1. Insomnia Treatment in the context of Predisposing Factors KANSAS Association of sleep Professionals November 4, 2017
Paul B. Glovinsky, Ph.D., CBSM, FAASM
St. Peter’s Sleep Center
Albany, NY

2. Spielman’s 3P Model (1986) Predisposing Factors Precipitating Factors
Perpetuating Factors

3. Spielman’s 3P Model

4. Clinical Responses to 3P Factors
Predisposing Factors are typically accepted as baseline conditions, or prompt referral to other specialties (e.g. psychiatry, pain management).

5. Clinical Responses to 3P Factors
Precipitating Factors may be expected to ease over time, or again, prompt other referrals (e.g. for grief counseling, job training).

6. Clinical Responses to 3P Factors
Perpetuating Factors have historically been targets for intervention with Cognitive Behavioral Therapy for Insomnia (CTB-I).

7. CBT-I for Perpetuating Factors
Learning that the bed is a place for struggle rather than sleep→ Stimulus Control Instructions
Going to bed early, oversleeping, or napping to compensate for lost sleep→ Sleep Restriction Therapy
Developing anticipatory anxiety over insomnia and its daytime consequences → Cognitive Therapy

8. CBT-I can be reframed as a set of interventions that facilitate sleepiness at the right time and place.

9. Sleepiness at the right time and place
Stimulus Control Instructions (Bootzin, 1972) explicitly pair the actions of going to bed, remaining in bed, and returning to bed with being sleepy.

10. Sleepiness at the right time and place
Sleep Restriction Therapy (Spielman et al., 1987) restricts time in bed, increasing homeostatic sleepiness.

11. Sleepiness at the right time and place
Cognitive Therapy for Insomnia (Morin, 1993) challenges dysfunctional beliefs that inhibit sleepiness at bedtime.

12. Insomnia Treatment in the Context of Predisposing Factors
Predisposing Factors also inhibit sleepiness. Taking these into account while administering CBT-I may improve clinical outcomes.

13. Insomnia Treatment in the Context of Predisposing Factors
Hyperarousal
Chronic Fatigue
Chronic Pain
Depression
Anxiety Disorder
Circadian Rhythm Disturbance

14. Insomnia Treatment in the Context of Predisposing Factors
Hyperarousal
Chronic Fatigue
Chronic Pain
Depression
Anxiety
Circadian Rhythm Disturbance

15. Hyperarousal
Hyperarousal refers to elevated physiological or cognitive activation, and can manifest as either a state or a trait.

16. State Hyperarousal
Appears in response to a perceived threat, as in the “fight or flight response.”
Is recruited to push through sleepiness under non-emergency conditions.
Overrides sleep regulatory mechanisms within seconds.

17. Trait Hyperarousal
Chronic hyperarousal may also be an inherited trait, or acquired as in Post-Traumatic Stress Disorder.
It is characterized by higher baseline arousal levels, and more easily triggered surges.

18. Treating Insomnia with Hyperarousal
A 28-year-old restaurant server with sleep-onset insomnia runs between kitchen and tables for six hours before prepping for the next day. She arrives home at midnight “totally exhausted” and plops into bed, where it usually takes two hours to fall asleep.

19. Treating Insomnia with Hyperarousal
A 42-year-old sales manager with sleep-maintenance insomnia insists that he finds his special-ops video game relaxing. “Reading “just makes me agitated,” he says. “Anyway, I must be in the right frame of mind because I fall asleep quickly.”

20. Treating Insomnia with Hyperarousal
Patients with hyperarousal may fall asleep quickly due to sheer homeostatic pressure.
After 2-3 hours they rouse with a start, perplexed to find themselves “wide awake.”
Relaxation only happens in wakefulness.

21. Treating Insomnia with Hyperarousal
Quiet “buffer periods” while seated (e.g. reading, listening to music, or conversation, lasting an hour or longer, are critical.
However, they are oftentimes dismissed as impractical.

22. Treating Insomnia with Hyperarousal
Sleep Restriction Therapy is often well tolerated in this group.
Mindfulness and Relaxation Training can be met with resistance, but even partially-acquired skills are helpful.

