Managing Insomnia Lesson 1 The Science of Sleep and Understanding Your Insomnia Welcome and Lesson Overview Welcome to the Managing Insomnia Course! This course is designed to teach you Cognitive Behavioural Therapy (CBT) skills to manage your insomnia. CBT is the gold-standard, first-line treatment for chronic insomnia. Leo’s story will be used to explain the techniques used in treatment. Of course, your story will be very personal, but we hope that you will relate to some aspects of his experience to learn the skills you need to become your own therapist and overcome your insomnia. This course is intended for people who have been experiencing insomnia for at least 3 months. If your sleeping difficulties have started more recently, we suggest you first see our Stress Management or Intro to Mindfulness course. This program involves four lessons to be completed in your own time at your own pace, aiming to complete a lesson every 1-2 weeks. Here is an overview the Program: Lesson 1 The Science of Sleep and Understanding Your Insomnia Lesson 2 Managing Sleep-Interfering Thoughts and Behaviours - Part 1 Lesson 3 Managing Sleep-Interfering Thoughts and Behaviours - Part 2 Lesson 4 Tackling Remaining Difficulties, Reviewing Your Skills, and Maintaining Your Gains We have prepared a Lesson Summary & Action Plan (like this one) for each of the four lessons in the course. This includes the key information from the lesson slides in a more detailed format as well as exercises to put the concepts and skills into practice in your daily life. In order to overcome your insomnia, it is important that you complete the tasks in these lesson summaries. We encourage you to print each one. To get the most out of the course, we suggest setting aside a regular time each week to complete the lessons. It might be helpful to block it out in your diary just as you would a regular session with a psychologist or doctor. This is your time to start becoming your own therapist as you learn the concepts and skills necessary to overcome your insomnia. We hope you find this course interesting and informative! Please don’t hesitate to contact us if you have any questions at any stage of this course, by email on contact@thiswayupclinic.org or by telephone 02 8382 1400. Good luck! The Team from This Way Up. www.thiswayup.org.au WWW.THISWAYUP.ORG.AU 2 Topics Covered In This Summary & Action Plan Here is a list of the topics we will cover in this Summary & Action Plan. Tick these off as you go: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. What is Insomnia? (page 3) The Role of Thoughts and Behaviours in Insomnia (page 5) Your Insomnia Model (page 5) What is CBT for Insomnia? (page 8) Your Goals for this Course (page 9) Understanding Normal Sleep (page 10) The Three Factors that Regulate Sleep (page 12) CHECK-POINT: Prioritising Sleep Hygiene (page 15) Sleep Diary (page 17) Calculating Sleep Efficiency (page 19) Sleep Medications (page 19) Appendix (page 21) − FAQs − Common Sleep Medications 1. What is Insomnia? Insomnia is a sleep disorder that involves dissatisfaction with the quality or quantity of your sleep. People with insomnia are concerned about initiating and/or maintaining sleep. You may experience: Difficulty falling asleep (“sleep onset insomnia”) Difficulty staying asleep, with frequent and prolonged awakenings in the night (“sleep maintenance insomnia”) Early morning wakening, with inability to fall back asleep (“late insomnia”) It’s normal to have a few nights of poor sleep when you are going through a stressful period (e.g., loss of a relationship, death of a loved one, work difficulties). For most people, the insomnia passes once the stressful situation passes. However, for some people, the insomnia persists despite the stressful period ending. Insomnia is only diagnosed when the symptoms listed above occur at least 3 days a week, for 3 or more months. WWW.THISWAYUP.ORG.AU 3 Insomnia may affect you in a number of different ways during the day. For example, it can affect your (tick all the boxes that apply to you): Energy Mood Anxiety Concentration Feeling sleepy Other: ______________ Strive to sleep Many people who have insomnia become preoccupied with their sleep and over time, get caught up in a vicious cycle, which is associated with physical and emotional arousal. Treatment for insomnia will help you to break this cycle. Harder to sleep Increased frustration Did You Know? Up to a third of the population report symptoms of insomnia – It is far more common than you might think. And about 10% of people meet criteria for an insomnia diagnosis. Conditioned Insomnia For many people, when their head hits the pillow, this is the first opportunity