CANADIANASSOCIATIONOFCOGNITIVEANDBEHAVIOURALTHERAPIES
ASSOCIATIONCANADIENNEDESTHÉRAPIESCOGNITIVESETCOMPORTEMENTALES
Cognitive Behaviour Therapy
for Insomnia in Individuals
with Depression,
Depression Trauma,
Trauma Pain
& Anxiety
Colleen E. Carney, PhD, CPsych
Sleep and Depression Laboratory
Agenda
Time
Topics
8:30--9:45
8:30
Welcome
Assessment (brief overview)
Explaining Sleep Regulation to Clients
10:15--10:45 Break
10:15
byy-Stepp CBTCBT-I: Stimulus Control and Time
Time--inin-Bed Restriction
10:45--12:00 Step10:45
Stepp-by
12:00--12:45 Lunch
12:00
12:45--2:30
12:45
Step
Step--byby-Step CBT
CBT--I: Cognitive Therapy and Counter Arousal
Methods
2:30--2:45
2:30
Break
2:45--4:00
2:45
Step
Step--byby-Step CBT
CBT--I: Troubleshooting and Implementation Issues
Remaining Issues and Questions
Faculty/Presenter
Disclosure
• Faculty: Dr. Colleen E. Carney
• Relationships with commercial interests:
– G
Grants/Research
/R
h Support:
S
T
Tri-council
i
il funding
f di for
f insomnia
i
i
research, previous National Institute of Health funding for
Cognitive Behaviour Therapy clinical trials.
– Scientific Advisory Board: General Sleep Corporation
•1
Mitigating Potential Bias
•Although my grant funding is not directly related to the lecture, I
provide the following objective references in support of the content:
1.
Fava, M., McCall, V. W., Krystal, A. D., Wessel, T., Rubens, R.,
Caron, J., . . . Roth, T. (2006). Eszopiclone co-administered with
fluoxetine in patients with insomnia co-existing with Major
Depressive Disorder. Biological Psychiatry, 59, 1052-1060
2.
Manber, R., Edinger, J. D., Gress, J. L., San Pedro-Salcedo, M. G.,
Kuo, T. F., & Kalista, T. (2008). Cognitive Behavioral Therapy for
insomnia enhances depression outcome in patients with comorbid
Major Depressive Disorder and insomnia. Sleep, 31(4), 489-495.
3.
Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C.
A., & Lichstein, K. L. (2006). Psychological and behavioral treatment
of insomnia: Update of the recent evidence (1998-2004). Sleep,
29(11), 1398-1414.
•I will not mention or promote the sleep corporation that I provide
advice to
Goals of Assessment
• Diagnose insomnia
– Other sleep disorders
– Comorbid conditions (DSM5)
– Substances (and medications)
• Suitability for CBT-I
• Perpetuating factors/treatment targets
What is insomnia?
• We will use different definitions, but:
– Difficulty sleeping (initiating and/or
maintaining sleep* OR nonrestorative sleep)
– Difficulty functioning: contemporary views of
insomnia conceptualize it as a 24-hour disorder
(daytime component) and/or distress
– >3 months duration (DSM5)
*Most CBT trials focus on these types of complaints. There is some controversy
with quantitative criteria (e.g., Lineberger, Carney, Means & Edinger, 2006)
•2
“Normal” sleep architecture
How to Assess?
• Ask (via clinical interview)
– Subjective disorder
• Retrospective recall OK for impression of
symptom severity and distress (see
Insomnia Severity Index) in handouts
• Limited utility of retrospective recall; need
prospective monitoring (see Core Sleep
Diary in handouts)
Sleep Constructs
Electrical
Prospective
Objective
Dubious validity
in insomnia
(Littner et al.,
2003)
Movement
Prospective
Objective
Dubious validity
in insomnia
(Chambers, 1994)
Experience
Prospective
Insomnia is a
subjective
disorder
Essential tool
(Buysse et al.,
2006)
Global
impressions
Retrospective
recall
Confounded by
distress/anxiety
(Hartmann et al.,
In press)
See Buysse et al., 2006 for discussion
•3
Other Sleep Disorders
Obstructive Sleep Apnea (OSA)
Restless Legs Syndrome (RLS)
Periodic Leg Movement Disorder (PLMD)
Circadian Sleep Disorders
Obstructive Sleep
Apnea: Who Cares?
At least 10 seconds
Increased mortality
Headache
Stroke
Depression
Glaucoma
Cardiac
C di Disease
Di
High Blood Pressure
Type II Diabetes
Obesity
Erectile dysfunction
Feet oedema as a
result of heart failure
Car accidents 2-7 x
***
*
*
*
**
*
*
Treating insomnia with untreated apnea is ineffective and unsafe
Apnea Screening:
STOPBANG
STOP
Yes to 2 or more → referral to sleep clinic
• BMI over 35 kg/m2?
• Age: Older than 50 years old?
• Neck size larger than 40 cm (15”+)?
• Gender: Male?
Chung et al. (2008)
http://www.thoracic.org/assemblies/srn/questionaires/stop-bang.php
•4
Summed score
greater than 10
suggestive of
clinically significant
sleepiness
Other disorders associated
with EDS (referral needed)
• Periodic Limb Movement Disorder
– “Has a bed partner ever complained about your leg
twitching?”
g ((demo))
– An overnight study is needed
– Exacerbated by SSRIs
• Comorbidity with Restless Leg Syndrome
– “Do you get a strange, irritating sensation in your
legs in the evening? Tell me more about that? What
do you do to manage it?” Interferes with sleep?
Circadian Rhythm Disorders
8pm
11pm
2am
6am
10am
Normal Sleep Phase
Delayed Sleep
Phase
Advanced Sleep Phase
Delayed Sleep Phase
Advanced
Sleep Phase
•5
Circadian Rhythm Disorder
Interview Questions
• Are your parents owls or larks?”
• “Did you have trouble as a kid staying up or
getting up?
up?”
• “Do you think your sleeping problem would go
away if I could wave a wand and make the world
conform to your schedule? Have you ever tried
this (e.g., on a vacation?)”
