The ABCs of CBT for Insomnia: CBT-I for the Non-Psychologist Michael Schmitz, PsyD, LP, CBSM Clinical Director, Behavioral Sleep Medicine Services Allina Health

 Explain model of development of insomnia that serves as basis for cognitive-behavioral therapy for insomnia (CBT-I)  Describe CBT-I modalities  Describe major behavioral elements of CBT-I  Discuss clinical challenges of each behavioral intervention Goals of Presentation

 million Americans affected by intermittent or chronic insomnia  Chronic Insomnia estimated to be between 9-12%  5-25% of persons with insomnia seek treatment  75% of insomnia is treated by primary physicians  Increased health care utilization  Increased work absenteeism  Predictor of depression Impact of Insomnia

 Who’s at risk?  Patients with medical/psychiatric conditions  Shift Workers  Women  Older individuals Impact of Insomnia

Three Factor Model of Insomnia

 Increased arousal level  Medical and mental health factors  Genetic predisposition Predisposing factors

 Life stress  Trauma  Medical stressor  Medication side effect Precipitating factors

 Sleep hygiene issues  Excessive time in bed  Sleep-incompatible behavior in bed  Cognitive arousal, worry about sleep, sleep effort  Conditioned arousal – “classical conditioning” Perpetuating factors

 Benefits of sleep medications inflated and offset by potential harm. (Buscemi, et al. (2005)  Meta-analysis of hypnotic use (Glass, J, et al. (2005) concludes that modest benefits outweighed by risk of harm in older adults  CBT-I compares favorably with sleep medication with behavioral treatments of equal or greater effectiveness and with sustained improvement at 12 and 18 months.  Sleeping pills present risk for falls and adverse health events in older adults. Why CBT for Insomnia?

Drug dependent insomnia Hauri, P, 1996

Meta-Analysis of CBT-I Results Statistical Significance  SOL reduced 44 ► 24 min.  WASO reduced 79 ► 40 min.  Awakenings reduced 2 ► 1  TST increased from 316 to 358 min  SE increased from 57% to 83% Okajima I, et al (2011) Sleep and Biological Rhythms, 9: Clinical Significance  Subjective rating of improved sleep quality.  50% improvement in target symptoms  Depression scores reduced  Reduced hypnotic use  Evidence of sustained improvement at 6 and 12 mo.

 Lack of provider and patient awareness  Techniques time intensive compared to prescribing meds  Lack of clinicians with skills/training to implement treatment  Limited research on what combination of strategies optimize effectiveness for particular populations. Why Aren’t Behavioral Interventions Used more frequently?

 Not all patients need office-based CBT-I  Key is to match patient’s clinical presentation with appropriate intervention Acute insomnia due Chronic insomnia to poor sleep habits associated with multiple medical, psychiatric and/or sleep disorder comorbidities Matching Intervention to Patient

Allina Health BSM CBT-I Model Population Served Increasing Complexity, Acuity, Failure to Respond CBT-I provided by Primary Care Psychologists with CBT-I Training Regional BSM Certified Psychologists Severity Index Web-basedCBT-I Least intensive interventions Patient instruction, Self – help books

 Stimulus control therapy (SCT)  Sleep restriction therapy (SRT)  Cognitive therapy  Relaxation training  Sleep hygiene instruction  Combined interventions are considered more effective than single interventions. Types of Cognitive-Behavioral Interventions for Insomnia

The sleep log as key tool for self-monitoring and treatment

 Bedtime vs. SL  WASO vs SL  Naps  Remind clients that all data is a “guesstimate”  Adherence – fit sleep log to patient Teaching clients how to keep track of their sleep

Assumption: Bed space associated with sleep incompatible behaviors/experience as individual tries to decrease physical and cognitive arousal associated with sleep effort. Goal: Re-associate bedroom with sleep. May influence homeostatic and circadian sleep mechanisms. Findings: Positive results for all sleep parameters. Considered by the American Academy of sleep medicine to be the first-line behavioral treatment for chronic insomnia Stimulus Control Therapy (SCT)