they have to process the day’s events and think through any problems or difficulties. This often makes it difficult to “switch off”, relax, and fall asleep. As you saw in the lesson slides, Leo leads a busy life and although he’s able to relax a bit in front of the TV in the evening, once he gets into bed, his mind becomes very active and he has difficulty falling asleep Many people with insomnia also develop an association between going to bed and not sleeping. Going to bed then becomes a trigger for worry and frustration about not sleeping. This, of course, increases arousal making it harder to sleep! We call this “Conditioned Insomnia”. So, instead of the bed being associated with relaxation and sleep, it becomes associated with frustration, worry, and being alert and awake. A major aim of this program is to help you to retrain your brain and body so that the bed once again becomes associated with calmness and sleep. To do this, you’ll first need to learn about the role of your thoughts and behaviours in maintaining insomnia. WWW.THISWAYUP.ORG.AU 4 2. The Role of Thoughts and Behaviours in Insomnia People with insomnia have three types of symptoms: thoughts, behaviours, and feelings, that interact to keep insomnia going. For example, in this lesson we saw how Leo worried excessively about his sleep, causing him to become aroused and frustrated at bedtime, which in turn caused him to engage in unhelpful behaviours. These symptoms all worked together to maintain Leo’s insomnia: “I’m going to be a wreck tomorrow if I don’t get to sleep.” Thoughts Insomnia Behaviours Stay in bed, watch the clock. Physical Symptoms/ Feelings Frustrated, worried, tense. 3. Your Insomnia Model Which Unhelpful Behaviours and Thinking Patterns Maintain Your Insomnia? Now let’s consider how your own thoughts, feelings, and behaviours interact to maintain insomnia. Understanding the symptoms that contribute to your insomnia is crucial to getting the most out of this program! On the next page, tick off any of the following that you recognise: WWW.THISWAYUP.ORG.AU 5 1. Common Unhelpful Behaviours (what I do) Nap Use the bed for activities other than sleep (e.g., watching TV, checking your email, work, etc.) Check your phone in bed when you can’t sleep Stay in bed when you can't sleep Have an irregular sleep schedule (e.g., sleep in later on the weekends, shift work) Don’t wake up at the same time each day Drink caffeine late in the day/evening Drink alcohol late in the evening Smoke cigarettes within two hours of bed time Watch the clock in bed Sleep in places other than your bed (e.g., the couch or spare room) Other: ____________________________________ Stay in bed longer in the morning to try to get extra sleep when you haven't had adequate sleep in the night Go to bed earlier than you need to because you are worried you won't get adequate sleep in the night ahead Cancel activities or call in sick when you haven’t slept well Eat a big meal before bed Exercise close to bed time Work or engage in stressful activities in the 1-2 hours before bed Use electronic devices in bed Sleep in a noisy environment Sleep in a bright room Sleep in a room that is too hot or too cold Under-stimulation (e.g., engage in only passive activities, do little exercise) Over-stimulation (e.g., fit in too much each day, especially close to bedtime) Common Unhelpful Thoughts (what I think to myself) Worry about not sleeping Worry about the impact of insufficient sleep on your next day functioning Worry about life stressors in bed (e.g., work, relationships, finances) Active mind (e.g., racing thoughts) Think about the day ahead Unrealistic or rigid expectations about sleep (e.g., “I must have 8 hours of sleep every night to function”, “My sleep must be uninterrupted in order for me to feel rested”) Other:___________________________ Common Physical Sensations/Feelings (what I feel in my body) Worry Anxiety Tension Frustration WWW.THISWAYUP.ORG.AU Hot Discomfort Other: ______________________________ 6 By making small changes in one of these areas, you can begin to break the cycle of insomnia because each component of the cycle affects the others. Now that you have identified the behaviours, thoughts, and feelings that are likely to contribute to your insomnia, complete your own insomnia model, like Leo’s example above. Your example: ………………………………………………………………… ………………………………………………………………… Thoughts Insomnia ……………………………… ……………………………… ……………………………… Behaviours Physical Symptoms /Feelings ……………………………… ……………………………… ……………………………… All of the symptoms in the list above can negatively impact your sleep. Most people with insomnia recognise that a number of these symptoms contribute to their