1060721 失眠的認知行為治療

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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