CLINICAL CASE CONFERENCE
Behavioral Treatment of Insomnia in Early Recovery Katherine A. Kaplan, PhD, John McQuaid, PhD, Steven L. Batki, MD, and Nicholas Rosenlicht, MD
(J Addict Med 2014;8: 395–398)
T
his clinical case discussion focuses on a veteran with alcohol dependence in early partial remission and comorbid insomnia. The case illustrates the use of cognitive behavioral therapy for insomnia (CBT-I) to treat sleep disturbance. After the case presentation, expert clinicians provide commentary on the case.
PATIENT A 23-year-old single white man, working part-time at a retail facility and enrolled full time at a local community college, presented to a VA Medical Center in Northern California for treatment of insomnia. According to a review of available records, the patient had served in the Army for 15 months before receiving a general discharge after sustaining a knee injury during basic training and getting in a physical fight with 2 sergeants over medical paperwork. The veteran had also tested positive for cannabis and oxycodone during routine urine testing while enlisted, and was subsequently mandated to an abstinence-based intensive outpatient treatment program.
HISTORY Psychiatric history at the start of treatment was notable for diagnoses of panic disorder without agoraphobia, alcohol dependence in early remission, opioid (oxycodone) dependence in full sustained remission, and nicotine dependence. He reported a family history of bipolar disorder and had been assessed for the illness. Although he denied a clear manic or hypomanic episode, he did describe some symptoms consistent with a bipolar profile (eg, racing thoughts). At the start of the treatment, the patient noted numerous trials of antidepressants and mood stabilizers/antipsychotics that he had discontinued because of reported side effects and/or lack of benefit. The patient also reported a childhood history of emotional and physical abuse by his biological father and From the Department of Psychiatry (KAK), Stanford University School of Medicine, Stanford, CA; and Department of Psychiatry (JM, SLB, NR), University of California, and San Francisco VA Medical Center, San Francisco, CA. Received for publication November 21, 2013; accepted May 17, 2014. Dr. Steven Batki has acted as Consultant to Gilead Sciences. No other conflicts of interest. Send correspondence and reprint requests to Nicholas Rosenlicht, MD, Department of Psychiatry, University of California, San Francisco, San Francisco VA Medical Center (116C), 4150 Clement St, San Francisco, CA 94121. E-mail: [email protected]. C 2014 American Society of Addiction Medicine Copyright ISSN: 1932-0620/14/0806-0395 DOI: 10.1097/ADM.0000000000000058
peers. Medical history was significant for right knee injury, tinnitus, and allergic rhinitis. The patient reported a history of alcohol abuse beginning in high school, though he denied symptoms of withdrawal after discontinuation. He had a history of oxycodone abuse (80 mg/d), first prescribed by a physician and later obtained illegally, last use 3 years prior. He also reported a history of cannabis use 5 days per week, last use 2 years prior. After testing positive for cannabis while in the military, the patient was mandated to attend an intensive outpatient program for cannabis use, which he completed. Regarding his history of sleep disturbance, the patient recalled his premorbid sleep schedule to be 11 PM to 8 AM with few awakenings, and noted that he awoke feeling refreshed in the morning. The patient reported that his insomnia began during basic training approximately 4 years prior, where he was required to adjust to a sleep schedule of 10:30 PM to 4 AM. After a knee injury, the patient was prescribed hydrocodone and began drinking heavily while using the medication, noting that his sleep schedule shifted to 12 to 4 AM. After discontinuation of the hydrocodone and alcohol, the patient noted that his sleep had still not returned to his prior pattern.
