Application of Principles of CBT-I for Management of Insomnia in Primary Care Presented by Kyle Davis, PhD

Disclosures I have no relevant financial relationships to disclose

Learning Objectives Define the 4-Factor Model of Insomnia Define the key fundamentals of CBT-I Explain the application of principles of Sleep Efficiency Therapy and stimulus control in primary care

DSM-V Definition and Prevalence of Insomnia “Dissatisfaction with sleep quality or quantity characterized by difficulty initiating sleep, maintaining sleep, or early morning awakenings that cause significant distress or impairment in daytime functioning and occur at least three nights per week for at least 3 months despite adequate opportunity for sleep.” Prevalence of chronic insomnia is 15-30% of population

Pop Quiz Genetics Learned behavior An overactive mind Insomnia is typically the result of … Genetics Learned behavior An overactive mind Chemical imbalance

Four Factor Model of Insomnia: Predisposing Factors Hyperarousability trait Female gender Aging Family history of insomnia Personal history of insomnia Presence of a psychiatric disorder Other sleep disorders ”Night owls” with irregular wake schedules What are YOUR Predisposing Factors? Perlis modification of Spielman model

Four Factor Model of Insomnia: Precipitating Factors Increased stress Changes in work schedule Traumatic events Physical health problems Mental health problems What were YOUR precipitating factors? Perlis modification of Spielman model

Risk Factors Acute Insomnia + Stress = In other words…. What do people do and/or think when they are having problems with acute insomnia?

Four Factor Model of Insomnia: Perpetuating Factors Unrealistic sleep requirement expectations Faulty appraisals of sleep difficulties Misattributions of daytime impairments Misconceptions about the causes of insomnia Excessive amount of time spent in bed Irregular sleep wake schedule Napping Engaging in sleep-interfering activities in the bedroom Using substances for sleep and/or wake Perlis modification of Spielman model

Four Factor Model of Insomnia: Conditioned Arousal Learned expectation to be awake in bed The more time you spend in bed awake, alert, frustrated, and/or anxious the stronger the association between being in bed and being awake becomes This is often why your brain “turns on” when you get in bed at night Perlis modification of Spielman model

How Does Chronic Insomnia Develop? Perpetuating Factors Conditioned Arousal Acute Insomnia Compensatory Behaviors & Beliefs About Sleep Learned Association Between Being Awake and Being in Bed Chronic Insomnia +

Targeting Perpetuating Factors in CBT-I Chronic Insomnia Circadian Disruption Improper/irregular sleep scheduling Arousal Cognitive Poor sleep habits Conditioned arousal Homeostatic Disruption reduced sleep drive Sleep Efficiency Therapy Stimulus control Cognitive Therapy/counter arousal Sleep hygiene

Sleep Efficiency Therapy in CBT-I Sleep less to sleep better? Sleep Efficiency Therapy in CBT-I Improving Sleep Efficiency on your own Keep sleep diary Restrict time in bed to the number of hours of sleep (≥5) Set wake and bed times Review strategies for staying awake Sleep will probably be less before it is more Goal is to consolidate sleep Gradually extend sleep opportunity (15 min/week as sleep improves) Only go to bed when you feel sleepy at night Get up at the same time every day regardless of how well you sleep Avoid napping/dozing to maximize your sleep debt The greater your sleep debt, the more likely you will fall asleep faster, get back to sleep faster, and stay asleep longer

Sleep Debt Normal Day-Night Sleep Deprivation Process S Daytime Nap

Do nothing in bed but sleep* AND sleep nowhere but the bed Stimulus Control Do nothing in bed but sleep* AND sleep nowhere but the bed *and sex

Stimulus Control Go to bed only when you are sleepy Do not use your bed or bedroom for anything other than sleep (or sex) If you are unable to fall asleep after about 15-20 minutes, leave the bed and bedroom Hide the clock Repeat as necessary Wake up at a regular time regardless of how well or how long you slept Avoid taking naps

Cognitive and Counterarousal Strategies in the Treatment of Insomnia Cognitive Restructuring Modify unhelpful beliefs about sleep and impact of sleep on daytime functioning Designated worry time Train your brain to worry at a specific time rather than when you are trying to sleep Constructive worry Categorize your worry and take action (or not) To-do lists Leave your worry at work Paradoxical intention Try to stay awake vs. falling asleep Mindfulness exercises Learn to recognize that you are separate from your thoughts and you can choose when to pay attention to them Progressive muscle relaxation Reduce physical tension and increase awareness of stress Diaphragmatic breathing Promote the relaxation response and learn to focus your mind Yoga Potentially induces relaxation, increases awareness of mind and body, redirects attention to present moment Guided imagery Evoke relaxation by using your imagination

Things to Promote Sleep Sleep Hygiene Things to Avoid Things to Promote Sleep Do not try to fall asleep Avoid caffeine after noon Avoid nicotine within 2 hours of bedtime (or completely!) Avoid alcohol near bedtime Do not go to bed hungry or too full Avoid excessive liquids in the evening Avoid naps Do not watch the clock  Use a bedtime ritual Help your body get to the right temperature for sleep (60-67 °F) Make sure your bedroom is a comfortable temperature Make sure your bedroom is comfortable and free from light and noise

Wind Down Routine Some people expect to be able to work or engage in other kinds of stimulating activity right up until the time they want to fall asleep Your brain likely needs more time to relax and slow down before it will be able to sleep, otherwise it will just take the time to slow down while you’re in bed Try giving yourself at least 30-60 minutes of wind down time before trying to sleep What can you do to relax during wind down time?

Recommendations PCP’s can give patients Go to bed only when sleepy Get out of bed when unable to sleep (after 20-30 min or if you feel wide awake) Get up at a consistent time every morning regardless of how well you sleep Avoid napping/dozing during day Use the bed and bedroom for sleep and sex only Practice good sleep hygiene Develop a consistent wind down routine that is relaxing Give patients “PISLEEPTIPS” smartphrase handout

Thank you! Please feel free to contact me at davisky@slhs.org with any questions!

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