Sleep disorders Insomnia

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Slide 1 :

Sleep disorders: Insomnia Dr Nic Wilkinson (Clinical Psychologist) Diabetes Centre Sheffield Teaching Hospitals NHS Foundation Trust nicolas.wilkinson@sth.nhs.uk

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Lecture plan What is sleep ? Sleep disorders What is Insomnia ? CBT for Insomnia (Espie, 1991) CT for Insomnia (Harvey, 2002)

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A rhythmic world Planets circle the sun Night follows day 4 seasons tidal movement birds migrate flowers close at night & open during day

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Biorhythms Circadian - approx 24 hr cycle e.g sleep/wake cycle Ultradian - cycles within a day e.g. sleep stages Infradian - cycles more than a day e.g. menstrual

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Human sleep A period a substantial neurological & physiological activity ‘car engine running but with the clutch depressed so the car is resting’ (Espie,1991) different types of sleep = sleep stages/ architecture exact functions of sleep remain unclear

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How much sleep? Amount changes with age & lifestyle Myth of 8 hours Adult Range 3 – 10hrs sleep 6 hours is probably enough (Horne, 1988) Less than 2/3 may have detrimental effect

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An night of sleep for a young adult

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Sleep Disorders - Sleep Apnoea Transient closure of the upper airway during sleep Symptoms - Snoring; headaches/shortness of breath on waking; daytime fatigue Prevalence rate 3-8% Risk factors – male, obese, small jaw, thick neck, alcohol Increased risk of accident, cardiovascular disease CPAP mask often effective

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SD - Restless Legs Syndrome Feeling of discomfort in deep tissues between knee and ankles, occurs when resting Appears in Stage 2 sleep Prevalence rate 2-5% - increases with age Associated with anaemia and heart failure Medication very effective

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SD - Narcolepsy Irresistible attacks of refreshing sleep occur daily for at least 6 months REM sleep disorder Cataplexy (sudden loss of muscle tone) and/or intrusions from REM stage (often described as hallucinations) Prevalence rare – 5 per 100,000…rare Cause unknown but strong familial component Prescribed stimulants can be effective

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Jet Lag and Shift Work Desynchronicity of internal body clock Sleepiness at wrong times of the day Light box treatment can be effective Melatonin resets circadian rhythm

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Parasomnias - Nightmares Prevalence rate – 5% Most common in childhood but can last into adulthood Occurs during 2nd part of the night Dreams involve threat to survival, security or self-esteem If no paralysis, may cause injury to self and others Often a feature of Post Traumatic Stress Disorder (PTSD)

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Parasomnias – Night Terrors Abrupt waking associated with features of terror Symptoms – rapid heart rate, sweating and confusion Occurs in Stage 3 and 4 sleep Most common in children Often related to emotional distress

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Parasomnias – Sleep Walking Person engaged in activity whilst asleep May undertake simple or complex tasks Usually unaware of behaviour Occurs during Stage 3 and 4 sleep Strong familial component

Slide 15 :

Insomnia - DSM IV criteria difficulty initiating or maintaining sleep, or non-restorative sleep, for at least 1 month. b) clinically significant distress or impairment in social/occupational functioning c) not exclusively due to another sleep disorder d) not exclusively due to another mental disorder e) not due to the physiological effects of a substance or a medical disorder

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Features of Insomnia Problems initiating sleep (greater than 30 minutes) Frequent and/or prolonged nocturnal awakenings Early morning awakenings with an inability to return to sleep Poor sleep quality and sleep efficiency Cognitive arousal typically reported Severity is judged along several dimensions, including frequency, intensity and duration of sleep difficulties. Also impact on daytime functioning, mood and quality of life.

