prof colin a espie - babcp.com · sleep diary (pdf) or recommendations for assessment ... the...

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Sleep workshop

[email protected]

Prof Colin A Espie Professor of Behavioural Sleep Medicine, Nuffield Department of

Clinical Neurosciences and Sleep & Circadian Neuroscience Institute, University of Oxford

Sleep and Circadian Neuroscience Institute (SCNi) for Mental Health

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Research interests

Understanding sleep problems •  Precipitating and perpetuating factors for sleep disorder phenotypes •  Pathophysiology of, and cognitive processes in, psychophysiological

insomnia •  The association between sleep disturbance and mental and physical

illness •  nREM arousal disorders and their management

Managing sleep problems •  Cognitive behavioural treatments for sleep disorders •  Critical mechanisms in CBT and issues of sleep therapy compliance •  Clinical effectiveness and community delivery models •  Use of online rich media to deliver CBT

Assessing sleep problems in routine clinical practice

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Generic aspects - taking a history

•  Personal details •  Presenting problem(s) •  Development of problem •  ABC model •  3 P’s model •  Treatment history •  Personal history •  Medical/ psychiatric history •  Personality – pre-morbid, coping, etc. •  Mental state •  Formulation •  Plan of action

The natural history of insomnia

Spielman, Glovinsky. The varied nature of insomnia. In Case studies in insomnia, ed. P. Hauri, pp.1-15. New York: Plenum Press. 1991

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The Sleep Condi-on Indicator (SCI): a prac-cal

clinical screening tool to evaluate DSM-‐5 Insomnia Disorder

pdf or www.sleepio.com

Espie et al (under review)

Objectives

•  To develop and test the psychometric properties of a brief clinical screening tool to evaluate DSM-5 Insomnia Disorder

•  To develop a short-form version for rapid (pre-)screening

•  GAD-7 and GAD-2 serves as a useful model

[Named the Sleep Condition Indicator (SCI)]

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SCI design logic – item coverage •  2 quantitative items on sleep continuity [item 1: getting to

sleep; item 2: remaining asleep] •  2 qualitative items on sleep satisfaction/dissatisfaction

[item 4: sleep quality; item 7: troubled or not] •  2 quantitative items on severity [item 3: nights per week;

item 8: duration of problem] •  2 qualitative items on attributed daytime consequences

[item 5: effects on mood, energy, or relationships (personal functioning); item 6: effects on concentration, productivity, or ability to stay awake (daytime performance)]

Sample: total n=30,941; 71% F Sample

Description

n

Age (y)

Gender

GBSS-1 Online survey in UK on dedicated site

12,628 38.7 (14.5) 72% F

GBSS-2 Online survey continued, extended worldwide

11,017 42.3 (16.5) 68% F

TV Data collected online by TV company

6,876 36.4 (13.3) 76% F

Science Centre

Visitors booth 256 40.3 (14.9) 56% F

RCT Trial participants 164 48.9 (13.7) 72% F

www.worldsleepsurvey.com

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DSM-5

0-32 score, converted to a 10 point scale. High scores indicate sleep in good condition

Short form •  Logistic regression analysis to determine which

subset of items explains greatest proportion of variance in the SCI-08

•  Two-items, comprising: item 3 ‘…how many nights’ (standardized ß = .515) item 8 ‘… troubled you in general’ (ß = .491)

predicted 82% of variance (Adjusted R2 = .820) •  SCI-02 correlates strongly with the SCI score total

(r = .904).