BASELINE ASSESSMENT OF SLEEP AND PSYCHIATRIC SYMPTOMS The patient was referred to the general psychiatric outpatient service for insomnia treatment. Baseline sleep measures included the Insomnia Severity Index (ISI; Morin et al., 2011), the Restless Leg Syndrome Rating Scale (RLS; Walters, 1995), the snoring, tiredness during daytime, observed apnea, and the brief STOP Screening Questionnaire for sleep apnea (Chung et al., 2008), and the Morningness/ Eveningness Questionnaire (MEQ; Horne & Ostberg, 1976) to assess for circadian phase preference. Mood was evaluated via the Beck Depression Inventory (BDI-II; Beck et al., 1996). Baseline assessment of sleep revealed moderate symptoms of insomnia (ISI = 18). He endorsed difficulty initiating and maintaining sleep, noting that it took between 45 and 120 minutes to fall asleep and that he woke up for 45 to 90 minutes in the middle of the night. He also met minimal threshold for a positive sleep apnea screen (STOP = 2), noting that he snored while on his back and that his girlfriend had noted pauses in his breathing of up to 1 minute. He was subsequently referred for further evaluation within the sleep clinic at the hospital. Despite this positive sleep apnea screen, insomnia treatment was still deemed clinically warranted and continued while referral for further sleep evaluation was in place. The patient endorsed symptoms of restless leg syndrome in the mild range (RLS = 7) and indicated on the MEQ that he had a
J Addict Med r Volume 8, Number 6, November/December 2014
Copyright © 2014 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
395
J Addict Med r Volume 8, Number 6, November/December 2014
Kaplan et al.
morning-type circadian phase preference. The patient reported that his primary difficulty involved prebed cognitive arousal and worry thoughts. At baseline he also noted numerous behaviors incompatible with sleep, including varying his wake time when sleeping with his partner, napping for 60 minutes 3 times per week, working out late in the evening, and eating candy/cake right before bed. The patient reported caffeine consumption of three 24-oz Mountain Dews daily, the last at dinnertime, and stated he had quit drinking energy drinks in the year prior. He also reported smoked cigarettes before bed. He reported his insomnia led to difficulties in the daytime, including difficulty focusing and emotional lability. The patient endorsed minimal symptoms of depression (BDI-II = 2). He stated at baseline evaluation that he was abstaining from drugs at present and attempting to abstain from alcohol. The patient reported smoking 10 to 20 cigarettes per day and drinking 6 beers once per week.
TREATMENT Table 1 illustrates session-by-session sleep diary parameters and treatment recommendations. The section that follows elaborates on behavioral and cognitive targets for intervention that were reviewed and expanded weekly. At the start of the treatment, the patient and the therapist reviewed the sleep diary (a sample of which is included in Figure 1), discussed CBT-I treatment principles, and began setting behavioral recommendations on the basis of information gathered during assessment. The patient and the therapist agreed on a collaboratively set goal for treatment to obtain 5 to 6 hours of “quality” sleep per night. The patient and the therapist discussed a model of insomnia in the context of his sleep diary and prior assessment, including a sleep drive that was reduced by napping, conditioned arousal from staying in bed, and the need to account for “lark” (morning-type) tendencies. The patient and the therapist also reviewed and discussed sleep hygiene issues (reducing late eating and exercise, no caffeine after noon, no smoking before bed). The rationale for stimulus control and sleep restriction was presented. After the first week of sleep diaries revealed a time in
bed of 6.6 hours and a total sleep time of 3.7 hours, the patient was counseled to adopt a sleep window of 5 hours of time in bed. In the remaining sessions, the patient and the therapist continued to identify and address sleep-incompatible behaviors, including going to sleep before tired, sleeping in and remaining in bed when not sleeping. Pre-bedtime worry was also addressed in numerous ongoing interventions. A thought record was introduced to the patient as a way of addressing sleep-disrupting cognitions, and common cognitive distortions (catastrophizing, probability estimation, emotional reasoning) were reviewed. The patient also agreed to schedule a daily worry time to minimize the likelihood of worrying in bed. Breath-focused meditation was also introduced as a way to address prebed arousal. As the patient continued to report short sleep duration even without napping, the possibility of hypomania was considered with the patient, though he denied any other related symptoms. The patient was educated on variability in sleep need and the possibility that his sleep need was shorter than that of others. The patient was generally compliant with all interventions. One exception of note was that he attended a sporting event, stayed up later than usual, and consumed alcohol (although he denied drinking to intoxication). This was addressed in the session, and the therapist reiterated the need for both stable sleep schedules and avoidance of alcohol from the perspective of sleep management. The patient was open to this feedback, and did not report further alcohol use for the duration of treatment. In addition, the patient reported he did not find the meditation strategies helpful, and chose to discontinue them. However, this was done in a discussion of other strategies that he preferred (eg, thought challenging).
