Insomnia Explained Clearly by MedCram.com | 4 of 6

Summary

This MedCram lecture explores behavioral therapy for insomnia, focusing on techniques like relaxation, sleep restriction, cognitive therapy, and cognitive behavioral therapy (CBT). The lecture outlines how these methods help eliminate perpetuating factors of insomnia when sleep hygiene and stimulus control are insufficient. It emphasizes the importance of monitoring patients closely, particularly during sleep restriction therapy, and highlights the effectiveness of CBT in improving sleep quality. The lecture sets the stage for a follow-up discussion on medications for insomnia treatment.

Takeaways

• 🛌 The lecture focuses on behavioral therapy for insomnia, especially when sleep hygiene and stimulus control are not effective.
• 🔄 The recommended approach involves combining behavioral therapy with medication when initial methods fail.
• 🎯 The goal of behavioral therapy is to eliminate perpetuating factors that maintain insomnia even after the initial cause has passed.
• 😌 Relaxation techniques include progressive relaxation and relaxation response, though they may not be effective alone.
• ⏰ Sleep restriction therapy is powerful but should be supervised by a physician. It aims to increase sleep efficiency by reducing time in bed.
• 📊 A sleep diary is used to track sleep patterns and adjust sleep time based on sleep efficiency, with no less than 5 hours in bed.
• 🧠 Cognitive therapy targets catastrophic thinking about insomnia, helping patients to reduce anxiety and negative thoughts associated with sleeplessness.
• 🛠 Cognitive Behavioral Therapy for Insomnia (CBT-I) combines multiple techniques, including cognitive therapy, sleep restriction, and sleep hygiene, for comprehensive treatment.
• 📚 Cognitive behavioral therapy provides patients with tools for long-term success in managing insomnia.
• 💊 While medications are often sought by patients, the lecture emphasizes the importance of behavioral therapy as a foundational approach.

Q & A

What is the primary goal of behavioral therapy in treating insomnia?

The primary goal of behavioral therapy in treating insomnia is to eliminate perpetuating factors that keep a person in a state of insomnia, even after the initial causes of insomnia have subsided.

When is behavioral therapy recommended for insomnia?

Behavioral therapy is recommended when sleep hygiene and stimulus control alone are not effective in treating insomnia. It is also recommended to be used in conjunction with medication.

What are the four types of behavioral therapies mentioned for treating insomnia?

The four types of behavioral therapies mentioned are relaxation technique, sleep restriction therapy, cognitive therapy, and cognitive behavioral therapy (CBT-I).

What are the two classes of relaxation techniques described?

The two classes of relaxation techniques described are progressive relaxation, where muscles are relaxed one at a time, and the relaxation response, where the patient lies down, closes their eyes, and focuses on peaceful thoughts.

How does sleep restriction therapy work?

Sleep restriction therapy works by limiting the time a person spends in bed to match their actual sleep time, thereby increasing sleep efficiency. Over time, the allowed sleep time is gradually increased as sleep efficiency improves.

What is cognitive therapy's role in treating insomnia?

Cognitive therapy aims to prevent catastrophic thinking related to insomnia, such as fears about not being able to sleep and the negative consequences that might follow. By addressing these thoughts, cognitive therapy helps reduce anxiety and improve sleep.

What is cognitive behavioral therapy for insomnia (CBT-I) and how does it differ from other therapies?

Cognitive behavioral therapy for insomnia (CBT-I) is a comprehensive approach that combines various behavioral techniques, including cognitive therapy, sleep restriction, relaxation techniques, and sleep hygiene. Unlike other therapies that focus on specific aspects, CBT-I addresses multiple factors contributing to insomnia.

What is the purpose of keeping a sleep diary in sleep restriction therapy?

The purpose of keeping a sleep diary in sleep restriction therapy is to track sleep patterns and sleep efficiency, which helps in adjusting the allowed sleep time and monitoring progress during the therapy.

What are some potential risks of sleep restriction therapy?

Some potential risks of sleep restriction therapy include sleep deprivation, which can be dangerous if not carefully monitored. It is important that patients undergoing this therapy are supervised by a physician to ensure safety, especially considering the impact on daily functioning.

Why is cognitive behavioral therapy (CBT-I) considered effective for improving sleep quality?

CBT-I is considered effective for improving sleep quality because it provides a comprehensive set of tools that address the underlying causes of insomnia, rather than just the symptoms. It has been proven to decrease awake time during the night and enhance overall sleep quality.

Outlines

00:00

🛏️ Behavioral Therapy Overview for Insomnia

This paragraph introduces behavioral therapy for treating insomnia, emphasizing that it should be used alongside medication when sleep hygiene and stimulus control are insufficient. The general approach is revisited, focusing on addressing perpetuating factors of insomnia. Four key behavioral therapies are mentioned: relaxation techniques, sleep restriction therapy, cognitive therapy, and cognitive behavioral therapy, with a note that medications will be covered in a subsequent lecture.

