The Behavioral Treatment of Insomnia Andrew Berger, PhD San Francisco and Dallas Mental Health Specialist

How much do you know?

Video #1 & #2

If You Have Insomnia You Are Not Alone 75% of Adults Had One Symptom of Sleep Disorder Percent of US Population Occasionally Suffers from Insomnia Partners Affected Americans Average 6.9 Hours of Sleep

Consequences of Poor Sleep Poor Health Higher Death Rates Physical Ailments

More Consequences of Poor Sleep Hormone and Metabolism Changes Sleep Debt Is Cumulative Sleep Deprivation and Driving Catastrophes Cost to Americans

Benefits of Sleep Alertness/Performance Memory/Concentration/Creativity Better Health

Many Types of Sleep Disorders Primary Insomnia Primary Hyperinsomnia Narcolepsy Breathing Related Disorders Circadian Rhythm Sleep Disorder Nightmare Disorder

Many Types of Sleep Disorders Sleep Terror Disorder Sleep Walking Disorder Substance Induced Sleep Disorder Sleep Disorder Due To Medical Condition

DSM4-TR Insomnia Essential Features Onset and Intermittent Insomnia Non-Restorative Sleep Preoccupation and Distress Better Sleeping Away From Home Decreased Well-Being and Concentration

DSM4-TR Primary Insomnia The predominant symptom is difficulty initiating or maintaining sleep or non-restorative sleep for at least one month The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or para- somnia

DSM4-TR Continued The disturbance does not occur exclusively during the course of another mental disorder (e.g., major depressive disorder, generalized anxiety disorder, a delirium). The disturbance is not due to the direct physiological effects of a substance (e.g., drug abuse, medication) or a general medical condition.

Primary Insomnia Occurs Independently Not Due To An Obvious Cause Rarely From Infancy Learned Predisposed Due To Overactive Nervous System

People With Insomnia Have: Higher Metabolic Rates Higher Levels of Stress Hormones Associate Bedroom with Anxiety Poor Coping

What Is Secondary Insomnia? Results From Another Cause Sleep Disorder Non-Sleep Condition Substances

Disorders That Can Disrupt Sleep Angina Diabetes Hyperthyroidism Parkinson’s Disease Epilepsy Alzheimer’s Headaches

More Disorders Affecting Sleep Strokes/Tumors Asthma Chronic Obstructive Pulmonary Disease (COPD) Anxiety Depression

More Disorders Affecting Sleep Bipolar Disorder Schizophrenia Gastro esophageal Reflux Disease (GERD) Kidney Disease Arthritis

Medications That Can Disturb Sleep Alpha blockers Anti-arrhythmic Beta blockers Diuretics Antidepressants

More Medications Affecting Sleep Beta Agonists Corticosteroids Nicotine Patches Stimulants Theophylline Thyroid Replacement Drugs

Types of Sleepers Standard Sleepers Larks Owls

Adolescent and Young Adult Sleep Patterns Teens Young Adults

Dr Lawrence Epstein’s Six Step Plan To A Good Night’s Sleep Recognizing the importance of sleep Adopting a healthy lifestyle Maintaining good sleep habits Creating the optimal sleep environment Seeking help for persistent sleep problems

Recognize The Importance of Sleep

Adopt A Healthy Lifestyle Exercise Regularly Maintain A Healthy Diet Don’t Drink to Excess or Smoke

Maintain Good Sleep Habits Keep A Regular Sleep/Wake Cycle Develop A Pre-Sleep Routine Reserve Bedroom for Sleep and Intimacy Avoid Naps If You Can’t Sleep Get Out of Bed

Create An Optimal Sleep Environment Control Bedroom Noise Block Out Light Keep It Cool and Well Ventilated Hide The Clock Make Your Bed Comfortable

Sleep Saboteurs Limit Caffeine Use Alcohol Cautiously Stop Smoking or Chewing Tobacco Find Right Balance of Fluids Avoid Heartburn Food

Seek Help For Persistent Sleep Problems

Behavioral Treatments of Insomnia Reconditioning/Stimulus Control Sleep Restriction Relaxation Techniques

Reconditioning/Stimulus Control Go To Bed Only When Sleepy Use Bed Only For Sleep or Sex Get Up After 20 Minutes of No Sleep Repeat Step 3 As Needed Get Up At Same Time Every Morning No Naps

Sleep Restriction Less Time In Bed Promotes More Efficient Sleep Estimate Sleep and Subtract From Wake Up Time Continue Adding 15 to 30 Min Less Than 5 Hours Not Recommended—Consult MD

Relaxation Techniques Progressive Muscle Relaxation Deep Breathing Meditation Visualization Biofeedback

Cognitive Therapy Misattributions Hopelessness Unrealistic Expectations Exaggerating Consequences Performance Anxiety

Cognitive Behavioral Therapy Often Provided with Behavioral Therapy—Cognitive Behavioral Therapy (CBT) CBT More Effective Than Any Behavioral Therapy Alone More Effective Than Sleeping Pills Largest Obstacle Lack of Patient Commitment

Sleeping Pills 10 Percent Adults Use Prescription or OTC Sleep Meds Short-Term Solution Causes Long Term Problem Do Not Help People Become Normal Sleepers Fail To Treat Causes of Insomnia

Herbal Supplements Valerian Lavender Chamomile Passionflower Melatonin

Bibliography (1)Ohayon MM. Epidemiology of Insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002:;6: (2)National Sleep Foundation. Summary of Findings: 2005 Sleep in America Poll. March (3)Alattar M, Harrington JJ, Mitchell CM, et al. Sleep problems in primary care: a North Carolina Family Practice Research Network study. J Am Board Faro Med. 2007;20:

Bibliography Continued (4) NIH State-of-the-Science Conference Statement on manifestations and management of chronic insomnia in adults. NIH Consens State Sci Statements. 2005; 22:1- 30 (5)American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4 th ed, Text Revision (DSM-IV-TR). Washington, De: American Psychiatric Association; 2000: (6)Sateia MJ, Pigeon WR. Identification and management of insomnia. Med Clin North Am. 2004;88:

Bibliography Continued (7) American Academy of Sleep Medicine. International Classification of Sleep Disorders, revised: Diagnostic and Coding Manual. Chicago, IL,: American Academy of Sleep Medicine; 2001 (8) Insomnia in the primary care practice. Journal of Family Practice, April, 2008 (9) Gregg D Jacobs, PhD Say Good Night To Insomnia, Henry Hold and Company, LLC 115 West 18 th Street, New York, New York 10011

Bibliography Continued (10) Lawrence J. Epstein, MD The Harvard Medical School Guide To A Good Night’s Sleep, McGraw Hill, 2007 (11) William C Dement, MD, PhD and Christopher Vaughan The Promise of Sleep, 1999, Dell Publishing, A division of Random House, Inc, 1540 Broadway, New York, New York 10036