How to Treat Insomnia and other sleep problems

Dr Kirstie Anderson

Consultant Neurologist

Regional Sleep Service

Newcastle

Cognitive Behavioural Therapy for Insomnia (CBT-i)

Psychiatry

Pain clinic

Neurology

Respiratory

medicine

Psychology

General Practice

Occupational

health

Talking

therapies

Pharmacy

Regional Sleep Service Newcastle

Course Overview

•SESSION 1 9.30-11.00

•The structure and function of normal sleep at all ages

•Understanding key features of primary sleep disorders

•Insomnia disorder – with or without comorbidities

•Evidence base for treatment

• drugs

• CBT-i

•SESSION 2 11.30 – 13.00

•Assessment

• taking the history

• sleep diaries

• questionnaires

• actigraphy

• sleep studies

•Taking patients through

• sleep education/sleep hygiene

• sleep restriction

• stimulus control

• cognitive control

• relaxation

• exercise

Course Overview

•SESSION 3 13.45 – 15.30

•Case studies (small groups)

• patient studies

• troubleshooting session by session

• drug reduction

• comorbidities

•SESSION 4 16.00 – 16.30

•CBT-i – for your patient / support

•Resources

www.neurone.org.uk/sleep-resources

• diaries/assessment and treatment

• sleep service leaflets

• self help – children/adults

• useful reading and references

Sleep and watchfulness, both of them when immoderate constitute disease Hippocrates c.400 bc

Session 1

How and why we sleep

“If sleep and dreaming do not perform some vital biological function, then they must represent nature’s most stupid blunder and most colossal waste of time” Anthony Stevens

Sleep – what is it?

A biological necessity – we all sleep!

Sleep – characterised by:

1. Species-specific sleep posture

2. Behavioural quiescence

3. Rapid reversibility to wakefulness

4. Increased arousal threshold

5. Compensation following sleep loss

People say, 'I'm going to sleep now,' as if it were nothing. But it's really a bizarre activity. 'For the next several hours, while the sun is gone, I'm going to become unconscious, temporarily losing command over everything I know and understand. When the sun returns, I will resume my life.’ David Carlin

How do we define sleep

•We have three normal behavioural

•POLYSOMNOGRAPHY

Three brain states

– Wake

– Non rapid eye movement sleep (NREM)

– Rapid eye movement (REM)

Polysomnography

PSG Output

EEG in NREM Sleep

•Wake a good sleeper in N2 ?

•Wake an insomniac in N2 ?

•Good and bad sleepers are poor at estimating wake after sleep onset

EEG during REM Sleep

Awake brain – paralysed body

Sleep Cycle Hypnogram

How the brain controls sleep – two process model

Two processes govern sleep and wakefulness

Homeostatic sleep drive – hours, increasing pressure to sleep the longer we have been awake

Intrinsic circadian rhythm – clocks, we are alert in the day and hard wired to light

Homeostatic Regulation of Sleep – the hours

Increased pressure to sleep for every hour awake

Flip flop switch

Circadian Rhythm

“Sleep is a criminal waste of time and a throwback to our cave days.” Thomas Edison

Circadian Rhythm Regulation of Sleep – the clocks

24 hr. endogenous cycles coupled with external pattern of light and dark that regulates all physiology (sleep, mood, metabolism, heart rate, BP etc.)

• Circadian rhythms generated from suprachiasmatic nucleus (SCN) of hypothalamus. Direct links to non rod, non cone retinal ganglion cells – we are hard wired to light to set the body clock every day

• Intrinsic rhythm of clock slightly longer than 24 hours (without light to entrain the clock)

– Synchronization occurs to 24hr schedule using external cues

– Zeitgeibers: Temporal timing signals, light exposure

– Melatonin secreted by the pineal gland

The two process model of sleep

Normal sleep over a normal life

Normal sleep over a normal life

The hours as we age

decreased slow wave sleep

increased wakenings

slight decrease in total sleep time. Average 8.5 hrs at 20

6.5hrs>60yrs

The clocks as we age

decreased melatonin

phase advance (larks not owls)

Sleep Hypnograms across the life cycle

“it is important to remember that, as one ages it

might be best to modify the expectations about

„„inalienable rights‟‟ to life, liberty, and 8 hours

of sound, uninterrupted sleep.”

Michael Vitiello. Sleep in Normal Ageing . Sleep Med Clin 2006.

Social jet lag

• Variation in sleep time between work days and free days

• Chronic sleep restriction and social jet lag more likely in those under 30

Sleep extension in healthy young adults.

Mantua et al. Sleep sci 2019

Sleep drugs

NREM

Wake REM

Dopamine

Noradrenaline

Histamine

Hypocretin

Acetylcholine

Glutamate

Acetylcholine

GABA

Glycine

Dopamine

GABA

Why do we sleep?

Sleep deprivation experiments

Randy Gardner at age 17 set a record of 264 hours

Initially claimed that sleep deprivation had little effect (he beat WD at pinball on day 10)

However memory disturbance, concentration difficulties, paranoia and delusions all well documented

Why do we sleep?

“sleep is the cement that glues our days together” Rob Auton

• Thermoregulation

• Energy conservation

• Regulation of metabolism

• Immune function

• Growth

• Consolidation of new memory

• Regulation of mood

Sleep and memory

Walker and Stickgold 2006 TED talk Matthew Walker Psychomotor vigilance test

Classification of sleep disorders (ICSD3) 2014

Epidemiology of Primary Sleep Disorders

• Insomnia disorder 6-15%

• Obstructive sleep apnoea 10% men 5% women

• Parasomnia 1-2% of adults

• Restless legs syndrome 5-10%

• Circadian rhythm disorder ?

