Recently I attended “Sleep 2016” the 30th anniversary meeting of the Associated Professional Sleep Societies (co-hosted by the American Academy of Sleep Medicine and the Sleep Research Society). With a combined membership of over 3,000, this is one of the largest conferences specifically focused on sleep disorders research and treatment. While a full review of the abstracts presented (over 1,000 in total) is obviously outside the scope of this blog post, I’d like to review some findings that may be of help to those we train and those we treat.
Sleep Disorders Often Misdiagnosed as Depression or Anxiety. In order to avoid misdiagnosing a sleep disorder as depression (shown to occur nearly 75% of the time; Krupinski & Tiller, 2001), providers were encouraged by Colleen E. Carney, PhD (Ryerson University) to inquire about environmental variables (i.e., sleep hygiene/stimulus control). If a patient whom you’ve diagnosed with MDD is violating a number of the sleep hygiene guidelines, then insomnia is likely a co-morbid condition. The point here is that some therapists who are looking for a cause for sleep complaints are quick to attribute them to depression or anxiety as opposed to dysfunctional coping behaviors such as excessive caffeine consumption, frequent napping, alcohol as a sleep aid, etc. If you are treating a patient’s depression or PTSD and you note no improvement in the sleep symptom, it may be time to use Cognitive Behavioral Therapy for Insomnia (CBT-I). There has been one published RCT using CBT-I with persons with both MDD and Insomnia (Manber & colleagues; 2008).
Non-Adherence to CBT-I. As most who have attempted to use CBT-I with insomniacs know, about half will not stick with sleep hygiene and stimulus control. The main recommendation from Carney was to educate and encourage patients to use the hygiene and restriction protocol and then to review diaries for non-adherence. Once you can see non-adherence, such as to keeping to the same wake-up time 7 days a week, then you can dig into the associated beliefs. Many will have an aversion to fatigue, suffer from excessive rumination, or hold very negative core beliefs about being defective (“There’s something wrong with me.”) and/or helpless (“There’s nothing I can do about it.”) which can contribute to their general non-adherence. Apply behavioral activation after analyzing any avoidance patterns. Propose to patients that they do something different as a simple test or experiment.
Show Me The Data. Another big push was for therapists to help patients test their avoidance-related beliefs and assumptions with data. Apply the adage of you can’t expect different results if you keep doing the same thing over and over. Carney discussed an example of a salesman who believed that he looked awful on nights of poor sleep. Carney challenged him with the experiment of taking a photo of himself each and every morning and then asking some friends to guess which pictures corresponded to various levels of sleep efficiency. No one could guess correctly. In another example, a patient would not get out of bed at an appropriate wake-up time because they believed their mood was always at its “worst” in the morning. Carney worked with the patient to collect a week’s worth of mood data and found that there really was no relationship: on average, the patient was only one point more depressed in the AM than the PM.
Low CPAP Adherence. Jack Edinger, Ph.D. (National Jewish Hospital, Denver) noted that among first-time users of CPAP less than 10% are using it regularly by month 12 (Stepnowsky & Moore, 2003). While there are a number of adherence related beliefs such as “I’m too young for this,” “I’m dating and it’s cramping my style,” anxiety related beliefs are more common. Exposure-based training can help, so that using it becomes second nature. He advised asking such patients how they might cope with a child afraid of the water. Usually they will describe some form of graded exposure and then this is what the therapist advises they do. Depending on the patient’s desired pace, they might first breathe with the mask to their face and watch TV. When they can tolerate this then they can actually wear it. Then they wear it with the machine running. When they can tolerate that for 20-30 minutes, they can try taking a nap in the daytime while wearing the mask with the machine on. When can do that consistently, then they can do it in bed at night. There is no set time course to this. It may take days or it may take weeks. As with any graded exposure, the patient should be tracking their behavior, duration, and SUDS. See Edinger & Radtke, 1993, and Means & Edinger for more details. Finally, for those who refuse to use a CPAP, Edinger advised that they be shown the video of their sleep study or to set-up a home recording of them sleeping without the CPAP to see all the arousals (see Aloia et al., Sleep (suppl) 2013).
