COGNITIVE - BEHAVIORAL THERAPY FOR INSOMNIA - ALVIN E. LAKE III, PHD, FAHS MICHIGAN HEAD-PAIN AND NEUROLOGICAL INSTITUTE - MICHIGAN ...

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COGNITIVE - BEHAVIORAL THERAPY FOR INSOMNIA - ALVIN E. LAKE III, PHD, FAHS MICHIGAN HEAD-PAIN AND NEUROLOGICAL INSTITUTE - MICHIGAN ...
Cognitive -
                               Behavioral
                               Therapy for
                               Insomnia

Alvin E. Lake III, PhD, FAHS
Michigan Head-Pain and
Neurological Institute
COGNITIVE - BEHAVIORAL THERAPY FOR INSOMNIA - ALVIN E. LAKE III, PHD, FAHS MICHIGAN HEAD-PAIN AND NEUROLOGICAL INSTITUTE - MICHIGAN ...
The worst thing in the world is
to try to sleep and not to.

                 F. Scott Fitzgerald
Prevalence: Types of Insomnia
  Community Sample (Primary Care, N=1181)

          Sleep Disturbance                    Prevalence (%)
Delayed Sleep Onset                                   10.3
Sleep Maintenance                                     25.2
Early Wakening                                        15.9
Non-Restorative Sleep                                 18.2
Restricted Social Activities (RSA)                    16.9
Significant Interaction of delayed sleep onset & pain (P
Sleep Onset Latency in a National Sample
 Community Sample (Primary Care, N=1181)

          Minutes to        Percentage of
          Fall Asleep       Respondents
              0-14                42%
             15-29                19%
             30-44                18%
             45-59                  3%
              60+                 18%

    Mean = 22 Minutes, SD = 19; Median = 15 Minutes

                          2007-2008 CDC National Health
                          and Nutrition Examination Survey
Sleep is the overlooked hero
and the poor man’s physician.

          Stephen King, Insomnia 1994
Sleep Deprivation and Pain
One Night of Total Sleep Deprivation (TSD)
Promotes Hyperalgesia in Normal Adults
• Healthy adults without pain or sleep problems
• N = 14 (6 female, 8 male)
• Crossover design – TSD vs normal night
• TSD → significant hyperalgesia to
      heat, cold, blunt pressure, pinprick
• TSD → significant increase in State Anxiety

              Scuh-Hofer, S et al Pain 2013 154(9): 1613-1621
Comorbidity: Insomnia & Medical Disorders
      Community Sample (Age 18-65, N = 3282)
Overall Prevalence of Insomnia = 21.4%
Increasing # Medical Disorders → Increased Prevalence Insomnia

          Medical Disorder                 Odds Ratio            95% CL        P
              Migraine                          1.8              1.5-2.1      .001
  Pain-
              Stomach Ulcers                    2.1              1.6-2.7      .001
  Related
              Arthritis                         1.8              1.5-2.2      .001

              COPD                              1.6              1.3-2.0      .04
  Breathing
              Asthma                            1.9              1.5-2.5      .001
              Cardiac, Hypertension,
  Other       Neurological, Menstrual
                                                1.7              1.2-2.7      .004

                                Budhiraja R et al Sleep 2011 34(7): 859-867
Longitudinal Effect of Sleep Disturbance on
  Emergence & Severity of Chronic Pain
    N=1753 Young Adults – Ages 18-25
    Sleep Problems at Initial Assessment
    • Baseline – significant comorbidity with
          chronic pain, musculoskeletal pain,
          headache & abdominal pain severity
    • 3-Year Follow-Up – predicted emergence of
          chronic pain & increased severity of
          musculoskeletal pain

                    Bonvanie, I. J. et al Pain 2016; 157(4): 957-963
Sleep Problems Increase Risk for Later
    Development of Chronic Pain
•   Sleep problems have a dose-dependent association (more
        significant sleep disturbance → higher risk) with both
        low back & neck/shoulder pain for both men & women
        at 10-year follow-up (N = 26,896).1
•   Sleep impairments are a stronger and more reliable predictor
        of pain than pain is of sleep impairments.2
•   Sleep patterns share common pathways with nociceptive
        stimuli.3
•   Sleep deprivation impairs descending pain-inhibition pathways
        that are important in controlling and coping with pain.4