• 1-4% teenage males

• much higher in mental health diagnoses

Insomnia Disorder

•Diagnostic criteria now simplified under both DSMV and ICSD3

•Insomnia disorder

Difficulty falling asleep

Difficulty maintaining sleep

Subjective daytime impairment

>3 months

At least 3 days a week

Not explained by environment or another sleep disorder

•The commonest sleep disorder 5-10%

•10% will become chronic

•F>M

•50% comorbid with another psychiatric disorder

•Increases with age

What is the insomnia phenotype?

•Excessive focus and heightened anxiety about sleep

•Intrusive thoughts

•Hypervigilant state

•Cognitive arousal and racing mind

•Vicious cycle – the harder you try to sleep the less you can

•Low Epworth Sleepiness Score 0-1

•“How do people go to sleep? I'm afraid I've lost the knack.”

•― Dorothy Parker

•The three P’s

Spielman model of

•P – predisposing

•P – precipitating

•P - perpetuating

What is the insomnia phenotype?

• Those with objective short sleep of < 6hours – Increased heart rate, blood

pressure, hyperarousal, longer duration and worse cardiometabolic health

• Those with total sleep time > 6hours – More misperception, anxiety,

shorter duration, NO increased risk for cardiometabolic health

Bathgate et al. Sleep 2016

Comorbid insomnia

•Insomnia disorder alone associated with ill health and an economic burden

•Insomnia comorbid with anxiety in 40%

•The strongest risk factor for future depression relapse. Baglioni et al. J Affect Disord. 2011

•Increases risk for first episode depression. Ellis et al. Sleep 2014

•Evidence for hypertension, stroke, diabetes and CVD in those with objective short sleep. Bonnet et al. Sleep Med Rev 2014

•The GoodNight study—effectiveness of an online insomnia prgram for the prevention of depressive episodes: a randomised controlled trial. Christensen et al. Lancet Psychiatry 2016

What mimics insomnia

Beware high Epworth Sleepiness Score

The three R’s

•Restless Legs

•Rhythm

•Reflux

•Obstructive sleep apnoea

-primary or comorbid

-20% will complain of a broken night

-older patients and post menopausal -women more likely to be thin

-hard to distinguish insomnia alone versus OSA/insomnia. Lichtstein KL et al. Sleep Med 2013.

Parasomnias

REM Sleep Behaviour Disorder

•0.5% of older males

•Insidious progressive disorder of dream enactment often with self injury and good dream recall

•Strong association with neurodegenerative disorders such as Parkinson’s disease and Dementia with Lewy Bodies (91% at 14 years)

Loss of normal REM atonia

NREM Parasomnia

•Incomplete awakenings from deep slow wave sleep

•Night terrors

•Hypnagogic hallucination

•Sleepwalking

•Sleep eating

•Sleep sex

•Confusional arousals

•Phenotype

•Young onset for most. 2-3% adults

•Often family history

•Typically first half of the night and without recall or only patchy, can occur first hour

•Affected by anything that disrupts sleep (OSA, RLS, insomnia)

•Strongly affected by daytime stresses/schedule

Circadian Rhythm Disorders

• Shift work disorder

• Delayed sleep phase syndrome

• Irregular sleep wake pattern

• Advanced sleep phase syndrome

• Jet lag disorder

• Non-24 hour (free running) sleep-wake pattern

Delayed sleep phase syndrome

•Beware of “insomnia” starting < 20

•Phenotype – when allowed to sleep can have consolidated periods of sleep

•Often a long standing pattern

•M>F and teenage onset for many

•Extreme night owls

Hypersomnias

Nobody loses money betting on obstructive sleep apnoea

Severe obstructive sleep apnoea seen on a respiratory sleep study

Clues if they live and sleep alone

Neck cirumference > 17inches, nocturia, insomnia (25%) dry mouth, sore throat, choking, unrefreshing night sleep. Screen with the STOPbang if they have troublesome symptomatic sleepiness.

Obstructive sleep apnoea

10% of men and 5% of women >40

High risk populations

Alcohol excess/opiates

Metabolic syndrome

Atrial fibrillation

50% of the pain clinic

20% in a local NE population with mental health diagnosis

(Anderson et al. JCSM 2012)

Too much sleep - Causes

Chronis sleep restriction (sleep diaries - better at weekends / holidays) Poor quality sleep

– Sleep apnoea, restless legs, external triggers A sleepy brain - hypersomnia

– medication, medical comorbidities, depression, narcolepsy

Circadian rhythm disorder

– Shift work (particularly those > 40), delayed sleep phase in younger patients

Restless legs

5-10% of the population risk factors – pregnancy, obesity, comorbid sleep apnoea, 50% have a FH, antidepressants, dopa depleting antiemetics, antipsychotics, antihistamines Episodic and chronic and can drive insomnia. Circadian rhythm, an unpleasant sensation and must produce desire to move and to some extent be relieved by movement “When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement?” Grade severity and nights per week. 25% have daytime symptoms Useful questions restless in your mind or body – up at night? check Epworth Sleepiness Score and get witness (? still in same bed) 80% overlap with periodic limb movements of sleep check ferritin, discuss nicotine, caffeine, alcohol, timing of exercise Signpost to RLS-UK

CBT and Pharmacotherapy for Insomnia

Treatment of Insomnia

“Many minor points are worthy of attention in the cure of chronic psychic insomnia. In most cases, whether he sleep well or badly, the patient ought, from day to day to go to bed at some fixed hour. Daily bodily exercise, short of great fatigue, must be enjoined. Riding in a carriage is good, walking better, riding on horseback the best of all.....Very often the surest way of keeping awake is to try hard to get to sleep. We do most things best when we forget ourselves; going to sleep is no exception to the rule.”