poor sleep, with some being more important than others in maintaining chronic insomnia. The good news is that once you have identified the symptoms that influence your poor sleep, you know what you need to change. The lessons in this course will address these three types of symptoms one by one so you know how to tackle them effectively. Once you’ve worked out the “what” (by creating your own insomnia model and learning more about normal sleep) we will show you the “how” (throughout this course). That is, we will teach you evidence-based skills to change unhelpful thoughts and behaviours so that you can get your sleep back on track. WWW.THISWAYUP.ORG.AU 7 4. What is CBT for Insomnia? Cognitive Behavioural Therapy or CBT is the gold-standard treatment for insomnia. This course uses an evidence-based, CBT approach. You will learn all the same skills and strategies that you would learn by seeing a clinical psychologist in-person. This online course, which has been developed by clinical psychologists and psychiatrists who specialise in CBT, is a new way of delivering treatment. Online CBT has been shown to be as effective as face-to-face CBT. CBT for insomnia, or CBT-I, is based on scientific knowledge about sleep. It combines cognitive and behavioural strategies to address thoughts, behaviours, emotions, and physical symptoms in your body (e.g., arousal) that interfere with your sleep. The aim of CBT-I is to help you to develop sleep-positive behaviours and to reduce anxiety about sleep and daytime functioning. Did you know? The C in CBT-I refers to Cognitive factors affecting your sleep. These include thoughts and expectations about sleep that interfere with good sleep. In particular, we will address anxiety about not sleeping, as well as worry about stressful life events and associated hyper-arousal. The B in CBT-I refers to Behavioural factors affecting your sleep. These include sleep habits that tend to prevent people from getting a good night’s sleep, such as extended time in bed, using your bed for activities other than sleep, and irregular sleep/wake times. We will also consider other factors such as alcohol and caffeine use as well as your sleep environment. CBT-I will assist you in developing more helpful behaviours that promote sleep. It will also assist you in better managing stress and anxiety as well as adopting more helpful ways of thinking about sleep so as to reduce arousal levels. Behaviours that promote sleep Helpful ways of thinking about sleep Good Sleep Manage stress and anxiety Reduce arousal WWW.THISWAYUP.ORG.AU 8 As cliché as it sounds – what you put in, is what you get out. The skills described in this program are not complex. However, it does take motivation to put the skills and strategies into place and to stick to them for several weeks. We recommend that you consider the next couple of months as “boot camp” for your sleep. Our courses have been shown to be highly effective, however the benefit is much less in those people who don’t complete all of the lessons in the course. If you are doing this course, you have been experiencing insomnia for a while now. It will likely take 2-3 months to get your sleep back on track. Don’t expect your sleep to improve over night (pardon the pun!). This will only place more pressure on your sleep, keeping you aroused, and making it harder to sleep. As best as you can, make an effort to implement the strategies in the course whole-heartedly – there may be some short-term pain for long-term gain. 5. Your Goals for this Course It’s important to spend a few minutes thinking about what your goals are for the course. What would you like to achieve as a result of doing this course? We have listed some common general goals below (Tick the boxes that apply to you): Understand why I experience insomnia Learn how to improve my sleep Reduce sedative medication use Improve my daytime functioning Sleep longer at night time Reduce time taken to fall asleep Feel less stressed about my sleep Keep a consistent sleep schedule Have better quality sleep Sleep like I used to before I had insomnia Reduce long periods of wakefulness in the night Other goals: _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________ Try to make your goals as realistic as possible. That is, it’s not realistic to have the goal of never waking in the night (because we know that brief wakings are a normal part of sleep) or to sleep 8 hours every night (because there are individual differences in sleep needs and people don’t typically get the same amount of sleep every single night). Plus, it isn’t helpful to put such unrealistic expectations on yourself. Start small with your goals and build