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General indices of sleep/ insomnia complaint

ü Pittsburgh Sleep Quality Index (commonly used, has established cut-off score

>5, equates to sleep disturbance not insomnia, also profiles other sleep problems so may be useful screening tool)

ü Insomnia Severity Index (specific to insomnia, profiles the insomnia

problem, brief, quite stringent) ü Sleep Condition Indicator (based on DSM-V criteria for Insomnia Disorder)

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The classification of sleep disorders, and the differential diagnosis amongst sleep disorders

Diagnostic algorithm (pdf)

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Morningness Eveningness Questionnaire (MEQ)

Example item One hears about ‘morning’ and ‘evening’ types of people, which one of these types do you consider yourself to be? q Definitely a morning type q Rather more a morning than an evening type q Neither q Rather more an evening type than a morning

type q Definitely an evening type

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Sleep laboratory assessment

Sample PSG output

EOG

EEG EMG

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SSTTAAGGEE 11 SSLLEEEEPP

SSTTAAGGEE 22 SSLLEEEEPP

SSTTAAGGEESS 33 && 44 ((SSWWSS))

AAWWAAKKEE -- AALLPPHHAA

AAWWAAKKEE -- AALLEERRTT

The EEG in nREM sleep

Courtesy of Dr. Michael Perlis, Rochester NY

REM sleep characteristics

Atonia

Phasic twitches

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Sleep diary (pdf) or www.sleepio.com

Recommendations for assessment

•  History •  Assessment of sleep pattern and quality (Sleep

diary for 2 weeks) •  Assessment of insomnia impact (e.g. SCI, ISI) •  Screening for other disorders •  Further assessment if required (e.g. PSG,

oximetry, MSLT, blood chemistries) •  Assessment of co-morbidities (e.g. depression,

PTSD) •  Assessment of psychological antecedents/ correlates

(formulation) •  Appraisal of outcomes (diary, impact, clinical

improvement)

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Insomnia the most common expression of mental dis-ease

% of Adults with a score >= 2 on neurotic symptoms

28

19

119

23

17

108.5

33

21

129.5

0

5

10

15

20

25

30

35

Sleepproblems

Worry Depression Anxiety

%

Total Men Women

0

0.2

0.4

0.6

0.8

1

1.2

Mean score

PHQ1 PHQ2 PHQ3 PHQ4 PHQ5 PHQ6 PHQ7 PHQ8 PHQ9

PHQ item

Figure 4: Profile of 4,355 cancer patients on the PHQ-9

Sharpe, Espie, Fleming et al, unpublished data

Fatigue (PHQ4) and sleep disturbance (PHQ3) are most prevalent symptoms in the depressive cluster; compared with feeling depressed (PHQ2), poor appetite (PHQ5), or difficulty concentrating (PHQ7).

Fatigue and insomnia are most common symptoms in medical populations

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INSOMNIA IS A RISK FACTOR FOR DEVELOPING DEPRESSION AND FOR RELAPSING INTO DEPRESSION

•  Riemann D, Voderholzer U. Primary insomnia: A risk factor to develop depression? Journal of Affective Disorders 2003;76:255-9.

•  Cole MG, Dendukuri N.

Risk factors for depression among elderly community subjects: a systematic review and meta-analysis. American Journal of Psychiatry 2003;160:1147-56.

“Insomnia Disorder … whenever diagnostic criteria are met, whether or not there is a co-existing psychiatric, medical, or another sleep disorder”

Insomnia Disorder •  difficulty initiating sleep •  difficulty maintaining sleep •  early morning awakening with inability to return to sleep •  non-restorative sleep [underlying dissatisfaction with quality/quantity] •  ≥ 3 nights per week, for > 3 months (persistent insomnia) •  occurs despite adequate opportunity and circumstance to sleep

•  results in daytime dysfunction: - fatigue, physical tension, low mood, impaired concentration, social/

relationship functioning impaired

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Prevalence & natural history of ID

•  10-12% of population meet criteria for ID •  3% of the population will experience ID on its

own (without co-morbidity) •  ID is persistent: 75% of those with ID will meet

criteria 1 yr later; nearly 50% 3 yrs later •  45% experience ID for > 6 yrs 25% of all ID patients slept poorly since

childhood

Morin et al. (2009). Arch Intern Med Espie et al. (2012). J Clinical Psychiatry

Associated morbidity

-  ID is a risk factor the future development of depression -  ID is a risk factor for non-response, non-remission, and

relapse into depression -  ID is an independent risk factor for hypertension, diabetes,

and cardiovascular disease -  Impairs day-to-day functioning, health-related quality of life

and global quality of life -  Mortality? [Insomnia (<6hrs sleep) 4 x more likely to have died at 14 yr follow-up than those without insomnia] Baglioni et al. (2011). J Affective Disorders

Kyle et al. (2010). Sleep Medicine Reviews. Kyle, Morgan & Espie (2010). Behavioural Sleep Med Vgontzas et al. (2010). Sleep; 33; 1159-1164

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Why is CBT relevant to insomnia?


