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28/01/2014
1
Sleep workshop
Prof Colin A Espie Professor of Behavioural Sleep Medicine, Nuffield Department of
Clinical Neurosciences and Sleep & Circadian Neuroscience Institute, University of Oxford
Sleep and Circadian Neuroscience Institute (SCNi) for Mental Health
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Research interests
Understanding sleep problems • Precipitating and perpetuating factors for sleep disorder phenotypes • Pathophysiology of, and cognitive processes in, psychophysiological
insomnia • The association between sleep disturbance and mental and physical
illness • nREM arousal disorders and their management
Managing sleep problems • Cognitive behavioural treatments for sleep disorders • Critical mechanisms in CBT and issues of sleep therapy compliance • Clinical effectiveness and community delivery models • Use of online rich media to deliver CBT
Assessing sleep problems in routine clinical practice
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Generic aspects - taking a history
• Personal details • Presenting problem(s) • Development of problem • ABC model • 3 P’s model • Treatment history • Personal history • Medical/ psychiatric history • Personality – pre-morbid, coping, etc. • Mental state • Formulation • Plan of action
The natural history of insomnia
Spielman, Glovinsky. The varied nature of insomnia. In Case studies in insomnia, ed. P. Hauri, pp.1-15. New York: Plenum Press. 1991
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The Sleep Condi-on Indicator (SCI): a prac-cal
clinical screening tool to evaluate DSM-‐5 Insomnia Disorder
pdf or www.sleepio.com
Espie et al (under review)
Objectives
• To develop and test the psychometric properties of a brief clinical screening tool to evaluate DSM-5 Insomnia Disorder
• To develop a short-form version for rapid (pre-)screening
• GAD-7 and GAD-2 serves as a useful model
[Named the Sleep Condition Indicator (SCI)]
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SCI design logic – item coverage • 2 quantitative items on sleep continuity [item 1: getting to
sleep; item 2: remaining asleep] • 2 qualitative items on sleep satisfaction/dissatisfaction
[item 4: sleep quality; item 7: troubled or not] • 2 quantitative items on severity [item 3: nights per week;
item 8: duration of problem] • 2 qualitative items on attributed daytime consequences
[item 5: effects on mood, energy, or relationships (personal functioning); item 6: effects on concentration, productivity, or ability to stay awake (daytime performance)]
Sample: total n=30,941; 71% F Sample
Description
n
Age (y)
Gender
GBSS-1 Online survey in UK on dedicated site
12,628 38.7 (14.5) 72% F
GBSS-2 Online survey continued, extended worldwide
11,017 42.3 (16.5) 68% F
TV Data collected online by TV company
6,876 36.4 (13.3) 76% F
Science Centre
Visitors booth 256 40.3 (14.9) 56% F
RCT Trial participants 164 48.9 (13.7) 72% F
www.worldsleepsurvey.com
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DSM-5
0-32 score, converted to a 10 point scale. High scores indicate sleep in good condition
Short form • Logistic regression analysis to determine which
subset of items explains greatest proportion of variance in the SCI-08
• Two-items, comprising: item 3 ‘…how many nights’ (standardized ß = .515) item 8 ‘… troubled you in general’ (ß = .491)
predicted 82% of variance (Adjusted R2 = .820) • SCI-02 correlates strongly with the SCI score total
(r = .904).