05:00

😴 Understanding Sleep Restriction Therapy

Sleep restriction therapy is highlighted as a powerful method to improve sleep efficiency by limiting the time spent in bed. The method involves setting strict bedtimes based on the actual hours of sleep a person gets, gradually increasing sleep time as efficiency improves. This approach requires careful monitoring to avoid sleep deprivation, with the ultimate goal of consolidating sleep and improving sleep efficiency.

10:04

💭 Managing Catastrophic Thinking in Cognitive Therapy

Cognitive therapy aims to address catastrophic thinking patterns that exacerbate insomnia. Patients who stress over the consequences of not sleeping well are taught to deconstruct these fears, realizing that the situation may not be as dire as they believe. By reducing anxiety and the negative associations with the bedroom, this therapy helps patients manage insomnia more effectively.

🧠 Comprehensive Approach: Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT-I) is described as a holistic approach combining all previously discussed techniques, including sleep hygiene and stimulus control. It is presented as an effective and long-lasting method for improving sleep quality and reducing nighttime awakenings. The paragraph underscores the importance of providing patients with tools for sustained success, emphasizing that CBT-I is often overlooked in favor of medications.

Keywords

💡Behavioral Therapy

Behavioral therapy in the context of the video refers to a set of techniques aimed at addressing insomnia by modifying behaviors that perpetuate the condition. This includes methods like relaxation techniques, sleep restriction therapy, cognitive therapy, and cognitive-behavioral therapy (CBT). The goal is to break the cycle of poor sleep habits and thought patterns that maintain insomnia.

💡Insomnia

Insomnia is a sleep disorder characterized by difficulty falling or staying asleep. The video discusses various approaches to managing insomnia, focusing on behavioral therapy when sleep hygiene and stimulus control are insufficient. It highlights that insomnia often persists due to perpetuating factors, which behavioral therapy aims to eliminate.

💡Sleep Hygiene

Sleep hygiene refers to practices and habits that promote good sleep quality. These include maintaining a regular sleep schedule, creating a comfortable sleep environment, and avoiding stimulants before bed. The video mentions sleep hygiene as a foundational step in treating insomnia before moving on to more intensive therapies.

💡Stimulus Control

Stimulus control involves changing the association between the bedroom and activities that are not conducive to sleep, like watching TV or worrying. The video discusses it as an initial strategy for managing insomnia, alongside sleep hygiene, to recondition the mind to associate the bedroom primarily with sleep.

💡Relaxation Techniques

Relaxation techniques are methods used to reduce physical and mental tension, which can help individuals fall asleep. The video describes two types: progressive relaxation, where muscles are relaxed one at a time, and the relaxation response, which involves calming the mind. While not always effective on their own, they are part of the behavioral therapy toolkit for insomnia.

💡Sleep Restriction Therapy

Sleep restriction therapy is a behavioral treatment for insomnia that limits the time spent in bed to increase sleep efficiency. The video explains how it works by initially reducing time in bed to match actual sleep time, gradually increasing it as sleep improves. This method requires careful monitoring to avoid excessive sleep deprivation.

💡Cognitive Therapy

Cognitive therapy focuses on changing negative and catastrophic thoughts about sleep that can worsen insomnia. The video illustrates how individuals with insomnia often worry excessively about the consequences of not sleeping, which exacerbates the problem. Cognitive therapy helps patients reframe these thoughts to reduce anxiety and improve sleep.

💡Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy for Insomnia (CBT-I) combines cognitive therapy with behavioral strategies to treat insomnia. The video presents CBT-I as the most comprehensive and effective approach, addressing both the thoughts and behaviors that contribute to insomnia. It includes sleep hygiene, stimulus control, and other techniques to create lasting improvements in sleep.

💡Sleep Efficiency

Sleep efficiency is the ratio of time spent sleeping to the total time spent in bed. The video emphasizes its importance in sleep restriction therapy, where the goal is to increase sleep efficiency by reducing the time spent awake in bed. A sleep efficiency above 85% is considered a target for improving sleep quality.

💡Perpetuating Factors

Perpetuating factors are behaviors or thoughts that maintain insomnia even after the initial causes (precipitating factors) have resolved. The video explains that these factors, such as spending too much time in bed or worrying about sleep, can keep individuals in a state of insomnia. Behavioral therapy aims to address and eliminate these perpetuating factors.

Highlights

Behavioral therapy is recommended if sleep hygiene and stimulus control do not work.

Behavioral therapy is often combined with medication for treating insomnia.