The essential feature of Psychophysiological Insomnia is heightened arousal and learned sleep-preventing associations… Arousal can also reflect a cognitive hypervigilance. Indeed, mental arousal in the form of a “racing mind” is characteristic … A cycle develops in which the more one strives to sleep, the more agitated one becomes, and the less able one is to fall asleep

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Borkovec et al: wakefulness experience when cortically asleep

Thinking processes remain part of the insomniac’s experience even when wakened

from light sleep

Borkovec, Lane, Van Oot. J.Abnorm.Psychol. 1981;90:607-9

ARAS ARAS

Thalamus

Mesial temporal cortex

Hypothalamus

Cingulate

Mesial temporal cortex Hypothalamus

ARAS

Insular cortex

Nofzinger et al.: Brain imaging studies in insomnia

Nofzinger et al. Psychiatry Research: Neuroimaging 2000;98:71-91

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Perlis et al. J Sleep Res 1997;6:179-88

Vulnerability or extant illness

Precipitating event

Maladaptive coping strategy

Conditioned arousal somatic cognitive CORTICAL

Cognitive alterations sensory processing information processing long-term memory formation

Complaint of insomnia can’t fall asleep wake up frequently perceived wakefulness vs polysomnogram sleep overestimation of wakefulness

Perlis:The neurocognitive perspective on insomnia

Harvey: a cognitive model of insomnia

Excessive worry

Distorted perception of deficit

Safety behaviours

Beliefs

Key. Leads to Exacerbates

Arousal and distress

Selective attention and monitoring

In bed/during the day

Real deficit

Harvey. Behav.Res.Ther. 2002;40:869-893

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DELTA * BETA1 WHOLE NIGHT

0

20

40

60

80

100

0 38 76 114

152

190

228

266

304

342

380

418

456

494

532

570

608

646

684

722

760

798

836

874

912

950

988

DELTA

0

2

4

6

8

10

BETA1

0

20

40

60

80

100

0 43 86 129

172

215

258

301

344

387

430

473

516

559

602

645

688

731

774

817

870

915

962

1005

DELTA

0

2

4

6

8

10

BETA1

0

20

40

60

80

100

0 41 82 123

164

205

246

287

328

369

410

451

492

533

574

615

656

697

738

779

820

862

903

947

988

DELTA

0

2

4

6

8

10

BETA1

DELTA BETA1

GOOD SLEEPER CONTROLS

DEPRESSION

PRIMARY INSOMNIA

SLEEP ONSET

SLEEP ONSET

SLEEP ONSET

Perlis et al. J.Sleep Res. 2001;10:93-104

Power spectral analysis of sleep in insomnia

Stressful life event

Psychological & physiological correlates of stress

Inhibition of sleep-related de-arousal

INSOMNIA SYMPTOMS

Arousal perpetuates sleep disturbance

Selective attention toward stressors

Selective attention SHIFT

A1 - implicit shift toward sleep cues

A2 - explicit shift toward sleep cues

E - sleep effort

I - explicit intention

Recovery of normal sleep


Espie et al. The Attention-Intention-Effort pathway in Psychophysiological Insomnia Sleep Medicine Reviews (2006)

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“Sleep (is like) a dove which has landed near one’s hand and stays there as long as one does not pay

any attention to it; if one attempts to grab it, it quickly flies away”

[Viktor E. Frankl (1965, p. 253)]

Espie: Psychobiological Inhibition Model What are the cognitive differences between NS and PI?

