COGNITIVE - BEHAVIORAL THERAPY FOR INSOMNIA - ALVIN E. LAKE III, PHD, FAHS MICHIGAN HEAD-PAIN AND NEUROLOGICAL INSTITUTE - MICHIGAN ...
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Cognitive -
Behavioral
Therapy for
Insomnia
Alvin E. Lake III, PhD, FAHS
Michigan Head-Pain and
Neurological Institute
The worst thing in the world is
to try to sleep and not to.
F. Scott FitzgeraldPrevalence: Types of Insomnia
Community Sample (Primary Care, N=1181)
Sleep Disturbance Prevalence (%)
Delayed Sleep Onset 10.3
Sleep Maintenance 25.2
Early Wakening 15.9
Non-Restorative Sleep 18.2
Restricted Social Activities (RSA) 16.9
Significant Interaction of delayed sleep onset & pain (PSleep Onset Latency in a National Sample
Community Sample (Primary Care, N=1181)
Minutes to Percentage of
Fall Asleep Respondents
0-14 42%
15-29 19%
30-44 18%
45-59 3%
60+ 18%
Mean = 22 Minutes, SD = 19; Median = 15 Minutes
2007-2008 CDC National Health
and Nutrition Examination SurveySleep is the overlooked hero
and the poor man’s physician.
Stephen King, Insomnia 1994Sleep Deprivation and Pain
One Night of Total Sleep Deprivation (TSD)
Promotes Hyperalgesia in Normal Adults
• Healthy adults without pain or sleep problems
• N = 14 (6 female, 8 male)
• Crossover design – TSD vs normal night
• TSD → significant hyperalgesia to
heat, cold, blunt pressure, pinprick
• TSD → significant increase in State Anxiety
Scuh-Hofer, S et al Pain 2013 154(9): 1613-1621Comorbidity: Insomnia & Medical Disorders
Community Sample (Age 18-65, N = 3282)
Overall Prevalence of Insomnia = 21.4%
Increasing # Medical Disorders → Increased Prevalence Insomnia
Medical Disorder Odds Ratio 95% CL P
Migraine 1.8 1.5-2.1 .001
Pain-
Stomach Ulcers 2.1 1.6-2.7 .001
Related
Arthritis 1.8 1.5-2.2 .001
COPD 1.6 1.3-2.0 .04
Breathing
Asthma 1.9 1.5-2.5 .001
Cardiac, Hypertension,
Other Neurological, Menstrual
1.7 1.2-2.7 .004
Budhiraja R et al Sleep 2011 34(7): 859-867Longitudinal Effect of Sleep Disturbance on
Emergence & Severity of Chronic Pain
N=1753 Young Adults – Ages 18-25
Sleep Problems at Initial Assessment
• Baseline – significant comorbidity with
chronic pain, musculoskeletal pain,
headache & abdominal pain severity
• 3-Year Follow-Up – predicted emergence of
chronic pain & increased severity of
musculoskeletal pain
Bonvanie, I. J. et al Pain 2016; 157(4): 957-963Sleep Problems Increase Risk for Later
Development of Chronic Pain
• Sleep problems have a dose-dependent association (more
significant sleep disturbance → higher risk) with both
low back & neck/shoulder pain for both men & women
at 10-year follow-up (N = 26,896).1
• Sleep impairments are a stronger and more reliable predictor
of pain than pain is of sleep impairments.2
• Sleep patterns share common pathways with nociceptive
stimuli.3
• Sleep deprivation impairs descending pain-inhibition pathways
that are important in controlling and coping with pain.4
1. Mork PJ et al Eur J Public Health 2014 24(6): 924-929
2. Finan PH et al J Pain 2013 14(12): 1539-1532
3. Fine L Phys Med Rehabil Clin N Am 2015 26(2): 301-308
4. Choy EH Nat Rev Rheumatol 2015 11(9): 513-520Sleep and Pain – Bidirectional Influence
Randomized, Controlled 12-Month Trial
Collaborative Treatment. N = 250 Veterans
• Change in sleep complaints at 3 months
predicted change in pain at 12 months
(PInsomnia, Headache and Mood
• During last night’s insomnia, as these thoughts
came and went between my aching temples,
I realized once again, what I had almost
forgotten in this recent period of relative calm…
• That I tread a terribly tenuous, indeed almost
non-existent soil spread over a pit full of
shadows, whence the powers of darkness
emerge at will to destroy my life…
Franz Kafka, Letters to Friends, Family and EditorsHow Much Sleep Does a Pain Patient Need?