• Assess beliefs about schedules (convention,
conformity, morality of an early schedule)
Who has a possible phase
delay?
y Who has insomnia?
Exercise
Case 1
Wednesday
Thursday
1:30
am
12:30
am
11:00
pm
1:00
am
2:00
am
11:15
pm
120 min
90 min
50 min
35 min
60 min
60 min
120 min
10 min
15 min
5 min
15 min
5 min
5 min
15 min
Wake
time
6
am
6:15
am
6:10
am
6
am
6:05
am
8:00
am
7:50
am
Rise
time
7:50
am
8:30
am
7:45
am
6:15
am
7:45
am
10:45
am
10:30
am
Bedtime
Time to
fall
asleep
Time
awake
during
night
Monday
Tuesday
11:00
pm
Friday
Saturday
Sunday
•6
Case 2
Wednesday
Thursday
1:30
am
12:30
am
12:00
am
2:30
am
3:00
am
12:30
am
180 min
90 min
150 min
170 min
35 min
5 min
120 min
10 min
15 min
5 min
10 min
5 min
5 min
15 min
Wake
time
8
am
8
am
8
am
8
am
8
am
2
pm
2:30
pm
Rise
time
8:30
am
8:45
am
8:30
am
9
am
8:45
am
2:15
pm
2:40
pm
Bedtime
Time to
fall
asleep
Time
awake
during
night
Monday
Tuesday
12:00
am
Friday
Saturday
Sunday
Referral
• Refer to sleep clinics for assessment:
– Excessive Daytime Sleepiness (i.e.,
involuntarilyy falling
g asleep)
p)
•
•
•
•
Sleep Apnea
Periodic Limb Movement Disorder
Restless Leg Syndrome
Circadian Rhythm Disorders
– Parasomnias
Contraindications for CBT-I?
•
•
•
•
•
•
Current substance use disorder
Psychologically unstable
Medically unstable,
unstable including epilepsy
Bipolar illness*
Excessive daytime sleepiness**
Untreated or inadequately treated apnea
– Adequate treatment = At least 4 hours a night on at
least 75% of nights associated with severe daytime
sleepiness
•7
Sleep Regulation
Understanding what regulates sleep to
understand insomnia
Homeostatic Mechanism Balances
Sleep and Wakefulness
SWS
Sleep drive determines the quantity of deep
sleep and the quality
Process C
The Body Clock
•8
Body Clock Essentials
1. TIMING
• Clock determines timing of sleep
especially REM sleep timing AND timing
of alertness
2. MANAGING DRIFT
• There is drift in our clock because it is
longer than 24 hours
– Regular bedtimes, regular rise times and regular
light exposure “set” the clock and manage drift
Strength of Alerting
A
Signal
Circadian alerting signals (24(24-hours)
Rest
Wake
Time
Ever had jetlag?
What were the symptoms?
We need to keep a schedule or we will suffer from
“social jetlag”
•9
Precipitating
factor(s)
Coping with the sleep disruption
Homeostatic Disruption
Reduced sleep drive
Arousal
Cognitive
Poor sleep habits
Conditioned
arousal
Circadian Disruption
Improper
Sleep Scheduling
Go to bed early
Drink alcohol
Worry about sleep
problem
Try to sleep-in
Try to nap…
Chronic Insomnia
(Spielman, 1987; Webb, 1988)
Homeostatic Perpetuating
Factors
• We need to “build” sleep drive to have
continuous and quality sleep, therefore
behaviours that will have a negative
impact on this build-up will be:
– Spending increased time in bed relative to how
much sleep you can currently produce
• Napping; Sleeping-in; Going to bed early
– Inactivity (Carney et al., 2006)
Sleeping-in
High
Sleep
Drive
(sleepy)
Medium
Sleep
Drive
(fatigue)
Low Sleep
Drive
(energetic)
7
am
12
pm
Wake-up
Wakelater
6 pm
11
pm
Reproduced from Quiet Your Mind and
Get to Sleep (Carney & Manber, 2008)
•10
Nap impact on building sleep
drive
High
Sleep
Drive
(sleepy)
Medium
Sleep
Drive
(fatigue)
Low Sleep
Drive
(energetic)
7
am
12
pm
6
pm
11
pm
Reproduced from Quiet Your Mind and Get to Sleep
(Carney & Manber, 2008)
“I spend about 8 hours in bed
every night”
Monday
Tuesday
Wednesday
Thursday
11:00
pm
11:30
pm
11:05
pm
10:35
pm
10:55
pm
12:15
am
10:15
pm
Time to
fall
asleep
25
20
40
60
35
15
95
Time
awake
during
night
20
25
15
35
20
45
60
Wake
time
7
am
7
am
7
am
7
am
7
am
8:40
am
7:50
am
7:15
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
11:45
am
Bedtime
Rise
time
Friday
Saturday
Sunday
Process C/Circadian
Perpetuating Factors
• Optimal sleep is produced during a
dynamic, idiosyncratic timing window,
therefore the following behaviours
would have a negative impact on sleep:
– Variable timing of going to bed and getting out
of bed
– Sleeping outside of your optimal window (i.e.,
keeping late hours if you are a lark or getting
up early if you are an owl)
•11
“I go to bed around 11 and
get up at 6 every morning”
Monday
Tuesday
Wednesday
Thursday
11:00
pm
12:30
am
1:05
am
10:35
pm
12:55
am
2:15
am
10:15
pm
Time to
fall
asleep
25
20
40
60
35
15
95
Time
awake
during
night
20
25
15
35
20
45
60
Wake
time
6
am
6
am
6
am
6
am
6
am
8:40
am
7:50
am
7:15
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
11:45
am
Bedtime
Rise
time
Friday
Saturday
Sunday
Delayed and Advanced
Chronotypes
8pm
11pm
2am
6am
10am
Normal Sleep Phase
Delayed Sleep Phase
Advanced Sleep Phase
The Third Process: The Arousal
System
• The arousal system can trump the sleep
promoting system
– allows us adequate respond to dangerous threats
• When overactive, the arousal system
interferes with the processes controlling
sleep. Hyperarousal issues:
1. Conditioned arousal
2. Cognitive arousal
3. Physiological arousal
•12
Conditioned Arousal
• Ask about “the switch”
Bed (bedroom, bedtime
routine)
+