Normal sleep

•  Minimal attention

•  Minimal intention

•  Minimal effort

•  Minimal concern

Espie. Ann.Rev.Psychol. 2002;53:215-243 (Psychobiological Inhibition Model of insomn

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Espie: Psychobiological Inhibition Model What are the cognitive differences between NS and PI?

Normal sleep

•  Minimal attention

•  Minimal intention

•  Minimal effort

•  Minimal concern

Psychophysiological Insomnia •  Selective attention to sleep,

sleeplessness, sleep consequences

•  Activated intention to sleep, purposive

•  Sleep effort, both direct and indirect

•  Sleep preoccupation, persistent insomnia complaint

Espie. Ann.Rev.Psychol. 2002;53:215-243 (Psychobiological Inhibition Model of insomn

AASM task force (Morin et al.) Sleep 1999: 22; 1134-56,

Sleep 2006: 29; 1398-1414 AASM practice parameter conclusions

based on APA criteria as “well established treatment”

þ  Stimulus control þ  Progressive muscle relaxation þ  Paradoxical intention þ  Sleep restriction þ  Multi-modal CBT

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Sleep Hygiene

Riemann D, Perlis ML. (2009) The treatments of chronic

insomnia: A review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Medicine Reviews, 13(3), 205-14

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“CBT has been found to be as effective as prescription medications are for short-term treatment of chronic insomnia. Moreover, there are indications that the beneficial effects of CBT, in contrast to those produced by medications, may last well beyond the termination of active treatment” (p.14)

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How can we deliver CBT?

Individual therapy

e.g. Ø Morin et al (2009)

Cognitive-Behavior Therapy, Singly and Combined with Medication, for Persistent Insomnia: Acute and Maintenance Therapeutic Effects. JAMA

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Brief therapy

e.g. Ø Edinger et al (2007)

Dose-response effects of cognitive-behavioral insomnia therapy: a randomized clinical trial. SLEEP 30:203-212

Ø Buysse et al (2011) Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Int Med 171:887-895

Group therapy

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Large groups e.g. Ø Swift et al (2012) The effectiveness of community day-

long CBT-I workshops for participants with insomnia symptoms: a randomised controlled trial. J Sleep Res 21, 270-280

Self-help books

e.g. Ø  Jernelov et al (2012)

Efficacy of a Behavioral Self-help Treatment With or Without Therapist Guidance for Co-morbid and Primary Insomnia; a Randomized Controlled Trial. BMC Psychiatry. 2012;12(5)

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Online

www.sleepio.com

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Integrating online and clinical practice

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Useful tools in working with insomnia

•  Pre-Sleep Arousal Scale •  Sleep Disturbance

Questionnaire •  Sleep Hygiene Practice

Scale •  Sleep Behaviour Rating

Scale •  Dysfunctional Beliefs and

Attitudes About Sleep scale •  Glasgow Content of

Thoughts Inventory •  Glasgow Sleep Effort Scale •  Glasgow Sleep Impact Index

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Sleep hygiene

Sleep hygiene

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Sleep hygiene

What is relaxation therapy?

•  Following Jacobson (1929), Abbreviated Progressive Muscle Relaxation (Bernstein & Borkovec, 1973) used by Borkovec et al (several studies from mid-1970’s to early 1980s)

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Abbreviated progressive muscle relaxation

From Espie (1991)



•  Schultz & Luthe (1959) Autogenic Training methods tend to be incorporated into relaxation routines

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Autogenic training •  A more ‘cognitive’ strategy •  Subject taught to rehearse simple standard

phrases referring to experiences of warmth and heaviness in the extremities (“my right arm is feeling warm and heavy”)

•  Instructs body to state of low arousal and attends to sensations

•  Responses more passive than in PMR •  Somewhat like self-hypnosis




•  Meditation in various forms applied to insomnia (e.g. Woolfolk et al, 1975; 1976)

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Meditation •  Various forms – yoga, transcendental •  In common they use a ‘mantra’ as focus •  Aims to transfer attention from external to

internal •  Primary focus is often on breathing “in”/ “out” •  Such stimuli may prove soporific/ block

competing mental activity •  Cue-controlled relaxation often uses the word

“relax”





•  (e.g. Graham et al, 1975)

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Self-hypnosis

•  Different techniques for hypnotic induction (e.g. eye fixation)

•  Suggestibility important •  Inference of trance-like state •  Implies (inevitable) biofeedback?





