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