POSTTREATMENT ASSESSMENT OF SLEEP AND PSYCHIATRIC SYMPTOMS At the conclusion of the treatment, the patient reported an average sleep efficiency of 73% on his last week of recorded sleep diaries, with decreased latency to fall asleep after incorporating pre-bedtime strategies. There was a 2-week
TABLE 1. Summary of Sleep Parameters and Treatment Recommendations Session No.
Average TST
Average TIB
Average SE, %
Average Bedtime
Average Rise Time
1
—*
—
—
—
—
2
3.7
6.6
51.1
00:20
07:14
3
2.9
4.6
62.3
1:00
5:34
4
3.1
4.6
53.6
1:00
6:34
5
2.9
4.6
61.2
1:00
5:38
6
2.4
3.9
60.8
1:47
5:44
7 8
— 3.4
— 4.6
70.0 73.0
— —
— —
Recommendations Baseline assessment of sleep and psychological symptoms Sleep window: 1:00–6:00 AM Out of bed if awake 10–15 min No caffeine after noon No heavy desserts before bed No cigarettes after dinner No modifications No bedtime earlier than 1:00 AM No napping Worry time 6:00 PM daily No modifications Sleep window: 2:00–6:00 AM Practice mindfulness 15–30 min before bedtime No modifications No modifications
*Dashes represent missing data. SE, sleep efficiency; TIB, time in bed; TST, total sleep time.
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2014 American Society of Addiction Medicine
Copyright © 2014 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
J Addict Med r Volume 8, Number 6, November/December 2014
Behavioral Treatment of Insomnia in Early Recovery
FIGURE 1. Sample sleep diary.
span between session 7 and the patient’s final session, although completed sleep diaries were available for only the first of these 2 weeks. However, the patient reported significantly improved sleep in the second week. His most recent night of sleep, recalled by completing sleep diary information in the session, yielded a sleep efficiency of 93%. Symptom measures indicated insomnia that was in a subclinical range (ISI = 7), and depression symptoms had remained low (BDI = 2). The patient noted that recording sleep in the diary and thought records were very helpful, though noted less success with mindfulness practice. The patient expressed satisfaction with treatment outcome.
COMMENTARY BY JOHN McQUAID, PHD Three key elements stand out in this case. First, the very low level of reported total sleep time is concerning. The therapist complied with standard procedures of not restricting sleep to less than 5 hours, but this may have been a case in which considering even greater restriction may have been warranted. However, the risks involved (possible activation of a manic episode or possible injury or accident because of daytime sleepiness) need to be weighed against treatment effectiveness. In the end, the patient reports benefit, and appears on the path to greater sleep efficiency. Thus, the choice to extend the length of treatment rather than to restrict sleep further seems like a reasonable compromise. Second, although substances in general were not a major factor, the history of substance dependence plays a role in the focus of treatment. Behavioral interventions as a whole provide an option for individuals who are concerned, for whatever reason, about the use of pharmacologic interventions. In this case, the patient was very enthusiastic about a nonpharmaco C
logic option. Also, although the veteran was denying use, his alcohol use in the context of a sporting event suggests that his sobriety could be vulnerable. It is possible that emphasizing the negative consequences of substance use on sleep in someone experiencing sleep disturbance could be an important motivating factor in care. Third, the case emphasizes the importance of multiple measures of outcome, including both objective and subjective reporting. Although sleep efficiency improved, it did not reach optimal levels until the last week (and that is by self-report, without the confirmation of sleep diary information completed prior to last session). However, the patient’s subjective experience of insomnia, as measured by the ISI, was clearly improved, and the patient expressed great satisfaction with the outcome. Overall, the patient showed meaningful improvement. Attending to patient satisfaction as well as measurable objective responses gives a more complete picture of treatment response.
