Behavioral Treatments for Sleep Disorders

A Comprehensive Primer of Behavioral Sleep Medicine Interventions

Michael L. Perlis, Mark Aloia, Brett Kuhn

• Publisher: Academic Press
• Year: 2010
• eBook ISBN: 9780123815231
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Sleep is a major component of good mental and physical health, yet over 40 million Americans suffer from sleep disorders. Edited by three prominent clinical experts, Behavioral Treatments for Sleep Disorders is the first reference to cover all of the most common disorders (insomnia, sleep apnea, restless legs syndrome, narcolepsy, parasomnias, etc) and the applicable therapeutic techniques. The volume adopts a highly streamlined and practical approach to make the tools of the trade from behavioral sleep medicine accessible to mainstream psychologists as well as sleep disorder specialists. Organized by therapeutic technique, each chapter discusses the various sleep disorders to which the therapy is relevant, an overall rationale for the intervention, step-by-step instructions for how to implement the technique, possible modifications, the supporting evidence base, and further recommended readings. Treatments for both the adult and child patient populations are covered, and each chapter is authored by an expert in the field.- Offers more coverage than any volume on the market, with discussion of virtually all sleep disorders and numerous treatment types- Addresses treatment concerns for both adult and pediatric population- Outstanding scholarship, with each chapter written by an expert in the topic area- Each chapter offers step-by-step description of procedures and covers the evidence-based data behind those procedures

PART I

BSM Treatment Protocols for Insomia

Part I: BSM Treatment Protocols for Insomia: Introduction

Chapter 1 Sleep Restriction Therapy

Chapter 2 Stimulus Control Therapy

Chapter 3 Sleep Hygiene

Chapter 4 Relaxation for Insomnia

Chapter 5 Sleep Compression

Chapter 6 Paradoxical Intention Therapy

Chapter 7 Behavioral Experiments

Chapter 8 Intervention to Reduce Unhelpful Beliefs about Sleep

Chapter 9 Intervention to Reduce Misperception

Chapter 10 Intervention to Reduce Use of Safety Behaviors

Chapter 11 Cognitive Therapy for Dysfunctional Beliefs about Sleep and Insomnia

Chapter 12 Cognitive Restructuring: Cognitive Therapy for Catastrophic Sleep Beliefs

Chapter 13 Intensive Sleep Retraining: Conditioning Treatment for Primary Insomnia

Chapter 14 Mindfulness-Based Therapy for Insomnia

Chapter 15 Brief Behavioral Treatment of Insomnia

Chapter 16 Using Bright Light and Melatonin to Reduce Jet Lag

Chapter 17 Using Bright Light and Melatonin to Adjust to Night Work

Part I: BSM Treatment Protocols for Insomia: Introduction

Michael L. Perlis

Department of Psychiatry and Nursing, University of Pennsylvania School of Medicine, Philadelphia, PA

Though Behavioral Sleep Medicine as a field is in its infancy (perhaps more accurately “in gestation”) [1–3], the state of the science with respect to insomnia might be best likened to the fourth decade of life: the organism is fully mature but much remains to be learned, said, and done.

With respect to the maturity of the insomnia area, at this point in time there is a well-defined infrastructure that includes (1) a variety of conceptual models, (2) standardized definitions, (3) a general approach to assessment, (4) well-established therapies that are evidence based (with respect to both efficacy and effectiveness), (5) published treatment manuals and courses available for treatment dissemination and implementation, and (6) a new generation of treatments that hold the promise of even better clinical outcomes than those obtained presently. These issues are briefly reviewed below, followed by a short commentary about future directions for the insomnia field.

State of the Science

Conceptual Models

This aspect of behavioral sleep medicine is perhaps the most developed, starting with, in the early era sleep research and sleep medicine (1970s and 1980s), the Bootzin Stimulus Control Perspective [4] and the Spielman Three Factor Model [5]. Since the 1990s there has been a proliferation of theoretical perspectives on the etiology and pathophysiology of insomnia that includes ten human models and three animal models [6]. Taken together, these perspectives provide a rich panoramic view of the factors that (1) may serve to “predispose, precipitate, and perpetuate” insomnia as a disorder, (2) may account for the efficacy of the current treatment modalities, and/or (3) may serve as targets for the development of new therapies.

Standardized Definitions

Insomnia is, without a doubt, the first of the sleep disorders to be described as either a symptom or a disease. References to this form of sleeplessness may be found in the oldest documents known to man, including The Iliad, The Epic of Gilgamesh, the Torah, the New Testament and the Koran. Presently, insomnia is described in each of the major nosologies that define human disease and mental illness, including the ICD-9, DSM-IV-TR, and the ICSD-2. These diagnostic classifications have been augmented with the delineation of formal research diagnostic criteria [7]. Perhaps the most significant accomplishment within this area in recent times has been the effort to challenge the validity and utility of the diagnostic classifications of “primary and secondary” insomnia [8,9]. At this juncture, many appear ready to doff the concept of “secondary” insomnia in favor of the concept of “comorbid” insomnia.

