WHEN COUNTING SHEEP FAILS: ADMINISTERING SINGLE-SESSION COGNITIVE-BEHAVIORAL THERAPY FOR INSOMNIA IN A GROUP PSYCHOEDUCATIONAL FORMAT - Kristin E ...

WHEN COUNTING SHEEP FAILS:
             ADMINISTERING SINGLE-SESSION
COGNITIVE-BEHAVIORAL THERAPY FOR INSOMNIA
     IN A GROUP PSYCHOEDUCATIONAL FORMAT

      Kristin E. Eisenhauer, PhD.
      Trinity University
      San Antonio, Texas

DISCLOSURE

 I have nothing to disclose.

INTRODUCTION

 Mood and anxiety disorders are often comorbid with insomnia
  (e.g., Ohayon, Caulet, & Lemoine, 1998).
 Neubauer (2004) describes this relationship as circular and
  synergistic.
 Therefore, it is important for clinicians to treat any insomnia
  that may contribute to (or be exacerbated by) their patients’
  mood and/or anxiety disorders.
 CBT for Insomnia (CBT-I; Jacobs 2000-2012) has been shown
  to be ef fective in reducing patients’ sleep onset and sleep
  maintenance insomnias.

INTRODUCTION

 CBT-I is generally administered in a five -session series that
  covers general sleep education, cognitive restructuring, sleep
  medication withdrawal, sleep scheduling techniques, stimulus
  control techniques, relaxation, and sleep hygiene techniques.
 Perlis and Smith (2008) stated that CBT-I should be made
  more readily available by diversifying how the treatment is
  delivered.
 The current presentation reviews the key components of CBT -I
  and explains how a two -hour single-session CBT-I program can
  be successfully delivered in a group psychoeducational
  format.

CBT-I SINGLE-SESSION DEVELOPMENT

RECRUITMENT

SCREENING

 Required phone screen.
 Explained that this is an educational program for people who
  have trouble falling and staying asleep .
 “Tell me about the nature of your insomnia.”
 Ruled out: delayed phase disorder; shift work; sleep d/o due
  to general medical condition; substance induced sleep d/o;
  breathing-related sleep d/o; parasomnias; nightly use of sleep
  aids.

CONSENT

 "Sleep School" is group administration of an evidence-based
  cognitive behavioral program for insomnia.
 Your participation in this program is voluntary and does not
  establish a counseling relationship with the presenter.
 Consequently, your participation and any remarks you make
  during the program will not be confidential, although
  discretion among fellow participants is strongly encouraged .
 With your consent, you will be asked to fill out three short
  follow -up surveys about your sleep progress and use of today’s
  sleep tips.

SELF-ASSESSMENT

General
THE NATURE OF SLEEP   Sleep
                      psycho-
      AND INSOMNIA    education

STAGES OF SLEEP

 Emphasizing:
   that because sleep grows lighter as the night proceeds, awakenings
    are more prone to occur in the second half of the night
   that core sleep is 5.5 hours

BODY TEMPERATURE

 Emphasizing:
   its circadian rhythm
   that body temperature & sleepiness are directly influenced by the
    daily cycle of sunlight and darkness and its effect on melatonin
   that the strongest desire for sleep is around 3:30am

ADENOSINE

 The accumulation of this neuromodulator in the brain each hour
  we’re awake makes us increasingly sleepy.

TEMPORARY VS. CHRONIC INSOMNIA

 Short- term (stress-related) insomnia develops into chronic
  insomnia when people become overly worried about sleep loss
  and associate their bed with sleeplessness and frustration.

COPING STRATEGIES THAT BACKFIRE

 e.g.:
     going to bed earlier; napping; sleeping in
     spending more time in bed to "catch up" on sleep
     trying to force sleep: “if I try just harder, I’ll sleep“
     ‘relaxing’ in bed by reading or watching TV

WHY ‘SLEEPING IN’ BACKFIRES

 reduces hours awake before bedtime, and therefore reduces
  adenosine accumulation
 delays the natural morning rise in body temperature because
  physical activity and exposure to sunlight are delayed
 also delays the evening temperature drop by the same amount
  of time so that people can’t fall asleep at their ‘normal time’
  because their body temperature is too elevated

THE COGNITIVE PIECE

NEGATIVE SLEEP THOUGHTS

 are instrumental in perpetuating the cycle of emotional
  arousal (anxiety, frustration) and insomnia
 lead to impaired daytime mood and functioning

NST CHECKLIST

THE BEHAVIORAL PIECE

SLEEP SCHEDULING CONCEPTS

 prior wakefulness
   the greater the PW, the greater the level of adenosine in the brain,
    the more exposure to sunlight & physical activity, so a greater rise
    and fall in body temperature, so a greater sleep drive

 sleep efficiency
   time actually asleep divided by time allotted for sleep
   ‘good sleepers’ have an SE of 90%; ‘poor sleepers’ have an average
    SE of 65%
   (participants calculate their sleep efficiency for the past week)

SELLING A SHOCKING NOTION . . .

 REDUCING ALLOTTED SLEEP TIME
   is CRUCIAL in re-associating the bed with sleep
   reduces stressful awake time in bed
   makes the bed a stronger cue for sleep

4 SLEEP SCHEDULING
             RULES

SLEEP SCHEDULING RULE #1

 Get out of bed around the same time ever y day, including
  weekends, no matter how little or poorly you sleep .
   you will fall asleep more easily, sleep more deeply, and wake less
    often for shorter periods of time
   you will also improve sleep efficiency, make the bed a stronger cue
    for sleep, and sleep even better as a result

WRITE DOWN YOUR ARISING TIME GOAL
        BEARING IN MIND:

 - YOUR CLASS/WORK SCHEDULE AND
- YOUR MORNING ROUTINE (EXERCISE,
          SHOWERING, ETC.)