Alcohol and Sleep. CBT-I therapists know to inquire about use of alcohol as a sleep aid. What many may not know is how long it takes any alcohol to leave the CNS so as to not impact sleep. J. Todd Arnedt, Ph.D. Associate Professor of Psychiatry and Neurology, University of Michigan Medical School notes that the math of one standard drink leaves the body in one hour does not apply. Indeed, the National Institute on Alcohol Abuse and Alcoholism found that it takes about three hours for a single standard drink to leave the CNS. Thus, so as not to impact sleep, light drinkers should abstain starting three hours before bed. To avoid sleep problems, those consuming three standard drinks should wait six hours before going to bed. (See NIAAA Alert No. 35, 1997. Alcohol Metabolism, Alcohol Alert No.35: NIAAA, 1997). Additionally, even small to moderate amounts of alcohol have a significant impact on most sleep variables (efficiency) as well as melatonin production and are more striking among women than men (Arnedt, 2011).
Pain and Sleep. Michael Smith, Ph.D., of Johns Hopkins University Pain Clinic, noted that studies reveal half or more of chronic pain patients have insomnia or sleep apnea. Noting the reciprocal relationship between sleep and pain, he ensures sleep is addressed among his chronic pain patients. Given the overlap of chronic pain, insomnia, and depression, new research is focusing on hybrid forms of treatment that include components of CBT-P, -I, and –D. For example, Pigeon (2012) provided patients with 10 sessions focusing on behavioral activation, pacing, cognitive restricting of related beliefs in all domains, relaxation training, etc., and found an effect size on pain of .34.
Melatonin and Light Applications to Sleep. James K. Wyatt, Ph.D., Associate Professor of Behavioral Sciences, Rush Medical College, discussed some particular aspects of melatonin and light therapy. Exogenous melatonin has a relatively short half-life of about 45 minutes. In general, most therapists are advising dosing melatonin in the later afternoon early evening to pull the natural bedtime forward (phase advance) or in the early morning hours to push the natural bedtime back (phase delay). Exposing oneself to light in the evening or early night time hours to push the natural bedtime back (phase delay) or in the early morning after waking up to pull the natural bedtime forward (phase advance). These types of effects can be important for shift workers, but also for those patients on a regular schedule who feel their natural bedtime is somehow offset from what their work schedule requires (i.e., someone who probably needs to be asleep by 9 P.M., but finds the usually don’t feel sleepy until 11 P.M.
David J. Reynolds, Ph.D., is the Deployment Behavioral Health Psychologist at Malcolm Grow Medical Clinics and Surgery Center (MGMCSC) located on Joint Base Andrews, Maryland.
Aloia, M., Harrington, J., Cartwright, A., Goelz, K., Edinger, J. D., & Lee-Chiong, T. (2013). Personalized video to improve adherence to PAP therapy. Sleep 36(suppl): A407-A408.
Arnedt, J. T., D. J. Rohsenow, A. B. Almeida, S. K. Hunt, M. Gokhale, D. J. Gottlieb & J. Howland (2011). Sleep following alcohol intoxication in healthy, young adults: effects of sex and family history of alcoholism. Alcohol Clin Exp Res 35(5): 870-878.
Edinger, J.D., & Radtke, R.A. (1993). Use of in vivo desensitization to treat a patient’s claustrophobic response to nasal CPAP. Sleep 16(7): 678-680.
Krupinski, J., & Tiller, J. W. G. (2001). The identification and treatment of depression by general practitioners. Australian and New Zealand Journal of Psychiatry 35:827–832.
Manber, R., Edinger, J. D., Gress, J. L., San Pedro‐Salcedo, M. G., Kuo, T. F., & Kalista, T. (2008). Cognitive Behavioral Therapy for insomnia enhances depression outcome in patients with comorbid Major Depressive Disorder and insomnia. Sleep 31(4), 489‐495.
Means, M. K., & Edinger, J. D. (2007). Graded exposure therapy for addressing claustrophobic reactions to continuous positive airway pressure: a case series report. Behavioral Sleep Medicine 5(2):105-116.
National Institute on Alcohol Abuse and Alcoholism (1997). Alcohol metabolism. Alcohol Alert 35. Retrieved from http://pubs.niaaa.nih.gov/publications/aa35.htm
Pigeon, W. R., Moynihan, J., Matteson-Rusby, S., Jungquist, C. R., Xia, Y., Tu, X., & Perlis, M.L. (2012). Comparative effectiveness of CBT interventions for co-morbid chronic pain & insomnia: a pilot study. Behaviour Research and Therapy, 50(11):685-689.