• The sweet spot may lie between 6-9 hours/night
• Representative national sample (N = 971) kept pain
and sleep diaries for 1 week1
• Either less than 6 or more than 9 hours sleep/night
significant association with greater next-day pain1
• Daytime pain prospectively predicted sleep duration,
but the effect was less robust1
• Both migraine and tension-type headache patients
may need more sleep than healthy controls2
1. Edwards RR et al Pain 2008 137(1): 202-207
2. Engstrom M et al Acta Neurol Scand Suppl 2014 198: 47-54Shift Work Disorder – 1
1. About 15% of full-time was and salary workers in US
work on shifts outside traditional daytime schedule
2. Most shift workers are in service occupations –
police, firefighters, food service, healthcare,
transportation
3. 63% of shift workers (vs 89% of non-shift workers) said
their schedule allows them to get enough sleep
4. Shift workers more likely to
sleep 6 hours on workdays
work more hours/week
experience drowsy driving at least once/month
National Sleep Foundation
(sleepfoundation.org)
accessed online 04/29/2018Shift Work Disorder – 2
Definition Circadian rhythm sleep disorder characterized by
insomnia and excessive sleepiness affecting people whose
work hours overlap with the typical sleep period
1. MedLine and Cochrane Library search found 29 articles
(reviews and research) with 3504 probands
2. About 33% of shift workers have insomnia
3. Up to 90% report regular fatigue & sleepiness at workplace
4. Detrimental effects – work performance, processing errors,
work accidents, absenteeism, reduced quality of life,
symptoms of depression
Richter, K et al EPMAJ 2016Cognitive Behavioral Treatment of Insomnia
American College of Physicians
Management of Chronic Insomnia Disorder in Adults
Clinical Practice Guideline Recommendations 2016
Based on Systematic Review of Randomized Controlled Studies
Published in English from 2004 through 9/2015
1. ACP recommends that all adult patients receive cognitive
behavioral therapy for insomnia (CBT-I) as the initial
treatment for chronic insomnia disorder.
2. ACP recommends that clinicians use a shared decision-making
approach, including a discussion of the benefit, harms,
and costs of short-term use of medications, to decide
whether to add pharmacological therapy in adults with
chronic insomnia disorder in whom cognitive behavioral
therapy for insomnia (CBT-I) alone was unsuccessful.
Qaseem A et al Ann Intern Med 2016; 165(2): 125-133Behavioral & Drug Therapies for
Randomized Controlled Trial – 1
1. Late Life Insomnia (mean age 65), N = 78 (50♀ 28♂)
2. Improvement = Reduction in time awake after sleep onset
measured by sleep diary and polysomnography
Treatment % Improvement
Pharmacotherapy + CBT 63.5
Cognitive-Behavioral Therapy 55.0
(stimulus control, sleep restriction, sleep hygiene, cognitive therapy)
Pharmacotherapy (temazepam) 46.5
Placebo 16.9
1. The three active treatments more effective than placebo
2. Trend for greater efficacy of combined treatment
Morin CM et al JAMA 1999 281(11): 991-999Behavioral & Drug Therapies for
Randomized Controlled Trial – 2
Sustained Improvement, Rated Efficacy, Satisfaction
• CBT treated subjects sustained gains at follow-up
• Drug therapy alone did not show sustained gains
• CBT (alone or combined with drugs) was rated as
more effective than drug therapy alone by
subjects, significant others and clinicians.
• Subjects were more satisfied with CBT
Morin CM et al JAMA 1999 281(11): 991-999American Academy of Sleep Medicine
Practice Parameters for the Psychological and
Behavioral Treatment of Insomnia: An Update
Effective Treatments Include
1. Stimulus Control
2. Relaxation and Biofeedback
3. Cognitive Behavior Therapy
4. Sleep Restriction
5. Paradoxical Intention
Morgenthaler T et al Sleep 2006 29(11): 1415-1419Sleep Onset Insomnia – Overthinking
• Insomnia is a variant of Tourette’s – the waking brain races,
sampling the world after the world has turned away,
touching it everywhere, refusing to settle, to join the
collective nod.
• The insomniac brain is a sort of conspiracy theorist –
believing too much in its own paranoiac importance,
as though if it were to blink, then doze, the world might
be overrun by some encroaching calamity, which its
obsessive musings are somehow fending off.
Jonathan Lethem, Motherless Brooklyn 1999Behavioral Management of Sleep
Set Appropriate Expectations
1. Educate patient about sleep
2. Need to quiet the mind
3. Bed is not the place to solve problems –
no matter how badly the emotional
mind may want to do so
4. Consistency is critical to success –
the insomniac may need more
consistency in following program
than bed partners or friends
5. Patience – Improvement may take
several weeks of adherenceStimulus Control
1. Facilitate “bed with lights out” becoming a conditioned
stimulus for rapid sleep onset – no competing activities
2. Reserve bed for sleep at night – no TV, reading, cell phone,
iPad, computer games, reading, worrying, planning, or
discussing stressful events with your bed partner
3. Avoid using bed for other activities during the day
4. If you need time to review your day, plan tomorrow, or
grapple with an emotionally difficult issue, give yourself
a limited time in a structured setting to do this before
starting bedtime preparation
5. Keep a notepad by the side of the bed to easily jot down any
thoughts you have difficulty getting out of your mindI don’t fall asleep easily, but
when I do, it’s a nightmare.