SLEEP SCHEDULING RULE #2

 Reduce the time you allot for sleep so that it more closely
  matches your average sleep time.
   To determine the maximum amount of time you should allot for
    sleep, add one hour to your average sleep duration for the week, but
    do not allot less than 5.5 hours.

CALCULATE YOUR AVERAGE SLEEP
   DURATION FOR THE PAST WEEK.
        THEN ADD ONE HOUR.
(DO NOT ALLOT LESS THAN 5.5 HOURS.)

  THIS IS YOUR TIME ALLOTTED FOR
   SLEEP FOR THE NEXT 2 WEEKS.

SLEEP SCHEDULING RULE #3

 Determine your earliest allowable bedtime.
   Start from your arising time goal and subtract the time you allotted
    for sleep this week.
   For example, if you have determined that your arising time goal is
    8:00 a.m. and your maximum time allotted for sleep is six hours, you
    should not get in bed before 2:00 a.m.

WEEKLY ADJUSTMENT

 Once you have maintained a sleep ef ficiency of at least 85%
  for two weeks, you can increase time allotted for sleep by 30
  minutes each week as long as you maintain a sleep ef ficiency
  of at least 85%.

BEDTIME

 Explain basic do’s and don’ts for the hour before bedtime.
 Give ideas for what to think about once in bed.

SLEEP SCHEDULING RULE #4

 Limit your naps.
   naps should be limited to less than 45 minutes
   naps should commence no later than 4:00 P.M.

STIMULUS CONTROL TECHNIQUES

 Make your bed a cue for sleep, NOT wakefulness:
   use the bedroom for sleep and sexual activity only
   if you are not drowsy at your calculated bedtime, do not go to bed
    until drowsy
   “half hour-half hour rule”

CREATING THE OPTIMAL SLEEP
                 ENVIRONMENT
   Room temperature
   Noise
   Light
   Disruptive bed partner

SLEEP HYGIENE

   Exercise
   Baths & Showers
   Sunlight exposure
   Caf feine
   Nicotine
   Alcohol
   Food

COMPLIANCE TIPS

 …are provided on a handout in participants’ packets.

ACTION PLAN

ACTION PLAN

RELAXATION EXERCISE

 Guided imagery

WRAPPING UP &
   FOLLOW-UP

RESOURCES

 pass out and review packet of handouts
 give participants referral information
 show participants Jacobs (1998) Say Good Night to Insomnia

EVALUATION

FOLLOW UP DATA COLLECTION

D u r in g t h e p a s t w e e k :

1 . H o w m a ny n i g h t s d i d yo u s p e n d m o r e t h a n 3 0 m i n ute s t r y i n g to f a l l a s l e e p w h e n yo u
f i r s t w e n t to b e d ?
2 . { S k i p l o g i c : A n s w e r o n l y i f t h ey r e s p o n d ed > 1 to Q 1 } H o w m a ny o f t h e s e n i g h t s d i d yo u
g et o u t o f b e d w h e n yo u n o t i c e d t h a t yo u h a d n ’ t f a l l en a s l e e p w i t h i n 3 0 m i n utes ?
3 . H o w m a ny n i g h t s d i d yo u ex p e r ie n c e u nw a n te d n i g h t t i me aw a ke n i n g s t h a t to o k m o r e
t h a n 3 0 m i n u te s f o r yo u to r et u r n to s l e e p ?
4 . { S k i p l o g i c : A n s w e r o n l y i f t h ey r e s p o n d ed > 1 to Q 3 } H o w m a ny o f t h e s e n i g h t s d i d yo u
g et o u t o f b e d w h e n yo u n o t i c e d t h a t yo u h a d n ’ t f a l l en b a c k to s l e e p w i t h i n 3 0 m i n u te s ?
5 . H o w m a ny m o r ni n g s d i d yo u ex p e r i e n c e u nw a n te d e a r l y m o r n i n g aw a ke n i n g s f r o m
w h i c h yo u c o ul d n o t r et u r n to s l e e p ?
6 . H o w m a ny d ay s d i d yo u a r i s e f r o m b e d w i t h i n 3 0 m i n ute s o f yo u r a r i s i n g t i m e g o a l ?
7. H o w m a ny d ay s d i d yo u m e et yo u r t i m e a l l o t te d f o r s l e e p g o a l ?
8 . H o w m a ny d ay s d i d yo u m e et yo u r e a r l i e s t a l l owa b l e b e d t i me g o a l ?
9 . H o w m a ny d ay s d i d yo u l i m i t a ny n a p s yo u m ay h av e t a ke n to l e s s t h a n a n h o u r ?
1 0 . H o w m a ny d ay s d i d yo u b e g i n a ny n a p yo u m ay h av e t a ke n b e f o r e 4 : 0 0 p . m .?
1 1 . H o w m a ny d ay s d i d yo u u s e yo ur b e d r o o m p r i m a r i ly f o r s l e e p ?
1 2 . H o w m a ny d ay s d i d yo u l i m i t yo u r aw a ke t i m e i n b e d p r i o r to g o i n g to b e d to l e s s
t h a n 1 0 m i n ute s ?
1 3 . H o w m a ny n i g h t s d i d yo u w a i t u n t i l yo u w e r e d r o w s y to g o to b e d ?
1 4 . H o w m a ny d ay s d i d yo u p r a c t i ce yo u r p o s i t iv e s l e e p t h o u g h t s ?