James Sawyer. The Lancet 1878

Cognitive behavioural therapy for insomnia CBT-i

• CBT-i

– Sleep education/(hygiene)

– Sleep restriction

– Stimulus control

– Cognitive control/relaxation

– Dysfunctional beliefs

– Exercise

• Multi component therapy delivered over a series of sessions that

– Educates about sleep and good sleep hygiene

– Realigns homeostat and circadian rhythm with sleep diary based sleep scheduling

– Addresses specific anxieties and dysfunctional beliefs about sleep

– Provides specific relaxation and cognitive control techniques to decrease racing mind

Evidence for CBT-i

• Morin CM et al. Sleep 2006

• Riemann D and Perlis ML. Sleep Med Rev 2009 – CBT greater long term benefits than phamacotherapy and better accepted

• Morgenthaler et al. Practice parameters from AASM Sleep.2006.

• Wilson S et al. BAP consensus statement. J Psychopharm. 2010

• Riemann D et al. ESRS guidelines J Sleep Res 2017

• Over 50 RCTs at the last count, over 4500 participants

• Also benefit in comorbid insomnia (Geiger-Brown JM et al. Sleep Med Rev 2014) including

– Chronic pain

– Depression

– Anxiety

– OSA

– Cancer

– Psychosis

– Bipolar disorder

NICE CKS Guidelines

Hypnotics

• NICE guidance hypnotics Jan 2017

• HSCICS data 2015 16 million hypnotics prescribed in England (increase from 2013) – Benzodiazepines

– Z drugs

– Antidepressants

– Antihistamines

– Melatonin

– Gabapentin

Zopiclone £1.11 28 days Temazepam £1.89 28 days

Not a new problem

British Medical Journal, 1892

"Sir, for several weeks I have been attending a case of chronic cardiac disease ..

complicated with congestion of the lungs. My patient, who has always been a man of

most temperate habits, suffers from a very distressing sleeplessness which does not

yield to any remedy which a consultant and myself have been able to prescribe.

Chloral, bromides of potassium and ammonium, ether, cannabis Indica, and various

combinations of the same drugs have been found wanting; and more frequently than not

my patient cannot find sleep. Hypodermic injections of morphia are of little service.

If any of your readers will have the kindness to communicate what they have found

reliable in similar cases, they will greatly oblige, your faithfully, ...."

British Medical Journal, 1892 - 2

"Sir, - if your correspondent, .., would advise his patient, who has been unable to

procure sleep from all sorts of narcotics prescribed, to try the effects of a pint bottle of

Guinness's extra stout; or if he objects to malt liquor, half a bottle of good sound claret

with his dinner, and followed, before going to bed, with two glasses of good Scotch

whiskey and water, I think the patient will enjoy a most refreshing sleep, and the trial of

which, for a night or two, cannot possibly do him much harm. - Yours truly ....

British Medical Journal, Dec 16 1892

"Sir, - Will you permit me to thank those gentlemen who replied to my inquiries for a

reliable remedy of insomnia, after which all the ordinary means had been tried and

found wanting?

I tried chloral .. combined with ether .. This mixture produced sleep more effectively

than anything else I have prescribed.

The death of my patient a week or two afterwards prevented my trying several drugs

which were suggested. “

Pharmacotherapy vs CBT

• CBT similar or better than hypnotics during short term treatment

– Am J Psychiatry 2002 – JAMA 2006 RCT comparing CBT vs

Zopiclone vs Placebo

• Better sustained benefit after completion of therapy

• Wilson SJ et al. Consensus statement from BAP. J Psychopharmacol 2010. Updated version 2019 due out this month

• Riemann D et al. European guidelines for the diagnosis and treatment of insomnia. ESRS. J Sleep Res. 2017.

• Best CBT results are seen when hypnotics are tapered during or soon after CBT techniques

• For those with objective short sleep time – there may be added benefit in CBT alongside a course of hypnotics

Benzodiazepines

• Target GABA receptor and non-selectively stimulate GABA subunits

• Temazepam 6 hr half life

• Short term trials

– Decrease sleep latency, increase total sleep time, decrease wake after sleep onset

– Decrease slow wave sleep and increase N2 (light sleep)

– No tolerance in 4-8 weeks

– Long term 1/3 have difficulty stopping

– No evidence for 2 weeks or intermittent use

– Note new DVLA offence 2015, driving under influence of controlled drugs including temazepam

• Insomnia comorbitities

– Good for restless legs, myoclonus, sleepwalking and REM sleep behaviour disorder

– Bad for obstructive sleep apnoea, cognitive impairment and the elderly

Zopiclone

• Slightly quicker onset 15-30 minutes and half life 3.5 -6 hours

• Possibly safer in patients with underlying respiratory disease

• Meta-analysis showed little difference between the Z drugs and BZP (Dundar et al. 2004)

• However some disagree (D Nutt)

Antidepressants

• Amitriptyline 10mg • Mirtazepine 15mg

– Side effects particularly in the elderly, long half life (antihistamine)

– Hangover effect – half life 22 hours

– Anticholinergic effects – dry mouth, blurred vision, constipation, urinary retention, weight gain

– Tolerance develops, no RCT datafor benefit

– Mayers AG and Baldwin DS. Hum Psychopharmacology. 2005

– Effect is via histamine pathways

• A good drug for? – Parkinson’s disease on

occasion, particularly if night time drooling

– Migraine – Irritable bowel syndrome

• Bad for – Restless legs/periodic limb

movements of sleep

Melatonin

• Short half life 15-30 minutes • Only licensed for use > 55 (possibly

due to clock effect?) • Modest benefit on sleep latency

Wade et al. 2007 (SL -24 vs -13 minutes).

• Benefit over 6 months but not predicted by melatonin levels

• New England Journal of Medicine editorial 2000: "With these recent careful and precise observations in blind persons, the true potential of melatonin is becoming evident, and the importance of the timing of treatment is becoming clear.”

• 0.3mg shift the clock

• Good for RBD (Kunz et al. JSR 2010) and PD sleep disturbance and possibly for cognitive performance

• Typical dose range RBD 2-12mg, average 6mg in most recent case series

• Bad for restless legs syndrome, increased fracture risk in elderly

• Good for the unlicensed indication of delayed sleep phase syndrome

• Melatonin drug information sheet including specials and their costs

Alcohol

Macbeth: Act 2, Scene 3

Drink sir, is a great provoker of three things….nose painting, sleep and urine. Lechery, sir, it provokes, and unprovokes; it provokes the desire but takes away the performance.