•  Self-hypnosis (e.g. Graham et al, 1975) •  EMG Biofeedback (Freedman & Papsdorf, 1976;

Coursey et al, 1980); EEG theta and SMR biofeedback (various studies by Hauri in 1970s and 1980s; Feinsetein et al, 1974)

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Biofeedback •  Forehead or other muscle electrodes for EMG

biofeedback •  Reduce audible tone that reflects muscle tension

(muscle tone) •  Concentrate on sensations and thoughts that

elicit such changes •  Way of rewarding/ reinforcing successful

relaxation response •  Requires equipment





•  Self-hypnosis (e.g. Graham et al, 1975) •  EMG Biofeedback (Freedman & Papsdorf, 1976;

Coursey et al, 1980); EEG theta and SMR biofeedback (various studies by Hauri in 1970s and 1980s; Feinsetein et al, 1974)

•  Davidson & Schwartz (1976) generic classification model

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Relaxation quadrant

How to relax

•  Need time •  Need to practice •  Need to acquire a skill •  Need to apply the skill •  Need to develop confidence that it is

useful

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Do you value relaxation?

Possibly a common pathway?

•  To de-arousal •  Physiological and mental •  Provides self-instruction; improves self-efficacy •  Attention focussing/ tension release cycles may not

be critical •  The human relaxation response (Herbert Benson)

http://www.relaxationresponse.org/HerbertBenson.htm e.g. Benson H, Beary JF, Carol MP. The relaxation response. Psychiatry

1974;37:37-46.

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Training in relaxation therapy for insomnia

•  Read script •  Listen to CD/ mp3 •  Be a subject •  Internalise the instructions •  Then make your own recording •  Try it out •  Practise with peers •  Practise with patients

Stimulus control therapy

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Sleep restriction

Homeostatic regulation of sleep

0

5

10

15

20

Late

ncy

to s

leep

ons

et (m

in)

0930 1130 1330 1530 1730 1930 Time of day

0 hours

9 hours 7 hours 5 hours

4 hours

Day 2 of deprivation

Young adults on the 2nd day of various nocturnal sleep time conditions. Subjects per condition: 9 hrs, n=20; 7 hrs, n=14; 5 hrs, n=10; 4 hrs, n=13; 0 hrs, n=6 From Roth, Roerhs, Carskadon & Dement, 1989

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Circadian drives •  Strong 24-hour rhythm •  Based in the SCN transcriptional/translational loop, timed by

light, through specialised retinal cells containing melanopsin and controlled by several genes – 3 Period, 2 Cryptochrome, CLOCK, and BMal1 (Brain and Muscle Anat-Like)

Temperature (°C)

Plasma growth hormone (ng/ml)

Plasma cortisol (µg/100 ml)

Urinary potassium (mEq/L)

Circadian time (hours)

Sleep restriction

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Sleep restriction

Sleep restriction

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Sleep restriction

Sleep restriction

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Sleep restriction

Sleep restriction

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Sleep restriction

Sleep restriction

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Sleep restriction

Sleep restriction

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Sleep restriction

•  Stick to new schedule 7 nights per week •  Try to achieve 90% SE •  Adjust TIB conditionally on a weekly basis •  e.g. by adding 15 mins if 90% achieved

Cognitive strategies for insomnia

Colin A. Espie

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‘Sleep architecture’ hypnogram of sleep across the life cycle

Sleep stage distribution across adult years

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A third (implicit) process in sleep regulation?

Sleep homeostat

Circadian pacemaker Automatic (not ‘manual’) process

What are the thoughts, beliefs and attitudes of people with insomnia?