Four behavioral therapies are discussed: relaxation techniques, sleep restriction therapy, cognitive therapy, and cognitive behavioral therapy (CBT).

Relaxation techniques include progressive relaxation and relaxation response, but they are often not effective alone.

Sleep restriction therapy is the most powerful method but should be supervised by a physician.

Sleep restriction therapy aims to increase sleep efficiency by limiting time in bed and gradually increasing it based on sleep quality.

Patients should maintain a sleep diary to monitor progress during sleep restriction therapy.

Cognitive therapy helps patients avoid catastrophic thinking about insomnia, reducing anxiety associated with sleeplessness.

Cognitive Behavioral Therapy for Insomnia (CBT-I) combines all aspects of behavioral therapy and is highly effective.

CBT-I is often conducted by psychologists, but physicians and others can also administer it.

CBT-I is proven to improve sleep quality and reduce awake time during the night.

Sleep efficiency should be maintained above 85% during sleep restriction therapy before allowing more time in bed.

No napping is allowed during sleep restriction therapy to ensure sleep pressure builds up.

Behavioral therapy is often skipped in favor of medication, but it is crucial for long-term success.

The next lecture will cover medications for insomnia, which many patients expect when seeking treatment.

Transcripts

okay welcome to another MedCram lecture we're gonna talk about behavioral

therapy here in relation to insomnia and we already talked earlier about the

general approach we want to look for diseases we want to do sleep hygiene and

stimulus control the other thing we want to do is now behavioral therapy this is

what we do if sleep hygiene and stimulus control don't work and the current

recommendations is that we do it in conjunction with medication but let's

talk about these separately here's another way of looking at it again a

little bit cleaner our general approach is we look for diseases do hygiene

handout and the stimulus control if that doesn't work we move on to a combination

of behavioral therapy and medication we'll deal with these separately but

we'll deal with behavioral therapy first so what we're going to talk about are

the four different behavioral therapies one is relaxation technique sleep

restriction therapy cognitive therapy and then cognitive behavioral therapy

medications that we'll talk about in a later lecture are the benzodiazepines

the non benzodiazepine sedatives the melatonin agonists and then finally the

antidepressants so the purpose of behavioral therapy if you'll recognize

this graph now little cleaned up here is remember in the pre morbid state we had

these predisposing factors which remain throughout our lifetime and then

sometimes these precipitating factors would occur that would take us over the

insomnia threshold and when that occurred even though that actual

precipitating factor would go down below that insomnia threshold the problem was

is that we unwittingly instituted these perpetuating factors that would keep us

in a state of insomnia the target of behavioral therapy is to get rid of

those perpetuating factors so let's talk about relaxation technique so relaxation

therapy is divided into two different classes there's progressive relaxation

and there's relaxation response both of these are somewhat helpful they

probably don't work by themselves so progressive relaxation is the technique

where one relaxes a muscle one of the time until the whole body is relaxed and

the thing is they start in the face for about one to two seconds and you go down

the body and you repeat it for about 45 minutes and I'm telling you if I did

this I would probably fall asleep before I got to my arms I'm just guessing

another technique is the relaxation response where the patient is lying down

they close their eyes they allow relaxation to spread throughout their

entire body and they turn their thoughts to more peaceful things so this is

basically a way of just getting probably some anxiety inducing thoughts out of

their body it probably doesn't work by itself but nonetheless it is mentioned

in the literature so I thought you should know about it the next one is

sleep restriction therapy this is probably the most powerful and I would

say again that this is not something that you want to do without supervision

you don't want to do this without a physician monitoring you but it's an

interesting situation now remember we talked about how long somebody was in

bed for it's possible that they could be in bed literally for 12 hours a day even

though they're only sleeping six hours and that of course would be a sleep

efficiency of 50% so 6 divided by 12 is 50% the problem is is that sometimes a

perpetuating factor of insomnia is that people tend to stay in bed longer as a

result of that which is not good and so you might get a circadian shift with a

decrease in homeostatic drive that means just basically you don't feel sleepy and

the more you don't feel sleepy the more you want to try to stay in bed so you

can make up your sleep this could be a vicious cycle the purpose of sleep

restriction therapy is to increase sleep drive and to consolidate sleep and sleep

efficiency so instead of having a huge denominator which is the amount of time

that you spend in bed and a small numerator which is the amount of sleep

that you get we want to decrease the denominator to such a small level that

your sleep efficiency even though your total sleep time may not be big your

sleep efficiency is and then slowly give back that

time so what we do is we add up all of the fragments by looking at a sleep

diary and hopefully it's no less than five hours of time because if it is it

could actually be counterproductive and we count back from the target wake time

so let's take something for example let's say you go to bed at 9 o'clock at

night and you get up at 6 but you're only sleeping for 5 hours during that 9

hour period though it's in bits and pieces what we would do is we say ok you

slept for five hours and you want to get up at 6 o'clock in the morning so let's

count 5 hours backwards from 6 o'clock in the morning and we'll figure out the

time that you should go to sleep well that's 1 o'clock in the morning so what

we would say then is the patient is only allowed to go to bed at 1 o'clock in the