• Gut enzymes that metabolise alcohol evolved 10 million years ago ADH

• Zero order kinetics – therefore constant metabolism (Becker CE, Calif Med. 1970)

• Decreases sleep latency but fragments REM sleep second half of the night

• Particularly bad for nightmare disorder, sleep apnoea, REM sleep behaviour disorder, restless legs

• Additive effect with benzodiazepines/Z drugs

Nicotine

• Overall a stimulant effect

• Half life is short at 1-2 hours, onset 10-20 seconds

• Increased acetylcholine, dopamine and noradrenaline

• Decreases pain at higher doses

• Stimulant to sedative at higher doses

• Worsens restless legs (W>M)

Caffeine

• 90% of population use caffeine regularly

• Half life 3.5 to 7 hours but fast and slow metabolisers (Cornelis et al. PlosGenet 2011)

• But if you drink 6-7 cups a day – steady state

• Greatest stimulant effect in non-caffeine consumers

• Nicotine decreases half life by 30-50%

Caffeine

• Single shot espresso 100mg (80-175mg)

• Tea 22-74mg (stewed 3 minutes)

• Pepsi max 69mg • Coca cola classic 34mg • Red Bull 80mg • Decaffeinated (isn’t!) 5-15mg • Milk chocolate 25mg/100g • Dark chocolate 80-160mg

/100g • Combination painkiller eg

solpadeine 30mg per tablet

• Most experiments looking at alertness use doses 200mg

• Therefore count the cups – coffee is much worse than all the rest. Much variability but worth decaffeinating if you have – Restless legs – Chronic headache – Tremor

Daytime drugs that affect the night

• Uppers

– Betahistine for vertigo

– Inhalers

– Decongestant nasal sprays

– Over the counter painkillers

• Downers

– Opiates - codeine and tramadol/MST/zomorph

– Gabapentin and pregabilin (RCT using gabapentin 200mg nocte showing improved sleep and no effect on sleep disordered breathing)

– Amitriptyline

– Clonidine (Bruxism)

Very simple drug switches that might help

• Proton pump inhibitor am to pm (nocturnal choking as reflux is worse at night)

• Longer acting opiate at night (stop tramadol) or non-steroidal

• Timing and dose of melatonin (lower NOT higher)

“There can be few physicians so dedicated to their art that they do not experience a slight decline in spirits on learning that their patient's complaint is insomnia”

Not quite said by Professor Brian Matthews

Session 2

To CBTi or not to CBTi ?

Assessment of Insomnia

A Sleep History - the basic questions

Main problem, duration, triggers, pattern

Do you snore heavily? OSA STOPBang Q’airre

Do you need to move your legs when you lie in bed? Restless legs

syndrome (restless in your mind or in your body?)

What drugs do you take? Medication or recreational, caffeine, alcohol

Past drugs and response

An average 24 hour day? Shift work, restricted sleep

Day time napping? Insomnia, fatigued but not sleepy

Parasomnia - present in childhood?, time of night?

BP BMI

Sleep Questionnaires

• Epworth sleepiness scale Johns 1991

• Range 0-24

• >10 sleepy

• Normals 2-10 (5.9)

• Typically 0-1 in insomnia

Sleep Questionairres

• Insomnia severity index (Charles Morin)

• 0-28

• >14 moderate to severe insomnia

• Validated for treatment response

• DASS-21 (or some measure of anxiety and low mood)

Sleep diaries

• www.neurone.org.uk/sleep-resources

• Emphasise tailoring of treatment, need to individualise therapy and putting it all together as a tool kit

• Cornerstone of assessment and the treatment

• Fill it in once a day – usually morning

• Not using apps such as fitbit/iphone as the marker of wake

• Two weeks better than one – minimum 10 days if work

Examples of diaries

Gadgets and apps

• Not validated as medical devices – over score movement as wake – often hot/light

• Some apps have sensible advice and software eg for snoring - sleep recorder

• www.kidssleepdr.com

Actigraphy

• Commonly used research tool within insomnia – less so in clinical practice

• Circadian rhythm vs insomnia

Sleep study ?

• Respiratory – Consider when very little difficulty

falling asleep – Older patients comorbid

OSA/insomnia common – High risk groups – chronic

pain/severe mental health problems/CFS and those who live alone

• Rare to need polysomnography

for insomnia – There is often sleep misperception

but this doesn’t change management !

– Within research objective short sleepers are higher risk

To CBT or not to CBT-i

• Yes as long as

– No time zones changes

– Are they ready? – will need 6-8 weeks of stability

– Anything else you will change first or are waiting for, they perceive insomnia as main problem

– Emphasise need for consistency, Team Sky approach

Session by session CBT-i

• Sleep education/hygiene

• Sleep scheduling – sleep restriction/stimulus control

• Cognitive control and relaxation strategies

• Cognitive restructuring – addressing sleep related worry

• Exercise

• Maintaining good sleep and planning ahead

Sleep education/hygiene

• Starts with the first assessment and discussion of diaries as the key tool – When you first assess, you

listen and then explain back the process of insomnia – losing the connection between bed and sleep and paying attention to something that needs to be ignored

– Hours and clocks – fundamental role of light both day and night, the sleep homeostat

– Pills – direct explanation of function and address their expectations

How bright is the light you are in now?

1. 10 Lux

2. 100 Lux

3. 1000 Lux

4. 10,000 Lux

5. 100,000 Lux

Sleep education/hygiene

• People have often tried a number of things before they see a sleep specialist but…

• Bedroom – Cool, dark, quiet

– Sleep and sex only

– Clocks – important for diary but NOT in sight

– TV/radio

“Reading—it’s the third best thing to do in bed.”