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What are the thoughts, beliefs and attitudes of people with insomnia?

What do they think about in bed?

Glasgow Content of Thoughts Inventory pdf

Harvey & Espie, 2004

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Source: GBSS/WSS, n=10,206

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A ‘wind down’ schedule is useful

Cognitive control; putting the day to rest (Espie & Lindsay, 1987)

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Putting the day to rest


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What about their beliefs and attitudes about sleep?

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DBAS-16 (Morin et al, 1993; 2003)

DBAS-16

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Cognitive restructuring

Cognitive strategies for changing beliefs and attitudes about sleep

1.  Keep expectations realistic 2.  Revise attributions about causes of insomnia 3.  Sleeplessness does not account for all

daytime 4.  Do not catastrophise after a poor night's

sleep 5.  Don't place too much emphasis on sleep 6.  Develop tolerance to effects of sleep loss 7.  Never try to sleep

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1. Keep expectations realistic e.g. understanding individual sleep need and the 'eight

hour fallacy'


2. Revise attributions about causes of insomnia e.g. consider a more multidimensional account of

insomnia; instead of focusing on one factor (e.g. 'chemical imbalance'). Emphasis should be placed on those factors that the patient can exert direct influence over (e.g. napping)

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3. Sleeplessness does not account for all

daytime impairments guide the patient to challenge the notion that poor

sleep uniquely explains daytime dysfunction, and to consider


4. Do not catastrophise after a poor night's sleep

assess for exaggerations of the impact of insomnia,

and guide patient to put in perspective their concerns: "What is the worst that can happen if you don't sleep tonight?". Reinforce the notion that insomnia is, on the whole, not dangerous.

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5. Don't place too much emphasis on sleep encourage patient to shift their focus away from sleep

as the centre of their existence. Discuss safety behaviours and their impact (e.g. avoiding social activities). Reduce feelings of being a helpless victim.


6. Develop tolerance to effects of sleep loss encourage patient to continue with normal daily

routine/activities after poor sleep. Prescribe a behavioural experiment where patient engages in a pleasurable activity after a poor night of sleep, to directly challenge and disprove the belief that sleeplessness impairs enjoyment of all daily activities.

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7. Never try to sleep explain to patient that sleep is an automatic process

that cannot be initiated by willful effort. Consider asking patient to try and stay awake (paradoxical intention) in order to reduce associated performance anxiety

Paradoxical intention

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Problem – Attention bias & trying to sleep

1.

I put too much effort into sleeping when it should come naturally

Very much

To some extent

Not at all

2.

I feel I should be able to control my sleep

Very much

To some extent

Not at all

3.

I put off going to bed at night for fear of not being able to sleep

Very much

To some extent

Not at all

4.

I worry about not sleeping if I cannot sleep

Very much

To some extent

Not at all

5.

I am no good at sleeping

Very much

To some extent

Not at all

6.

I get anxious about sleeping before I go to bed

Very much

To some extent

Not at all

7.

I worry about the consequences of not sleeping

Very much

To some extent

Not at all

Probing questions can be useful 1. What is the evidence that supports this idea? 2. What is the evidence against this idea? 3. Is there an alternative explanation? 4. What is the worst that could happen? Could I

live through it? 5. What is the best that could happen? 6. What is the most realistic outcome? 7. What would I tell (a friend) if he or she

were in the same situation? 8. How would someone else interpret the same

situation? after Beck, J. (1995). Cognitive Therapy: Basics and beyond. Guilford Press.

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Example of thought record/ diary

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Imagery training (Espie, 2006)

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Essentials of imagery training

Be prepared - don’t just wait until the time comes and try to think something up. Develop a screenplay! You are the director, so shoot the scenes and edit them until you have got what you want. Your imagery sequence should take about 10 minutes to go through in your mind’s eye.


Be prepared - don’t just wait until the time comes and try to think something up. Develop a screenplay! You are the director, so shoot the scenes and edit them until you have got what you want. Your imagery sequence should take about 10 minutes to go through in your mind’s eye. Practice regularly – you are also a participant! You must learn the scenes and the sequences so that they flow as the movie rolls! You need to set time aside to learn the ‘‘script’’ and you should practice in the evening or during the day too.

