1. 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 612-832-7920 Michael.schmitz@allina.com

2.  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

4.  40-70 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

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

7. Three Factor Model of Insomnia

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

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

10.  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

11.  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?

12. Drug dependent insomnia Hauri, P, 1996

13. 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, 9:24-34. 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.

14.  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?

15.  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

16. 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

18.  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

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

20.  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

21. 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)

22. 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 15-200 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

23.  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

24. 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)

25. 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

26. 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

27. 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

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

29. 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

30. 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

31.  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

32.  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

33.  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

34. 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.

35. Thank you!