23. Treating Insomnia with Hyperarousal
Aerobic exercise in the early evening expends energy and accentuates a core body temperature spike.
Passive heating via a warm soak in the middle or late evening may also be helpful.

24. Cognitive Hyperarousal
Mind racing: “I can’t shut off my brain.”
Distractibility: “I get antsy and can’t focus. Reading is impossible.”
Obsessional Thinking: “I can’t get that thought out of mind.” Especially, “I’m not thinking about anything except sleep.”

25. Treating Cognitive Hyperarousal
Stimulus Control Instructions
Breathing exercises
Mindfulness exercises
Guided imagery
Mental tasks: Count Sheep; State Capitals
Patter Substitution: TV, Radio, Podcasts
Lyric Reconstruction

26. Lyric Reconstruction
1) Listen once in the evening to a tune by a favorite songwriter who uses lots of words (e.g. Bob Dylan; Cole Porter)
2) If your mind races, try to remember the lyrics. Use musical cues such as rhyme, rhythm and repetition. Fill in missing words with humming.
3) This ceases to be fun after five minutes or so. Try a bit longer, and then let your mind rest. But if it starts racing, you must resume your efforts!

27. Can’t Read, Can’t Sleep Reading lulls because it is: sedentary
continuous, like driving on a highway
cognitively taxing
about someone else’s experience

28. Can’t Read, Can’t Sleep
Avoid value judgments about video games, Instagram, Facebook and TV. Instead, introduce a new perspective:
“Your inability to sit still and read is the opening act of tonight’s insomnia.”

29. Insomnia with PTSD Hyperarousal
Create a safe environment:
Avoid triggers
Not too dark, not too quiet
Perimeter checks
Sleep at the front of the house
Access to escape routes

30. Insomnia with PTSD Hyperarousal
Specialized Interventions:
Imagery Rehearsal Therapy (Krakow et al., 2001)
Mindfulness Meditation (Ong et al., 2008)
Some therapies, such as Prolonged Exposure, may initially exacerbate insomnia.

31. Insomnia with PTSD Hyperarousal
Sedatives several hours before bedtime.
Hypnotics are less effective when evening hyperarousal has run unabated.
Antidepressants with sedating and/or anxiolytic effects.
Atypical Antipsychotics
Prazosin to counter recurrent nightmares (Raskind et al, 2003).

32. Insomnia Treatment in the Context of Predisposing Factors
Hyperarousal
Chronic Fatigue
Chronic Pain
Depression
Anxiety
Circadian Rhythm Disturbance

33. Treating Insomnia with Depression
Insomnia was historically considered a symptom of depression, that would lift once the mood disturbance was treated.

34. Treating Insomnia with Depression
A major achievement of modern sleep research has been to demonstrate the interdependence of sleep and depression.
Sleep and Depression interact, and affect each other’s course (Manber et al., 2008).

35. The Interactions of Sleep and Mood
Early Morning Awakenings
Reduced REM Latency
Diurnal Mood Variation

36. The Interactions of Sleep and Mood
REM Suppressant Effects of Antidepressant Medication
Antidepressant Effects of REM Deprivation

37. The Interactions of Sleep and Mood
Bright Light Treatment phase shifts sleep and treats seasonal depression (Rosenthal et al, 1984).
Increasing evidence that non-seasonal depression (Kripke, 1981; Terman and Terman, 2005; Perera, et al., 2016) also responds to light therapy.

38. Treating Insomnia with Depression
Both pharmacologic and cognitive behavioral interventions are useful for treating comorbid insomnia and depression

39. Treating Insomnia with Depression
Antidepressants are commonly employed.
First generation SSRIs such as fluoxetine (Prozac) may exacerbate sleep disturbance.
Other antidepressants such as mirtazapine (Remeron), trazodone (Desyrel), doxepin (Sinequan) and amitriptyline (Elavil) typically consolidate sleep, although daytime sedation may be problematic.

40. Treating Insomnia with Depression
Changing behavior and thinking improves both sleep and mood.
However, depressed patients often feel too helpless and hopeless to believe change is possible.

41. Treating Insomnia with Depression
“Depression has already changed your thinking and behavior. If it changed once, it can change again.”

