Sleep restriction theory
-maurer
-improve consolidation of sleep
-therapist prescribed TIB equals average TST
-Sleep efficiency criterion changes to TIB
-SOL reliably decreased reflecting increased sleep pressure
-3P model (diathesis-stress model) basis for application SRT
predisposing=increase vunerability to insomnia
precipitating=trigger the onset of insomnia
perpetuating=maintain symptoms
-SRT addresses to perpetuating factors that maintain symptoms
The triple-R model of SRT
-maurer
- psychological processes dysregulate sleep
- modification to sleep can feed-back psychological processes
- this interaction maintains insomnia
- Restricting time in bed awake, Regularising time of sleep and wake, Re-conditioning the association between bedroom factors and sleep
The role of personality traits in insomnia
- 3 factor model
- van de laar
- 3 factor model describes predispositions, precipitants and perpetuating factors interact to induce and maintain insomnia
- predisposing=biological traits, personality traits, social factors
- precipitating=medical illness, psychiatric illness, stressful life events
- perpetuating=excessive TIB, napping, conditioning, worrying, perception
Role personality traits in insomnia
- worrying
- primary, psychophysiological and paradoxical insomnia
- van de laar
- tendency to be overconcerned (lacking self-confidence and doubts about actions)
- associated with perfectionism and self-imposed strain
- primary insomnia high neuroticism, internalization, high concern over bodily functioning, social introversion
- psychophysiological insomnia normal but also more pessimistic, fearful, shy and more easiliy fatigued
- paradoxical insomnia (i.e. sleep state misperception) more focus on somatic complaints and also higher neuroticism, extraversion and hysteria scores
Personality and treatment responses
-van de laar
- association between baseline personality characteristics and treatment results
- scores on different personality scales reflect the severity of the subjective insomnia complaints
The internalizing hypothesis
-van de laar
- high neuroticism, perfectionism traits and anxiety related to different areas
- introverted and express negative feelings less easily
- hypothesis describes how an internalizing process could account for a state of constant emotional arousal
- not expressing feelings –> emotional arousal –> initiating or maintaining sleep
CBT of insomnia
-dolan
- positive changes noted in all sleep diary
- CBTi resulted in remission of insomnia
- majority of improvements in sleep diary within first 2 sessions of treatment
- sleep efficiency increased with CBTi
- sleep medication declined
Insomnia disorder
- definition
- manber
-charachterized by persistent difficulty initiating or maintaining sleep, accompanied by distress and perceived negative daytime consequences
Insomnia disorder
- treatment
- manber
- CBTi aims to strengthen the sleep drive and improve placement of the sleep opportunity window and reduce physiological and cognitive arousal
- stimulus control aim to strengthen the bed as a cue for sleep, only in bed in a state of mind conducive for sleep
- SRT reduced time in bed then gradually increasing time in bed as sleep is consolidated and sleep quality improves
- Relaxation practice
- psycho-education and sleep hygiene
Diagnosis and treatment of insomnia
- definition and diagnosis
- Riemann
- non-organic insomnia is subjective experience
- A disturbance of nocturnal sleep (difficulty initiating/maintaining sleep, early waking up, difficulty sleeping without parent, resistant going to bed early)
- B related daytime impairment (fatigue, concentration impairment, impaired social performance, irritability, daytime sleepiness, behavioral problems, reduced energy, proneness accidents, concerns about sleep)
- C cannot explained by inadequate opportunity or inadequate circumstances
- D at least 3 nights a week for period of 3 months
- E not explained by another sleep disorder
Diagnosis and treatment of insomnia
- Diagnostic procedure
- Riemann
- medical and psychological anamnesis is mandatory
- often suffer from a co-morbid mental disorder or neurodegenerative disorder
- sleep history assessment
- pseudo-insomnia/sleep state misperception/paradoxical insomnia because TST reduced with 25 minutes but subjective TST reduces by 2 hours
Diagnosis and treatment of insomnia
- health risks of insomnia
- Riemann
- risk factor for cardiovascular diseases and type 2 diabetes
- short sleep duration risk factor for obesity, type 2 diabetes, hypertension and cardiovascular disease
Diagnosis and treatment of insomnia
- treatment of insomnia
- Riemann
- CBTi is psychoeducation, sleep hygiene rules, relaxation training, stimulus control therapy, SRT and cognitive therapy
- Relaxation therapy aimed at reducing somatic tension or intrusive thoughts at bedtime
- SRT curtail the time in bed to the actual amount of sleep being achieved
- Stimulus control therapy are behavioral instructions designed to re-associate the bed with sleep and to re-establish a consistent sleep-wake schedule
- Cognitive therapy are methods to identify, challange and change misconceptions about sleep (mindfullness and hypnotherapy)
Diagnosis and treatment of insomnia
- Pharmacotherapy
- Riemann
- BZs (benzodiazepines) and BZRAs (benzodiazepine receptor agonists) used for short term
- Antidepressants used for short term
- antihistamines, antipsychotics, melatonin and phytotherapy not recommended
Diagnosis and treatment of insomnia
- light therapy and exercise
- Riemann
- light therapy used for seasonal affective disorder and circadian rhythm disorder
- exercise has positive effects on physiological and physical healt
- both recommended by insomnia
Diagnosis and treatment of insomnia
- algorithm for diagnostic and therapeutic process
- Riemann
Patient with sleep onset and/or sleep maintenance disturbance/early morning awakening and daytime impairment
–> clinically significant impairment?
no–> psychoeducation/prevention
yes–>sleep pattern in sychrony with circadian rhythm?
no–>psychoeducation/prevention
yes–>intake of substances effect sleep?
yes–>change of medication
no–>comorbid somatic or mental disorder?
no–>treatment insomnia with CBTi as first line, BZ,BZRA or sedating antidepressants short term
yes–>treatment of comorbid and insomnia