― Jarod Kintz, This Book Title is Invisible

Sleep education/hygiene

• Caffeine

• Alcohol

• Nicotine

• Other drugs on their prescription

• Activity/exercise

– Prescriptive and daily

– Emphasis on intensity and heart rate (as per WHO)

How to exercise

How to deliver

• Tailor – emphasise intensity not type, fit into their day

• Not within 2 hours of bedtime

• Aggravates restless legs

• 20-30 minutes

• WHO guidelines

• Particular evidence for benefit in older adults/comorbid anxiety/low mood

Evidence for Exercise

• Hartescu et al. Increased physical activity improves sleep and mood outcomes in inactive people with insomnia: a randomized controlled trial. J Sleep Res. 2015 Apr

• Sustained benefit at 6 months in ISI and mood and independent of light

• Passos et al. Sleep Med 2011 – also

improvement of mood and anxiety and timing did not effect outcome

• Now 6 RCTs that show clear evidence when used alone or within sleep hygiene and recent meta-analysis Yang et al. J Physio. 2012

Reid et al. Sleep Med 2010

Sleep education/hygiene

• Sleep diaries

• Reviewing bedroom/light/activity/drugs

• Education

• Addressing any resistance/concerns

Theories of insomnia

• What is the underlying problem in insomnia?

• A number of models including – Hyperarousal (Bonnet and Arand.

Sleep Med Rev 2010)

– Dysregulating the homeostat – too long in bed, variable routine

– Neglecting the clock – going to bed when not sleepy, trying to catch up and sleeping at the wrong times, decreased daytime activity

– Putting effort in “trying”

The Three P model of insomnia

Spielman AJ, Caruso LS, Glovinsky PB: A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987 Dec;10(4):541-53.

Leading to – breaking the bed-sleep connection

• Arousal becomes conditioned eg reading in bed

• Behaviour and physiology connects bed with wakefulness

• Increasing attention to a process reversed by attention!

Therefore treatment is...

Many minor points are worthy of attention in the cure of chronic psychic insomnia. In most cases, whether he sleep well or badly, the patient ought, from day to day to go to bed at some fixed hour. Daily bodily exercise, short of great fatigue, must be enjoined. Riding in a carriage is good, walking better, riding on horseback the best of all..... Very often the surest way of keeping awake is to try hard to get to sleep. We do most things best when we forget ourselves; going to sleep is no exception to the rule. James Sawyer. The Lancet 1878

Sleep scheduling

• Sleep scheduling

• Sleep restriction

• Stimulus control

– Reinforcing the connection between bed and

sleep

– Driving the homeostat – we are creating sleepiness

– Realigning circadian rhythm

Reviewing the Sleep diary

• Days and nights – Any daytime napping and pattern

– Nocturia

– Caffeine and alcohol

– Pattern and timing of any medication

– Variability (occasional good nights)

– Calculating their sleep efficiency (SE)

– Total sleep time/time in bed

– Discuss clock and time cues in bedroom

Sleep scheduling

• Stabilising the system – for patient “resetting”

• Negotiate a wake time (a little) – Seven days a week, absolutely fixed

• Do you feel sleepy when you go to bed? – Sounds obvious but many do not

– Or sleepy on the sofa, climb the stairs “as if a light has switched on”

– Therefore bed every single night when really really sleepy (nodding dog) – we do NOT fix a bedtime

– If not asleep within 15 minutes – out of the bedroom

Sleep restriction

• Calculate average SE and total sleep time (TST)

• What is normal?

• <80%

• < 50% severe insomnia

• Discuss the paradox of long periods in bed awake making things worse

• Discuss time in bed when sleep felt normal

Sleep restriction

• Negotiate a fixed period in bed to achieve SE>90%

• Taking the gaps out of the night and creating sleepiness

• Eg recording average 4.2hrs TST with SE 55% - no more than 5 hours in bed every night for the next week

– Anticipate resistance!

Can you always sleep restrict

• Short answer – no

• Long answer – potential concerns in bipolar / psychosis, in this case sleep compress 6.5 hours

• Think hard about professional drivers and high Epworth sleepiness score

Sleep restriction

• No pain, no gain

• How much sleep restriction depends on review

– Emphasise short term (max 2 weeks)

– You will monitor

– Increasing restorative sleep

– Remind them of structure of sleep

– Discuss driving safety when relevant

Sleep diaries

Sleep diaries

Stimulus control

• Review of sleep diaries

• Gaps in the night? – What are they doing?

– Wide awake?

– Thinking dark thoughts about peacefully sleeping bed partner?

– “Taking agitation out of the bedroom”

– Discuss heart rate/adrenaline as alerting

Stimulus control

• If wide awake and cross about it – out of the bedroom

• This needs planning

– Where in house

– What to do

– Temp/light

– What not to do

Titration of Sleep restriction

• Exhausted but sleeping in a chunk - now what?

• Review diaries and if SE >90% then start to extend time in bed

• Keep SE 85-90%

• About 15 minutes every 3-4 days (if reviewing frequently)

• Stop when time to fall asleep increases – aim for 85% most days

Titration of sleep restriction

• Not working then why?

• Address barriers, point out the times they did it and it worked

• Rediscuss the times

• Sleep misperception?

• Not insomnia?

Racing mind

• “I have nothing to worry about”

• Rehearsing or planning thoughts

• Thinking about sleeping

• Tuning in to your body

• Part of hypervigilance

“Sleep is like a cat – it only comes if you ignore it” from Gone Girl Gillian Flynn

Cognitive control techniques

• Racing mind – “run another program” – Not sheep !

– Practice in the day and during the session

– Visual

– Verbal

– Numerical

– Emotionless

– Some complexity

Further Cognitive control

• Progressive muscle relaxation

– If patient describes muscle tension

• (Thought blocking)

Review of sleep diaries

• What are we going to do tonight?