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General indices of sleep/ insomnia complaint
ü Pittsburgh Sleep Quality Index (commonly used, has established cut-off score
>5, equates to sleep disturbance not insomnia, also profiles other sleep problems so may be useful screening tool)
ü Insomnia Severity Index (specific to insomnia, profiles the insomnia
problem, brief, quite stringent) ü Sleep Condition Indicator (based on DSM-V criteria for Insomnia Disorder)
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The classification of sleep disorders, and the differential diagnosis amongst sleep disorders
Diagnostic algorithm (pdf)
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Morningness Eveningness Questionnaire (MEQ)
Example item One hears about ‘morning’ and ‘evening’ types of people, which one of these types do you consider yourself to be? q Definitely a morning type q Rather more a morning than an evening type q Neither q Rather more an evening type than a morning
type q Definitely an evening type
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Sleep laboratory assessment
Sample PSG output
EOG
EEG EMG
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SSTTAAGGEE 11 SSLLEEEEPP
SSTTAAGGEE 22 SSLLEEEEPP
SSTTAAGGEESS 33 && 44 ((SSWWSS))
AAWWAAKKEE -- AALLPPHHAA
AAWWAAKKEE -- AALLEERRTT
The EEG in nREM sleep
Courtesy of Dr. Michael Perlis, Rochester NY
REM sleep characteristics
Atonia
Phasic twitches
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Sleep diary (pdf) or www.sleepio.com
Recommendations for assessment
• History • Assessment of sleep pattern and quality (Sleep
diary for 2 weeks) • Assessment of insomnia impact (e.g. SCI, ISI) • Screening for other disorders • Further assessment if required (e.g. PSG,
oximetry, MSLT, blood chemistries) • Assessment of co-morbidities (e.g. depression,
PTSD) • Assessment of psychological antecedents/ correlates
(formulation) • Appraisal of outcomes (diary, impact, clinical
improvement)
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Insomnia the most common expression of mental dis-ease
% of Adults with a score >= 2 on neurotic symptoms
28
19
119
23
17
108.5
33
21
129.5
0
5
10
15
20
25
30
35
Sleepproblems
Worry Depression Anxiety
%
Total Men Women
0
0.2
0.4
0.6
0.8
1
1.2
Mean score
PHQ1 PHQ2 PHQ3 PHQ4 PHQ5 PHQ6 PHQ7 PHQ8 PHQ9
PHQ item
Figure 4: Profile of 4,355 cancer patients on the PHQ-9
Sharpe, Espie, Fleming et al, unpublished data
Fatigue (PHQ4) and sleep disturbance (PHQ3) are most prevalent symptoms in the depressive cluster; compared with feeling depressed (PHQ2), poor appetite (PHQ5), or difficulty concentrating (PHQ7).
Fatigue and insomnia are most common symptoms in medical populations
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INSOMNIA IS A RISK FACTOR FOR DEVELOPING DEPRESSION AND FOR RELAPSING INTO DEPRESSION
• Riemann D, Voderholzer U. Primary insomnia: A risk factor to develop depression? Journal of Affective Disorders 2003;76:255-9.
• Cole MG, Dendukuri N.
Risk factors for depression among elderly community subjects: a systematic review and meta-analysis. American Journal of Psychiatry 2003;160:1147-56.
“Insomnia Disorder … whenever diagnostic criteria are met, whether or not there is a co-existing psychiatric, medical, or another sleep disorder”
Insomnia Disorder • difficulty initiating sleep • difficulty maintaining sleep • early morning awakening with inability to return to sleep • non-restorative sleep [underlying dissatisfaction with quality/quantity] • ≥ 3 nights per week, for > 3 months (persistent insomnia) • occurs despite adequate opportunity and circumstance to sleep
• results in daytime dysfunction: - fatigue, physical tension, low mood, impaired concentration, social/
relationship functioning impaired
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Prevalence & natural history of ID
• 10-12% of population meet criteria for ID • 3% of the population will experience ID on its
own (without co-morbidity) • ID is persistent: 75% of those with ID will meet
criteria 1 yr later; nearly 50% 3 yrs later • 45% experience ID for > 6 yrs 25% of all ID patients slept poorly since
childhood
Morin et al. (2009). Arch Intern Med Espie et al. (2012). J Clinical Psychiatry
Associated morbidity
- ID is a risk factor the future development of depression - ID is a risk factor for non-response, non-remission, and
relapse into depression - ID is an independent risk factor for hypertension, diabetes,
and cardiovascular disease - Impairs day-to-day functioning, health-related quality of life
and global quality of life - Mortality? [Insomnia (<6hrs sleep) 4 x more likely to have died at 14 yr follow-up than those without insomnia] Baglioni et al. (2011). J Affective Disorders
Kyle et al. (2010). Sleep Medicine Reviews. Kyle, Morgan & Espie (2010). Behavioural Sleep Med Vgontzas et al. (2010). Sleep; 33; 1159-1164
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Why is CBT relevant to insomnia?
Why is CBT relevant to insomnia?