                  1.   Mork PJ et al Eur J Public Health 2014 24(6): 924-929
                  2.   Finan PH et al J Pain 2013 14(12): 1539-1532
                  3.   Fine L Phys Med Rehabil Clin N Am 2015 26(2): 301-308
                  4.   Choy EH Nat Rev Rheumatol 2015 11(9): 513-520
Sleep and Pain – Bidirectional Influence

    Randomized, Controlled 12-Month Trial
    Collaborative Treatment. N = 250 Veterans
    • Change in sleep complaints at 3 months
         predicted change in pain at 12 months
         (P
Insomnia, Headache and Mood

• During last night’s insomnia, as these thoughts
      came and went between my aching temples,
      I realized once again, what I had almost
      forgotten in this recent period of relative calm…

• That I tread a terribly tenuous, indeed almost
      non-existent soil spread over a pit full of
      shadows, whence the powers of darkness
      emerge at will to destroy my life…

          Franz Kafka, Letters to Friends, Family and Editors
How Much Sleep Does a Pain Patient Need?

 • The sweet spot may lie between 6-9 hours/night
 • Representative national sample (N = 971) kept pain
       and sleep diaries for 1 week1
 • Either less than 6 or more than 9 hours sleep/night
       significant association with greater next-day pain1
 • Daytime pain prospectively predicted sleep duration,
       but the effect was less robust1
 • Both migraine and tension-type headache patients
       may need more sleep than healthy controls2

           1. Edwards RR et al Pain 2008 137(1): 202-207
           2. Engstrom M et al Acta Neurol Scand Suppl 2014 198: 47-54
Shift Work Disorder – 1

1. About 15% of full-time was and salary workers in US
       work on shifts outside traditional daytime schedule
2. Most shift workers are in service occupations –
       police, firefighters, food service, healthcare,
       transportation
3. 63% of shift workers (vs 89% of non-shift workers) said
       their schedule allows them to get enough sleep
4. Shift workers more likely to
       sleep 6 hours on workdays
       work more hours/week
       experience drowsy driving at least once/month

                                   National Sleep Foundation
                                   (sleepfoundation.org)
                                   accessed online 04/29/2018
Shift Work Disorder – 2
Definition  Circadian rhythm sleep disorder characterized by
insomnia and excessive sleepiness affecting people whose
work hours overlap with the typical sleep period

 1. MedLine and Cochrane Library search found 29 articles
        (reviews and research) with 3504 probands
 2. About 33% of shift workers have insomnia
 3. Up to 90% report regular fatigue & sleepiness at workplace
 4. Detrimental effects – work performance, processing errors,
        work accidents, absenteeism, reduced quality of life,
        symptoms of depression

                                     Richter, K et al EPMAJ 2016
Cognitive Behavioral
Treatment of Insomnia
American College of Physicians
Management of Chronic Insomnia Disorder in Adults
Clinical Practice Guideline Recommendations 2016
Based on Systematic Review of Randomized Controlled Studies
Published in English from 2004 through 9/2015

  1.   ACP recommends that all adult patients receive cognitive
          behavioral therapy for insomnia (CBT-I) as the initial
          treatment for chronic insomnia disorder.

  2.   ACP recommends that clinicians use a shared decision-making
          approach, including a discussion of the benefit, harms,
          and costs of short-term use of medications, to decide
          whether to add pharmacological therapy in adults with
          chronic insomnia disorder in whom cognitive behavioral
          therapy for insomnia (CBT-I) alone was unsuccessful.