COMMENTARY BY STEVEN L. BATKI, MD Sleep disturbances are common in patients with substance use disorders, and the relationship between these 2 problems is bidirectional: the effects of substance use are known to impair sleep, and insomnia is often a trigger for using substances in an attempt to improve sleep (Haario et al., 2013). This patient has a history of using a number of substances including caffeine, nicotine, alcohol, cannabis, and opioids. Because the use of each of these 5 substances may be associated with sleep disturbances, it is important to clearly assess the types, amounts, and frequency of use when beginning treatment of a sleep disorder. The initial assessment is key to understanding the potential effects of substance use and
2014 American Society of Addiction Medicine
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397
Kaplan et al.
should therefore include detailed questions addressing these variables. Whenever possible, the interview should be augmented with objective assessments such as urine drug testing and relevant blood tests such as mean cell volume and serum hepatic transaminases including AST, ALT, and GGT. As both intoxication and withdrawal have effects on sleep architecture, it is therefore important to simultaneously address substance use while treating the sleep disorder. Such treatment can consist of office-based motivational counseling, using, for example, the patient’s stated goals of reducing his sleep problems as a source of health-based motivation to become free or remain free of substance use. Although there is evidence for behavioral treatments for insomnia having efficacy in patients with substance use disorders, it is as yet unclear whether improvement of sleep can, in turn, assist in reducing or stopping substance use (Roth, 2009). However, it may be reasonable to assume that improving sleep could reduce the need to use certain types of substances, especially depressants such as alcohol. Finally, if behavioral treatment had proved ineffective in this patient, one could consider the use of medications with low abuse potential. There is a small but growing literature examining the use of pharmacologic treatment of sleep disorders in patients with substance use disorders (Kolla et al., 2011), pointing to the possible utility of generally safe and nonaddictive agents such as gabapentin (Brower et al., 2008), although always weighing carefully the risks of potential misuse. Given this patient’s history of cannabis and alcohol use disorder, it is of particular interest that in addition to possibly helping with sleep, gabapentin has been shown to have potential utility in the treatment of both alcohol (Mason et al., 2014) and cannabis use disorders (Mason et al., 2012).
COMMENTARY BY NICHOLAS ROSENLICHT, MD This case demonstrates the importance of a flexible approach combined with the use of structured assessments. Patients will rarely find all aspects of CBT-I (or pharmacologic treatment) helpful or even palatable. This gentleman’s rejection of the meditation strategies was not and should not be seen as a major barrier to treatment. Allowing him to pick and choose a bit, while focusing on the core elements of the treatment such as improving sleep efficiency and distorted cognitions, can help foster a sense of competence and mastery over sleep problems—which is key to reducing distress over sleep problems. The use of the sleep diary and ISI, rather than relying on remote recollection of sleep time and quality, is also crucial. These instruments, especially when reviewed with the patient, highlight both objective and subjective gains made in treatment. Furthermore, they may relieve the sense of helplessness and distress so common with sleep problems, and can generalize to an overall sense of competency and mastery that can help in the recovery process. I frequently find, especially in reluctant patients, that the simple intervention of a sleep diary, collaboratively reviewed, can be a powerful tool in improving sleep and reducing distress. In this case, the ISI decreased from 18 to 7. Despite a relatively small increase in sleep time, an improvement in sleep efficiency and use of CBT-I techniques can