Sleeplessness, tossing,
turning, upset
= conditioned arousal
Two basic (transdiagnostic)
core beliefs
Consequences
Defective
• There is something
wrong with me
Helpless
• There is nothing I
can do about it
And I need to
exert effort to
fix it (Espie et
al., 2006)
Subsequent
anxiety about
failed attempts
to fix it
Beck (1999)
Physiologic Hyperarousal on
Multiple Sleep Latency Test
Propensity to nap
• Insomnia
• Hyperaroused good sleepers (caffeine)
• Sleep-deprived insomnia (yoked)
Bonnet & Arand 1992, 1995, 1996, 1998
•13
Perpetuating Factors and CBT-I
Cognitive
Therapy
Relaxation
Homeostatic Disruption
Reduced sleep drive
Arousal
Cognitive
Poor sleep habits
Conditioned
arousal
Circadian Disruption
Improper/irregular
Sleep Scheduling
Stimulus Control
Sleep Restriction
Chronic Insomnia
Sleep Hygiene
Adapted from Webb (1988)
Empirically Supported Insomnia
Treatments Morin et al. (1999; 2006)
Treatment
# of studies
Classification
Stimulus control*
6
Well
Well--established
Relaxation*
8
Well
Well--established
Paradoxical Intention*
3
Well
Well--established
Sleep Restriction*
3
Well
Well--established
6
Well
Well--established
CBT (no relaxation)
*
CBT + relaxation*
6
Well
Well--established
EMG Biofeedback
4
Probably efficacious
Other Multi-component
3
Probably efficacious
Cognitive Therapy
0
Not supported
Sleep Hygiene
3
Not supported
Selected Evidence for CBT-I in
MDD-I
• Mixed psychiatric disorders
 Lichstein et al., 2000
 Edinger et al., 2007; 2009
• Depression




Morawetz (2001) Case series bibliotherapy
Kuo et al. (2001) Case series group CBT
Manber and colleagues (2008) RCT CBT
BBIT helps with refractory depression and
residual insomnia (Watanabe et al., 2011)
•14
Selected evidence for
chronic pain
• CBT-I in pain patients effective (comparable ES to PI
trials); durable effects at 3-12 month follow-ups
– Chronic pain patients with insomnia (Currie et al., 2000)
– Older
Old adults
d l mixed
i d disorders
di d including
i l di RA
A (Rybarczyk
( b
k et
al., 2002)
– Mixed outpatient cancer patients in primary care (Espie et
al., 2008)
– Fibromyalgia (Edinger et al., 2005)
– Osteoarthritis (Vitiello et al., 2009)
– Chronic neck and back (Jungquist et al., 2010)
Step-by-Step Guide to CBT-I
Stimulus Control
If wakefulness and the bed have become
associated, re-associate bed with sleep by:
1. Going to bed only when sleepy
2. Getting out of bed when unable to sleep
3. Getting out of bed at a consistent time each
morning (irrespective of how you slept)
4. Using the bed and bedroom only for sleep
(and sex)
5. Refraining from daytime naps
Bootzin (1972)
•15
Stimulus control: Putative
sleep mechanisms
• Unpair bed and wakefulness
• Contribute to sleep drive
• Steady input to the clock (regular rise time)
Delivering pro-energy/pro-sleep
and anti-pain messages about
resting/napping
• Recovery comes first—if total bed rest needed,
rest
• If light activity is acceptable, teach paced
activity with scheduled breaks
• Schedule rest but in a place other than the bed
and if medically acceptable, not supine: provigor, pro-sleep
“What should I do when out
of bed?”
•16
Explore activities with curiosity
Activity
Result of the
Experiment
Likelihood that it
would prevent
sleepiness from
occurring
Watch DVD set
50/50
Seemed ok. Went back
to bed 40 minutes later
Surf internet
60%
Too interesting. Stopped
after 2 hours
Listen to jazz
10%
Worked well. Fun and I
got sleepy quickly
Adapted from Quiet Your Mind and Get to Sleep
(Carney& Manber, 2009)
“I can’t get up at the
designated rise time”
Find out why.
Difficulty
Possible plans
Rationale not
compelling/understood
Review multiple times; bridging
bridging, check-in; handouts
Comfort
Consider a transition plan to address comfort
Anhedonia
Contingences: plan activities (that involve commitment
to others); elicit help from significant others.
Alarm
Use multiple, staggered alarm clocks; elicit help from
others
Eveningness
Light sets the clock and increases alertness
Activities that involve light are helpful
“I don’t feel like getting up in the
morning.”
Martell, Dimidjian, & Herman-Dunn (2010)
PLAN
OUTSIDE
→ IN
ACTION
CONTINGENCIES
INSIDE
→ OUT
WAIT FOR
MOTIVATION
ACTION
LESS LIKELY
•17
Coping Card Example
• “I
cannot get out of bed at 7:30 AM”
Thought
Coping
Card
• I know this will help improve my sleep.
• I will go the coffee shop around the corner and read the
paper. I enjoy doing this.
• I will meet with Joe at the Gym at 8:00AM on Mondays
and Wednesdays.
• It is hard, but I have to do it if I want to sleep better.
• I can handle getting out of bed at 7:30AM.
Sleep/the Bed as an escape
Stimulus Control candidate?
Monday
Tuesday
Wednesday
Thursday
11:00
pm
9:30
pm
11:00
pm
10:35
pm
9:15
pm
12:00
am
10:30
pm
100 min
50 min
60 min
120 min
45 min
55 min
90 min
5 min
15 min
15 min
10 min
15 min
15 min
20 min
Wake
time
6
am
6
am
6
am
6
am
6
am
8:40
am
7:50
am
Rise
time
7:15
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
8:45
am
Bedtime
Time to
fall
asleep
Time
awake
during
night
Friday
Saturday
Sunday
•18
Stimulus Control Candidate?
