Elisabeth Hertenstein ACBS World Conference, July 18th, 2015 Klinik für Psychiatrie und Psychotherapie Acceptance and Commitment Therapy for Insomnia

 Why could ACT be effective for insomnia?  Why is a new insomnia treatment needed?  Our Pilot Study  Future Plans Outline

Sleep complaint  Sleep onset, sleep maintenance, early awakening  Three times per week, ≥ three months Daytime impairment  Fatigue  Reduced concentration  Mood disturbance  prevalence of insomnia 10%, primary insomnia 2–4%  insomnia is a risk factor for mental and somatic disorders 3 Insomnia Ohayon et al., 2002, Sleep Medicine Reviews Baglioni et al. 2011, Journal of Affective Disorders Chien et al. 2010, Journal of Sleep and Sleep Disorders Research

Human behavior is over-regulated by inflexible cognition.  falling asleep can hardly be described verbally  falling asleep is an „automatic“ process  sleep is inhibited by attention, intention and effort 1 4 ACT Core Assumptions and sleep Espie et al., 2006, Sleep Medicine Reviews

Contact with actual experience is often lost.  patients with insomnia overestimate their wake time  potentially overestimate daytime impairment  ruminate over the past and the future 5 ACT Core Assumptions and sleep

Humans spend too much time avoiding what they fear and too little time approaching what they appreciate.  Patients with insomnia avoid valued acitivities in order to sleep better (e.g. evening appointments). 6 ACT Core Assumptions and sleep

Pragmatism: evaluate thoughts in terms of their helpfulness, not in terms of true or false.  Patients with insomnia often have dysfunctional thoughts that are not totally wrong, but unhelpful when trying to fall asleep:  „I will be less productive if I don‘t get enough sleep“  „Sleep loss is bad for my health“ 7 ACT Core Assumptions and sleep

8  establish contact with actual experience  mindfulness  stop fighting what cannot be changed  acceptance  find out what YOU want your life to be like  values  shape your life according to your values  commitment ACT Therapeutic Elements

9  effective, but... ... only evidence-based for short-term treatment (< 4 weeks) 1 ... risk of undesired side effects:  tolerance, dependence  sedation  complex sleep-related behaviors  falls Evidence Based Insomnia Therapy Benzodiazepines 1 Riemann & Perlis, 2009, Sleep Medicine Reviews

10  effective, but... ... average symptom improvement 50-60% 1 ... 25% non-responders 1 ... effects on quality of life rarely investigated and rather small 2 Evidence Based Insomnia Therapy Cognitive Behavioral Therapy 1 Harvey & Tang, 2003, Sleep Medicine Reviews 2 Kyle et al., 2010, Sleep Medicine Reviews

 Test the feasibility of ACT as a group treatment in patients with primary insomnia  Collect preliminary efficacy data for subjective sleep quality & sleep related quality of life Pilot Study Aims

sample Starters/Completers11/10 m/w5/5 Age (years)51.1±12.0 insomnia duration (years)24.2±11.2 experienced with CBT-I11 medication: Benzo./AD/none 1/2/7 Pilot Study Sample

T-1T0 ACT 6 sessions T1T2 weeks Pilot Study Design

( ) * * * * a b Pilot Study Main Results Hertenstein et al., 2014, Psychother Psychosom

Pilot Study Subjective Treatment Satisfaction

 test the efficacy of ACT for insomnia in a larger randomized trial  combine ACT with elements of CBTI  focus on quality of life as an outcome  extend the target group, including patients with „insomnia disorder“ Future Plans

Christoph Nissen, Dieter Riemann, Nicola Thiel, Marianne Lüking, Anne Katrin Külz, Elisabeth Schramm, Chiara Baglioni, Kai Spiegelhalder, Bernd Feige, Bernd Tritschler, Mathias Berger FAZIT Stiftung Acknowledgements