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Prevalence - Insomnia Up to 10% adults (Ancoli-Israel & Roth, 1999) Up to 25% older adults 15-25% individuals in sleep clinics women > men shift workers Course: 50-75% of people with insomnia have symptoms > year

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Impact of Insomnia Biological Increased surveillance of immune system Functional impairments Increased risk of accidents More likely to report lack of concentration and motivation Reduced productivity, work absenteeism Increased use of medical services Psychological health Increases risk of developing depression, anxiety or substance dependence Risk factor in suicide (Ohayon et al., 1997: Harvey, 2001: Ancoli-Israel & Roth, 1999: McCrae & Lichstein, 2001)

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Psychological Assessment - Screen for other disorders Depression and GAD common co-morbid problems Eg.s other problems: PTSD/Acute stress: drug/alcohol dependence, low self esteem Use psychometrics BDI II/PSWQ etc Interview: Which problem started first? Which is most distressing? Which causes most interference with functioning?

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Insomnia assessment Medical assessment to rule out other sleep disorders/ medical problems Clinical interview Psychometric Hospital Anxiety & Depression scales (HADs) Sleep Disorders Questionnaire Beck Depression Inventory-II Penn State Worry Questionnaire

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Insomnia - drug therapy Benzodiazepines (e.g. temazepam, diazepam) Nonbenzodiazepine hypnotics (e.g. Zolpidem, Zopiclone, Zaleplon) Side effects: changes in sleep architecture,drowsiness, tolerance, withdrawal effects

Slide 22 :

Insomnia - CBT model (Espie,91)

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Cognitive Behaviour Therapy (CBT) for Insomnia (Espie et al 90’s) Stimulus control Sleep hygiene Sleep restriction Relaxation Paradoxical intention Cognitive restructuring Worry postponement

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Insomnia Stimulus Control Insomnia is a conditioned response to temporal and environmental cues Promote consistent sleep / wake cycle Re-associate the bedroom with sleeping Well established treatment

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Insomnia Sleep Hygiene Education Factors that affect sleep, e.g caffeine, alcohol etc Not primary cause of insomnia but can maintain problem Limited benefits if used alone

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Insomnia Sleep Restriction Reducing time in bed to match sleep obtained To increase sleep efficiency Adherence is problematic Probably effacious treatment

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Insomnia Relaxation to deactivate arousal system various types - muscular, imaging, hypnosis well established treatment

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Insomnia Paradoxical Intervention Engage in the feared outcome (not sleeping) Break cycle of performance anxiety Large variance in response

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Insomnia Cognitive Therapy Identify thought processes to reduce anxiety Includes self-talk, distraction, rationalisation Helpful in altering dysfunctional sleep beliefs Postponing worry episodes Efficacious treatment

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Insomnia - Efficacy of CBT Two meta analyses (Morin et al., 1994; Murtagh & Greenwood, 1995) - Significantly more effective than no treatment Review by the AASM (Chesson ET al., 1999; Morin et al ., 1999) However 19-26% fail to respond overall average improvement is 50-60% effect sizes for pre to post treatment/ follow-up < 1.0

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Slide 32 :

Towards a cognitive theory of insomnia? (Harvey, 2002) majority of people with insomnia report that they can’t get to sleep because of …. Uncontrollable worry Intrusive thoughts “Racing mind” (Geer & Katkin, 1966) Cognitive theories have lead to advances in treatment for several psychological disorders ..

Slide 33 :

‘Distortions of reality’ (Beck, 1976) Anorexia nervosa: People think they are fat when they actually thin Hypochondriasis: People think they are suffering from a grave illness when actually they are well Panic disorder: People think they are going to have a heart attack when actually they are experiencing the symptoms of anxiety

Slide 34 :

Sleep Deficit People with insomnia honestly and persistently describe that they don’t get enough sleep The difference in sleep duration between good sleepers and individuals with insomnia is not enough to account for the severity of the complaints (Chambers & Keller, 1993, n=14, 35 mins.) Many people with insomnia overestimate sleep onset latency and underestimate total sleep time (Adam et al., 1986; Bonnet, 1990)

Slide 35 :

Daytime Deficit People with insomnia honestly and persistently describe wide-ranging daytime deficits Not detected by majority of studies using MSLT, pupillometry, and neuropsychological testing (see Riedel & Lichstein, 2000 for review)

Slide 36 :

Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40, 869-893

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