2. Insomnia Treatment New habits Cognitive interventions Stress management

3. Why is Sleep Important? Assists in: Physical and emotional regulation Learning and memory consolidation Attention & decision making

4. What is Insomnia? A persistent disorder that can make it hard Fall asleep or stay asleep Insomnia can lead to stress, anxiety, and wakefulness. 6-8 hours consistent with optimal health Time to fall asleep: ≤ 30 min = normal Returning to sleep: ≤ 30 min = normal Early awakening: ≤ 30 minutes = normal

5. Screening 1. Rule out general medical conditions first 2. Rule out Sleep Apnea Do you snore? Do you feel tired or sleepy during the day? Wake up choking, gasping, short of breath? Has anyone observed you stop breathing during your sleep? Do you have high blood pressure?

6. Myths about Sleep I should fall asleep as soon as my head hits the pillow I should NEVER wake up in the middle of the night Nighttime awakening or restroom breaks signify insomnia I wake up too early on the weekends I worry at night

7. CIRCADIAN DRIVE FOR WAKEFULNESS HOMEOSTATIC DRIVE FOR SLEEP Sleep-Wake Regulation

8. Sleep Reversal Beware of factors that reverse sleep: Caffeine Alcohol Nicotine Naps

9. Improve Sleep Quality Fixed bedtime and wake time, everyday Bed is ONLY for sleep (and sex) Sleep only in your bed (and nowhere but your bed) Do not stay in bed awake for more than 30 minutes No naps

11. Talk Overview Case Brain structures involved Sleep problems and acute TBI Chronic sleep problems associated with TBI Treatments Key Points

12. Studies of Sleep and TBI (human)

13. Possible Brain Structures Involved Brain stem Basal forebrain Hypothalamus

14. Possible Markers/Etiologies Hypothalamic-pituitary insufficiency (Belmont and co- workers, 2006) Significantly lower levels of hypocretin in CSF (Baumann and co-workers, 2007) Disruption of normal patterns of melatonin secretion (Paparrigopoulos et al., 2006)

15. Early Reports of TBI and Sleepiness First reports 1941 by Gill in Lancet: head trauma and narcolepsy Guilleminault and co-workers (1983) at Stanford reported on a series of 20 individuals with TBI and sleep complaints

16. Sleep Complaints Common # SubjectsPrevalence TBI Severity/ Acute vs Chronic Authors 8746%All/chronicCastriotta et al., 2007 5141 mo. 55% 1 yr. 27% All/acute & chronic Watson et al., 2007

17. Wide Range of Sleep Disorders Diagnosis Prevalence (general pop.) TBI Severity/ Acute vs Chronic Authors Insomnia30%All/acute & chronic Fichenberg, 2000 29.4% (9%)All/chronic Ouellet, 2006 OSA30%All/chronic Verma, 2007 23% (4-20%)All/chronic Castriotta, 2007 CRSD36%Mild/?Ayalon, 2007

18. Wide Range of Sleep Disorders DiagnosisPrevalence (general pop.) TBI Severity/ Acute vs Chronic Authors Parasomnias25%; 13% with RBD All/chronicVerma, 2007 Narcolepsy6% (0.5%)All/chronicCastriotta, 2007 PTH11%All/chronicCastriotta, 2007 PLMS7%All/chronicCastriotta, 2007

19. Other Issues Complicate Sleep Problems Pain -> 2-fold increase in insomnia complaints (Beetar et al., 1996) Neuropsychological function being more intact  greater sleep dysfunction (Mahmood et al., 2004) Older individuals and women more likely to have sleep problems (Clinchot et al., 1998)

20. Treatments Little data on response to treatments Direct treatments to underlying sleep issue CPAP for sleep disordered breathing Light and melatonin for circadian rhythm disorders Aggressively treat co-morbidities (eg. pain, depression)

21. Key Points Many sleep complaints have an identifiable underlying cause Treatments are available

22. In Bed: Sleep If you are not asleep, get out of bed. Staying in bed creates negative associations during sleep time Wakefulness + bed Worry + bed TV/Phone + bed Planning + bed In bed: Only sleep or sexual intercourse

23. Recommendations: LASO Do not stay in bed for more than 30 minutes while awake A. Leave the bedroom B. Avoid: Activity or light (i.e., television, smoking, exercising, computers/phones) C. Soothe: Read, listen to soothing music, practice relaxation exercises, journal D. Only when sleepy: return to bed

24. Create a Sleep Climate Go to bed and wake up daily, on a regular schedule Manage exercise and food intake around bedtime and wake time Sleep-conducive environment Noise, light, temperature, comfort

25. Thoughts 1. What were saying to yourself while you were lying awake? 2. Estimate probability of negative consequence 3. Address likelihood this will happen 4. Is your thought helpful? 5. Mindfulness: Bring focus to the moment, to the breath, without judgement

26. Stress and Impact on Sleep

27. Practice What to do when you can’t sleep? Meditation Prayer Reading Diaphragmatic breathing

28. Diaphragmatic Breathing

29. Summary New habits Sleep environment Cognitive reframing Stress management