Monday
Tuesday
11:00
pm
9:30
pm
11:00
pm
10:35
pm
9:15
pm
12:00
am
10:30
pm
35 min
25 min
15 min
20 min
25 min
15 min
30 min
100 min
50 min
60 min
120 min
45 min
55 min
90 min
Wake
time
6
am
6
am
6
am
6
am
6
am
8:40
am
7:50
am
Rise
time
7:15
am
7:20
am
7
am
7:25
am
7:15
am
10:50
am
8:45
am
Bedtime
Time to
fall
asleep
Time
Ti
awake
during
night
Wednesday
Thursday
Friday
Saturday
Sunday
3 naps attempted this week
Sleep Restriction Therapy
(SRT)
Time in Bed Restriction
Sleep Quality Training
Sleep Efficiency* Training
*Sleep efficiency is the percent of time asleep
relative to the time spent in bed
How to Present Rationale
• “If you could only choose one, would you prefer 8
hours of poor quality sleep or 6 hours of deep
qualityy sleep?”
q
p
• To improve sleep quality you must increase your
sleep drive
– A strong sleep drive will reduce wakefulness and lead
to better quality sleep
• Over time, as your sleep quality improves, the
time-in-bed prescription will slowly be extended
•19
Sleep Restriction Therapy (SRT)
or Time-in-Bed Restriction
To restore homeostatic sleep drive:
• Match time-in-bed with current average sleep
production (add 30 minutes for normal sleep
onset latency)
• Once sleep normalizes and there is sleepiness
(self-reported or a mean sleep onset latency 10
min or less or a sleep efficiency above 90%) we
extend time-in-bed in 15 or 30 minute increments
Spielman et al., 1987
Determine Where to Place the
Time-In-Bed (TIB) Window
Sleep opportunity window should consider
Eveningness/morningness
tendency
Life constraints (e.g., work
schedule)
Collaborate to determine out
out--ofof-bed (rise) time
Instruct to get out of bed shortly after waking
Determine bedtime based on timetime-in
in--bed and rise time
Count back from rise
time
Example: Time in bed=6 hours
Rise time=6AM  Bedtime=12AM
“I can’t stay up until this
bedtime. I’m too sleepy”
• Acknowledge it is difficult
• Ensure they know the difference between sleepiness and
fatigue/sluggish/low mood
• Develop positive association with sleepiness and their
sleep system working (hidden benefits to sleep
deprivation).
• Other solutions include: light, activity, enlisting others
• Collaborate on whether earlier bedtime is needed
•20
When a new bedtime differs from
couple’s habitual bedtime
Sleep extension
• Sometimes you overshoot and must provide
MORE time in bed, for example:
–
–
–
–
Normal sleep indices
Subjective
S
bj ti complaints
l i t off sleepiness
l i
Sleep efficiency upwards of 90%
Sleep onset latencies less than 10 minutes
• Renegotiate where to allot the additional
15-30 minutes. If sleep suffers, scale back,
if sleepiness continues and sleep is still ok,
increase by another 15-minutes
Would you increase the TIB?
Monday
Tuesday
12:00
am
12:30
am
12:30
am
12:00
am
12:30
am
1:30
am
12:15
am
15 min
25 min
20 min
25 min
25 min
20 min
20 min
10 min
15 min
5 min
10 min
5 min
5 min
15 min
Wake
time
6:15
am
6:15
am
6:35
am
6:15
am
6:35
am
8:00
am
7:30
am
Rise
time
6:30
am
6:40
am
7:00
am
6:25
am
7:05
am
8:30
am
8:00
am
6:10
82%
6:30
87%
6:10
91%
7:00
87%
8:15
87%
Bedtime
Time to
fall
asleep
Time
awake
k
during
night
TIB
Sleep
6:30
84%
Wednesday
Thursday
Friday
6:35
85%
Saturday
Sunday
Efficiency:
•21
Combined SRT/ Stimulus
Control Summary
1. WakeWake-up and get out of bed at ________ every day.
2. Go to bed when you are sleepy,
but not before ________.
3. Get up (out of bed) when you can’t sleep.
4. Use the bed only for sleeping. Do not read, eat, watch
TV, etc. in bed. Sex is the only exception.
5. Avoid daytime napping.
“If I Get Out Of Bed I Will Be Up
Longer Than If I Stay In Bed”
•
•
•
•
•
Acknowledge poor sleep feels bad, however:
Are there benefits if this is true?
Wh t does
What
d
getting
tti outt off bed
b d mean about
b t sleep
l
effort?
Is there fatigue avoidance? Catastrophizing about
performance?
Would they be willing to sacrifice a pawn to win the
game?
Sleep Hygiene:
Focus on Lifestyle Factors
• Caffeine – timing and reduction
• Nicotine reduction/elimination
• Prescribed exercise - timing
• Light bedtime snack (milk, peanut butter)
• Avoid middle of the night eating
• Reduce alcohol, marijuana & other substances
• Optimize environment: light, noise, temperature
•22
Counterarousal strategies
• Buffer zone
• Relaxation therapies
• Cognitive therapy
Create a “buffer zone”
• Time to unwind (~ 1 hour) before bedtime
• Transition between goal-oriented activities of the
day and quiet, more peaceful time of sleep
• Chronotypes
yp
– Those who have hard time staying awake until
designated bedtime may have to
lengthen/shorten? “buffer zone” (e.g., older
adults)
– Those who are delayed sleep phase/teens may
have to lengthen/shorten? their buffer zone
Relaxation*
• Progressive muscle relaxation
• Diaphragmatic breathing
• Breathing meditation
• Guided imagery
*Relaxation therapy is a well-established therapy with mod. ES
Morin et al, 1999; Morin et al, 2006
•23
Th
Thought
ht Records
R
d
Socratic questioning
Behavioral experiments
COGNITIVE THERAPY
Cognitive Therapy: Thought
Records
Situation
Coming
back to
the office
from my
l
lunch
h
break
and
noticed
how tired
I was
Mood
(Intensity 0100%)
Tired
(100%)
Upset
(
(100%)
)
Worried
(80%)
Thoughts
Evidence for the
thought
I’m going to get
sick if I keep
going like this
I’m not
exercising any
longer
I can’t
’t k
keep
going on like
this
I don’t
d ’ feel
f l llike
k
doing things
Something
really terrible is
going to happen
if this doesn’t get
resolved.