The essential feature of Psychophysiological Insomnia is heightened arousal and learned sleep-preventing associations… Arousal can also reflect a cognitive hypervigilance. Indeed, mental arousal in the form of a “racing mind” is characteristic … A cycle develops in which the more one strives to sleep, the more agitated one becomes, and the less able one is to fall asleep
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Borkovec et al: wakefulness experience when cortically asleep
Thinking processes remain part of the insomniac’s experience even when wakened
from light sleep
Borkovec, Lane, Van Oot. J.Abnorm.Psychol. 1981;90:607-9
ARAS ARAS
Thalamus
Mesial temporal cortex
Hypothalamus
Cingulate
Mesial temporal cortex Hypothalamus
ARAS
Insular cortex
Nofzinger et al.: Brain imaging studies in insomnia
Nofzinger et al. Psychiatry Research: Neuroimaging 2000;98:71-91
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Perlis et al. J Sleep Res 1997;6:179-88
Vulnerability or extant illness
Precipitating event
Maladaptive coping strategy
Conditioned arousal somatic cognitive CORTICAL
Cognitive alterations sensory processing information processing long-term memory formation
Complaint of insomnia can’t fall asleep wake up frequently perceived wakefulness vs polysomnogram sleep overestimation of wakefulness
Perlis:The neurocognitive perspective on insomnia
Harvey: a cognitive model of insomnia
Excessive worry
Distorted perception of deficit
Safety behaviours
Beliefs
Key. Leads to Exacerbates
Arousal and distress
Selective attention and monitoring
In bed/during the day
Real deficit
Harvey. Behav.Res.Ther. 2002;40:869-893
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DELTA * BETA1 WHOLE NIGHT
0
20
40
60
80
100
0 38 76 114
152
190
228
266
304
342
380
418
456
494
532
570
608
646
684
722
760
798
836
874
912
950
988
DELTA
0
2
4
6
8
10
BETA1
0
20
40
60
80
100
0 43 86 129
172
215
258
301
344
387
430
473
516
559
602
645
688
731
774
817
870
915
962
1005
DELTA
0
2
4
6
8
10
BETA1
0
20
40
60
80
100
0 41 82 123
164
205
246
287
328
369
410
451
492
533
574
615
656
697
738
779
820
862
903
947
988
DELTA
0
2
4
6
8
10
BETA1
DELTA BETA1
GOOD SLEEPER CONTROLS
DEPRESSION
PRIMARY INSOMNIA
SLEEP ONSET
SLEEP ONSET
SLEEP ONSET
Perlis et al. J.Sleep Res. 2001;10:93-104
Power spectral analysis of sleep in insomnia
Stressful life event
Psychological & physiological correlates of stress
Inhibition of sleep-related de-arousal
INSOMNIA SYMPTOMS
Arousal perpetuates sleep disturbance
Selective attention toward stressors
Selective attention SHIFT
A1 - implicit shift toward sleep cues
A2 - explicit shift toward sleep cues
E - sleep effort
I - explicit intention
Recovery of normal sleep
Why is CBT relevant to insomnia?
Espie et al. The Attention-Intention-Effort pathway in Psychophysiological Insomnia Sleep Medicine Reviews (2006)
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“Sleep (is like) a dove which has landed near one’s hand and stays there as long as one does not pay
any attention to it; if one attempts to grab it, it quickly flies away”
[Viktor E. Frankl (1965, p. 253)]
Espie: Psychobiological Inhibition Model What are the cognitive differences between NS and PI?
Normal sleep
• Minimal attention
• Minimal intention
• Minimal effort
• Minimal concern
Espie. Ann.Rev.Psychol. 2002;53:215-243 (Psychobiological Inhibition Model of insomn
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Espie: Psychobiological Inhibition Model What are the cognitive differences between NS and PI?
Normal sleep
• Minimal attention
• Minimal intention
• Minimal effort
• Minimal concern
Psychophysiological Insomnia • Selective attention to sleep,
sleeplessness, sleep consequences
• Activated intention to sleep, purposive
• Sleep effort, both direct and indirect
• Sleep preoccupation, persistent insomnia complaint
Espie. Ann.Rev.Psychol. 2002;53:215-243 (Psychobiological Inhibition Model of insomn
AASM task force (Morin et al.) Sleep 1999: 22; 1134-56,
Sleep 2006: 29; 1398-1414 AASM practice parameter conclusions
based on APA criteria as “well established treatment”
þ Stimulus control þ Progressive muscle relaxation þ Paradoxical intention þ Sleep restriction þ Multi-modal CBT
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Sleep Hygiene
Riemann D, Perlis ML. (2009) The treatments of chronic
insomnia: A review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Medicine Reviews, 13(3), 205-14
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“CBT has been found to be as effective as prescription medications are for short-term treatment of chronic insomnia. Moreover, there are indications that the beneficial effects of CBT, in contrast to those produced by medications, may last well beyond the termination of active treatment” (p.14)
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How can we deliver CBT?
