Insomnia

This Update investigates non-pharmacological management options for insomnia. It is by Dr Anup Desai, MBBS, PhD, FRACP, and Rosemary Clancy, BA Psych (Hons), M App Psych (Clin), MAPS CCLIN.

Dr Anup Desai, MBBS, PhD, FRACP
Dr Desai is a Senior Staff Specialist, Department of Respiratory and Sleep Medicine, Prince of Wales Hospital, Sydney; a Consultant Physician in private practice, Camperdown and Randwick; and a Clinical Senior Lecturer, Discipline of Sleep Medicine, University of Sydney, NSW.

Rosemary Clancy, BA Psych (Hons), M App Psych (Clin), MAPS CCLIN
Rosemary Clancy is Senior Clinical Psychologist at the Sydney Clinic, Bronte NSW

INTRODUCTION
INSOMNIA is defined as a distressing difficulty with sleep onset, sleep maintenance and/or early morning wakening where the individual’s sleep is insufficient for their needs. These symptoms arise despite adequate time in bed to achieve sleep.

Chronic insomnia is defined as sleep difficulties being present for at least one month and occurring three times or more per week.¹

Insomnia is often seen as a symptom of ‘other’ physical and psychosocial factors, but is more frequently being defined as a disorder due to its negative consequences, possibly resulting from a pathological response.

INSOMNIA AND ITS RELATIONSHIP TO MENTAL HEALTH
Prevalence rates for insomnia range from 4–48% of the population depending on the criteria used.

In a review paper examining the epidemiology of insomnia, about 33% of the population reported experiencing at least one insomnia symptom, such as sleep-onset difficulties.

Prevalence is reduced when daytime dysfunction is reported, dropping to 9–15%, while the range broadens from 8–18% with the addition of sleep dissatisfaction.

Major depressive disorder and generalised anxiety disorder are highly comorbid with chronic insomnia.^2,5 Pre-existing insomnia is the highest attributable risk factor for first-episode depressive disorder.⁶ 

Rates of 40% psychiatric comorbidity and almost 40 times the risk of developing new major depression have been found in those with insomnia compared with those without.⁴

A growing paediatric research base highlights the relationship of children’s sleep disorders to anxiety and depression, highlighting the need for adequate assessment when assessing childhood sleep disturbance.³

Recently, the Australian DRIVE study of 2937 young adult drivers found that short sleep duration was linearly associated with psychological distress.⁷

Those non-distressed at baseline with fewer than five hours’ sleep had an increased risk for onset of psychological distress at follow-up.

HISTORY-TAKING
Understanding the patient’s current sleep patterns, family history and factors associated with the onset and maintenance of insomnia gives the clinician a better understanding of the problem and enhances rapport. The following points may be useful to cover in the insomnia history:

• The predominant problem for the patient and how they feel their lifestyle may have been compromised by poor sleep.
• The patient’s normal bed routine, which might identify unhelpful behaviours or concerns (e.g. lying in bed for long periods awake, watching television in bed, anxiety about sleeping).
• The patient’s normal sleep routine, which will help to determine whether the patient suffers from sleep-onset or sleep-maintenance problems, or both. Very variable sleep routines may be identified at this stage. A two-week sleep diary is often useful to more objectively characterise a patient’s bed and sleep routine.
• The impact of the sleeping problem on daytime function – fatigue, sleepiness, quality of life, etc. Typically, patients with primary insomnia experience more ‘fatigue’ than ‘sleepiness’. If the patient is falling asleep frequently during the day, rather than just being tired or fatigued, sleep-breathing disorders (especially obstructive sleep apnoea) should be carefully looked for.
• Whether the patient is undertaking behaviours known to interfere with sleep such as using caffeine, alcohol, nicotine, recreational drugs; daytime napping; late-evening exercise; working late on the computer and being available for work 24 hours per day.
• An evaluation for secondary causes, especially other sleep disorders such as obstructive sleep apnoea, restless legs syndrome, shift-work sleep disorder and sleep-phase syndromes (see Table 1).
• The clinical features of obstructive sleep apnoea are generally well known to medical practitioners.
• Restless legs syndrome is identified by the presence of an urge to move the legs, usually accompanied by uncomfortable and unpleasant sensations in the legs; and symptoms that begin or worsen during periods of rest or inactivity and are partially or totally relieved by movement. The symptoms tend to be worse in the evening or night than during the day. Sufferers frequently experience at least one sleep-related symptom (e.g. one or more of an inability to fall asleep, inability to stay asleep, and disturbed sleep).
• Shift-work sleep disorder and advanced or delayed sleep-phase syndromes represent disorders of circadian rhythm, whereby the patient’s physiological sleep time (as set by their ‘circadian’ body clock) is at odds with their desired/required sleep time. If these sleep disorders are present, they may require treatment first or in tandem with treatment for insomnia.
• An evaluation for other secondary causes, such as medical and psychiatric conditions, and substance abuse (see Table 1). These conditions need to be optimally treated.