• The same thing we do every night

“If you can’t sleep get up and do something instead of lying there worrying, it’s the worrying that gets you, not the lack of sleep”

Dale Carnegie 1936

Good versus bad sleepers

Normal sleep

• Minimal attention

• Minimal effort

• Minimal intention

• Minimal concern

Insomnia disorder

• Selective attention to sleep, consequences of sleeplessness

• Purposeful intention to sleep

• Sleep effort

• Sleep preoccupation

Espie C. Ann Rev Psychol

Daytime anxieties driving poor sleep

• Putting day to rest

– List for the next day

– Early evening

• Bedtime wind down

– ?importance, not too long

– Think about activity and light levels, non-work, mindless and easy tasks

Worries and dysfunctional beliefs

• Distorted perception of deficit

• Excessive worry about sleep

• Selective attention and monitoring of sleep

Worries and dysfunctional beliefs

• List specific worries and anxieties about sleep – Normal sleep

– Amount needed

– Effect on work/driving

– Start with duration of insomnia – number of bad nights, night of times bad things happen, probability table

Nightmares

• Image rehearsal therapy

– For children and adults

– 2-3 sessions

– “Ridikkulus” Rowling JK

– www.neurone.org.uk/sleep-resources

– “managing bad dreams”

Date of download: 6/10/2015 Copyright © 2015 American Medical

Association. All rights reserved.

From: Imagery Rehearsal Therapy for Chronic Nightmares in Sexual Assault Survivors With Posttraumatic

Stress Disorder: A Randomized Controlled Trial

JAMA. 2001;286(5):537-545. doi:10.1001/jama.286.5.537

Data are shown for nights with nightmares and number of nightmaresper week (n = 77), Pittsburgh Sleep Quality Index (PSQI) (n =

73), and thePTSD Symptom Scale (PSS) (n = 66).

Figure Legend:

Good bedtime reading

Typical CBT-i components

• Changing the conditioned associations (stimulus control)

• Sleep restriction

• Reducing sleep preoccupation and effort

• Relaxation procedures

• Changing beliefs and attitudes about sleep

• (sleep hygiene)

I’ll name it in three

• Decrease time in bed

• Get up if you can’t sleep

• Don’t worry about it

CBT i components in one visit

• Think of insomnia as bad habits that that break the bed-sleep connection. Using the following instructions you can reset the connection.

• Think carefully about whether sleeping tablets are really helping you sleep at the moment and if you want to stop them, talk to your doctor and agree a clear timetable.

• Good nights follow good days and your daytime activities affect your sleep so exercise at moderate to high intensity (heart rate > 55% of your maximum) daily or near daily for at least 20 minutes. You may do this already but if you don’t it will make you feel more alert during the day and help deepen night sleep.

• The bedroom needs to be cool, dark and quiet and only used for sleeping or sex, clocks and gadgets out – the alarm can always be at the door for when you need it.

• Cut down any evening smoking and don’t smoke if you wake and avoid late evening alcohol, it usually disrupts sleep. Stop caffeine or morning only.

CBT-i components in one visit

• Fix a time to get up – same time every day and all week, so make it the time you were comfortable getting up at before you had bad sleep.

• Set your time in bed using your sleep diaries to calculate how much sleep you are getting at present and then follow that schedule for 7 days a week.

• Take the agitation out of the bedroom – so don’t get into the bed until you are feeling as sleepy as possible – this may mean waiting longer on some nights. If you wake and feel agitated or bothered and it feels like a long time (more than 15-20 minutes) then head out of the bedroom with a plan for reading or music until you feel calm and sleepy again. Then head back in.

• Practice relaxation exercises and the mental exercises that work for you if you do wake during the night but feel comfortable. Remember to try these during the day so that they come easily and you know which techniques work best for you.

• Remember sleep comes naturally for all of us and many good sleepers have occasional bad nights. If you do have a bad night or two then a better night will follow.

Case histories

Case 1

• Female 36yr

– Night owl & long sleeper with intermittent insomnia

– with acute stress, resolved after 2/52

– 15/12 hx difficulty falling and staying asleep with no clear trigger

– PC. Bed at 1am, sleep onset latency > 30 mins. Awake 1-2 times during night for up to 1 hour

– Awake at 4.30am since citalopram commenced recently

– Alarm 6.30am, up at 7.30 or much later

– Melatonin not effective

– Low mood – on and off citalopram over

At assessment 1

• Insomnia severity index – 21 (normal <11)

• DASS 21 – D-4, A-3, S-2 (therefore normal)

• No sleep diaries at first session

• Epworth sleepiness score 4 (normal <10)

• For discussion

– Chances of sleep apnoea?

– How would you start?

Negotiated plan

• No caffeine 6 hours before bed

• Bed 2am

• Up- 7am

• Up after 30 mins during night.

• Exercise every day, out of breath & heart rate up. Belly dancing & aqua fit

Session 2

• Sleep Efficiency 60-80% Av 71%

• Positives – Coffee reduced – Mostly stuck to bed and

get up times – Sleep onset – within 30

mins – Up during night, reading,

bed when sleepy again – Now settled with

citalopram

• Negatives – No chance to exercise – Feeling run down, cold

sore. Attributes this to return to work. HR officer for large retail store

– Difficult getting up at 7am

Session 2 plan

• Titrate bed time 15 mins up twice

• Titrate down again if awake more

• Up at 7am no matter how tired

• Exercise

– Reinforce sleepy versus

tired, anything out of breath

Session 3

• SE 63-91% Av 73%

• Positives

– Bed 1.45am

– Getting up – mother encouraging this (nurse)

– Less time out of bed during night

• Negatives

– none

• Plan

– Continue to titrate bed time

– Up 6.45am – better for work shifts

Session 4

• SE 76-84% Av 80%

• Positives – Good week

– Slowly titrating bed time up

– Bed 1.15am

– No long periods awake

– Up 6.15am

– Making good progress

• Plan – Continue to titrate up

– Return in a fortnight

Session 5

• Positives

• First week good – Titrating bed times up and

down according to length of sleep onset latency

– Happy with progress

– More concentration at work

– Delivered 6 hour induction for new staff ok

– Own manager has noticed improvement

• Negatives

• Plan – Retitrate, cognitive control

techniques, explain variability and back over diaries

Session 6

• ISI 10, ESS 3, SE Av 81%

• Positives – Bed 12.30 – Short periods awake and

back to sleep – Coping better at work – When mood is low,

severity of this is much less – Keen to continue at home

until best bed time achieved

– Happy !

