Insomnia: A Cognitive Behavioral Manual for Therapy

Stephen L. Newman, M.D., M.B.A., FACP, FCCP, FAASM Diplomat of the American Board of Sleep Medicine V 4.7 July 6, 2014

INTRODUCTION

Prior to beginning therapy, it is essential that you complete the supplied diary recording your sleep characteristics. This diary will be crucial in determining several aspects of therapy. In addition, I have asked you to complete a questionnaire regarding your attitudes and beliefs about sleep. The program of therapy will last from 4-8 sessions to achieve a more restful sleep. I will ask you to make significant changes to your current patterns of sleep throughout the program. The program requires your active participation, involvement, and practice and most of all commitment

Session 1: Why do we sleep? Key to overcoming your difficulty with falling or staying asleep, it is helpful that you develop a better understanding of the factors influencing sleep quantity and quality. This knowledge should help you to develop reasonable goals regarding your sleep and help us both to improve your slep. Before making any changes to your current pattern of poor sleep, the first step is to recognize how much time you require to sleep throughout a 24-hour day. Although there is a wide normal variation in this figure, most adults sleep between seven (7) and nine (9) hours. At one end are those individuals that regularly sleep four (4) hours a night awakening to feel refreshed and function normally throughout the day. At the other end of normal are those that sleep 10 hours a night and feel unwell if they sleep less. It is important to understand that not everyone sleeps exactly 8 hours every night and that to perform your activities of daily living you may require substantially more or less sleep. So please, set aside your notion of what is the optimal amount of time that you need to sleep. I would Iike to answer some commonly asked questions and teach you more about how the human body sleeps. 1. Why do we sleep? Although one would think that sleep is necessary to rest and restore our body, it is clear that our brain is quite active during sleep and we

consume as many calories asleep while we are awake, sitting, and lying still. It is interesting to note that some mammals, such as the dolphin are able to sleep with one-half of their brain, while the other half remains awake. It is clear that if we do not obtain the appropriate amount and type of sleep, that we are not as alert and vigilant during wakefulness. Specifically we are less capable of performing activities that require coordination such as driving a car. Also our ability to remember, think, calculate and recognize are impaired. More recent studies show that during sleep our brain reorganizes and consolidates our memory. Our body functions on a length of a day that is slightly longer than 24 hours. We have our own internal clock that regulates the rhythm of a wide range of functions in our body and in our daily interaction with the environment. This pattern, called circadian rhythm, is best demonstrated in the timing of sleep and wakefulness, the regulation of our body chemistry and temperature. We know that our lowest body temperature occurs in the early morning hours, 3 to 4 A.M. and reaches it highest point in the late afternoon around 4 PM. Our circadian rhythm coincides with the rhythm of our social habits such as eating and working. A variety of signals from our environment, such as light, entrain the rhythm of wake and sleep. When our life changes this schedule, we can experience a disruption of sleep and wakefulness. The most common demonstration occurs in springtime when we set the clocks forward by one hour when we phase advance to Daylight savings time, this effect is magnified when we fly across time zones, most dramatically when we fly in an easterly direction. This delay between the perception of a new clock time and our own internal, circadian rhythm, results in the fatigue and insomnia known commonly as jet lag. The affected individual's own circadian rhythm lags several hours behind the new clock time. There is a disconnect between between the sensation of sleepiness and the light of the day. The adjustment to the new time zone is gradual.

2. Why do we dream? The role played by dreaming, whenever it occurs, is another question that is unanswered. Some feel that dreams represent information that our brain would like to discard. Others feel that dreaming is necessary for the growth and maturation of the brain, recognizing that infants spend a greater part of their time spend asleep in the REM sleep, conventionally associated with dreaming. It is also interesting to observe that dreams occur at all stages of sleep. Recent studies indicate that different aspects of sleep, dreams included are essential in consolidating and organizing memory. 3. What happens to sleep as we age? Many sources of evidence support that as we age our sleep becomes less efficient: we spend more time in bed but the time we spend asleep is less, Often, sleep in the elderly is interrupted by accompanying medical illness or side effects of medications. Moreover, several problems are known to cause us to awake more easily, sleep apnea (snoring followed by stopping breathing) and periodic leg movement syndrome (restless legs). Moreover, most people tend to cope with their sleep troubles by creating more problems. Our goal, as patient and physician, is to identify these problems and work to correct your pattern of sleep.

