Shelby Harris on CBT for Sleep Problems – Part 3 of 3

By Lynn Mollick

Sleep Apnea
Sleep apnea is an arousal disorder characterized by loud snoring, gasping for breath during sleep, frequent arousal, daytime sleepiness despite adequate hours of sleep, accidents, morning headaches, difficulty concentrating, falling asleep at inappropriate times and in inappropriate places, and concentration problems, memory difficulties and depression. If you suspect Sleep Apnea, bed partners will often provide confirming information.

Sleep apnea sometimes causes insomnia, but CBT-I will not improve the quality of sleep unless the apnea is also treated. They are easily confused but apnea causes sleepiness and insomnia causes fatigue. The gold standard treatment for sleep apnea is continuous positive airway pressure (CPAP), a mask that fits over the nose and/or mouth, and gently blows air into the lungs during sleep. Patients often reject the CPAP, often during the first week of use. You can improve compliance by finding out what wearing the CPAP means to patients and by helping them accommodate to its use.

In addition to good sleep hygiene, other helpful interventions for sleep apnea are: losing weight, clearing up nasal congestion, and changing sleep position, usually turning off the back. Surgery, which is painful, is only 50% effective.

Nightmares & Night Terrors
Nightmares and bad dreams, which both have visual content, can be treated with Imagery Rehearsal Therapy (IRT). Tell the patient to:

1. Choose any nightmare, but not the most distressing one.
2. Write out the nightmare in the first person, present tense, with many details. Do this during a therapy session to ensure that the nightmare is richly described.
3. Also in session, change the nightmare any way the patient wants, including creating a whole new dream.
4. Homework: Patients sit comfortably with their closed eyes, imagining the new dream in images, not words, making the experience as vivid, detailed, and dream-like as possible. If the patient’s old dream or unwanted images pop up, patients should refocus and ground themselves with mindfulness or briefly open their eyes take a breath, and then continue. They should follow this procedure twice a day, for at least 3 days before you introduce another, perhaps more disturbing, dream.

IRT can be used with all nightmares including trauma dreams.

When sleep apnea coexists with nightmares, using the CPAP will resolve both.

Night terrors are different from nightmares. They are characterized by screaming, flailing, fear, and disorientation upon awakening. Night terrors usually occur during the first third of a night’s sleep, when sleep is deepest. Arousal from night terrors is difficult. Unlike dreams, they seldom have content.

Night terrors are similar to sleep walking. Both are disorders of arousal and are lumped together as “parasomnias.” Sleep walking and night terrors are usually of short duration. Safety planning is the main concern with sleep walking.

Circadian Rhythm Disorders
Circadian rhythm disorders are disruptions in the normal sleep-walk cycle, i.e. sleep occurs at the wrong time of day. Circadian rhythm disorders are different from insomnia. Patients with circadian rhythm disorders complain about when they sleep, not about the quality or amount of their sleep.

There are a number of circadian rhythm disorders:

1. Delayed Sleep Phase Disorder is the most common. Sufferers fall asleep and awaken later than they would like. Blue light emanating from digital screens exacerbates the problem.
2. Advanced Sleep Phase Disorder, where the patient falls asleep and awakens earlier than they would like. This problem is usually seen among the elderly.
3. Irregular Sleep Phase Disorder, where patients sleep at varying, random times. This pattern is common among severely depressed patients.

Severe cases of circadian rhythm disorders may be treated with Chronotherapy. Delay bedtime 180 minutes per day keeping to rigid sleep and waking times. Or, if time is short and motivation is strong, instruct the patient to stay up for a full day and go to sleep at the proper time the next day.

“Light Therapy” involves moving the patients’ preferred bed and awakening times 30 minutes earlier per day, with bright light at the wake-up hour and dim light before the hour of sleep.

Melatonin is helpful for treatment of circadian rhythm disorders, but not for insomnia. It is often combined with light therapy. Suggest between .5 mg. and 3 mg. about 3 hours before desired sleep onset. Doses larger than 5 mg. are ineffective.

Dr. Harris recommended caution in the use of melatonin because melatonin affects brain chemistry and its manufacture is unregulated. Also, melatonin may create fertility problems. Melatonin should not be used for longer than 3 months.

Wearing an actigraphy monitor, a watch-like device that tracks movement throughout the day, is helpful for diagnosing circadian rhythm disorders and insomnia. However, popular exercise monitors, e.g. the Fit Bit or iWatch, exacerbate concerns about sleep.

Narcolepsy, Catalepsy, REM Sleep Behavior Disorder, Restless Legs
Narcolepsy refers to complaints of an irrepressible desire to sleep and/or falling asleep periodically throughout the day.

Catalepsy, which is a sudden loss of muscle tone triggered by strong emotions, is often comorbid with narcolepsy. A variety of medications can be helpful.

Restless Legs is a movement disorder in which discomfort in the legs that only movement relieves. Restless legs worsens at night and interferes with sleep, especially for bed partners. When restless legs occurs, get a medical evaluation; iron deficiency may be the cause. Many medications are used to treat restless legs. Possible psychological interventions include: massage, progressive muscle relaxation, and good sleep hygiene.

In REM Sleep Behavior Disorder, patients speak or perform complex behaviors during REM sleep. When they awaken, they are alert and not confused. Episodes are more common during the later hours of sleep. Sometimes REM sleep disorder is a precursor of Parkinson’s disease.

Conclusion
Dr. Harris emphasized that comprehensive data from sleep diaries and careful interviewing about wakefulness and sleep during a 24 hour day is essential for proper assessment of sleep difficulties. Good sleep hygiene provides the basis for any successful treatment. CBT-I is the gold standard therapy for insomnia, but other specific interventions are needed for other sleep problems.