Individual therapy
e.g. Ø Morin et al (2009)
Cognitive-Behavior Therapy, Singly and Combined with Medication, for Persistent Insomnia: Acute and Maintenance Therapeutic Effects. JAMA
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Brief therapy
e.g. Ø Edinger et al (2007)
Dose-response effects of cognitive-behavioral insomnia therapy: a randomized clinical trial. SLEEP 30:203-212
Ø Buysse et al (2011) Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Int Med 171:887-895
Group therapy
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Large groups e.g. Ø Swift et al (2012) The effectiveness of community day-
long CBT-I workshops for participants with insomnia symptoms: a randomised controlled trial. J Sleep Res 21, 270-280
Self-help books
e.g. Ø Jernelov et al (2012)
Efficacy of a Behavioral Self-help Treatment With or Without Therapist Guidance for Co-morbid and Primary Insomnia; a Randomized Controlled Trial. BMC Psychiatry. 2012;12(5)
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Online
www.sleepio.com
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Integrating online and clinical practice
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The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
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Useful tools in working with insomnia
• Pre-Sleep Arousal Scale • Sleep Disturbance
Questionnaire • Sleep Hygiene Practice
Scale • Sleep Behaviour Rating
Scale • Dysfunctional Beliefs and
Attitudes About Sleep scale • Glasgow Content of
Thoughts Inventory • Glasgow Sleep Effort Scale • Glasgow Sleep Impact Index
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Sleep hygiene
Sleep hygiene
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Sleep hygiene
What is relaxation therapy?
• Following Jacobson (1929), Abbreviated Progressive Muscle Relaxation (Bernstein & Borkovec, 1973) used by Borkovec et al (several studies from mid-1970’s to early 1980s)
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Abbreviated progressive muscle relaxation
From Espie (1991)
What is relaxation therapy?
• Following Jacobson (1929), Abbreviated Progressive Muscle Relaxation (Bernstein & Borkovec, 1973) used by Borkovec et al (several studies from mid-1970’s to early 1980s)
• Schultz & Luthe (1959) Autogenic Training methods tend to be incorporated into relaxation routines
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Autogenic training • A more ‘cognitive’ strategy • Subject taught to rehearse simple standard
phrases referring to experiences of warmth and heaviness in the extremities (“my right arm is feeling warm and heavy”)
• Instructs body to state of low arousal and attends to sensations
• Responses more passive than in PMR • Somewhat like self-hypnosis
What is relaxation therapy?
• Following Jacobson (1929), Abbreviated Progressive Muscle Relaxation (Bernstein & Borkovec, 1973) used by Borkovec et al (several studies from mid-1970’s to early 1980s)
• Schultz & Luthe (1959) Autogenic Training methods tend to be incorporated into relaxation routines
• Meditation in various forms applied to insomnia (e.g. Woolfolk et al, 1975; 1976)
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Meditation • Various forms – yoga, transcendental • In common they use a ‘mantra’ as focus • Aims to transfer attention from external to
internal • Primary focus is often on breathing “in”/ “out” • Such stimuli may prove soporific/ block
competing mental activity • Cue-controlled relaxation often uses the word
“relax”
What is relaxation therapy?
• Following Jacobson (1929), Abbreviated Progressive Muscle Relaxation (Bernstein & Borkovec, 1973) used by Borkovec et al (several studies from mid-1970’s to early 1980s)
• Schultz & Luthe (1959) Autogenic Training methods tend to be incorporated into relaxation routines
• Meditation in various forms applied to insomnia (e.g. Woolfolk et al, 1975; 1976)
• (e.g. Graham et al, 1975)
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Self-hypnosis
• Different techniques for hypnotic induction (e.g. eye fixation)
• Suggestibility important • Inference of trance-like state • Implies (inevitable) biofeedback?
What is relaxation therapy?
