美国医学院医生清晰讲解如睡眠卫生(sleep hygiene)和失眠刺激管控(stimulus control)失败后,应对病人实施新的失眠疗法,包括放松疗法(relaxation technique)、睡眠限制(sleep restriction)、行为疗法(behavioral therapy)、认知疗法(cognitive therapy)和行为-认知疗法(behavioral-cognitive therapy)。

CBTI Stimulus Control, Sleep Hygiene Continued

Welcome to another MedCram lecture. We’re going to talk about behavioral therapy in relation to insomnia. 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 behavioral therapy. This is what we do if sleep hygiene and stimulus control don’t work. The current recommendation 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 will deal with these separately, but we’ll deal with behavioral therapy first.


What we’re going to talk about are the four different behavioral therapies: relaxation technique, sleep restriction therapy, cognitive therapy, and then cognitive-behavioral therapy. The medications that we’ll talk about in a later lecture are the benzodiazepines, nonbenzodiazepine 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 in the premorbid state, we had these predisposing factors which remained throughout our lifetime, and then sometimes these precipitating factors would occur that would take us over the insomnia threshold. 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 the relaxation technique. 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 at a time until the whole body is relaxed. The thing is they start in the face for about one to two seconds and then go down the body and repeat it for about 45 minutes. 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 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 stay in bed literally for 12 hours a day, even though they’re only sleeping six hours, and that, of course, would be asleep efficiency of 50%, so 6 divided by 12 is 50%.


The problem is that sometimes a perpetuating factor of insomnia is that people tend to stay in bed longers, which is not good. 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 is big even though your total sleep time may not be big, and then slowly give back that sleep 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. We count back from the target wake time. For example, let’s say you go to bed at nine o’clock at night and you get up at six, but you’re only sleeping for 5 hours during that nine-hour period though. It’s in bits and pieces.


So what we would do is we say okay, 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 six o’clock in the morning, and we’ll figure out the time that you should go to sleep. Well, that’s one 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. 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 or two things will happen. Either the patient won’t be able to go to sleep and they’ll get less than five hours of sleep at six 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 one o’clock in the morning, and hopefully stay asleep until 6:00. Once that sleep efficiency gets above 85%; in other words, once they’re sleeping a solid five hours between one o’clock in the morning and six o’clock in the morning, then we’ll give a back 15 minutes now.


They get to go to bed at 12:45, and if they can continue to maintain an 85% sleep efficiency, then we’ll continue to march back every week or two weeks every 15 minutes until finally where you get seven, eight hours of sleep, and their sleep efficiency is maintaining above 85%. The rule is that there is no napping.


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 an example again: the down arrow is when they go to bed; the up arrows when they wake up, but you can see here there’s significant breaks 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.


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 the baseline of insomnia: 11 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 90 percent here in this case, then they get to go to bed a little bit earlier in Week Two.


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 5 hours. If you do, it could be dangerous. The patient’s time in bed and out of bed is inflexible. They cannot change that; it has to be exactly that way.


We try to review ways to stay awake during these times, here with they want to go to bed, but they can’t. They keep this diary and their ticket to get more sleep time is when they come back after one week and show that they’re able to stay asleep, and the titrate it based on the diary data that we get from the patient.


So sleep restriction therapy: the key there is you got to monitor these patients very carefully for sleep deprivation. You got to assess what kind of a job they have and how safe is this because this is pretty serious behavioral therapy.


Let’s talk about cognitive therapy. Cognitive therapy is to prevent people from making a mountain out of a molehill. Basically, this is 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 think this is not good for my health. I’m going to die young. I’m going to lose my job, and that type of thinking of course is not very conducive to falling asleep, right?


So, 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. So by deconstructing that catastrophization 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 multifaceted.


Finally, this cognitive behavioral therapy is really the whole kit and caboodle put together. In fact, you’ll see this often regarded as CBTI, and this is what psychologists do specifically. When we sleep specialists send our patients for CBTI, 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, sleep hygiene and stimulus control. So there’s education, stimulus control, sleep restriction, cognitive therapy, sleep hygiene. Basically what you’re doing here is providing your patience the tools for their future success not only to get better, but to stay better. Very few can do a good job of this, so got to do a lot of reading and figure this stuff out to not only understand it but execute on your patience. 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: behavioral therapy, sleep hygiene, 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. What kind of medication can they give me to fall asleep a lot of times though.


This behavioral therapy is skip that 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.



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