I got into
trouble for
coming to work
late last month.
I could get fired
and eventually
become homeless
Evidence against
the thought
I usually start
to feel a little
better later in
the afternoon
99.9% of the
time I am ontime and have
no problems at
work
My sleep
problems have
been going on
for years and
nothing bad
has happened
Adaptive/Coping
statement
Although I
tend to feel
lousy at
different
times during
d
the day, the
reality is that
I always
make it
through and
nothing bad
has ever
happened as
a result of the
insomnia
Do you feel
any
differently?
Tired
(90%)
Upset
(
(50%)
)
Worried
(45%)
My job is secure—I
am not going to
be fired
Socratic Questioning
• Overestimating the relation between sleep and
functioning (focus on exceptions in both directions)
•24
Worry about Consequences
• What other factors affect your mood or functioning
during the day?
• Focus on positive instances of coping; what are some
of y
your successful coping
p g strategies?
g
• Orient towards coping: Sounds like you anticipate
being tired this week, what strategies should we put
into place?” (More on this in behavioral experiments)
• Could cancelling activities/plans have a negative effect
on your sleep? (Avoidance figures prominently in BA)
• Could focusing on the negative consequences of sleep
have a negative effect on your sleep?
Cognitive Therapy
Behavioral Experiment
Belief
Alternative?
Experiment
I have a limited store of
energy
Conserving energy may
increase fatigue
Expend versus conserve
Poor sleep is dangerous
I may be able to cope
reasonably after poor sleep
Restrict sleep and monitor
coping
I can
can’tt control sleep because
my mind is too active
Perhaps because there isn't
isn t
time to process the day?
Constructive worry in
evenings versus status quo
Being tired makes me look
bad
Perhaps others are not
particularly attuned to this
Took series of photos and
tested people’s ratings
Monitoring how I feel helps
me to keep track, in case I
have to make an adjustment
Monitoring increases the
likelihood that you will
perceive minor changes in
energy
Monitor external stimuli and
mood for two hours and then
internal stimuli for 2 hours
I need to nap to get through
the day
If I don’t nap, my nighttime
sleep will improve, and I can
cope
Monitor napping, tiredness
and coping for one week of
naps and one week without
Ree & Harvey, 2004
Explore what contributes to how
one feels during the day
•
•
•
•
•
Jetlag
Level of activity
Hydration
Caffeine withdrawal
Residual symptoms of sleep or antidepressant
medication
• What fatigue management strategies could
help?
•25
Paradoxical Intention
• Anxiety and sleep effort reduced through
paradox
• Likely more suited for sleep onset
difficulties (Broomfield & Espie, 2003)
Outside-in approach to fatigue
Don’t leave work
Martell, Dimidjian, & Herman-Dunn (2010)
PLAN
OUTSIDE
→ IN
ACTION
CONTINGENCIES
MANTRA: Follow a
plan, not a feeling
Increase light
Movement: stretch, move
Scheduled breaks
Hydration
Healthy meals and snacks
Coping card: the post lunch dip is
normal and will pass
Excessive mentation: Rumination
• Rumination – try to suppress
• Use rumination as a cue for an alternative response
– Day: rumination as a cue for activation
– Night: rumination as a cue for Stimulus Control
•26
Out of a TRAP → Back on TRAC
Martell, Dimidjian, & Herman-Dunn (2010)
TRAP
TRIGGER
LOW
ACTIVITY
RESPONSE
AVOIDANCE
PATTERN
FEEL LOW,
RUMINATION
NEGATIVE (DISENGAGEMENT)
THOUGHTS
OUTCOME
FEEL
HORRIBLE
TRAC
TRIGGER
RESPONSE
LOW
ACTIVITY
FEEL LOW,
NEGATIVE
THOUGHTS
ALTERNATIVE
COPING
ACTIVATE
OUTCOME
?
GATHER DATA
Session Outline
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Psychoeducation, Stimulus Control, Sleep Restriction
Therapy, Sleep Hygiene (if needed), Buffer zone
At-home implementation
Troubleshoot adherence, determine if changes necessary
to schedule,
schedule add counterarousal and cognitive therapy
At-home implementation
Troubleshoot adherence, determine if changes necessary
to schedule, continue with cognitive therapy, introduce
termination issues, relapse prevention homework
At-home implementation
Troubleshoot adherence, determine if changes necessary
to schedule, cognitive therapy, termination issues and
relapse prevention
Edinger & Carney, 2015
IMPLEMENTATION ISSUES
•27
Combining depression and
sleep therapies
33
42
In bed
In bed
In bed
In bed
In bed
In bed
In bed
In bed
In bed awake
In bed awake
Internet
bath
Internet
Internet
Internet, newspaper Internet
tv
tv
Reading
I Internet
Reading
on phone (bed)
Reading
tv
tv
tv
Reading
I Internet
dinner
tv
tv
tv
In bed
I Internet
In bed
on phone (bed)
In bed
In bed
In bed
In bed
In bed
In bed
In bed
In bed
In bed
In bed
33
In bed
In bed
In bed
In bed
In bed awake
Internet
Groceries
Breakfast
tv
In bed
tv
Internet
tv
In bed
In bed
tv
In bed
In bed
Internet
In bed
In bed
In bed
In bed
In bed
In bed I
In bed
In bed
,
in bed awake
shower
Internet
Internet, pay bills
tv
Internet
Internet
lunch
,
tv
Internet
Internet
tv
Internet
Internet
In bed
,
In bed
In bed I
In bed
In bed
,
TST = 6.5 hours
SOL = 90 minutes
63
In bed
In bed
In bed
In bed
In bed awake
Internet
Reading
Coffee
tv
nap
lunch
reading
tv
nap
dinner
tv
In bed
In bed
In bed
In bed
In bed
In bed
In bed
In bed
In bed
In bed
In bed
Internet
Internet
Back to bed
Resting
tv
computer
Computer
cook
dinner
computer
computer
tv
In bed
In bed
In bed
In bed
In bed
In bed
In bed
In bed awake
In bed awake
In bed
In bed
In bed awake
Internet
Internet
Back to bed
tv
shower
lunch
Visit Mom
Visit Mom
dinner
tv
tv
In bed awake
In bed
In bed
In bed awake
In bed awake
In bed
In bed
Possible mood mechanisms for
SC? Complements CBT-D?