• Following Jacobson (1929), Abbreviated Progressive Muscle Relaxation (Bernstein & Borkovec, 1973) used by Borkovec et al (several studies from mid-1970’s to early 1980s)
• Schultz & Luthe (1959) Autogenic Training methods tend to be incorporated into relaxation routines
• Meditation in various forms applied to insomnia (e.g. Woolfolk et al, 1975; 1976)
• Self-hypnosis (e.g. Graham et al, 1975) • EMG Biofeedback (Freedman & Papsdorf, 1976;
Coursey et al, 1980); EEG theta and SMR biofeedback (various studies by Hauri in 1970s and 1980s; Feinsetein et al, 1974)
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Biofeedback • Forehead or other muscle electrodes for EMG
biofeedback • Reduce audible tone that reflects muscle tension
(muscle tone) • Concentrate on sensations and thoughts that
elicit such changes • Way of rewarding/ reinforcing successful
relaxation response • Requires equipment
What is relaxation therapy?
• Following Jacobson (1929), Abbreviated Progressive Muscle Relaxation (Bernstein & Borkovec, 1973) used by Borkovec et al (several studies from mid-1970’s to early 1980s)
• Schultz & Luthe (1959) Autogenic Training methods tend to be incorporated into relaxation routines
• Meditation in various forms applied to insomnia (e.g. Woolfolk et al, 1975; 1976)
• Self-hypnosis (e.g. Graham et al, 1975) • EMG Biofeedback (Freedman & Papsdorf, 1976;
Coursey et al, 1980); EEG theta and SMR biofeedback (various studies by Hauri in 1970s and 1980s; Feinsetein et al, 1974)
• Davidson & Schwartz (1976) generic classification model
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Relaxation quadrant
How to relax
• Need time • Need to practice • Need to acquire a skill • Need to apply the skill • Need to develop confidence that it is
useful
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Do you value relaxation?
Possibly a common pathway?
• To de-arousal • Physiological and mental • Provides self-instruction; improves self-efficacy • Attention focussing/ tension release cycles may not
be critical • The human relaxation response (Herbert Benson)
http://www.relaxationresponse.org/HerbertBenson.htm e.g. Benson H, Beary JF, Carol MP. The relaxation response. Psychiatry
1974;37:37-46.
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Training in relaxation therapy for insomnia
• Read script • Listen to CD/ mp3 • Be a subject • Internalise the instructions • Then make your own recording • Try it out • Practise with peers • Practise with patients
Stimulus control therapy
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Stimulus control therapy
Stimulus control therapy
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Stimulus control therapy
Stimulus control therapy
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Sleep restriction
Homeostatic regulation of sleep
0
5
10
15
20
Late
ncy
to s
leep
ons
et (m
in)
0930 1130 1330 1530 1730 1930 Time of day
0 hours
9 hours 7 hours 5 hours
4 hours
Day 2 of deprivation
Young adults on the 2nd day of various nocturnal sleep time conditions. Subjects per condition: 9 hrs, n=20; 7 hrs, n=14; 5 hrs, n=10; 4 hrs, n=13; 0 hrs, n=6 From Roth, Roerhs, Carskadon & Dement, 1989
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Circadian drives • Strong 24-hour rhythm • Based in the SCN transcriptional/translational loop, timed by
light, through specialised retinal cells containing melanopsin and controlled by several genes – 3 Period, 2 Cryptochrome, CLOCK, and BMal1 (Brain and Muscle Anat-Like)
Temperature (°C)
Plasma growth hormone (ng/ml)
Plasma cortisol (µg/100 ml)
Urinary potassium (mEq/L)
Circadian time (hours)
Sleep restriction
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Sleep restriction
Sleep restriction
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Sleep restriction
Sleep restriction
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Sleep restriction
Sleep restriction
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Sleep restriction
Sleep restriction
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Sleep restriction
Sleep restriction
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Sleep restriction
• Stick to new schedule 7 nights per week • Try to achieve 90% SE • Adjust TIB conditionally on a weekly basis • e.g. by adding 15 mins if 90% achieved
Cognitive strategies for insomnia
Colin A. Espie
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‘Sleep architecture’ hypnogram of sleep across the life cycle
Sleep stage distribution across adult years
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A third (implicit) process in sleep regulation?
Sleep homeostat
Circadian pacemaker Automatic (not ‘manual’) process
What are the thoughts, beliefs and attitudes of people with insomnia?