COGNITIVE BEHAVIOURAL THERAPY AND INSOMNIA
Cognitive behavioural therapy (CBT) is the most effective non-pharmacological treatment option for insomnia. CBT challenges maladaptive (i.e. ‘safety-seeking’) behaviours and cognitions, which maintain insomnia, and introduces sleep-conducive behaviours while raising the individual’s awareness of unhelpful and unrealistic expectations about sleep and daytime functioning.

CBT approaches, though more time-consuming for clinicians than hypnotics, are more effective in both the short-term and long-term. A meta-analysis examining CBT techniques and pharmacotherapy found that CBT significantly reduced sleep-onset times compared with hypnotic medication.

Overall, CBT, either individually or in group settings, improves total sleep time and general sleep quality, reduces sleep latency times and wakes after sleep onset, and positively alters cognitions about sleep.

INSOMNIA BEHAVIOURAL TREATMENTS
Two of the most effective behavioural methods of treating insomnia are stimulus control therapy and sleep restriction, or bed restriction (Table 2).

These treatments can be instigated from the GP’s surgery along with a rationale of the benefits of changing present habits to improve sleep.

It is worth noting that some individuals may also have defined their work/home situation/relationships by their insomnia and may perceive that change is not possible or wanted.

Stimulus control therapy
The rationale is to re-associate the bed and bed environment with successful sleep, and has more recently been called the ‘quarter-hour rule’ by Broomfield and colleagues (patients get out of bed after 15 minutes of wakefulness, returning only when sleep is imminent).

Sleep restriction
Most individuals try to make up for poor sleep by spending more time in bed, supposedly to increase sleep opportunity. The result is less consolidated sleep, more time in bed awake, and more time spent worrying about not sleeping. Under these circumstances, bed becomes a place of spending more time awake than asleep.

Restricting time in bed to the reported sleep time increases the homeostatic drive for sleep. Good sleepers will have a sleep efficiency of >85%, which means that sleep time and time in bed are closely matched.

Education about good sleep habits
Education about sleep is an important component of understanding how present behaviours can be changed to improve sleep. There are many myths about sleep and challenging these beliefs allows individuals to be more aware of their current responses.

Learning about behaviours known to interfere with sleep (such as use of caffeine, alcohol, nicotine, recreational drugs; daytime napping; and late-evening exercise) can be helpful in maintaining a good sleep-conducive routine.

The bed and bedroom needs to be somewhere that is comfortable, quiet, dark and allows the individual to look forward to sleep time. Setting aside some downtime before sleep is an important component of relearning sleep.

Not being available for work 24 hours a day is another important issue to address in relation to sleep and having ‘time out’.

Exercise, light and relaxation therapy
Exercise reduces muscle tension and physiological arousal, promoting better sleep. It improves mood, and allows the individual to get out there and ‘do something’, especially in the mornings; it is a positive active behaviour compared with lying awake in the morning waiting for more sleep.