Technique: 1.Go to bed only when sleepy 2.Use bedroom only for sleep and sex. 3.Get out of bed if awake for more than minutes and go to another room.. 4.Return to bed when sleepy. Repeat steps 3 and 4 as often as necessary. 5.Maintain consistent wake time 6.Avoid napping Stimulus Control Therapy

 Finding the best wake time.  Method alone does not specifically address the effect that maladaptive beliefs and cognitions may have on arousal, anxiety, and maintenance of wakefulness.  Individuals with mobility and pain issues may find instructions difficult to follow.  Prescribing a “sleep window” with SCT Stimulus Control Treatment Challenges

Assumption: Individual spends excessive time in bed in an effort to cope with sleep loss and obtain more sleep. This may affect the homeostatic drive mechanism of sleep Goal: Promote mild sleep deprivation, increase homeostatic pressure for sleep Findings: Good results for most sleep parameters. Used in most multiple component CBT therapies Sleep Restriction Therapy (SRT)

Technique: 1. Cut time in bed (TIB) to amount of time sleeping. 2. Increase TIB when sleep efficiency is >90%. 3. Decrease TIB when sleep efficiency is <85% 4. Keep hours same with sleep efficiency 85%--90% 5. Adjust schedule weekly until optimum duration of sleep achieved. Sleep Restriction Therapy

Sleep Restriction Therapy Challenges  Patients often equate extended time in bed with the opportunity to get more sleep and fear sleep restriction with be counterproductive to their effort to improve their sleep.  Preparing patients for the intervention  Educating about improving sleep consolidation  Managing sleep deprivation side effects

Assumption: High levels of somatic and cognitive arousal prevent sleep initiation and maintenance. Goal: Reduce arousal with specific techniques Findings: Most demonstrate significant improvements in reducing problems with sleep initiation. May be less effective than stimulus control Relaxation Training

Techniques:  PMR - tensing and relaxing muscle groups  Biofeedback - audio or visual feedback  Deep Breathing  Guided Imager y Relaxation Training

Assumption: Poor sleepers have worse sleep habits than good sleepers. Goal: Improve environmental factors and health behaviors Findings: Limited benefits used alone. Often used as placebo control in CBT-I RCTs. Used in conjunction with other behavioral therapies in most CBT protocols. Sleep Hygiene Instruction

1.Avoid alcohol, nicotine, caffeine 4-6 hours before bed. 2.Avoid a visible bedroom clock with a lighted dial 3.Establish a relaxing bedtime routine 4.Establish a regular sleep schedule 5.Get regular exercise 6.Make sure bedroom in comfortable, cool, cark and quiet. Sleep Hygiene Instructions

 Assumption: Maladaptive thoughts produce stress and arousal affecting sleep  Goal: Alter faulty beliefs about sleep to reduce emotional distress.  Identify beliefs about sleep that are incorrect  Challenge their truthfulness  Substitute realistic thoughts Cognitive therapy

 Misconceptions about causes of insomnia “Insomnia is a normal part of aging.”  Unrealistic expectations re: sleep needs “I must have 8 hours of sleep each night.”  Faulty beliefs about insomnia consequences “Insomnia can make me sick or cause a mental breakdown.”  Misattributions of daytime impairments “I’ve had a bad day because of my insomnia.” “I can’t have a normal day after a sleepless night.” Maladaptive beliefs about sleep

 Techniques require psychological insight and homework  Thought-stopping does not work  May be resistance to cognitive homework  Patient education is not cognitive therapy though accurate patient information is part of it. Challenges in Cognitive Therapy

Multi-Component CBT for Insomnia  Assumption: Perpetuating factors and increase psychophysiological arousal affect intrinsic sleep promoting processes.  Goal: Identify primary factors contributing to maintenance of insomnia and apply appropriate cognitive-behavioral components to reduce arousal and promote behaviors that are sleep compatible  Findings: Most clinician -based CBT-I interventions are multi- component and in comparison trials with pharmacological intervention have demonstrated equal or greater efficacy.

Thank you!