to bed early
“Give myself more of a chance to get
some sleep”
• Sleep in (wake up later)
“Catch...
Erratic sleeping patterns
• Your bedtime varies greatly depending
on your mood, favorite television
program, or the day of...
Counter Fatigue measures/
Stimulants
• Increased use
• Inappropriately-timed
• Avoid or decrease physical activity
• Cons:...
Rituals and Strategies
• Increase in non-sleep in bedroom and
bed
• Sleep in other places
• “Rituals” for sleep
• Avoidanc...
Dysfunctional Beliefs
• Rewards and reinforcement
• Forcing the issue
• Catastrophic thinking
• Rigid expectations
•I think, therefore I …
Cognitive vs Somatic
Lichstein & Rosenthal 1980
• Cognitive arousal 10x more likely
to be cited as major cause than
somati...
Unwanted intrusive thoughts
• Worry or Cognitive arousal
• Most Common - Racing thoughts
• “I am unable to empty my mind”
...
Pre-sleep stress/cognitive
activity
• Hall, et al 1996
• Wicklow & Espie 2000
• Good sleepers threatened with making
a spe...
WHAT ARE YOU THINKING?
Watts, Coyle, East 1994
• Mental activity and rehearsal
• Thoughts about sleep
• Family and long-te...
Affect-laden thoughts
Vicious cycle (again)
Anticipation
Performance Anxiety
Arousal
Similar to Panic Disorder
Start to dread, avoid bed and bed...
Perception of sleep (memory)
• Subjective vs Objective Measures
• Overestimate sleep latency
• Underestimate Total Sleep T...
Neitzer, Semler and Harvey
• Positive and Negative Feedback study
• Negative feedback increased: negative
thoughts, sleepi...
Mendelson 1990
• Another key study applying to
use of benzodiazepines
• Objectively: benzos decrease
SWS
• Subjectively: r...
Attention
Insomniacs more aware of:
• body sensations
• environment
• clock
• needing to use the bathroom
• mood
• perform...
Worry about negative
consequences of poor sleep
• Catastrophizing / awfulizing
• Negative prediction
Similar to Cognitive ...
Unhelpful beliefs in
Maintenance of insomnia
• Morin 1993
• Less Realistic about sleep
required
• Strongly endorse – negat...
Rewards and reinforcement
• By rewarding yourself with your
favorite foods, beverages, or drug of
choice when you can’t sl...
Forcing the issue
• When unable to fall asleep, you try to
force sleep to happen with statements
such as, “I must get to s...
Harvey 2003b
• Attempts to stop, modify, suppress
cognitive arousal may be counter
productive
• Other options (discuss cog...
Catastrophic thinking
• Being unable to sleep, you predict that
tomorrow will be a disaster.
• You tell yourself things su...
Rigid expectations
• You believe that sleep is dependent on
rigidly imposed expectations. You
create a flexible work sched...
Self-medication
• Alcohol
• Marijuana
• OCT – [Benadryl, Nyquil, Unisom,
Tylenol PM]
• Melatonin as hypnotic
• Cons: REM-s...
Medication dependence
• You take a nightly sleeping pill “just in
case”—without first determining
whether you really need ...
Chronic, perpetual problems
• Pain, disability
• Are you managing or coping as best
as you can?
• Resources, trying new wa...
• Mental Disorders
• Pain
• Hormone: menopause,
hyperthyroidism
• Medication
• Neurological
• Medical
Organic disorders
• Similar symptoms of primary or
psychophysiologic insomnia
• Delayed Sleep Onset
• Sleep maintenance, e...
Sleep-Disordered Breathing -
SDB
• Obstructive Sleep Apnea
• Central Sleep Apnea
• Mixed Apnea
• Upper Airway Resistance S...
Symptoms
• Snoring
• Apnea: snort, gasp, choke, pause, puff
• Dry throat/dry mouth
• Heart racing
• Shortness of breath
• ...
Risks
• Daytime impairment, sleepiness
• Heart Disease
• Hypertension
• Diabetes
• Stroke
Limb movement Disorders
Restless Leg Syndrome
• Do you feel a strong desire to move
your legs from time to time, often when
they make you uncomfor...
Other RLS symptoms
• Burning
• Creeping
• Crawling
• Aching
• Tingling
• Itching
• Tugging
Periodic Limb Movement
Syndrome
• PLMS
• Prevalence of PLMS seems to increase with
age.
• 45% elderly adults aged 65 years...
Parasomnias
• Nightmare disorder
• Sleep terror disorder
• Sleepwalking disorder
• Sleep talking
• REM-Behavior disorder
•...
Confusional arousals
• Arousals during REM
• Vs sleep talking
Narcolepsy
• Cataplexy: a sudden loss of muscle
tone while in a conscious state
• Hallucination
• Sleep paralysis
AWP 2010, Portland, OR
Hex of Insomnia
homeostat
arousallife style
rhythm
associations beliefs
Circadian Rhythm Biology
Normal Sleep Pattern
Monday Morning Blues
Delayed Sleep-Phase Disorder
DSPS
• “Night Owl”
• Teens
• Seasonal Affective Disorder
• Jet Lag/Shift Work
Advanced Sleep-Phase
Disorder
Entrainment
Zeitgerbers
• How to reset your body clock every
day?
• Retrain your body:
• Daytime
• Nighttime
Light exposure
Light Box
Light and Sleep-Wake
Rhythm
Physical Activity
Meal times
Wake Time
Insomnia presentation
Insomnia presentation
Insomnia presentation
Insomnia presentation
Insomnia presentation
Insomnia presentation
Insomnia presentation
Insomnia presentation
Insomnia presentation
Insomnia presentation
Upcoming SlideShare
Loading in …5
×

Insomnia presentation

981 views

Published on

Published in: Health & Medicine, Business
  • Be the first to comment

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

×