up! WWW.THISWAYUP.ORG.AU 9 6. Understanding Normal Sleep Sleep is not one continuous process but rather it consists of cycles of different sleep stages. Sleep cycles last for about 90 minutes and we have about 4 or 5 of these a night. Sleep cycles are divided into REM (Rapid Eye Movement) and non-REM sleep. Why is REM and non-REM sleep important? REM sleep, during which dreaming occurs, is important in learning and memory, and is particularly important in helping you to process and regulate emotions. Non-REM sleep appears to be important for conservation of energy and restoration as well as the consolidation of certain types of memories. Non-REM sleep is divided in to three stages (Stages 1, 2, and 3). Stage 1 – Light Sleep. This stage only lasts for 5-10 minutes, mostly as you are falling off to sleep. If you are woken during this phase, you may not actually realise that you had been sleeping. Stage 2 – Moderate Sleep. This stage lasts for about 30-45 minutes in each sleep cycle. Our minds are active during sleep. If you are woken in this phase, you may think you were already awake. Stage 3 – Deep Sleep. A restorative period of sleep in which slow wave sleep occurs. The graph below shows an example of a normal sleep pattern in an average adult. As you can see, it’s normal to wake up a few times during the night. These awakenings can be brief and you may not even be aware of them. Graph adapted from http://www.howsleepworks.com/types_cycles.html WWW.THISWAYUP.ORG.AU 10 What is Melatonin? Exposure to light and darkness plays a very important role in regulating sleep, through its action on melatonin. − Melatonin is a natural hormone in the body that makes us sleepy. − It is released in darkness and suppressed in light. − Melatonin levels rise in the evening. − When you’re exposed to light, melatonin release gets turned off, which tells your brain it’s time to wake up. − It’s not just the sunlight that will turn off the melatonin switch. Light from your computer screen, phone, and TV also reduces melatonin. Did you know? The number of times you wake up after falling asleep typically increases with age. This graph shows the average number of awakenings in “good sleepers” across age groups. Awakenings after sleep onset 9 8 7 6 5 4 3 2 1 0 3-5 6-9 10-12 13-15 16-19 20-29 30-39 40-49 50-59 60-69 70-79 Age Group Graph adapted from: http://sleepdisorders.sleepfoundation.org/chapter-1-normal-sleep/age-and-sleep Remember, − − − − The amount of sleep one needs varies from person to person. Sleep needs change from about middle-age. Older adults typically experience less deep sleep and more lighter sleep as they age. This lighter sleep does not impact daytime functioning. Studies suggest that older adults cope better with sleep loss, than younger adults. − Even if you have a great night’s sleep, your energy levels do not stay consistently high throughout the day. − It’s normal to experience peaks and dips in energy throughout the day. − Most people experience a dip in energy in the mid-afternoon, after lunch. WWW.THISWAYUP.ORG.AU 11 7. The Three Factors that Regulate Sleep Understanding the factors that regulate normal sleep is crucial when tackling symptoms of insomnia. Sleep regulation is dependent on three key factors: sleep drive, circadian rhythm, and arousal. 1. SLEEP DRIVE Sleep drive is an automatic process involving the normal build-up of sleep debt as the day goes on. You can think of your sleep drive or pressure to sleep like your “sleep appetite”. Sleep drive is lowest in the morning when you wake up and gradually increases as the day goes on. It decreases again when you sleep. Sleep drive is dependent on the time since your last sleep, as well as the duration of the previous sleep. Therefore, sleep drive is highest when the last sleep was some time ago and also when we are sleep deprived. What factors weaken your sleep drive? (Tick those that apply to you) Napping. − You can think of this like having a snack before you go out for dinner. In that situation, your appetite is reduced so you don’t feel as hungry for dinner. Similarly, when you nap or doze, your “sleep appetite” is reduced for your main sleep in the night time. Sleeping longer than usual (e.g., oversleeping in the morning). − When you oversleep in the morning, less time is available to build up sleep drive before your next habitual bedtime. Consuming caffeine. CBT-I aims to strengthen your sleep drive, thereby making it easier to fall asleep. What can you do to strengthen your sleep drive? − Refrain from napping and dozing. − Be active during the day – exercise, work, socialise. − Don’t spend excessive time in bed. − Sleep deprivation will also strengthen sleep