Exercising in the evening artificially raises core body temperature and must be completed at least 3-4 hours before the expected bedtime (to allow the body to cool down, which is necessary for sleep onset). Individuals should aim for about 30 minutes of exercise per day.

A constant waking time is a crucial component of setting sleep boundaries. Getting up at the same time means there is a definite end to the sleep time, regardless of the quality of the night-time sleep. Getting-up time is more important than a regular bedtime, which does not necessarily guarantee sleep onset. Early morning light also resets the brain sleep clock.

Relaxation reduces high levels of both physical and mental arousal.  Relaxation techniques need to be seen in the context of reducing tension and the over-arousal response compared with being a means of getting to sleep, which puts pressure and effort onto sleep.

Relaxation techniques include progressive muscle relaxation, focused breathing strategies, imagery training, meditation and hypnosis.

Relaxation needs to become a part of the individual’s usual lifestyle, a means of having ‘time out’ where they learn to recognise increased stress responses and become more confident in reducing those stress responses that result from day-to-day living.

COGNITIVE THERAPY: CHANGING NEGATIVE SLEEP THOUGHTS
The cognitive factors believed to maintain chronic insomnia include worry, monitoring for sleep-related threats, distorted perception, unhelpful beliefs about sleep and safety behaviours. Cognitive therapy allows clients to recognise the connection between thoughts, mood and behaviour, and generate more realistic appraisals and behaviour change that are genuinely sleep-conducive.

Using behavioural experiments to challenge unhelpful beliefs and associated safety behaviours, cognitive therapy seeks to uncover evidence that helps individuals challenge catastrophic expectations about insomnia-induced consequences for health and functioning. Common maladaptive beliefs include, ‘If I don’t have eight hours of sleep I won’t be able to function the next day’, and ‘Clock-watching helps me calculate and maintain a sense of control’.

Once the target thoughts and associated safety behaviours (e.g. excessive time spent in bed, ‘catching up’ on sleep during the day, excessive monitoring) are identified, experiments targeting safety behaviours seek to raise evidence for and against the prediction, leading to more realistic appraisals: ‘It’s not ideal, but I can function okay with less than eight hours’ sleep’; ‘The more I strive for “ideal” sleep, the worse my performance anxiety and sleep will be’; ‘Ideal sleep sure isn’t as simple as X number of hours.’

This reframing of unhelpful thoughts is a key factor in improving self-efficacy and restoring sleep confidence. Simultaneously using a daily ‘worry session’ can help reduce ongoing worries about sleep. This involves giving full attention to one’s worries at a specific time and place daily, writing down the worry and then using problem-solving techniques to start resolving the issue, so as to reduce vulnerability to worry-driven sleep disruption at night.

WHEN TO REFER PATIENTS
GPs are well placed to identify insomnia, characterise it and look for secondary causes. Patients with suspected obstructive sleep apnoea, restless legs syndrome, or difficult-to-control psychiatric problems should be referred to specialists for further investigations and management.

In other cases, therapy should be initiated by GPs depending on their interest and expertise. This therapy might include education regarding good sleep habits, addressing active psychosocial stressors, and initiation of cognitive behavioural approaches.

Referral to experienced sleep psychologists or sleep physicians is important in these latter cases if the insomnia does not improve.

Pharmacotherapy, if required, should only be used in the short-term in conjunction with the initiation of non-pharmacological strategies to treat insomnia.

CASE STUDY
Tina  was a 44-year-old woman with generalised anxiety disorder whose 20-year experience of insomnia had markedly worsened after the birth of her first, ‘hard to settle’ child five years previously. She reported that her fragmented sleep worsened her tendency to worry, and vice versa. She strongly believed that eight hours of sleep nightly was crucial to preventing physiological and psychological damage, and to cope with daily work and life stressors. She felt that an accumulation of ‘poor’ sleep hours over several days would be dangerous to her emotional and physical health.

