失眠的認知行為治療
高雄市立小港醫院 神經內科 謝升文醫師
睡眠有如停在手 邊的鴿子,如果不注 意牠,牠會一直停在手邊;如果你要伸 手去抓,牠反而很快就飛走了
VIKTOR FRANKL 1905 - 1997
Outlines Introduction Evaluation of Insomnia Management of Chronic Insomnia -Psychological and behavioral treatment
Circadian rhythm
Sleep structure
你需要多少睡眠時間才夠?
Kryger et al. Principle and Practice of Sleep Medicine 4th edition
你需要多少睡眠才夠? - 每個人需要的睡眠時間不一樣 - 短眠者與長眠者 - 但是 睡眠時間短於 6.5 小時或長於 9 小時的 人 高於一般人 1.7 x 的致病率和致死率
COST OF INSOMNIA
Insomnia is defined as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime impairment.
Definition Symptoms-focused definitions Difficulty initiating sleep Difficulty maintaining sleep Waking up too early Non-restorative sleep
Diagnostic Criteria for Insomnia
Classification Primary insomnia Secondary insomnia Acute insomnia Chronic insomnia
Possible Causes of Insomnia
Ohayon MM, Guilleminault C. Epidemiology of Sleep Disorders. In Lee-Chiong T eds. Sleep : A Comprehensive Handbook. pp.73-98.
Epidimiology-Average Prevalence of Insomnia Symptoms and Diagnoses
Ohayon MM (2002). Sleep Med Rev 6(2), 97-111
Risk factors Sociodemographic factors Female Aging Lower incomes Lower education Comorbid disorders Physical illnesses psychiatric disorders Sleep disorders Substance use Life styles High stress, without work, shift/ night worker
Primary sleep disorders Periodic limb movement disorder Restless leg syndrome Sleep related breathing disorders Circadian rhythm disorders
Psychiatric disorders Mood disorders Posttraumatic stress disorders Generalized anxiety disorders Substance use disorders
Ohayon MM, Guilleminault C. Epidemiology of Sleep Disorders. In Lee-Chiong T eds. Sleep : A Comprehensive Handbook. pp.73-98.
Outlines Introduction Evaluation of Insomnia Management of Chronic Insomnia -Psychological and behavioral treatment
Sleep History Primary insomnia complaint Pre-Sleep Conditions Sleep-Wake Schedule Nocturnal Symptoms Daytime Activities and Function
Primary insomnia complaint Characterization of Complaint • Difficulty falling asleep • Awakenings • Poor or unrefreshing sleep Onset , Duration , Frequency , Severity , Course , Perpetuating factors ,Past and current treatments and responses
Pre-Sleep Conditions Pre-bedtime activities Bedroom environment Evening physical and mental status
Sleep-Wake Schedule Time to fall asleep • Factors prolonging sleep onset • Factors shortening sleep
Awakenings • number, characterization, duration; • associated symptoms • associated behaviors
Amount of sleep obtained
Nocturnal Symptoms Respiratory Motor Behavioral and psychological
Daytime Activities and Function Identify sleepiness versus fatigue Napping Work Lifestyle Travel Daytime consequences • Quality of Life • Mood disturbance • Cognitive dysfunction • Exacerbation of comorbid conditions
Physical and Mental Status Examination Evaluate risk factors for sleep apnea and comorbid medical conditions Mental status exam Provide important information regarding comorbid conditions and differential diagnosis
Supporting Information A general medical/psychiatric/medication questionnaire The Epworth Sleepiness Scale or other sleepiness assessment A two-week sleep log to identify sleep-wake times, general patterns, and day-to-day variability.
Sleep log • Bedtime • Sleep latency (SL: time to fall asleep following bedtime) • Number of awakenings and duration of each awakening • Wake after sleep onset (WASO: the sum of wake times from sleep onset to the final awakening) • Time in bed (TIB: time from bedtime to getting out of bed) • Total sleep time (TST: time in bed minus SL and minus WASO) • Sleep efficiency percent (SE equals TST divided by TIB times 100) • Nap times (frequency, times, durations)
Objective Assessment Tools Polysomnography 睡眠多項生理檢查 Actigraphy 腕動儀
Polysomnography Comprehensive measurement of sleep Diagnosing many sleep disorders Not usually necessary in the assessment of an insomnia complaint
Actigraphy Based on measurements of body movement Sleep-wake pattern Not recommended for the routine diagnostic evaluation of insomnia
Outlines Introduction Evaluation of Insomnia Management of Chronic Insomnia
Indications for Treatment Treatment is recommended when the chronic insomnia has a significant negative impact on the patient’s sleep quality, health, comorbid conditions, or day time function.