42. Behavioral Changes in Depression that Impair Sleep
Daytime Activity
Nighttime Repose
Interests and Engagement
Social Interaction
Exposure to Daylight
Healthy Eating

43. Cognitive Changes in Depression that Impair Sleep
Unfounded Beliefs
Catastrophic Thinking
Distortions of Self-Image

44. Effects on Sleep-Regulating Mechanisms
Reduced activity, excessive bedrest, loss of interest, and decreased engagement impair daytime alertness and diminish homeostatic sleep drive.

45. Effects on Sleep-Regulating Mechanisms
Reduced daylight exposure, haphazard sleep and meal schedules, and social isolation interfere with entrainment of circadian rhythms.

46. Treating Insomnia with Depression
“You want me exercising, socializing, engaging in new interests, getting outdoors, and being more positive. If I could do all that, I wouldn’t be depressed!”

47. Treating Insomnia with Depression
“Your bed has become a good place to be depressed, but not to sleep.”

48. Treating Insomnia with Depression
Make sustainable changes to waking patterns.
Find the right degree of challenge.
Track your progress.
Lighten up.
Rethink your way to sleep.

49. Rethink Your Way to Sleep
Cognitive Restructuring (Ellis, 1958; Beck, 1970)
Weigh Pros and Cons
Constructive Worry
Add a New Ingredient to the cognitive mix

50. Rethink Your Way to Sleep
Dysfunctional beliefs seem deeply rooted right up until the moment they are dislodged.
Karen’s epiphany

51. Insomnia Treatment in the Context of Predisposing Factors
Hyperarousal
Chronic Fatigue
Chronic Pain
Depression
Anxiety
Circadian Rhythm Disturbance

52. Treatment of Circadian Rhythm Disturbance
Chronotherapy (Czeisler et al., 1981)
Bright Light Therapy (Rosenthal et al., 1990)
Melatonin (Lewy et al., 1992)

53. Treatment of Circadian Rhythm Disturbance
Dodson and Zee, 2010

54. Treatment of Circadian Rhythm Disturbance
Physiological doses of exogenous melatonin, supplied when the pineal gland is not itself producing the hormone, facilitate phase shifts without producing significant sleepiness.

55. Treatment of Circadian Rhythm Disturbance
Lightboxes should be large enough to allow for adequate exposure, have an effective UV filter, and ideally provide light from above (Terman, cet.org).

56. Treatment of Circadian Rhythm Disturbance
Blue-blocking goggles are helpful in the treatment of sleep phase disorders, shift work and jet lag (Eastman et al., 1994).

57. Treatment of Circadian Rhythm Disturbance
Software such as F.LUX blocks blue pixels from screens during evening and nighttime hours.

58. Treatment of Circadian Rhythm Disturbance
Rapid phase shifts are commonly demonstrated in both laboratory and jet-lag protocols.

59. Treatment of Circadian Rhythm Disturbance
In real-world practice, treatment of delayed sleep phase disorder and shift work disorder is often more of a slog.

60. Challenges in the Treatment of Delayed Sleep Phase Disorder
“Swimming upstream” against circadian current
Weekend drift
Pull of social cues
A lifetime of feeling and functioning better at night

61. Challenges in the Treatment of Shiftwork Disorder
Constantly shifting sleep schedules due to weekend realignment
Ill-timed light exposure after night shift
Inadequate buffer period after evening shift
Burning candle at both ends

62. What about Jet Therapy?
Michael’s proposal to move to Hawaii won’t work, but it does bring up some instructive issues.

63. What about Jet Therapy? The circadian clock is not set in stone.
The fact that Michael would be in sync with Hawaiians for a short while, and then reestablish his old night owl pattern, demonstrates that endogenous circadian rhythms can shift.

64. What about Jet Therapy?
While that shift was a phase delay (always a breeze for Michael), we could just as easily have packed him off to London for a phase advance!

65. What about Jet Therapy?
Relative to the internal clock, switching time zones brings shifts in the timing of
light exposure
meals
school and business hours
social opportunities

66. What about Jet Therapy?
“None of these will factors change in your home town unless you change them. You can’t sleep at a new time in your old life.”
“Perhaps most important, you will have to form a new notion of when it is getting late.”

67. Schematic Treatment for DSPD