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result in a dramatic improvement in subjective sleep quality— the overarching goal of any sleep treatment. A final comment should be made regarding the observed pauses in his breathing during sleep as assessed via the STOP questionnaire. This warrants further evaluation, and a referral was placed for subsequent polysomnographic screening. However, proceeding with CBT-I in the presence of suspected obstructive sleep apnea (OSA) (especially with minimal daytime sleepiness, as this patient reports) is both clinically indicated and common practice for CBT-I dissemination within the Veterans Health Administration (Manber et al., 2012). In patients with comorbid insomnia and OSA, research suggests that administering CBT-I before any treatment for OSA helps to increase total sleep time and reduce sleep onset latency (Guilleminault et al., 2008). Furthermore, research suggests that CPAP adherence is poor with sleep maintenance insomnia complaints, which this patient reports (Wickwire et al., 2010). Thus, the acceptance of CPAP, and most importantly the CPAP mask, is likely to be more successful after distress over his sleep has diminished. REFERENCES Beck AT, Steer RA, Brown G. Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation, 1996. Brower KJ, Myra Kim H, Strobbe S, et al. A randomized double-blind pilot trial of gabapentin versus placebo to treat alcohol dependence and comorbid insomnia. Alcohol Clin Exp Res 2008;32:1429–1438. doi: ACER706 [pii] 10.1111/j.1530-0277.2008.00706.x Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008;108:812–821. doi:10.1097/ALN.0b013e31816d83e4 Guilleminault C, Davis K, Huynh NT. Prospective randomized study of patients with insomnia and mild sleep disordered breathing. Sleep 2008;31:1527–1533. Haario P, Rahkonen O, Laaksonen M, et al. Bidirectional associations between insomnia symptoms and unhealthy behaviours. J Sleep Res 2013;22:89–95. doi:10.1111/j.1365-2869.2012.01043.x Horne JA, Ostberg O. A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms. Int J Chronobiol 1976;4:97–110. Kolla BP, Mansukhani MP, Schneekloth T. Pharmacological treatment of insomnia in alcohol recovery: a systematic review. Alcohol Alcohol 2011;46:578–585. doi: 10.1093/alcalc/agr073 Manber R, Carney C, Edinger J, et al. Dissemination of CBTI to the non-sleep specialist: protocol development and training issues. J Clin Sleep Med 2012;8:209–218. doi: 10.5664/jcsm.1786 Mason BJ, Crean R, Goodell V, et al. A proof-of-concept randomized controlled study of gabapentin: effects on cannabis use, withdrawal and executive function deficits in cannabis-dependent adults. Neuropsychopharmacology 2012;37:1689–1698. doi: 10.1038/npp .2012.14 Mason BJ, Quello S, Goodell V, et al. Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Intern Med 2014;174:70– 77. doi: 10.1001/jamainternmed.2013.11950 Morin CM, Belleville G, Belanger L, et al. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep 2011;34:601–608. Roth T. Does effective management of sleep disorders reduce substance dependence? Drugs 2009;69(suppl 2):65–75. doi: 6 [pii] 10.2165/11531120000000000-00000 Walters AS. Toward a better definition of the restless legs syndrome. The International Restless Legs Syndrome Study Group. Mov Disord 1995;10:634– 642. doi: 10.1002/mds.870100517 Wickwire EM, Smith MT, Birnbaum S, et al. Sleep maintenance insomnia complaints predict poor CPAP adherence: a clinical case series. Sleep Med 2010;11:772–776. doi: 10.1016/j.sleep.2010.03.012. C
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Behavioral Treatment of Insomnia in Early Recovery Katherine A. Kaplan, PhD, John McQuaid, PhD, Steven L. Batki, MD, and Nicholas Rosenlicht, MD
(J Addict Med 2014;8: 395–398)
T
his clinical case discussion focuses on a veteran with alcohol dependence in early partial remission and comorbid insomnia. The case illustrates the use of cognitive behavioral therapy for insomnia (CBT-I) to treat sleep disturbance. After the case presentation, expert clinicians provide commentary on the case.
PATIENT A 23-year-old single white man, working part-time at a retail facility and enrolled full time at a local community college, presented to a VA Medical Center in Northern California for treatment of insomnia. According to a review of available records, the patient had served in the Army for 15 months before receiving a general discharge after sustaining a knee injury during basic training and getting in a physical fight with 2 sergeants over medical paperwork. The veteran had also tested positive for cannabis and oxycodone during routine urine testing while enlisted, and was subsequently mandated to an abstinence-based intensive outpatient treatment program.