drive. WWW.THISWAYUP.ORG.AU 12 2. CIRCADIAN RHYTHM We all have an internal biological clock that regulates many of our bodily processes such as digestion, body temperature, and sleep. This clock works approximately on a 24-hour period. Irregular sleep schedules weaken our internal clock, which is why it is helpful to keep regular wake times. Light is a particularly powerful cue to reset our internal clock each day. The most important thing you can do to optimise your circadian rhythm is to wake up at the same time each day, including weekends. Wake time is the anchor to your sleep-wake cycle. You need to reset your body clock every morning and the best way to do this is to wake up at the same time every day. You can also help keep your circadian rhythm in alignment by exposing yourself to light at around the same time each morning. What factors weaken circadian rhythms? (Tick those that apply) Irregular sleep patterns Irregular meal times Irregular light exposure Travel to other time zones will also alter your internal body clock temporarily CBT-I aims to strengthen circadian rhythms through regular sleep-wake times and routines, thereby making it easier to fall asleep. What can you do to strengthen your circadian rhythm? − Wake up at the same time each day (including weekends), even when you haven’t slept much the previous night. − Get exposure to light first thing in the morning. − Reduce light exposure at night time – dim the lights before bed. − Try to stick to regular meal times. WWW.THISWAYUP.ORG.AU 13 3. AROUSAL Feeling on edge or anxious interferes with sleep. When we worry or perceive a threat of any kind, our arousal levels increase and we can often feel tense in our body. Worry or having an active mind makes it difficult to “switch off”, relax, and fall asleep. In addition, many people with insomnia develop an association between going to bed and not sleeping. In turn, going to bed becomes a trigger for worry and frustration about not sleeping. This, of course, increases arousal making it harder to sleep. What factors increase arousal? (Tick those that apply) Worrying about current problems Worry about sleep Sleep effort (actively trying to sleep) CBT-I aims to reduce emotional and physiological arousal by quieting your mind, eradicating sleep effort, and reducing physical tension, thereby making it easier to fall asleep. Did you know? General worry = worry about things that are causing you stress, like work and family. Sleep worry = worry about the consequences of not sleeping. Sleep effort = putting too much pressure on needing to fall asleep and actively trying to fall asleep. What can you do to reduce arousal? − Reduce sleep effort (more on this in the next lesson!). − Engage in a competing task. − Keep the bed for sleep and intimacy only. − Challenge catastrophic concerns about insufficient sleep. − Manage your worries through cognitive restructuring, problem solving, worry time, and mindfulness (more of this in the next lesson!). − Practice relaxation (see Lesson 4). − Physical exercise. − Unwind before bed time (see Lesson 2). We will expand on these strategies in the coming lessons. WWW.THISWAYUP.ORG.AU 14 8. CHECK-POINT Are you prioritising sleep hygiene? Sleep hygiene simply refers to habits that promote good sleep. Here is a checklist. Tick off the ones that apply to you and start making these sleep promoting changes today! Sleep Hygiene Checklist Prioritise exercise − It will increase your amount of deep sleep and also help you to reduce your anxiety and stress, and improve your mood. − Don’t exercise too close to bed time as this may hype you up and disrupt your sleep. • Improve your sleep environment Keep a routine Keep active Don’t do vigorous exercise within 4 hours of bed time. − Do try to do exercise every day or most days. − Relaxing exercises like stretching and yoga can be done before bedtime to promote relaxation. − Keep it comfortably cool (but not cold), dark, and quiet. − Sometimes there are noises that we can’t control – try to keep calm and use ear plugs if you can. − A drop in body temperature can cue your body for sleep. Taking a bath or shower 60-90 minutes before bed is not only relaxing but it also allows your body to then experience a dip in temperature at the time you want to sleep. Consider making this part of your pre-bedtime routine. − Our circadian system likes it when we eat at regular times, socialise at regular times, and perform other daily activities at regular times so keep a routine. − Living a sedentary lifestyle isn’t helpful for good quality sleep. Sometimes people reduce their activity levels because of insomnia (e.g., feeling too tired to go out or feeling that they need to conserve energy or stick to very rigid night time routines). However, it’s important to stick to your regular activities. This will increase your sleep drive and improve your sleep. − Sometimes people reduce their activity levels because of life changes (e.g., retirement or physical injury). • • WWW.THISWAYUP.ORG.AU Plan activities each day to ensure adequate stimulation and activity levels (see Lesson 4 for more details). If you have a physical condition that has altered your capacity for activity, see a physio or GP to make a plan to safely ensure adequate daily stimulation. 