Standardized Assessment Methods

What exists presently is the general agreement that:

• prospective assessment with sleep diaries is required;

• an evaluation of depressive and anxiety disorders is necessary;

• it may be helpful to retrospectively assess insomnia severity (e.g., the ISI), and insomnia timing and frequency (e.g., the TPQ [10]); and

• it may be useful to assess the factors that are thought to moderate, if not mediate, illness severity, including such factors as sleep hygiene infractions (e.g., the SHI [11]), dysfunctional beliefs about sleep (e.g., the DBAS [12]), sleep effort (e.g. the GSES [13]), and the selective attention to sleep “threats” (e.g., the SAMI [14]).

Efficacy and Effectiveness Data

Most would agree that the first case series studies, if not full-blown clinical trials, occurred in the 1930s as tests of the efficacy of progressive muscle relaxation (PMR). Since that time approximately 200 trials have been conducted on either single interventions (Stimulus Control, PMR, and Sleep Restriction) or multi-component interventions that may be characterized as Cognitive Behavioral Therapy for Insomnia (or CBT-I). This extensive literature has been quantitatively summarized using meta-analytic statistics on at least three occasions [15–17], and there is at least one comparative meta-analysis that evaluates the relative efficacy of CBT-I as compared to benzodiazepine receptor agonists (BZRAs) [18]. The data from this literature suggest, consistent with the conclusions of the NIH State of the Science Conference [19], that (1) CBT-I is highly efficacious, (2) BZRAs and CBT-I produce comparable outcomes in the short term, and (3) CBT-I appears to have more durable effects when active treatment is discontinued.

Beyond the issue of efficacy is the issue of effectiveness. That is, are the clinical outcomes observed in clinical trials comparable to investigations of treatment outcome in (1) patients with insomnia comorbid with other medical and/or psychiatric illnesses (e.g., Edinger, Savard, Currie, Jungquist, Lichstein, and their colleagues [20–25]), and/or (2) studies of patients who are treated in clinical care settings (e.g., Perlis and colleagues [26,27])? To date there have been more than 20 studies in patient samples who suffer such co-morbidities as cancer, chronic pain, depression, and PTSD. The data from these studies not only show CBT-I to be effective, but also show that the clinical outcomes are, by and large, comparable to those found with patients with primary insomnia. In some cases, the effects are actually larger [21,24]. As noted above, there has also been a variety of clinical case series studies. The effect sizes for these studies also appear comparable to those obtained in randomized clinical trials. Taken together, these findings clearly suggest that CBT-I is more than ready for mass dissemination and implementation.

Treatment Dissemination and Implementation

Significant advances have been made in recent years within this domain, particularly with respect to the issues of training and credentialing. First, there are at least three published treatment manuals that delineate how to conduct CBT-I [28–30]. Second, there are several multi-day courses that are available on an annual or biannual basis. One such course, which is largely an introduction to Behavioral Sleep Medicine, has been available through the American Academy of Sleep Medicine (AASM) since 2004, and will continue to be available through the newly formed Society of Behavioral Sleep Medicine (SBSM) for the foreseeable future; another such course, which is a dedicated training seminar in CBT-I, has been offered annually since 2006 through the University of Rochester, and is currently offered through the University of Pennsylvania. Third, in 2005 and 2006 the BSM committee of the AASM established training opportunities via the credentialing of BSM fellowships and mini fellowships. Fourth, as result of the vision and generosity of the AASM, there is (as of 2004) a credentialing board for BSM that is underwritten by the academy and administered by the American Board of Sleep Medicine.

New Treatments

In recent years, there has been a substantial resurgence in the effort to develop new treatments. In many ways, it is this spirit and the fruits of these labors that give rise to the impetus for this book: the need to collect into one place a description of each of the procedures that not only comprise CBT-I but also the therapies that have recently been developed. With respect to insomnia, these new therapies include the following:

1. The use of bright light as adjuvant therapy (see Chapter 17)

2. Sleep re-training (see Chapter 13)

3. Utilization of cognitive therapy including behavioral experiments to treat dysfunctional beliefs and safety behaviors (see Chapters 7–10)

4. Adaptation of cognitive therapy for catastrophic thinking from exercises intended for patients with anxiety disorders to patients with insomnia (see Chapter 12)

5. Application of mindfulness and meditation as methods to enhance coping with insomnia (see Chapters 4 and 14).

Future Directions

While much has been accomplished, there can be no question that much remains to be done.

Conceptual Models

The existing theories need to be put to the test with experiments that allow for falsification. The animal models need to be assessed for their validity (although less so, ironic as it may be, for the Drosophila model [6,31]). New animal models need to be developed that focus on the factors delineated in the human models and, conversely, findings from animal models need to be examined in human models.

Standardized Definitions

The existing nosologies need to be critically evaluated so as to allow for proper phenotyping of the disorder. Such an effort will require a thorough-going a...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• About the Author
• Dedication
• Contributors
• Abbreviations
• Introduction
• PART I: BSM Treatment Protocols for Insomia
• PART II: BSM Protocols for Adherence and Treatment of Intrinsic Sleep Disorders
• PART III: BSM Protocols for Pediatric Sleep Disorders
• Index