• Increasing time out of bed in the 24 hour period
– Behavioral Activation - BA
• Engaging alternative coping strategies during
stress
– Behavioral Activation - BA
• Behavioral experiment that tests whether ↑ or ↓
effort is most helpful
– Cognitive Therapy - CT
• Challenges learned helplessness (CT)
•28
Sleep Restriction: Putative
mechanisms
• Increases sleep drive
• Sleep deprivation can reduce rumination
How is it complementary to CBT
CBT-D?
D?
• ↑ time out of bed in the 24 hour period (BA)
• Challenges learned helplessness (CT), i.e., it
increases self-efficacy
• Behavioral experiment that tests whether ↑ or ↓
effort is most helpful (CT)
Case Study
• Dan is a 33 year old male graduate student
participating in CBT for depression treatment
complaining of daytime fatigue, decreased
motivation and sleeping difficulties
difficulties.
• He spends an average of 10 hours in bed and
his total sleep time is 7.9 hours.
• His Epworth Sleepiness Scale is within
normal limits (ESS = 4). You review his sleep
logs.
Monday
Tuesday
9:00 pm
11:30 pm
25
20
20
Wake
time
Rise time
Bedtime
Time to fall asleep
Time awake during night
Wednesday
11:05 pm
Thursday
Friday
Saturday
Sunday
10:35 pm
10:55 pm
11:15 pm
11:15 pm
40
60
35
15
95
25
15
35
20
45
60
8:30 am
7:30 am
7 :30
am
7:15
am
7:20 am
8:40 am
8:50 am
9:15
am
8:20
am
8:15
am
8:25
am
7:35
am
8:50
am
11:45
am
Mean Time in Bed = 10 hours
Mean Total Sleep Time = 7.93 hours; Sleep onset latency = 42 minutes Mean Wakefulness after sleep onset (WASO) = 32 minutes
Sleep Efficiency (Time asleep/time‐in‐bed) = 79%
•29
Plan
DAN: diurnal m
mood worsening
• You want to eliminate jetlag with a set
schedule (stimulus control) and want to
(
p
limit his time-in-bed to 8.5 hours (sleep
restriction)
• Problem: he says that he can’t get up at a
regular time in the morning because this is
when his mood is at it’s worst.
7 am
MON
TUES
WED
THURS
FRI
SAT
SUN
SLEEP
SLEEP
SLEEP
SLEEP
SLEEP
SLEEP
SLEEP
8 am
SLEEP
IN BED 8
IN BED 7
IN BED 8
CAFÉ 2
SLEEP
SLEEP
9 am
IN BED 7
LAPTOP 8
GYM 3
LAPTOP 8
WALK 3
SHOWER 5
IN BED 8
10 am
SHOWER 5
LAPTOP 8
BRFT 6
PHONE 5
SHOP 3
IN BED 8
IN BED 8
11 am
BRFT 7
TV 8
GAMING 6
SHOWER 4
BILLS 5
TV IN BED 8
READING 8
12 pm
SCHOOL 5
SCHOOL 5
GAMING 7
SCHOOL 5
SHOWER 4
GAMING 7
SHOWER 6
1 pm
SCHOOL 5
SCHOOL 5
GAMING 7
SCHOOL 5
LUNCH 5
GAMING 6
BRFT 7
2 pm
SCHOOL 5
SCHOOL 5
GAMING 7
SCHOOL 5
TV 8
GAMING 7
NAP 7
3 pm
SCHOOL 5
LAPTOP 8
GAMING 7
SCHOOL 5
COUCH 8
LAPTOP 8
NAP
4 pm
NAP 7
LAPTOP 8
SHOWER 6
LAPTOP 8
COUCH 8
LAPTOP 8
LAPTOP 8
5 pm
READING 5
LAPTOP 8
READING 6
LAPTOP 8
READING 7
LAPTOP 8
LAPTOP 8
6 pm
COOK 4
GAMING 7
GAMING 7
GAMING
GAMING 8
LAPTOP 8
DINNER 4
7 pm
DINNER 5
GAMING 8
NAP 6
GAMING
GAMING 8
GAMING 7
GAMING 5
8 pm
GAMING 8
DINNER 4
DINNER 5
DINNER 4
DINNER 5
READING 6
9 pm
IN BED 7
GAMING 7
GAMING 6
GAMING 6
GAMING 7
GAMING 7
GAMING 6
10 pm
IN BED 6
TV 7
LAPTOP 6
IN BED 7
GAMING 7
DINNER 7
READING 8
PHONE 3
11 pm
TV IN BED 6
TV IN BED 6
TV IN BED 6
TV IN BED 6
TV IN BED 8
IN BED 8
IN BED 7
12 am
TV IN BED 9
TV IN BED 6
TV IN BED 7
TV IN BED 6
TV IN BED 7
TV IN BED 8
IN BED 8
1 am
SLEEP
SLEEP
SLEEP
SLEEP
TV IN BED 8
SLEEP
SLEEP
Troubleshooting Dan’s Rising
Adherence Problems
•30
Behavioral Activation + Behavioral
Insomnia Therapy (BABIT)
Memo
ory Aide
• Sleep restriction and stimulus control
• Behavioral activation with concentration in
morning or evening
• Employing a behavioral formulation and
strategy for rumination
• Increased activation for fatigue
management and to challenge avoidance
Sleep and chronic pain
*Sedentary
lif →
life
weight gain;
some pain
medications
↑ events
(muscle
relaxants,
morphine)
Chronic pain
11-55%
39-75%
Obstructive
Sleep Apnea
(OSA)
4-20%
50-88%
Insomnia
10-20%
•31
Chronic Pain and Stimulus
Control
• Belief that lying in bed awake is preferable to getting up
– “You may rest…you just need to do it somewhere other than
in your night bed.”