morning and until the sleep efficiency is greater than 85% nothing is going to

change so every night that patient has to stay up and go to bed at 1 o'clock in

the morning now one of two things will happen either the patient won't be able

to go to sleep and they'll get less than 5 hours of sleep and at 6 o'clock in the

morning when it's time to get up they're going to be really tired which is great

because that'll help us the next night have them fall asleep more easily at 1

o'clock in the morning and hopefully stay asleep until 6

once that sleep efficiency gets above 85% in other words once they're sleeping

a solid 5 hours between 1 o'clock in the morning and 6 o'clock in the morning

then we'll give them back 15 minutes now they get to go to bed at 12:45 and if

they can continue to maintain a 85% sleep efficiency then we'll continue to

march back every week or two weeks every 15 minutes until finally we get seven

eight hours of sleep and their sleep efficiency is maintaining above 85% and

the rule is is that there is no napping so here's an example of a sleep diary

and you can see here that we have the days of the week they mark a line here

when they go to bed and the next morning they shade in the areas here where they

actually slept okay here's here's an example again the down arrow is when

they go to bed the up arrow is when they wake up but you can see here there's

significant break in their sleep so this is called sleep

fragmentation this is a low sleep efficiency and what we'd like to do is

consolidate this kind of like you defragment a computer hard drive we want

to slide all of this here toward the front end and say they cannot go to

sleep until that time and if they can maintain the sleep efficiency then they

get time back here it is again graphically so here's baseline insomnia

11:00 p.m. 7:00 a.m. you can see here clearly that they're only sleeping for a

certain amount of time for five hours so what we do is we push it all the way to

the front and say you are not allowed to go to sleep until this period of time

and if they maintain that sleep efficiency at 95% here in this case then

they get to go to bed a little bit earlier in week two and so the key here

is to restrict the number of hours in bed and that should be around the

average total sleep time and you really don't want to limit it to less than five

hours if you do it could be dangerous the patience time in bed and out of bed

are inflexible they cannot change that it has to be exactly that way and we try

to review ways to stay awake during these times here where they want to go

to bed but they can't they keep this diary and their ticket to get more sleep

time as when they come back after we can show that they're able to stay asleep

and the titrated based on the diary data that we get from the patient so that

sleep restriction therapy the key there is you gotta monitor these patients very

carefully for sleep deprivation okay you got to assess what kind of a job they

have in how safe is this because this is pretty serious behavioral therapy okay

okay let's talk about cognitive therapy cognitive therapy is to prevent people

from making a mountain of out of a molehill

basically there's catastrophic thinking so this is the type of patient that goes

to bed and they can't go to sleep and they say this is horrible this is a

disaster I have a meeting tomorrow I this is not good for my health I'm gonna

die young I'm gonna lose my job and that type of thinking of course is not very

conducive to falling asleep so what we need to do is we need to

deconstruct that perpetuating factor of catastrophic thinking we have to say

look you didn't sleep tonight but you haven't slept well for months

and you're still alive you still haven't lost your job so it's actually not as

bad as you think and so by deconstructing that

catastrophes ation of insomnia hopefully we can actually get these patients to

bed and forget the anxiety that they have and forget that association of

anxiety with the bedroom so it's it's multifaceted and then finally this

cognitive behavioral therapy is really the whole kit and caboodle put together

in fact you'll see this often regarded as CBT I and this is what psychologists

do specifically when we a sleep specialist send our patients for CBT i

they're actually very good at doing this although physicians can do it and you

don't even have to be a physician to do this sort of stuff so basically

cognitive behavioral therapy is a combination of everything we've just

talked about under the banner of behavioral therapy even sleep hygiene

and stimulus control so there's Education stimulus control sleep

restriction cognitive therapy sleep hygiene and basically what you're doing

here is providing your patients the tools for the future for future success

not only to get better but to stay better very few can do a good job of

this so it got to do a lot of reading and figure this stuff out to not only

understand it but execute it on your patients it has been proven to be

effective to improve sleep quality and decrease awake time during the night so

cognitive behavioral therapy is basically the summation of all of what

we've talked about here behavioral therapy and sleep hygiene and stimulus

control therapy I know this is a quick run through behavioral therapy we are

going to talk about medications next this is really what people expect when

they come and see their physician is what kind of medication can they give me

to fall asleep a lot of times though this behavioral therapy is skipped and I

think that's that's not doing our patients a service but let's talk about

medications in the next lecture thanks for joining us

you