15 Avoid Caffeine & Nicotine Limit alcohol use close to bed time Limit fluid intake 2hrs before bed Limit food intake before bed − Avoid having caffeine after about 3pm, as it interferes with getting to sleep and staying asleep. − Some people are more sensitive to caffeine than others, so you may need to have your last intake even earlier than 3pm, whilst some people can tolerate drinking it later in the afternoon. − At the very least, avoid caffeine within 6 hours of when you want to sleep because the half-life of caffeine is 6 hours – That is, it takes your body about 6 hours to break down only half of the amount of caffeine you’ve consumed. − Nicotine is also a stimulant so reduce intake before bedtime. − Although many people use alcohol to unwind, it interferes with your sleep quality. − Even if it helps you to fall asleep, alcohol reduces sleep quality and causes you to wake up more in the night. − Try to limit consuming alcohol too close to bedtime. − It takes about 1 hour for your body to process one standard drink. − If you find that your sleep is disturbed because you need to get up to urinate, try to limit drinking of beverages before bed. − Be aware that both caffeine and alcohol stimulate your bladder so if night-time urination is a major problem for you, it may be a good idea to cut back on these altogether. − If you get hungry at night time or wake up in the night hungry, a light snack before bed can be helpful. WWW.THISWAYUP.ORG.AU 16 9. Sleep Diary Now that you’ve identified some of the thoughts and behaviours that could be maintaining your insomnia, it is important to start keeping a diary of your sleep. Keeping a Sleep Diary is an integral part of this program and getting your sleep back on track. Filling out a sleep diary each morning will give you important information about your sleep so that you can better understand your sleep, track your progress, and help you to make the necessary adjustments to improve your sleep. You can complete the one below or the electronic one on your dashboard when you log in to your course. We encourage you to use the electronic one because this will automatically calculate your “Sleep Efficiency” for you, which you need to keep track of throughout the program. But the main thing is that you complete a sleep diary each day, so use whichever diary you think will make it most likely that you complete the sleep diary consistently. − When completing the sleep diary, just use your best guess. That is, don’t use the clock to work out exactly how long it took you to fall asleep or how long you were up in the night - studies have shown that checking the time increases anxiety about sleep, making it harder to sleep. − It’s normal to feel groggy for the first 15-30 minutes after waking up, and this can last up to 60 minutes. We call this ‘Sleep Inertia’. Because of this, don’t rate your sleep quality until about an hour after waking up. − Please complete the sleep diary every day! We have included a copy with space for one week’s entries in each of the Lesson Summaries. If you take more than one week in between lessons, please copy the diary so that you can complete the sleep diary every day. − A copy of the sleep diary can be found on the last page of this document. WWW.THISWAYUP.ORG.AU 17 Sleep Diary - Complete This Every Morning (or use the electronic version on your dashboard when you log in to your course) Week: ______ Example In the morning, fill out the information for the prior night. Night Date Tuesday 25/03 1. Yesterday, I napped from ___ to ___ (Note the times of all naps) 1:50pm to 2:30pm 2. What time did you go to bed last night? 10:45pm 3. What time did you try to go to sleep/turn off the lights? 11:15pm 4. How many minutes did it take for you to fall asleep after turning out the lights? 5. How many times was your sleep interrupted last night, not counting your final awakening? 