• Use of the bed and bedroom for rest rather than only for
sleep may strengthen the bed as a cue for pain and
suffering and weaken the bed as a cue for sleep
– Should rest in a different place
• It may be physically difficult to get out of bed or
transition to another room
– Consider Counter control (sitting up in bed); most effective
for middle of night awakenings, not onset problems
Davies, Lacks, Storandt,
Storandt, Bertelson (1986); Hoelscher & Edinger (1988)
Considerations for chronic pain
• Is pain adequately managed?
Ambivalence about pain meds may interfere with
optimal pain management at night
• Iss tthee bed used for
o nocturnal
octu a ssleep
eep aalso
so used for
o rest
est
during the day? Is resting supine? Dozing?
• Does pain-related sedentary lifestyle contribute to
sleep problem?
• Do beliefs about pain and sleep contribute to sleep
effort?
• Can’t get up? Try counter control
Anxiety and Counter-Control
• When SC instructions cannot be tolerated
• When SC instructions are contraindicated
• Over-zealous
Over zealous about getting out of bed in
middle of night does not allow enough calm
time in bed to fall back to sleep
• When need to overcome fear of bed (e.g.,
some clients with PTSD)
•32
Common treatment
challenges in those with
PTSD
Please get into groups (we need 5). Each
group will have a common treatment-related
issue to troubleshoot (10 minutes) and then
report back to the group.
Group
Treatment Issue to Troubleshoot
1
Fear of Silence, “I can’t sleep without a t.v. on”
2
Fear of loss of vigilance: “I may not be able to react if
something bad happens while I am asleep”
3
Delayed bedtime, “I am not tired at night”
4
Sleep avoidance,
avoidance “Every
Every night I dread going to bed”
bed
5
Prolonged Nightmare Awakenings: “I cant get back to
sleep because I try to figure out the meaning of the
nightmare”
Nightmares
• Those interested in nightmare treatment can
refer to original cites (e.g., Krakow JAMA
p
protocols
p
(e.g.,
( g , Carney
y
2001)) or published
& Edinger, Insomnia and Anxiety, Springer
2010)
• Evidence for prazosin (Raskind et al., 2003;
2007; Taylor, Freeman, & Cates, 2008)
•33
Insomnia vs. PTSD targets
Insomnia
only
PTSD +
insomnia
Erratic sleep scheduling


Daytime napping


Alcohol to aid sleep


H
Hyper-arousal
l as bedtime
b d i approaches
h


Unhelpful beliefs about sleep-conducive habits/needs


Excessive time in bed*

Common Targets

Sleep avoidance – limiting time in bed at night
Using bed for non-sleep activities*


Hypervigilance during sleep – on guard/checking
Unhelpful beliefs that raise anxiety about sleep loss*

Unhelpful beliefs that raise anxiety about being asleep

Considerations for SRT in
those with Panic Disorder
• Partial sleep deprivation lowers panic
thresholds (Mellman & Uhde, 1989; Roy-Byrne, Uhde,
& Post, 1986)
• Perhaps we should restrict time spent in bed
to a lesser extent in those with frequent NP
(Smith, Huang, & Manber, 2005)
– Sleep compression
– Focus on stimulus control, even counter control or counter arousal
Rolling With Sleep-Anxiety
and High Arousal
High sleepanxiety
Stimulus
May need
Control
counter-control
instead of strict
Stimulus Control
May need sleep
Sleep
compression
Restriction
instead of SRT
Therapy
High arousal in bed
Use Stimulus
Control and
emphasize counterarousal
Use SRT and
emphasize counterarousal
Cognitive therapy
•34
Sleep Compression
An alternative to SRT wherein time-in-bed (TIB)
is restricted gradually
 Reduce TIB 30 min/week from actual TIB
Example: if TIB = 8 hrs and Average TST = 6 hrs
– Standard SRT

– Sleep Compression 
TIB = 6.5 hours
TIB = 7.5 hours for week 1
TIB = 7.0 hours for week 2, etc.
Stop when sleep efficiency (SE) is
high and/or sleepiness
(e.g.,
(e.g
., Lichstein et al., 2001; Riedel
Riedel,, Lichstein & Dwyer, 1995)
Is Hypnotic Discontinuation
Necessary?
• No. Evidence that CBT-I and meds can be
paired, with continued CBT-I support during
taper (Morin et al., 2009)
• No
N advantage
d
to pairing
i i (Jacobs
(J b et al.,
l 2004)
• But, eliminate contingent sleep med use undermines self-efficacy
– Collaborate with doctor to stop or maintain
consistent daily dose (lrd) and timing throughout
treatment
• ↑ Cognitive Therapy; safety issues
Questions
•35
Case formulation:
Recommended Reading
Manber, R. & Carney, C.E. (2015). Treatment Plans
and Interventions: Insomnia. A Case Formulation
Approach. Part of the “Treatment Planner” Series
(R b L.
(Robert
L Leahy,
L h Ed.).
Ed ) The
Th Guilford
G ilf d Press,
P
Berkeley, CA.
Case Conceptualization
What factors weaken the sleep drive?
What factors impact the circadian clock?
What manifestations of hyperarousal are present?
What unhealthy sleep behaviors are present?
What comorbidities affect client’s presentation and how?
What medications may impact client’s sleep/sleepiness?
What other factors are relevant to client's presentation?
What treatment factors will address the targets above?
Case Formulation Form:
Selecting Strategies
Domains
Targets
1.
Sleep Drive: Are there any
factors weakening the sleep
drive?
N.B. Low sleep drive can
interfere with sleep onset and
continuity as well as sleep
depth/quality.
Resolution
Time-in-bed is 30 minutes
greater than average total
sleepp time?
Any evidence of dozing?
Any evidence of napping?
Any substances that block
sleep drive (e.g., caffeine)?
Evidence of decreased
physical activity in a 24-hour
period?
Lingering in bed greater than
30 minutes post-wake in the
morning?