4. How do we obtain a resolution to our insomnia? Everyone wants a rapid or quick solution to any problem in life and health. People who have problems sleeping often will seek a vitamin, herb, alcohol, and potion or prescription medication to relieve their insomnia. Perhaps the most important point to learn is that there are no quick fixes with medication reserved for exceptional circumstances under exceptional conditions. One of the most powerful tools in treating insomnia is sleep restriction. As unusual as this may seem at first glance, sleep researchers are well aware that as we reduce the time in bed, our sleep period becomes more efficient: more of the time spent in bed is spent asleep.

The Ten Commandments of Good Sleep I.

Establish a favorable sleep environment. Please adjust the sound and light of your bedroom to your level of comfort. If your bed partner desires the room cooler or warmer there are devices, The Chili mattress that heats or cools one side of the bed. Although most of us sleep better in an environment that is dark and quiet, this is by no means a rule fixed in stone! With the temperature and humidity suited to you and your bed partner's comfort level, please remove all clocks and watches, cellphones, computers from your bedroom. Noting that your current bedroom may present a mental barrier to obtaining good sleep, If possible, change your bedroom.

II.

Establish a firm wake up time regardless of how long you sleep. This wake up time will create the necessary rhythm in your body to make you sleepy at each bedtime.

III.

Do not worry, think, plan or perform other activities that require mental concentration in your bedroom. Instead, write out a list of activities for the next day, several hours before bedtime. If you find yourself planning, thinking or worrying in your bed, go to a bedside chair or another quiet dark room in your home.

IV.

Your bedroom is reserved for the two SS: sex and sleeping. Do not read a book, talk on the telephone, work, use a computer, use your cellphone, text, skype, twitter,eat or watch television in your bedroom. You want to associate the bedroom with sleeping.

V.

Eliminate caffeine in all of its forms entirely from your diet. Even the morning

cup of tea or coffee can affect our ability to fall or stay asleep. Be aware that many beverages such as orange soda and "decaffeinated" coffee and tea often contain small amounts of coffee. THUS AVOID THE WORDS CAFFEINE AND DECAFFEINATED. VI.

Do not eat within four hours of bedtime. Food could provoke digestive upset that could prevent one from falling asleep. Do not drink alcohol within eight hours of bedtime. Alcohol may help certain individuals fall asleep, but this sedative effect rapidly wears off and results in rebound insomnia. Do not smoke at all and particularly within four hours of bedtime. Nicotine has been shown to simulate our level of alertness.

VII.

Avoid all sedative medications whether over the counter, herbal therapy, homeopathy, dietary or by prescription. Indeed, it is essential that you wean off these medications as they may actually prevent good sleep. There are exceptional circumstances during which sedative medications could be prescribed for a brief period of time.

VIII.

Never, ever nap during normal waking hours. Sleeping during the normal waking hours reduces your ability to fall or stay asleep at your regular sleep time.

IX.

Exercise regularly in he morning or early afternoon. Try to avoid strenuous physical activity within three hours of bedtime.

X.

Never remain in your bed at any time of the night, beginning, middle or end, if you are awake for long periods of time. Staying awake for long periods of time leads to a level of frustration and concern that prevents you from falling back asleep. Instead, get out of bed go to another room, without eating, drinking, reading watching television working at the computer, and return to your bedroom within a period of 30 minutes.