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What are the thoughts, beliefs and attitudes of people with insomnia?
What do they think about in bed?
Glasgow Content of Thoughts Inventory pdf
Harvey & Espie, 2004
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Source: GBSS/WSS, n=10,206
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A ‘wind down’ schedule is useful
Cognitive control; putting the day to rest (Espie & Lindsay, 1987)
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Putting the day to rest
Putting the day to rest
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Putting the day to rest
What about their beliefs and attitudes about sleep?
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DBAS-16 (Morin et al, 1993; 2003)
DBAS-16
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Cognitive restructuring
Cognitive strategies for changing beliefs and attitudes about sleep
1. Keep expectations realistic 2. Revise attributions about causes of insomnia 3. Sleeplessness does not account for all
daytime 4. Do not catastrophise after a poor night's
sleep 5. Don't place too much emphasis on sleep 6. Develop tolerance to effects of sleep loss 7. Never try to sleep
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Cognitive strategies for changing beliefs and attitudes about sleep
1. Keep expectations realistic e.g. understanding individual sleep need and the 'eight
hour fallacy'
Cognitive strategies for changing beliefs and attitudes about sleep
2. Revise attributions about causes of insomnia e.g. consider a more multidimensional account of
insomnia; instead of focusing on one factor (e.g. 'chemical imbalance'). Emphasis should be placed on those factors that the patient can exert direct influence over (e.g. napping)
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Cognitive strategies for changing beliefs and attitudes about sleep
3. Sleeplessness does not account for all
daytime impairments guide the patient to challenge the notion that poor
sleep uniquely explains daytime dysfunction, and to consider
Cognitive strategies for changing beliefs and attitudes about sleep
4. Do not catastrophise after a poor night's sleep
assess for exaggerations of the impact of insomnia,
and guide patient to put in perspective their concerns: "What is the worst that can happen if you don't sleep tonight?". Reinforce the notion that insomnia is, on the whole, not dangerous.
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Cognitive strategies for changing beliefs and attitudes about sleep
5. Don't place too much emphasis on sleep encourage patient to shift their focus away from sleep
as the centre of their existence. Discuss safety behaviours and their impact (e.g. avoiding social activities). Reduce feelings of being a helpless victim.
Cognitive strategies for changing beliefs and attitudes about sleep
6. Develop tolerance to effects of sleep loss encourage patient to continue with normal daily
routine/activities after poor sleep. Prescribe a behavioural experiment where patient engages in a pleasurable activity after a poor night of sleep, to directly challenge and disprove the belief that sleeplessness impairs enjoyment of all daily activities.
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Cognitive strategies for changing beliefs and attitudes about sleep
7. Never try to sleep explain to patient that sleep is an automatic process
that cannot be initiated by willful effort. Consider asking patient to try and stay awake (paradoxical intention) in order to reduce associated performance anxiety
Paradoxical intention
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Problem – Attention bias & trying to sleep
1.
I put too much effort into sleeping when it should come naturally
Very much
To some extent
Not at all
2.
I feel I should be able to control my sleep
Very much
To some extent
Not at all
3.
I put off going to bed at night for fear of not being able to sleep
Very much
To some extent
Not at all
4.
I worry about not sleeping if I cannot sleep
Very much
To some extent
Not at all
5.
I am no good at sleeping
Very much
To some extent
Not at all
6.
I get anxious about sleeping before I go to bed
Very much
To some extent
Not at all
7.
I worry about the consequences of not sleeping
Very much
To some extent
Not at all
Probing questions can be useful 1. What is the evidence that supports this idea? 2. What is the evidence against this idea? 3. Is there an alternative explanation? 4. What is the worst that could happen? Could I
live through it? 5. What is the best that could happen? 6. What is the most realistic outcome? 7. What would I tell (a friend) if he or she
were in the same situation? 8. How would someone else interpret the same
situation? after Beck, J. (1995). Cognitive Therapy: Basics and beyond. Guilford Press.
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Example of thought record/ diary
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Imagery training (Espie, 2006)
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Essentials of imagery training
Be prepared - don’t just wait until the time comes and try to think something up. Develop a screenplay! You are the director, so shoot the scenes and edit them until you have got what you want. Your imagery sequence should take about 10 minutes to go through in your mind’s eye.