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Be prepared - don’t just wait until the time comes and try to think something up. Develop a screenplay! You are the director, so shoot the scenes and edit them until you have got what you want. Your imagery sequence should take about 10 minutes to go through in your mind’s eye. Practice regularly – you are also a participant! You must learn the scenes and the sequences so that they flow as the movie rolls! You need to set time aside to learn the ‘‘script’’ and you should practice in the evening or during the day too. Get good quality images - vivid and clear in your mind’s eye is what you want. Notice the colours, the smells, the sounds, the sensations that you make part of your imagery routine.


Be prepared - don’t just wait until the time comes and try to think something up. Develop a screenplay! You are the director, so shoot the scenes and edit them until you have got what you want. Your imagery sequence should take about 10 minutes to go through in your mind’s eye. Practice regularly – you are also a participant! You must learn the scenes and the sequences so that they flow as the movie rolls! You need to set time aside to learn the ‘‘script’’ and you should practice in the evening or during the day too. Get good quality images - vivid and clear in your mind’s eye is what you want. Notice the colours, the smells, the sounds, the sensations that you make part of your imagery routine. Relax and enjoy! – who wants to watch a movie that is uninteresting? This is something that you should look forward to. But at the same time remember you want to develop an imagery story that is calming, soothing, and not evocative of strong emotions!

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Thought blocking; articulatory suppression

Levey et al, 1991

Thought blocking; articulatory suppression

•  While lying in bed with your eyes closed •  Repeat the word ‘the’once or twice every

second in your head •  Don’t say it out loud, but it may help if

you’ mouth it’ •  Keep up these repetitions for about 5

minutes or until sleep ensues

Levey et al, 1991

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Avoid clock-watching

Awareness of time

Dysfunctional thought

Self-evaluation Emotional response

“Look at that, it’s gone 12:30 … … and I should be well asleep by now”

I have failed Annoyance

“I’ve been lying awake for almost 2 hours now and only caught a few minutes’ sleep …

… if I don’t sleep soon I’ll be wrecked tomorrow”

I have lost control Anxiety

“Awake again … so what’s the time now? … Great (!) 4 a.m. …

… I can’t stand this any more; I’m going to go mad”

I can’t cope Despair

Online

www.sleepio.com

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Espie, Hames & McKinstry Sleep Medicine Clinics (in press)

Search engine activity growing 4% per month

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CBT for insomnia: a stepped care approach

Espie SLEEP (2009)

A revised stepped care model?


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Henry Ford

“If I had asked people what they wanted, they would have said faster horses.”

Invention of the printing press

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What is CBT? Espie, Hames & McKinstry Sleep Medicine Clinics (in press)

www.sleepio.com

2 million permutations in 3 minutes

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Integrating online and clinical practice

Integrating with devices


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Oxford Programme in Sleep Medicine

PriSM

(online)

To register interest and receive email updates [email protected] Visit our website (www.ndcn.ox.ac.uk/scni) for news and information

Oxford Programme in Sleep Medicine •  Master of Science in Sleep Medicine •  Postgraduate Diploma in Sleep Medicine •  Postgraduate Certificate in Sleep Medicine

28/01/2014

76

Oxford Programme in

Sleep Medicine

PriSM (online)

Oxford Programme in Sleep Medicine •  Master of Science in Sleep Medicine •  Postgraduate Diploma in Sleep Medicine •  Postgraduate Certificate in Sleep Medicine

28/01/2014

77

28/01/2014

78

Why would people want to take this course?

ü Emerging discipline ü  International need ü  Inter-disciplinary health

professionals How would it work? ü  100% online ü  Interactive ü Concept proven (12 countries so

far) Why Oxford? ü Reputation as a centre of excellence -  Draws students -  Draws contributors

prof colin a espie - babcp.com · sleep diary (pdf) or recommendations for assessment ... the...

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