Management Pharmacological treatment Psychological and behavioral treatment of insomnia (PBT-I)
Medications Benzodiazepine Receptor Agonists Melatonin and Melatonin Receptor Agonists Antidepressants Antipsychotics Antihistamines Anticonvulsants Herbal
Benzodiazepine Receptor Agonists BzRAs act as allosteric modulators of GABA activity by binding to benzodiazepine receptors at GABAA receptor complex Rapid: Zaleplon, Triazolam, Zolpidem Intermediate: Estazolam, Temazapam, Eszopiclone Slow: Flurazepam, Quazepam
Benzodiazepine Receptor Agonists Contraindications Obstructive sleep apnea Substance abuse disorder Advanced liver disease Pregnancy
Management Pharmacological treatment Psychological and behavioral treatment of insomnia (PBT-I)
PBT-I Sleep restriction Stimulus control Relaxation training Cognitive therapy Sleep hygiene education
Sleep restriction Curtailing the amount of time spent in bed as close as possible to the actual amount of time asleep
Sleep restriction Allowable time in bed is increased by about 15 to 20 minutes for a given week when sleep efficiency exceeds 85%, it is decreased by the same amount of time when sleep efficiency is lower than 80%, and it is kept stable when sleep efficiency falls between 80% and 85%
Sleep restriction Time in bed should not be reduced to less than 5 hours per night Contraindicated in patients with a history of seizures, some parasomnias (e.g., sleepwalking), or bipolar illness
Stimulus control therapy A set of instructions designed to reassociate the bed/bedroom with sleep and to reestablish a consistent sleep-wake cycle schedule.
Stimulus Control Therapy Go to bed only when sleepy Get out of bed when unable to sleep Curtail all sleep-incompatible activities Arise at a regular time Avoid daytime napping
Relaxation-Based Interventions progressive muscle relaxation, guided imagery, or abdominal breathing, is designed to lower somatic and cognitive arousal states which interfere with sleep.
Cognitive therapy Psychgotherapeutic method aimed at changing faulty beliefs and attitudes about sleep, insomnia, and the next-day consequences. Other cognitive strategies are used to control intrusive thoughts at bedtime and prevent excessive monitoring of the daytime consequences of insomnia
Cognitive Therapy Keep realistic expectations Do not blame insomnia for all daytime impairments Never try to sleep Do not give too much importance to sleep Do not catastrophize after a poor night's sleep Develop some tolerance to the effects of insomnia
Sleep Hygiene Education Avoid stimulants Avoid alcohol around bedtime Exercise regularly Keep the bedroom environment quiet, dark, and comfortable Maintain a regular sleep schedule
PBT-I Technique
Patient Symptoms
Stimulus control
Delayed sleep onset
Sleep restriction
Excessive time spent in bed; fragmented or poor quality sleep
Relaxation
High physiologic, cognitive, or emotional arousal
Cognitive
Racing or obsessive thoughts around bedtime
Sleep hygiene education
Any of the above or general poor sleep hygiene 57
Psychological and behavioral treatments
More specialized
Cognitive therapy Sleep restriction Relaxation Stimulus control Sleep hygiene General advice
Sleep information Less specialized Earlier in management
Later in management
PBT-I Should be the 1st-line therapy for persistent insomnia Indicated for Primary insomnia and comorhid insomnia Young adults and older adults Chronic hypnotic user
No absolute contraindication
Treatment Outcome of PBT-I 1.4 1.19
1.2 Effect size Largr Medium Small
1
0.94 0.84
0.8
0.66
0.6
0.46
0.4 0.2 0 Sleep-onset latency
Wake after Number of Total sleep Sleep quality sleep onset awakenibgs time
Adherence of PBT-I for 2 year Follow up 73% → SGmulus control 53% → RelaxaGon 38% → Sleep hygiene
Engle Friedman el of (1992) J clin. Psychol (4871; 77-90)
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