                      Qaseem A et al Ann Intern Med 2016; 165(2): 125-133
Behavioral & Drug Therapies for
     Randomized Controlled Trial – 1
1. Late Life Insomnia (mean age 65), N = 78 (50♀ 28♂)
2. Improvement = Reduction in time awake after sleep onset
   measured by sleep diary and polysomnography

                        Treatment                                         % Improvement
Pharmacotherapy + CBT                                                        63.5
Cognitive-Behavioral Therapy                                                 55.0
(stimulus control, sleep restriction, sleep hygiene, cognitive therapy)

Pharmacotherapy (temazepam)                                                  46.5
Placebo                                                                      16.9
1. The three active treatments more effective than placebo
2. Trend for greater efficacy of combined treatment
                                                    Morin CM et al JAMA 1999 281(11): 991-999
Behavioral & Drug Therapies for
    Randomized Controlled Trial – 2
Sustained Improvement, Rated Efficacy, Satisfaction

   • CBT treated subjects sustained gains at follow-up
   • Drug therapy alone did not show sustained gains
   • CBT (alone or combined with drugs) was rated as
        more effective than drug therapy alone by
        subjects, significant others and clinicians.
   • Subjects were more satisfied with CBT

                         Morin CM et al JAMA 1999 281(11): 991-999
American Academy of Sleep Medicine
   Practice Parameters for the Psychological and
   Behavioral Treatment of Insomnia: An Update
        Effective Treatments Include
            1.   Stimulus Control
            2.   Relaxation and Biofeedback
            3.   Cognitive Behavior Therapy
            4.   Sleep Restriction
            5.   Paradoxical Intention

                   Morgenthaler T et al Sleep 2006 29(11): 1415-1419
Sleep Onset Insomnia – Overthinking

  •   Insomnia is a variant of Tourette’s – the waking brain races,
          sampling the world after the world has turned away,
          touching it everywhere, refusing to settle, to join the
          collective nod.

  •   The insomniac brain is a sort of conspiracy theorist –
           believing too much in its own paranoiac importance,
           as though if it were to blink, then doze, the world might
           be overrun by some encroaching calamity, which its
           obsessive musings are somehow fending off.

                        Jonathan Lethem, Motherless Brooklyn 1999
Behavioral Management of Sleep
  Set Appropriate Expectations
  1. Educate patient about sleep
  2. Need to quiet the mind
  3. Bed is not the place to solve problems –
       no matter how badly the emotional
       mind may want to do so
  4. Consistency is critical to success –
       the insomniac may need more
       consistency in following program
       than bed partners or friends
  5. Patience – Improvement may take
       several weeks of adherence
Stimulus Control

1. Facilitate “bed with lights out” becoming a conditioned
        stimulus for rapid sleep onset – no competing activities
2. Reserve bed for sleep at night – no TV, reading, cell phone,
        iPad, computer games, reading, worrying, planning, or
        discussing stressful events with your bed partner
3. Avoid using bed for other activities during the day
4. If you need time to review your day, plan tomorrow, or
        grapple with an emotionally difficult issue, give yourself
        a limited time in a structured setting to do this before
        starting bedtime preparation
5. Keep a notepad by the side of the bed to easily jot down any
        thoughts you have difficulty getting out of your mind
I don’t fall asleep easily, but
when I do, it’s a nightmare.

                  Parth Shiralkar
Relaxation, Meditation, Mindfulness

  1. Slow abdominal breathing – 4 seconds in, 4 seconds out
  2. Repeat a word – e.g., “Re…lax” – in rhythm with breathing
  3. Alternatively, some patients with a strong faith may prefer a
         verse of scripture or word with special meaning in their
         religious tradition – e.g., “The Lord is my shepherd…”
  4. Become a neutral, casually interested, passive observer of
         intrusive thoughts and images – “Oh, that’s interesting”
         while continuing to redirect attention to the slow
         abdominal breathing rhythm and chosen word
  5. Take the emotion out of any sensory stimuli – e.g., let “pain”
         transform to a “certain feeling” at the periphery of
         the mind rather than a negative emotional state at the
         center of awareness
Somatically Focused Relaxation