6. In total, how long did these awakenings last? 7. How many times did you leave your bed last night? _______ / _______ / _______ / 1 6:30am 10. What time did you get out of bed for the day? 6:45am Comments (if applicable) _______ / 60 min. 9. What time had you planned to wake up at? (1 = Very poor, 2 = Poor, 3 = Fair, 4 = Good , 5 = Very Good). ______ / 2 6:15am 12. What was the quality of your sleep? _______ / 40 min. 8. What was the time of your final awakening? 11. Did you take any over-the-counter or prescription medication(s) to help you sleep last night? _______ / Medication: Relaxo, 5mg 3 I have a cold Time in bed 8hr Total sleep time 5hr,20min. WWW.THISWAYUP.ORG.AU 18 10. Calculating Sleep Efficiency Often people with insomnia spend a lot of time in bed trying to sleep while actually sleeping very little. For example, you might be in bed for 9 hours but only sleep for 5. The longer you are in bed without sleep, the more likely you are to feel frustrated, which only keeps your insomnia going. That’s why throughout treatment, we’ll be aiming to improve your sleep efficiency. You will be able to work out your Sleep Efficiency from your sleep diary. − Your sleep efficiency is a calculation of how much you’re sleeping in relation to the time you spend in bed. − We calculate your sleep efficiency by working out how much time you spent asleep divided by how much time you spent in bed, and then multiply this number by a hundred. − So, if you were in bed for 8 hours but only slept for 6 hours, your sleep efficiency would be 6/8 x 100 = 75%. − Over treatment, we are aiming for a sleep efficiency of 85% or more. − This number will be calculated automatically if you use the online sleep diary. − If you want to calculate it yourself, do the following based on your sleep diary entries for the past week: A. Work out the average time you spent in bed per night. Time in Bed = ______ B. Work out the average amount of sleep you got per night. Total Sleep Time = ______ Sleep efficiency = Total Sleep Time x 100 Time in Bed − Although you will calculate your sleep efficiency each night of the week, the more important number is your average sleep efficiency over the week. 11. Sleep Medications There are many medications that are frequently prescribed to treat insomnia. Even though the most effective long-term treatment for insomnia is Cognitive Behavioural Therapy (CBT) rather than medications, medications are still sometimes used in the short-term (maximum 1-2 weeks). Ongoing use of sleeping tablets may not only lead to side effects and even addiction, but also interfere with developing good sleep habits independent of medication, thereby only prolonging sleep difficulties. It is important to know a few things about these medications before starting and make sure you discuss these with your General Practitioner (GP) or Psychiatrist before commencing any medication. WWW.THISWAYUP.ORG.AU 19 Do not take any medications if you are pregnant or trying to become pregnant (even over the counter medications) without discussion with your doctor first. Side Effects All medications have potential side effects and sleeping pills are no different; these include over-sedation, headache, dizziness, amnesia, confusion, disinhibition and difficulty breathing, all of which can be worsened when mixed with other medications, drugs or alcohol. Careful consideration with driving or operating machinery must be considered. Longer term use of sleeping tablets can lead to “addiction”, where higher and higher doses are needed to get the same effect and considerable difficulty or “withdrawal” when trying to come off sleeping tablets. Discontinuation Stopping medications suddenly can lead to rebound insomnia and (if used for a longer period, such as a few weeks or more) a withdrawal syndrome. Withdrawal symptoms can include; rebound insomnia, increased agitation, anxiety, shakes and in extreme circumstances, seizures and even death. It is important to discuss with your doctor before stopping any medication, especially if you have been using it for a prolonged period. Most doctors will recommend a gradual tapering regime of lower and lower doses over the course of weeks, sometimes months (and even a switch to a longer acting mediation) to lessen any of these potential withdrawal symptoms. See the Appendix at the end of the summary for information about common medications used for insomnia. 