•36
Case Formulation Form:
Selecting Strategies
Domains
Targets
Resolution
An hour or more variability in
2. Biological clock: Are there
factors weakening the signal from rise time
An hour or more variabilityy in
the biological
g
clock?
rise time
N.B. Without regular habits
Are
they a night owl keeping
congruent with one’s chronotype,
there will be weak alerting signals an early bird’s schedule, or
reverse?
(e.g., fatigue) and social jetlag
(e.g., sleep and mood problems).
Case Formulation Form:
Selecting Strategies
Domains
Targets
3. Arousal: Any evidence of
hyperarousal?
Are there rituals to produce
sleep even though sleep continues
to be bad, e.g., no alarm clock,
sleeping separate from bed
partner,
t
knockout
k k t shades,
h d white
hit
noise machine/masks, tv or
reading in bed…?
Are they worried about sleep?
Are they worried about other
things (in bed)?
Are they wide awake upon
getting into bed?
Do they stay in bed when
awake?
Do they feel
frustrated/anxious/distressed
while awake in bed?
Any behaviours engaged to
“produce sleep” (i.e., sleep
effort)?
N.B. Sleep effort is related to and
perpetuates anxiety—a state
incongruous with sleep.
Additionally, pairing wakefulness
or negative activities with the bed
will produce conditioned arousal.
Resolution
Case Formulation Form:
Selecting Strategies
Domains
4. Unhealthy sleep behaviors:
Any sleep behaviors that interfere
with sleepp depth?
p
Targets
Resolution
Excessive or late caffeine?
Alcohol?
Marijuana?
j
Short-acting sleeping pills?
Nocturnal eating?
Vigorous evening exercise?
•37
Case Formulation Form:
Selecting Strategies
Domains
Targets
5. Medications: Any medications
that could produce sleepiness or
insomnia?
Sedating antidepressant
producing daytime sedation
Resolution
Case Formulation Form:
Selecting Strategies
Domains
Targets
6. Comorbidities: Any
comorbidities that impact sleep?
Sleep apnea, if yes, is it
adequately treated?
Restless Legg Syndrome,
y
if yyes,
is it adequately treated?
Periodic Limb Movement, if
yes, is it adequately treated?
Chronic pain, if yes, is it
adequately treated?
Others?
Resolution
Case Formulation Form:
Selecting Strategies
Domains
Targets
7. Any other factors? Consider
sleep environment, care taking
duties at night,
g , life pphase sleep
p
issues; mental status, and
readiness for change.
Sleep environment optimal?
Care taking or on-call duties at
night?
g
Cognitive or learning issues?
What stage of readiness for
change?
Any resistance to engaging in
short-term behavior changes?
Resolution
•38
From Case Conceptualization
To Treatment Planning
Consider the Big Picture
• Relative strength of the different factors
impacting sleep
• Identify the top factors
– If possible rank order them
• Consider client’s readiness when deciding
which components to start with
Case Conceptualization
Case 1: Lucy
A 78 year old married female,
retired nurse
nurse, complaining of
sleep maintenance problems,
depression and arthritis. Her
husband is currently being
treated for prostate cancer.
Lucy’s Clinical Interview Results
Stressors: husband with prostate cancer; socially isolated
History: insomnia during periods of depression, increased with menopause
Bedtime: 7:00 PM watches TV, Dozes on and off
minutes
Sleep onset < 30
Middle night: 3-4 times a night, up 20-40 minutes each time
Wake time = 3 AM
Out of Bed = 4:30 AM
Daytime effects: tired, does not drive, tries to nap during the day
Comorbidities: arthritis, depression, RLS
Medications: Motrin, Mirapex, Cipralex, calcium
Substances: Coffee and a glass of wine with dinner at 4:30 PM
Goal: sleep at least 8 hours and not worry about it
•39
Lucy’s Sleep Log
Monday
Bedtime
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
7:00 pm
7:30
pm
7:30
pm
7:00
pm
7:30
pm
7:00 pm
7:30
pm
40 min
15 min
25 min
40 min
35 min
25 min
15 min
180 min
90 min
150 min
170 min
55 min
50 min
120 min
Wake time
3:35 am
3:05 am
3:20 am
3:10 am
3:30 am
3:30 am
2:30 am
Rise time
4:30 am
4:45 am
4:30 am
4:00 am
4:45 am
4:15 pm
4:40 pm
Nap
duration
ETOH
0
15 min
0
35 min
5 min
5 min
40 min
1 wine
1 wine
2 wine
1 wine
1 wine
2 wine
1 wine
Time to
fall asleep
Time
awake
during
night
Average time in bed is over 9 hours + nap attempts on most days
Case Conceptualization: Lucy
•
•
•
•
•
•
•
What factors weaken the sleep
drive?
What factors impact the
circadian clock?
What manifestations of
hyperarousal are present?
What unhealthy sleep
behaviors are present?
What comorbidities affect
patient’s presentation and how?
What medications may impact
patient’s sleep/sleepiness?
What are the predisposing,
precipitating, and maintaining
factors?
•
•
•
•
•
•
•
Dozing; nap opportunities; >9 hrs in
bed
Extreme morningness; few
activities to cue biological clock ?
Worry about sleep (e.g.,
clockwatching); cannot nap
Coffee; ETOH; worry in bed;
extended time in bed
Pain lightens sleep; ↑awakenings;
depression – ↓activities, ↑ TIB (?)
Celexa (??)
Predisposing/precipitating: pain,
depression, anxiety, and hot flashes
Maintaining: Worry about sleep and
compensatory behaviors
Lucy: Treatment Planning
Factor to Consider
Treatment Component
Modifications
Weak sleep drive (extended time Sleep restriction
in bed, dozing off in evening etc) Stimulus control
Anticipate and creatively
troubleshoot adherence
and safety issues
Advanced circadian tendency
Relevant to time in bed
window
May need evening light
exposure
D
Depression
i
Behavioral
B
h i l activation
ti ti
(evening)
Ensure depression
E
d
i is
i
adequately treated
Anxiety (intrusive thoughts)
Buffer zone
Shorten “buffer zone”;
Assess/enhance coping with
current stressors
Beliefs about sleep needs (at
least 8 hours)
Sleep education and
cognitive restructuring
Pain
Propping
CBT for chronic pain
•40