Essentials of imagery training
Be prepared - don’t just wait until the time comes and try to think something up. Develop a screenplay! You are the director, so shoot the scenes and edit them until you have got what you want. Your imagery sequence should take about 10 minutes to go through in your mind’s eye. Practice regularly – you are also a participant! You must learn the scenes and the sequences so that they flow as the movie rolls! You need to set time aside to learn the ‘‘script’’ and you should practice in the evening or during the day too.
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Essentials of imagery training
Be prepared - don’t just wait until the time comes and try to think something up. Develop a screenplay! You are the director, so shoot the scenes and edit them until you have got what you want. Your imagery sequence should take about 10 minutes to go through in your mind’s eye. Practice regularly – you are also a participant! You must learn the scenes and the sequences so that they flow as the movie rolls! You need to set time aside to learn the ‘‘script’’ and you should practice in the evening or during the day too. Get good quality images - vivid and clear in your mind’s eye is what you want. Notice the colours, the smells, the sounds, the sensations that you make part of your imagery routine.
Essentials of imagery training
Be prepared - don’t just wait until the time comes and try to think something up. Develop a screenplay! You are the director, so shoot the scenes and edit them until you have got what you want. Your imagery sequence should take about 10 minutes to go through in your mind’s eye. Practice regularly – you are also a participant! You must learn the scenes and the sequences so that they flow as the movie rolls! You need to set time aside to learn the ‘‘script’’ and you should practice in the evening or during the day too. Get good quality images - vivid and clear in your mind’s eye is what you want. Notice the colours, the smells, the sounds, the sensations that you make part of your imagery routine. Relax and enjoy! – who wants to watch a movie that is uninteresting? This is something that you should look forward to. But at the same time remember you want to develop an imagery story that is calming, soothing, and not evocative of strong emotions!
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Thought blocking; articulatory suppression
Levey et al, 1991
Thought blocking; articulatory suppression
• While lying in bed with your eyes closed • Repeat the word ‘the’once or twice every
second in your head • Don’t say it out loud, but it may help if
you’ mouth it’ • Keep up these repetitions for about 5
minutes or until sleep ensues
Levey et al, 1991
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Avoid clock-watching
Awareness of time
Dysfunctional thought
Self-evaluation Emotional response
“Look at that, it’s gone 12:30 … … and I should be well asleep by now”
I have failed Annoyance
“I’ve been lying awake for almost 2 hours now and only caught a few minutes’ sleep …
… if I don’t sleep soon I’ll be wrecked tomorrow”
I have lost control Anxiety
“Awake again … so what’s the time now? … Great (!) 4 a.m. …
… I can’t stand this any more; I’m going to go mad”
I can’t cope Despair
Online
www.sleepio.com
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Espie, Hames & McKinstry Sleep Medicine Clinics (in press)
Search engine activity growing 4% per month
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CBT for insomnia: a stepped care approach
Espie SLEEP (2009)
A revised stepped care model?
Espie, Hames & McKinstry Sleep Medicine Clinics (in press)
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Henry Ford
“If I had asked people what they wanted, they would have said faster horses.”
Invention of the printing press
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What is CBT? Espie, Hames & McKinstry Sleep Medicine Clinics (in press)
www.sleepio.com
2 million permutations in 3 minutes
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Integrating online and clinical practice
Integrating with devices
Espie, Hames & McKinstry Sleep Medicine Clinics (in press)
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Oxford Programme in Sleep Medicine
PriSM
(online)
To register interest and receive email updates [email protected] Visit our website (www.ndcn.ox.ac.uk/scni) for news and information
Oxford Programme in Sleep Medicine • Master of Science in Sleep Medicine • Postgraduate Diploma in Sleep Medicine • Postgraduate Certificate in Sleep Medicine
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Oxford Programme in
Sleep Medicine
PriSM (online)
Oxford Programme in Sleep Medicine • Master of Science in Sleep Medicine • Postgraduate Diploma in Sleep Medicine • Postgraduate Certificate in Sleep Medicine
28/01/2014
77
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Why would people want to take this course?
ü Emerging discipline ü International need ü Inter-disciplinary health
professionals How would it work? ü 100% online ü Interactive ü Concept proven (12 countries so
far) Why Oxford? ü Reputation as a centre of excellence - Draws students - Draws contributors