12. Your Action Plan Congratulations on completing Lesson 1! Your tasks to do following this lesson are: Review Lesson 1 slides again. Print out, complete, and re-read this lesson summary. Complete your Insomnia Model (page 5-7) so you know what symptoms to work on in the remaining lessons to get your sleep back on track. Fill out your sleep diary every morning. − Calculate your average Sleep Efficiency over the week. Start implementing sleep hygiene today. Lesson 2 will be available in 5 days, please schedule a time to complete Lesson 2 in your diary. It is important that you read this lesson summary and complete the homework tasks before you go onto Lesson 2. Good luck! The Team from This Way Up. www.thiswayup.org.au WWW.THISWAYUP.ORG.AU 20 13. Appendix Frequently Asked Questions (FAQs) My mood has become much worse - what should I do? Many people who have insomnia also experience anxiety and depression. If at any stage of the course you feel that your mood has severely deteriorated or your anxiety has worsened, then please contact your GP or other mental health provider. If you cannot get in contact your GP, you can also call Lifeline on 13 11 14 (www.lifeline.org.au). Lifeline is available 24/7. I am feeling suicidal - what should I do? If you are suicidal and feel at serious risk of self-harm, you should immediately call emergency services (Ambulance/Police) on 000 or your local hospital mental health crisis team. I have some suggestions for improving the Course – who should I tell? Please send us all your positive and negative feedback, and please keep it constructive. We are dedicated to helping you to feel better, so we want to do the best job that we can. We value your feedback in helping us to do this! You can contact the This Way Up team by emailing contact@thiswayupclinic.org, or by calling 02 8382 1400. Common medications for insomnia Benzodiazepines These are probably the most commonly prescribed sleeping tablet, taken by up to 10% of people at one stage over the course of a year. They come in varying forms and speed of action and not only aid sleep and decrease anxiety but may be used medically for muscle relaxation or to stop seizures. When used for longer periods, these medications can be highly addictive. Benzodiazepines include temazepam (Temaze), diazepam (Vaium, Valpam, Antenex, Ranzepam), nitrazepam (Alodorm, Mogadon), oxazepam (Serepax, Murelax, Alepam) flunitrazepam (Rohypnol, Hypnodorm), clonazepam (Rivotril), and alprazolam (Xanax). Zopiclone and Zolpidem Zopiclone (Imovane, Imrest) and zolpidem (Stilnox, Somidem, Dormizol, Stildem) work in a similar way to benzodiazepines and long term use is also not advised due to the potential for addiction. Side effects are similar to benzodiazepines but also include taste disturbance and even hallucinations, nightmares, and sleep-walking has been reported. Melatonin Melatonin is a naturally occurring hormone that rises in levels in the evenings preceding the onset of natural sleep. Melatonin (Circadin) tablets may be beneficial in shifting sleep time in those that have problems falling asleep late and waking up late, or in shifting sleep patterns due to jetlag or shift work, but there is little evidence for their use in insomnia. Side effects include headache, stomach upset, back and joint pain. WWW.THISWAYUP.ORG.AU 21 Sedating antihistamines Antihistamines such as doxylamine (Dozile, Restavit), promethazine (Allersoothe, Phenergan), and diphenhydramine (Snoozaid) are commonly used as sleeping tablets as they can be bought without a prescription in Australia. While they might be effective for use for 1-2 nights, they appear to be not effective in chronic insomnia. Antidepressants Some antidepressants such as mirtazapine (Avanza, Mirtazon), doxepin (Deptran, Sinequan), nortriptyline (Allegron), and amitriptyline (Endep) may cause secondary sedation, however they are not recommended for use solely as a sleeping tablet. Bibliography Buscemi, N., Vandermeer, B., Hooton, N., Pandya, R., Tjosvold, L., Hartling, L., Baker, G., Klassen, T.P. and Vohra, S. (2005). The efficacy and safety of exogenous melatonin for primary sleep disorders. Journal of general internal medicine, 20(12), 1151-1158. Carskadon, M. A., & Dement, W. C. (2005). Normal human sleep: an overview. Principles and practice of sleep medicine, 4, 13-23. Demyttenaere, K., Bonnewyn, A., Bruffaerts, R., De Girolamo, G., Gasquet, I., Kovess, V., Haro, J.M. and Alonso, J. (2008). Clinical factors influencing the prescription of antidepressants and benzodiazepines: Results from the European study of the epidemiology of mental disorders (ESEMeD). Journal of Affective Disorders, 110(1), 84-93. Kaplan, K.A. & Harvey, A.G. (2013). Treatment of sleep disturbance. In D. Barlow (Ed), Clinical Handbook of Psychological Disorders, 5th Edition. New York: Guilford Press. Manber, R., & Carney, C. E. (2015). Treatment Plans and Interventions for Insomnia: A Case Formulation Approach. Guilford Publications. Mason, E. C. and Harvey, A. G. 2015. Insomnia and Sleep Disorders. Emerging Trends in the Social and Behavioral Sciences: An Interdisciplinary, Searchable, and Linkable Resource. 1–12 WWW.THISWAYUP.ORG.AU 22