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Lecture 11

Clinical Psych Lecture 11

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Ryerson University
PSY 335
Tara M Burke

Cognitive Behavioural Therapy for Insomnia DSM-5 Insomnia Disorder • The predominant complaint is a dissatisfaction with sleep quantity or quality (difficulty initiating or maintaining sleep, or non-restorative sleep). • The sleep complaint is accompanied by significant distress or impairment in daytime functioning (e.g., fatigue, mood, cognitive complaints, interpersonal, occupational or academic functioning) • You are anxious about sleep, it does NOT mean you have depression or GAD, it’s insomnia • Sleep difficulty occurs at least three nights per week • Sleep difficulty is present for at least three months • Sleep difficulty occurs despite adequate opportunity for sleep What % of the general population have insomnia characterized by sleep difficulty at night along with associated daytime deficits? 10-15%!! Several Studies Show That Insomnia Is a Risk Factor for Major Depressive Disorder (MDD) i m ) i ( v a D d M O d h i ( Insomnia does not always go away with the comorbid condition • Insomnia is a risk factor for developing another disorder- especially depression! • Residual insomnia • Residual insomnia increases risk for relapse- even after depression treatment, insomnia often remains • In those completing treatment (CBT or PT) and remitting from depression (i.e., no longer meeting MDD criteria and HRSD<7), 53% had at least one residual sleep problem at post-treatment (Carney et al., 2007) • Residual insomnia in other disorders (e.g., Zayfert & Deviva rate after PTSD recovery is 50%) Why Worry about Insomnia The risk that insomnia confers in the context of depression. Insomnia: 1. can remain after remission from depression (residual insomnia) 2. enhances risks for poorer response to depression therapy 3. predicts the recurrence of depressive episodes 4. is associated with increased risk for suicide 5. can predate and predict the initial onset of the depression 6. exacerbates depression symptoms (when you’re exhausted, you stop doing things) Two Process Model of Sleep: Implications for Insomnia What regulates how well we sleep? A Multi-factorial Model Webb’ s1988Model CircadianMechanism “Biologicalclock” Facilitators--Inhibitors HomeostaticMechanism SleepScheduling Behavioral SSleepdrive Environmental Sleep Homeostatic Regulation of Sleep • Like a thermostat for sleep • Based on hours spent awake or asleep Sleep Drive • The less time you spend awake during a 24 hour period, the less sleep drive you have • Making-up for poor sleep rarely works • When your sleep drive is low but your time spent in bed is high –sleep is light • Slow wave sleep= deep sleep, which restores the tissues in your body • SWS= Slow wave sleep Naps and Sleeping-In • Sleeping-in morning not restorative because no drive built-up • Naps later in day are restorative b/c of built-up debt • Naps then wipe-out drive for nocturnal sleep • Adenosine buildup- makes you more tired and only occurs during cell expendature How much Sleep is Enough? • Sleep need is dependent on multiple factors (age, illness, activity levels, and prior wakefulness). TWO PROCESS MODEL • One size does NOT fit all • Sleep drive is not based on desire for sleep, it is based on physiological need Circadian Clock - The MOST important thing for this clock is light - It is very predictive Sometimes the Body Clock Gets out of Alignment • Regular bedtimes, regular rise times and regular light exposure “set” the clock and prevent drift • Variability = Jetlag symptoms (mismatch between the clock on the wall and the clock in your body • Important to keep a schedule Individual Differences- can be genetic Owls Get sleepy late, have trouble getting up in the morning Teens and young adults They are able to adjust better Larks Get sleepy early, wake feeling fairly alert More regular schedules Children and older adults Body Clock Summary • Keep bedtime and rise time: Regular Also include regular exposure to daylight and other regular daily activities • Be consistent with your body clock (larks need to be larks etc…) • Most of our REM sleep happens in the second half of the night • REM is NOT restorative, but it is good for memory and learning CBT Perpetuating Factors Spielman’s model describing the evolution of chronic primary insomnia CUnhelpfulBeliefs Worry&intrusivethoughts InhibitoryFactors HomeostaticDisruption Poorsleephygiene ExcessivenocturnalTIBCircadianDisruptionConditionedarousal DaytimeNapping SleepScheduling Pre-bed&In-bed habits ChronicInsomnia Treatment Approach: You may resort to naps, alcohol, try and sleep in- which all increases Treatment Strategies & Targets Edinger and Carney (2007)u risk for insomnia. Overcoming Insomnia - Behavioural Treatments That Work series Alter sleep-disruptive habits Alter unhelpful belieEducational & cognitive arousal Improve sleep knowledge & hygiene • Excessive time in bed • Irregular sleep • Unrealistic sleep • Sleep incompatibleexpectations activities • Sleep Misconceptihinder responsecan • Conditioned arousaanxietyanticipatory • Poor coping skills • Bedtime cognitive arousal Sleep Restriction Therapy: Restore Homeostatic Drive and Schedule • Trying to restore the homeostatic drive problem that we have • Excessive time in bed (TIB) given current sleep drive • Solution? Match TIB with current drive- to build up adenosine • Ascertain average sleep time - AST (Log): take a sleep drive log! Figure out their average sleep time • Limit time in bed (TIB) toAST + 30 min. Calculations for Sleep Restrictionalculations for Sleep Restriction From Sleep Log Mon. Tues. Wed. Thurs. Fri. Sat. Sun. Total time in 510-2 540-2 535-19 465-18 510-2 570-16 Into bed 11:30 11:45 10:15 minus the total time1465-24 Time to fall asleep awake in bed 80 = 25 = 5 = 0 = 70 = 5 = 30 90 120 15 30 45230 30 =225 315 340 285 240 405 (min.) = Total sleep time Time awake Total average sleep time = Total sleep time for all days divided by number of days during the night45 60 90 15 45 30 15 (230 + 225 + 315 + 340 + 285 + 240 + 405) / 7 days = 291 minutes Waking time 4:45 6 7 5 6:15 5:45 6:30 Out of bed Divide by 60 to convert it to hours = about 5 hours (4.85) Time in Bed 8 7:30 7:15 7:45 8 8:30 8:30 8.5 7.75 9 8.75 7.75 8.5 9.5 Add all the time awake and then subtract it from the time spent in bed Stimulus control: decreased conditioning factors • Bed is paired with distress and wakefulness which becomes a CS for wakefulness • Solution: unpair them • Avoid sleep-incompatible activities in bed • Get out of bed when unable to sleep • Avoid daytime napping • Retire only when sleepy • Select a standard wake-up time CBTRegimen 6:00 AM  12:30 AM  Collaboration is the key Cognitive Therapy Techniques and Research Findings - Negative thoughts lead to distress Cognitive Insomnia Model - Worry-based thoughts are Night  Day  driven by beliefs Beliefs  - Engage in coping behaviours Negative Thoughts  Key Cognitive Targets Distress  Behaviours  1. Inaccurate beliefs about sleep Attentional bias  It’ I’ m never going 2. Overactive mind and worry: conceto be able to unfinished business and/or Chronic Insomnia  sleep conditioning 3. Thought/beliefsèdistress connection Harvey, 2002 4. Attentional Bias 5. Safety Behaviors Correcting Inaccurate Beliefs • Sleep Norms & requirements Ú sleep needs • Effects of Aging on Sleep Ú sleep needs • Effects of Sleep Deprivation Ú effects of insomnia • Controlling Mechanisms Ú sleep promoting habits • Homeostatic factors controlling sleep • Circadian • Psychological/Environmental Myth* Why it is not true Consequence of believing this myth “I need 8 hours to function” There is a wide range of sleep needs. The Eight hours becomes a magical number that average amount of sleep needed for an adultsignals anxiety if it is not reached. It may be an is unknown but it is probably less than 8 unrealistic number for you (and for most adults). hours. Secondly, sleep duration is only one of many determinants of daytime functioning—sleep quality is probably more important than the total amount of sleep. “If I have a good sleep I It is natural to spend up to 30 minutes after Can become a self-fulfilling prophesy. If you should wake-up feeling waking feeling “groggy”. This is called awaken and think, “I feel terrible; I am never going refreshed”. sleep “inertia” or sleep “drunkenness” to be able to get through today.” Chances are you which is transient and is likely impacted by will have a more difficult time and that sleep the sleep stage from which you were performance anxiety will increase, leading to awakened.. The best way to determine howworse sleep. well you slept is by how well you feel throughout the day. “I wake up a couple of timesThe average number of awakenings per Believing that you should never wake-up in the each night. Even though I night is about 12 (Bonnet &Arand, 2007). night, even if you fall back to sleep right away is fall back to sleep pretty The convention for a normal amount of unrealistic and will only produce anxiety. The quickly, I know it must betime to spend awake in bed is up to 30 anxiety may eventually produce a more serious having a negative effect” minutes. insomnia. “If I spend more time in Sleep quality is more important that its Worsening of your sleep and mood. Aweakened bed, I will get more sleepquantity. In addition to interfering with the sleep driver compensate for increased time in bed and feel better the next day”.sleep driver and your biological clocby decreasing the drive for sleep. spending extra time in bed has been linked to increased depression. “I’m older so insomnia is While there are increased awakenings from Changes that could improve your sleep are not just a fact of life” sleep with aging, not all older adults made. develop insomnia. There are also things that you can do (as outlined in this book) to prevent insomnia as you age. “Sleep is due to a chemical There is no evidence of this, and sleepSends the message that you have no power to imbalance” pills do not target an “imbalance” affect your sleep. Aloss of confidence in your ability to sleep further undermines your sleep. Overactive Mind? Stimulus Control • Leave the room when worrying. • Thoughts tend to be more lucid and reasonable in the other room anyway Constructive Worry • Sometimes worry/planning occurs because it is the first opportunity • Scheduling worry can help • Empirical evidence: Espie and Lin
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