Case 2

GP referral “I would be grateful for your review of this 66year old lady who has been suffering from insomnia for over 20 years. She describes going through periods where her sleep is not too bad, but then will have prolonged periods where she cannot get off to sleep and will only get about 3 hours of sleep per night. She feels unrefreshed from her sleep and although will get a reasonable night’s sleep if she takes a Temazepam, does not want to rely on medication. She denies feeling depressed or anxious and has no breathing difficulty or any history suggestive of sleep apnoea. She would be very keen to explore options of trying to improve and manage her sleep pattern...”

Past medical history

• Previous anxiety and depression

• Osteoarthritis

• BMI 26.1

• Medication

– Lansoprazole

– Temazepam 10mg nocte

– Amitriptyline 100mg (>10 years)

Baseline assessment

• Epworth sleepiness score 2, Insomnia severity index 19, DASS normal, a lark

• Total sleep time 4.1

• Sleep Efficiency 61%

• Further questions?

How to treat ?

• Attempted one shot

• “It is always pleasant to be right, but it is generally a much more useful thing to be wrong.” Gowers 1949

Review at 4 weeks

• Disaster!

– Couldn’t do diaries

– Everything worse with sleep restriction, rapid escalation of anxiety and in particular going to bed at a different time to her husband

– Tearful in clinic

– What next?

• Keep the wake time fixed at 06.30

• Simply write down out of bed time every day

• Into bed with husband (negotiated slightly later for him) and progressive muscle relaxation explained

• If / when wake in the night – chair in the bedroom, read with night light

• Fluoxetine 10mg added am, titrate to 20mg after 2 weeks

Telephone consult 4 weeks

• Much better

• Improved anxiety and able to get out of bed

• Estimating gaps decreasing

• Reinforcement of up time fixed, changed advice to only up if agitated and try cognitive control techniques instead

Review at 6 months

• “Much better”

• Bed for 6-7 hours

• Meds – amitriptyline dose stable and slightly reduced to 75mg, fluoxetine 20mg, not been back on temazepam

• Insomnia severity index 9

Case 3

• 37yr old lecturer

• 2 young children

• Coming up to exams

• Seen in first fit (with syncope) but she felt increasing fatigue, poor sleep as cause

• Slim, otherwise well, episodic restless legs

• Insomnia severity index 20, Epworth sleepiness score 1

• Sent sleep diaries – did not complete

• Family members unwell abroad

Opted for online 4 months later

Sleep restriction to 5 hrs

“I am finding the restricted sleep pattern hard. It is not easy

when one suffers from exhaustion on all levels, physical,

mental and emotional.”

Therapy and barriers along the way

• Wake set to 05.45

• Sleep Restriction to 5 hours for 2 weeks

• Total Sleep Time increased to 5.5 and then 6 hours over next 4 weeks – Clocks in bedroom, daytime napping and noise

– Stimulus control – week 3

– Cognitive control – week 4

– Exercise – week 5

– Completion TST set at 7 hours

Completion SE 91% TST 6.5hrs

• Prompted along the way with failure to follow sleep restriction (x2). Suspended during a cold (with fever)

• 4, 12 and 36 months follow up – good quality sleep and sleeps through alarm at weekends

• Meta-analyses show benefit from digital CBTi for those who complete, Ye et al. BMJ Open 2017

Online CBTi

• Previously available on prescription via ereferral but not at present UK-wide

• Used by some talking therapies within low intensity but not in region

• Available privately (but cost 200-400)

• Sleepio

• Sleepstation

Case 4

“when pain is over, the remembrance of

it often becomes a pleasure”

• Referred by Dr Anderson for face to face CBT-i

• 33 year old woman

• Insomnia disorder

• Anorexia disorder in teens

• Recurring bad dreams

• Chronic fatigue syndrome

• Chronic Pain

• Depression & anxiety

Social history

• Lives with husband and 3 children

• Part time administrator for children`s charity

• Generally active

• Exercise when free from pain – dancing class

• Little alcohol

Sleep pattern

• Bed 7.30pm – 11.30pm

• Up at 6.00am

• Difficulty initiating sleep

• Fragmented / restless sleep

• Prolonged gap in the middle

• Average total sleep time 2- 6 hours over 24 hour period

• Self-reported sleep efficiency 47%

• Epworth sleepiness score 1 - but fatigued. Insomnia severity index 21/28

Bedroom environment

• Not specifically a place to sleep

• ‘Safe place’ to retreat to during daytime

• Comfortable bed – supports her body when in pain

• TV

• Eat & drink

Session 1 targets

•Bed at 11.30pm

•Up 6am

•More daylight in evenings

•No TV in bedroom

•Wax ear plugs for any noises – light sleeper

Session 1 did she stick to targets?

NO

• Bedroom is still a ‘safe place’

• Worried about exacerbation of CFS

• Struggling with food issues

• Could not wear ear plugs

Renegotiation

Long discussion about aims & expectations of programme. Re-set targets:

•Sleep diaries

•Aerobic exercise early evening

•Snack in evening

•Stay awake until bedtime – housework

•Bed at 11.30pm

•Cognitive relaxation exercises for up to 20-30 minutes when awake in bed

• Back to sitting room to read boring article until sleepy

• Up at 6am

• Stay out of bedroom during the daytime

• No daytime napping

• Get plenty of natural daylight

• Managing bad dreams leaflet for recurring nightmares – if needed

Session 2

Negatives:

• Hysterical crying on stairs

• Husband physically blocking stairs / bedroom before11.30pm

• Still in bed after 6am on some days

• Exacerbation of pain

• Sleeping in bedroom during daytime

Positives:

• Sleep onset latency within 20-30 minutes

• Less restless during sleep

• If up at 6am, better during the day

Plan:

• Stick to targets every day

Session 3-5

•Some positives but lots of excuses not to stick to plan = limited progress

•‘How can I work if sleep deprived’?