Our first step is to review your sleep diary and prescribe an appropriate initial amount of time in bed. New bedtime: _____________ New rise time: _______________

HOMEWORK ASSIGNMENT # 1 Please write down the time you fell asleep, the time you awoke and on a 10 point scale, rate the ease of falling asleep your quality of sleep and how you felt the following day as follows: 10: excellent 9: very, very good 8: very good 7: good 6: neutral: neither bad nor good 5: fair 4: poor 3: very poor 2: very, very poor 1: horrible For example: Day Bedtime example 11pm Day Bedtime Rise time 1 2 3 4 5 6

Rise time Sam

Ease of falling Quality of How you felt during the following day asleep: sleep 2 8 5 How you felt during the Ease of falling Quality of following day asleep: sleep

7

GNAT identification: Throughout the course of this program we will explore together, one psychologist has coined the term GNAT ( Giant Nasty Annoying Thoughts) to describe thoughts that may cause or perpetuate insomnia. Please list ten of those thoughts (such as “I am afraid of the dark” ) 1. 2. 3. 4. 5.

_______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

We will address two of these GNATS at the next session.

Session Two: Relaxation One of the easiest tasks to accomplish on road to better sleep is to change our sleep environment and sleep time. Thus the First Commandment:

I:

Establish a favorable sleep environment. Please keep your room dark and quiet. With the room's temperature and humidity suited to you and your bed partner's comfort level. Please remove all clocks and watches from your bedroom. If possible, change your bedroom as your current bedroom may present a mental barrier to obtaining good sleep.

The second point we will review is Second Commandment:

//.

Establish a firm wake up time regardless of how long you sleep. This wake up time will create the necessary rhythm in your body to make you sleepy at each bedtime.

This rationale set forth by Dr. Richard Bootzin of Northwestern University is part of the stimulus control therapy. A fixed wake up time couples the daytime light with the rhythm of your body. The finish of the daily rhythm is bedtime and the approach to bedtime stress. Crucial to the treatment of insomnia is limiting our daily stress if at all possible and particularly learning to relax when we approach bedtime. Therefore, let us learn eight excellent relaxation techniques 1. Stretch: Let us slowly stretch our muscles: straighten your arms and spread out your fingers. Then rest your hands by your side. Repeat 5 times 2. Neck: Bend your neck forward to the right side, then to the back and then to your left side. Repeat 5 times 3. Hands: Make a fist with both hands and then slowly extend your fingers 5 times 4. Wet noodle technique: Make your body limp all over. 5. Sequential Relaxation: make a fist with your right hand , tense your right forearm and upper arm and slowly extend your fingers, open your hand and then relax your forearm and upper arm. Then, perform the same exercise with your left arm. Then, flex your left thigh, and bend your left knee, curl your toes. Then extend your toes, straighten your leg. Then perform the same exercise with your right leg. Repeat this cycle five times. 6. Imagination: place yourself in the last place that you fell asleep easily and stayed asleep. Think of that place and that time only, over and over and over.

7. Floating balloon: as soon as a thought comes into your head blow it into an imaginary balloon and let the balloon float away. Repeat this with every thought. 8. Deep breathing: take slow deep breaths in by expanding your chest and your belly, and slowly breathe out. Key to successful relaxation is the environment of your bedroom. Your mattress and pillow should be comfortable. There is little documented evidence to suggest that a firm mattress promotes sleep. I feel that a mattress and pillow that conforms to your body, such as the Tempurpedic™or Duxiana ™ are probably most appropriate in this regard. In any event, as you change a mattress, please make sure that the retailer accepts the mattress back after you are able to test in the setting of your own home. There is evidence that cold hands and feet and high body trunk temperature may prevent the onset of sleep.

HOMEWORK ASSIGNMENT # 2 Much like last week, please write down the time you fell asleep, the time you awoke and on a 10 point scale, rate the ease of falling asleep your quality of sleep and how you felt the following day as follows: 10: excellent 9: very, very good 8: very good 7: good 6: neutral: neither bad nor good 5: fair 4: poor 3: very poor 2: very, very poor 1: horrible For example: Day Bedtime example

11pm

Rise time 5am

Ease of falling asleep: 2

Quality of sleep 8

How you felt during the following day 5

Day Bedtime

Rise time

Ease of falling asleep:

Quality of sleep

How you felt during the following day

1 2 3 4 5 6 7

Again write down at least three GNATS so that we can address at least two next time

1.______________________________ 2.______________________________ 3._____________________________