She also believed that she had only a limited amount of energy that would drain away over the day and must be conserved, as the only way to regenerate energy would be through sleep or rest.

Despite reducing her worries about sleep using a daily ‘worry session’ (giving attention to her worries at a specific time and place so as to reduce vulnerability to worry-driven sleep disruption at night), Tina remained fearful of the effects of poor sleep and energy loss.

Two experiments were used to gather evidence to challenge her fears. Tina agreed to a two-day trial, on the first day spending a three-hour period conserving energy (i.e. avoiding social interactions, doing only mundane tasks at a slow pace), then a three-hour period using up energy. On the second day, she did this in reverse order. Tina rated her fatigue, mood and coping after each period and unexpectedly found that many factors (including exercise and socialising) influenced her energy levels during the day.

This experiment allowed Tina to contrast her original belief – that energy levels drain away through the day – with the finding that energy levels are like elastic, and can be stretched with invigorating activity.

The second experiment, targeting the fear that poor sleep is dangerous, involved Tina restricting her sleep to 6.5 hours for several nights, ensuring that she would stay awake and energised with a socially rewarding event beforehand, and monitoring the experiment’s effects on her ability to cope, tiredness, productivity, and mood.

Over a series of nights, Tina unexpectedly found that, instead of her expectation that she would feel low, sick, tired and unmotivated, her mood, tiredness and functioning were not worsened, and she could manage just as well on 6.5 hours’ sleep as well as she might on eight.

Other experiments included challenging monitoring of tiredness symptoms, allowing Tina to discover that through monitoring she was more, not less, likely to notice innocuous mood and energy changes as pathological, and so generate further worry; challenging clock monitoring, allowing her to discover that removing the clock reduced her anxiety and improved her sleep, rather than monitoring and sleep calculation creating the ‘control’ she craved; and challenging the use of coffee to create daytime energy and promoting alternate beliefs that other strategies exist to increase energy, since coffee increases the likelihood of sleep disruption.

CONCLUSION
After excluding secondary causes of insomnia, such as suspected obstructive sleep apnoea, restless legs syndrome, or difficult-to-control psychiatric problems, GPs are well placed to initiate therapy including education about good sleep habits, addressing active psychosocial stressors, and initiation of cognitive behavioural approaches.

One of the ironies about insomnia management is that most GPs have considerable knowledge of CBT and insomnia strategies but are not always sure how to instigate these treatments. There also appears to be a common perception that patients expect a script for hypnotics, which is often not the case. Pharmacotherapy should only be used in the short term, in conjunction with non-pharmacological strategies.

There is obviously a case for improvement in communication from both sides of the consultation in relation to the management of insomnia.

KEY POINTS

• GPs are well placed to identify insomnia, characterise it and look for secondary causes.
• Cognitive behavioural therapy (CBT) is the most effective non-pharmacological treatment option for insomnia.
• Two behavioural methods of treating insomnia can easily be instigated by the GP.
• The cognitive factors believed to maintain chronic insomnia include worry, monitoring for sleep-related threats, distorted perception, unhelpful beliefs about sleep and safety behaviours.      

REFERENCES
1. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Fourth edition. American Psychiatric Association, Washington, DC. 2000.
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3. Chorney DB, Detweller MF, Morris TL, Kuhn BR. The interplay of sleep disturbance, anxiety, and depression in children. J Pediatr Psychol 2008;33:339-48.
4. Ford DE, Kamerow DB. Epidemiological study of sleep disturbance and psychiatric disorders. An opportunity for prevention? JAMA 1989;262:1479-84.
5. Buysse DJ, et al. Diagnostic concordance for DSM-IV sleep disorders: a report from the APA/NIMH DSM-IV field trial. Am J Psychiatry 1994:151:1351-60.
6. Cole MG, Dendukuri N. Risk factors for depression among elderly community subjects: a systematic review and meta-analysis. Am J Psychiatry 2003;160:1147-56.
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