•‘I can`t physically get up!’

•Time to discontinue?

Turning point

•No – ‘I must treat insomnia’

•Will commit to targets

•Will take prescribed pain relief

•Husband to force out of bed at 6am

Session 6 ‘It nearly killed me, but….’

•Very happy with progress and sleep pattern

•Regular exercise in the evenings

•Regular bed and get up times

•Sleep onset latency within 30mins of going to bed

•Better quality of sleep

•Short awakenings for toilet or if disturbed then

back to sleep

•Awaking to an alarm clock

• Certain that good sleep will be achieved

• Confident to continue titrating bed time

• Ability to differentiate between sleepiness and fatigue during daytime

• Insomnia severity index – 9 (start – 21)

• SE – 73% & 83% in last 2 weeks (47%)

• Sleeping 6 – 8.5 hours (2 – 6 hours)

How to treat insomnia within your service

Session 4

One Bear

• Sleep diary

• 15 minute rule

• Decrease time in bed

• Heart rate up exercise

Which patient gets CBTi

Immediate access psychological therapies (IAPT)

• Launched October 2008 to support better access to NICE initially recommended CBT for anxiety and depression.

• 252 listed services

• Roll out curriculum for long term conditions, functional, updated insomnia guidelines written alongside latest updates in curriculum (KA)

• Insomnia CBT is appropriate for PWP and low intensity

• Newcastle talking therapies have successfully developed group CBTi (4 sessions, one telephone call follow up)

For a sleep service

• Bucks health – local IAPT services all trained in CBT-i and see direct from GP referral, small group and ongoing since 2010. 55% success

• Liverpool – previously one shot from secondary care. 50% success.

• Sheffield – see, self help with bibliotherapy and single follow up 30% success

• UCL, St Thomas, Papworth all offer secondary CBTi group and individual

• Newcastle – stepped care

– Self help leaflet/book and resources (NTW and aligned to the IAPT resources)

– KA – 1-4 sessions face to face (sleep diaries brought to first OPA)

– Nurse specialist 5-6 sessions complex, now small groups 4-5

– Online discussed as an option

– Annual training for PWP IAPT diploma since 2015

– Newcastle talking therapies see for group CBTi

Digital CBTi

• Sleepstation and Sleepio in UK – commercial and £200-£475. Either fully automated or with email / telephone support

• Screening – IAPT dataset plus sleep screening – ESS, PSQI, sleep apnoea, restless legs – 25% rejected and redirected to GP with possible other sleep disorders

• 6-8 weeks with sleep diaries followed by standardised CBT-I modules

• Integrates to deliver the minimum IAPT dataset and key outcome measure of change in sleep efficiency, sold to a number of IAPT services

• Patient perception is that online is less effective

• “Real world evaluation of digital CBT for insomnia – many have another sleep disorder and should not log on to doze off.“ Xu and Anderson CBT therapist (in press)

High versus low intensity

• Acute/chronic and with or without comorbidities

• Options

– Face to face 5-6 sessions, single or group

– Online

– Guided self help with eg telephone support

– One shot – possibly best for acute/early insomnia

– Self help (not just sleep hygiene)

When to treat

• In primary care red flags – Off work

– >1 hypnotic

– Previous depression/anxiety

– Chronic pain

– Exclusions – pregnant, shift work

– Mitchell et al. BMC Fam Pract 2010

When to treat

• In secondary care – Pain clinic - Many >40 will have comorbid sleep apnoea

(central and obstructive), particularly male, on opioids, increased BMI. All need sleep study

– 61% male fibromyalgia patients and 32% female moderate or severe obstructive sleep apnoea (Prados Clin Exp Rheum 2013)

– Rose AR et al. JCSM 2014. patients 18-75 on long term opioids. 46% had severe sleep apnoea, and 9 patients had chronic respiratory failure.

– Nicola Tang in Warwick has shown clear benefit in those with chronic pain and insomnia (RSM – Sleep and pain day 5/2020)

Do you need to treat

• In the psychiatry clinic, typically high intensity

• Taylor DJ and Pruiksma KE. Int Rev Psychiatry 2014. A systematic review of CBT-i in psychiatric populations

• High intensity version developed for acute in-patients. – Adapted CBT to stabilize sleep on psychiatric wards: a

transdiagnostic treatment approach. Sheaves et al. 2018

Adherence to treatment

• Adherence versus compliance • CPAP – UK data 60% at 1 year (80% in Newcastle at 1 year) • Adherence to medical therapies 50% (30% epilepsy) 65.5% for sleep related

treatments (CPAP and CBT-i) DiMatteo et al. Med Care 2002.

• Espie et al. benefit from health visitors delivering group therapy (n=4-6) over Behav Res Ther 2001. Outcomes maintained at 1 year and patients still off hypnotics

• Manual delivered in GP 47% improvement in Insomnia severity index but drop off with follow up Bothelius K et al J Sleep Res 2013

• RCTs – perfect situations may not replicate real world therapy 14-40% drop out before mid way through therapy, internet delivered no different (Sleepio 25% drop out)

• Who is at high risk of drop out – Short sleep and depression

Sleeping well in the North East

Sleep well group NTW

Patient network of those successfully treated ?

Making the adults of tomorrow sleep well is tomorrow!

Credential for sleep medicine within Royal College of Physicians, work ongoing

And so to bed...