•   Body scan – focus on different area of your body from the toes
         to the top of the head, relaxing each area, with
         sensations of loose heaviness
•   Progressive relaxation – tighten and then relax muscles from
         the feet to the forehead, with a sense of “letting go,
         farther and farther” as each area releases before moving
         on to the next
•   Biofeedback – focus on warming the fingers or toes (reduction
         in sympathetic nervous system outflow) or relaxing
         specific muscle areas (e.g., jaw, neck, eyes, forehead)
Hypnotically-Induced Relaxation
  1. Letting go of intention, following a prearranged script
  2. Descending imagery – going down a staircase or
          floating like an autumn leaf in a light warm breeze
  3. Repetitive counting – e.g., backwards slowly from 100,
          or up from 1 to 10 while opening and closing the
          eyes, letting the eyes feel heavier and heavier,
          until they feel too heavy to open, finding it easier
          to just let them effortlessly remain closed
  4. Passively observe whatever experiences occur
          through the process
  5. Repeat as needed – repetition of the script facilitates
          conditioning
Sleep Restriction
Limit Time in Bed when Not Sleeping
 1. Avoid lying in bed for prolonged periods not sleeping –
         interferes with condition rapid sleep onset
 2. Go to bed when sleepy – stay up later but engaged in
         non-stimulating activity during the hour before bed
 3. If not asleep within about 20 minutes, get out of bed,
         preferably go into another room, do something
         non-stimulating – reading light fiction or a book
         you have read before, listening to music or a story
         with which you are familiar, return to bed when
         feeling sleepy
 4. Repeat if not asleep in about 20 minutes
 5. No napping during the day
Paradoxical Intention
1. Insomniacs often try too hard to fall asleep – they set
       goals that they must be asleep by a certain time in
       order to be rested for the next day’s activities, they
       track the time they are not sleeping, and at some
       point become frustrated with their lack of success
       in falling asleep, which further interferes with sleep
2. The therapeutic goal each night is to follow the plan,
       and accept whatever happens – to give up the
       goal of trying to fall asleep
3. True paradoxical intention means trying to stay awake
       rather than trying to fall asleep – directly
       confronting the fear of not falling asleep
I’ve got rhythm…

       George and Ira Gershwin
Circadian Rhythms of Human Subjects
Without Timepieces or Indication of the Alternation of Day or Night

    •   One (1) subject lived alone in cave for 127 days –
            activities & sleep cycle averaged 25.1 hour rhythm

    •   Seven (7) solitary subjects spent 5-7 days in isolation unit –
            3/7 developed 25-27 hour rhythm
            1/7 first developed 27 hour rhythm, then 24-25 hours
            1/7 maintained 30 hour rhythm
            2/7 alternated sleep of 8 or 16 hours, followed by 24
                hours of activity

    •   One group of four (4) individuals awoke every 24 hours after
            sleep alternating between about 4 and 8 hours

                               Mills JN et al J Physiol 1974 240(3): 567-594
Geologist Michel Siffre – “Caveman”

       Michel Siffre in 1999 before starting 76-day sojourn in a cave
       without a phone or a watch – Getty Images. Accessed online New
       York Post 01/22/17
When Time Flies – Michel Siffre

•   Michel Siffre (geologist) spent extended periods underground
          three (3) times, without knowledge of passage of days
          on earth’s surface – the last in his 60’s lasting 76 days
•   He slept, rose and ate as he wished & kept detailed diaries
•   In his first 2-month trip, sleep/activity cycles varied from 6-40
          hours (mean = 24.5)
•   Longest period of isolation was 7 months –
          for the first 5 weeks, his rhythm was 26 hours
          then his “days” ranged from 26 to 40-50 hours
          experienced severe depression with suicidal ideation

             Burdick, Alan When Time Flies: A Mostly Scientific Investigation
                     2018 NY: Simon & Schuster
Manage the Circadian Rhythm
 1. Patients with sleep problems may need to be
        more rigid than others to maintain a stable
        circadian rhythm
 2. Get up at the same time every day – include
        weekends
 3. “Sleeping in” on the weekends interferes with
        the circadian rhythm – like going on Daylight
        Savings every Monday when you have to get
        up earlier for work or school
 4. A consistent time of getting up in the morning
        drives the circadian rhythm – not the more
        popular concept of going to bed earlier,
        which may leave the insomniac with more
        time to lie in bed awake and not sleeping
Conclusion

The best cure for insomnia
is to get a lot of sleep.

              W. C. Fields
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