Parth ShiralkarRelaxation, Meditation, Mindfulness
1. Slow abdominal breathing – 4 seconds in, 4 seconds out
2. Repeat a word – e.g., “Re…lax” – in rhythm with breathing
3. Alternatively, some patients with a strong faith may prefer a
verse of scripture or word with special meaning in their
religious tradition – e.g., “The Lord is my shepherd…”
4. Become a neutral, casually interested, passive observer of
intrusive thoughts and images – “Oh, that’s interesting”
while continuing to redirect attention to the slow
abdominal breathing rhythm and chosen word
5. Take the emotion out of any sensory stimuli – e.g., let “pain”
transform to a “certain feeling” at the periphery of
the mind rather than a negative emotional state at the
center of awarenessSomatically Focused Relaxation
• Body scan – focus on different area of your body from the toes
to the top of the head, relaxing each area, with
sensations of loose heaviness
• Progressive relaxation – tighten and then relax muscles from
the feet to the forehead, with a sense of “letting go,
farther and farther” as each area releases before moving
on to the next
• Biofeedback – focus on warming the fingers or toes (reduction
in sympathetic nervous system outflow) or relaxing
specific muscle areas (e.g., jaw, neck, eyes, forehead)Hypnotically-Induced Relaxation
1. Letting go of intention, following a prearranged script
2. Descending imagery – going down a staircase or
floating like an autumn leaf in a light warm breeze
3. Repetitive counting – e.g., backwards slowly from 100,
or up from 1 to 10 while opening and closing the
eyes, letting the eyes feel heavier and heavier,
until they feel too heavy to open, finding it easier
to just let them effortlessly remain closed
4. Passively observe whatever experiences occur
through the process
5. Repeat as needed – repetition of the script facilitates
conditioningSleep Restriction
Limit Time in Bed when Not Sleeping
1. Avoid lying in bed for prolonged periods not sleeping –
interferes with condition rapid sleep onset
2. Go to bed when sleepy – stay up later but engaged in
non-stimulating activity during the hour before bed
3. If not asleep within about 20 minutes, get out of bed,
preferably go into another room, do something
non-stimulating – reading light fiction or a book
you have read before, listening to music or a story
with which you are familiar, return to bed when
feeling sleepy
4. Repeat if not asleep in about 20 minutes
5. No napping during the dayParadoxical Intention
1. Insomniacs often try too hard to fall asleep – they set
goals that they must be asleep by a certain time in
order to be rested for the next day’s activities, they
track the time they are not sleeping, and at some
point become frustrated with their lack of success
in falling asleep, which further interferes with sleep
2. The therapeutic goal each night is to follow the plan,
and accept whatever happens – to give up the
goal of trying to fall asleep
3. True paradoxical intention means trying to stay awake
rather than trying to fall asleep – directly
confronting the fear of not falling asleepI’ve got rhythm…
George and Ira GershwinCircadian Rhythms of Human Subjects
Without Timepieces or Indication of the Alternation of Day or Night
• One (1) subject lived alone in cave for 127 days –
activities & sleep cycle averaged 25.1 hour rhythm
• Seven (7) solitary subjects spent 5-7 days in isolation unit –
3/7 developed 25-27 hour rhythm
1/7 first developed 27 hour rhythm, then 24-25 hours
1/7 maintained 30 hour rhythm
2/7 alternated sleep of 8 or 16 hours, followed by 24
hours of activity
• One group of four (4) individuals awoke every 24 hours after
sleep alternating between about 4 and 8 hours
Mills JN et al J Physiol 1974 240(3): 567-594Geologist Michel Siffre – “Caveman”
Michel Siffre in 1999 before starting 76-day sojourn in a cave
without a phone or a watch – Getty Images. Accessed online New
York Post 01/22/17When Time Flies – Michel Siffre
• Michel Siffre (geologist) spent extended periods underground
three (3) times, without knowledge of passage of days
on earth’s surface – the last in his 60’s lasting 76 days
• He slept, rose and ate as he wished & kept detailed diaries
• In his first 2-month trip, sleep/activity cycles varied from 6-40
hours (mean = 24.5)
• Longest period of isolation was 7 months –
for the first 5 weeks, his rhythm was 26 hours
then his “days” ranged from 26 to 40-50 hours
experienced severe depression with suicidal ideation
Burdick, Alan When Time Flies: A Mostly Scientific Investigation
2018 NY: Simon & SchusterManage the Circadian Rhythm
1. Patients with sleep problems may need to be
more rigid than others to maintain a stable
circadian rhythm
2. Get up at the same time every day – include
weekends
3. “Sleeping in” on the weekends interferes with
the circadian rhythm – like going on Daylight
Savings every Monday when you have to get
up earlier for work or school
4. A consistent time of getting up in the morning
drives the circadian rhythm – not the more
popular concept of going to bed earlier,
which may leave the insomniac with more
time to lie in bed awake and not sleepingConclusion
The best cure for insomnia
is to get a lot of sleep.
W. C. FieldsYou can also read