HISTORY Psychiatric history at the start of treatment was notable for diagnoses of panic disorder without agoraphobia, alcohol dependence in early remission, opioid (oxycodone) dependence in full sustained remission, and nicotine dependence. He reported a family history of bipolar disorder and had been assessed for the illness. Although he denied a clear manic or hypomanic episode, he did describe some symptoms consistent with a bipolar profile (eg, racing thoughts). At the start of the treatment, the patient noted numerous trials of antidepressants and mood stabilizers/antipsychotics that he had discontinued because of reported side effects and/or lack of benefit. The patient also reported a childhood history of emotional and physical abuse by his biological father and From the Department of Psychiatry (KAK), Stanford University School of Medicine, Stanford, CA; and Department of Psychiatry (JM, SLB, NR), University of California, and San Francisco VA Medical Center, San Francisco, CA. Received for publication November 21, 2013; accepted May 17, 2014. Dr. Steven Batki has acted as Consultant to Gilead Sciences. No other conflicts of interest. Send correspondence and reprint requests to Nicholas Rosenlicht, MD, Department of Psychiatry, University of California, San Francisco, San Francisco VA Medical Center (116C), 4150 Clement St, San Francisco, CA 94121. E-mail: [email protected]. C 2014 American Society of Addiction Medicine Copyright ISSN: 1932-0620/14/0806-0395 DOI: 10.1097/ADM.0000000000000058
peers. Medical history was significant for right knee injury, tinnitus, and allergic rhinitis. The patient reported a history of alcohol abuse beginning in high school, though he denied symptoms of withdrawal after discontinuation. He had a history of oxycodone abuse (80 mg/d), first prescribed by a physician and later obtained illegally, last use 3 years prior. He also reported a history of cannabis use 5 days per week, last use 2 years prior. After testing positive for cannabis while in the military, the patient was mandated to attend an intensive outpatient program for cannabis use, which he completed. Regarding his history of sleep disturbance, the patient recalled his premorbid sleep schedule to be 11 PM to 8 AM with few awakenings, and noted that he awoke feeling refreshed in the morning. The patient reported that his insomnia began during basic training approximately 4 years prior, where he was required to adjust to a sleep schedule of 10:30 PM to 4 AM. After a knee injury, the patient was prescribed hydrocodone and began drinking heavily while using the medication, noting that his sleep schedule shifted to 12 to 4 AM. After discontinuation of the hydrocodone and alcohol, the patient noted that his sleep had still not returned to his prior pattern.
BASELINE ASSESSMENT OF SLEEP AND PSYCHIATRIC SYMPTOMS The patient was referred to the general psychiatric outpatient service for insomnia treatment. Baseline sleep measures included the Insomnia Severity Index (ISI; Morin et al., 2011), the Restless Leg Syndrome Rating Scale (RLS; Walters, 1995), the snoring, tiredness during daytime, observed apnea, and the brief STOP Screening Questionnaire for sleep apnea (Chung et al., 2008), and the Morningness/ Eveningness Questionnaire (MEQ; Horne & Ostberg, 1976) to assess for circadian phase preference. Mood was evaluated via the Beck Depression Inventory (BDI-II; Beck et al., 1996). Baseline assessment of sleep revealed moderate symptoms of insomnia (ISI = 18). He endorsed difficulty initiating and maintaining sleep, noting that it took between 45 and 120 minutes to fall asleep and that he woke up for 45 to 90 minutes in the middle of the night. He also met minimal threshold for a positive sleep apnea screen (STOP = 2), noting that he snored while on his back and that his girlfriend had noted pauses in his breathing of up to 1 minute. He was subsequently referred for further evaluation within the sleep clinic at the hospital. Despite this positive sleep apnea screen, insomnia treatment was still deemed clinically warranted and continued while referral for further sleep evaluation was in place. The patient endorsed symptoms of restless leg syndrome in the mild range (RLS = 7) and indicated on the MEQ that he had a
J Addict Med r Volume 8, Number 6, November/December 2014
Copyright © 2014 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
395
J Addict Med r Volume 8, Number 6, November/December 2014
Kaplan et al.
morning-type circadian phase preference. The patient reported that his primary difficulty involved prebed cognitive arousal and worry thoughts. At baseline he also noted numerous behaviors incompatible with sleep, including varying his wake time when sleeping with his partner, napping for 60 minutes 3 times per week, working out late in the evening, and eating candy/cake right before bed. The patient reported caffeine consumption of three 24-oz Mountain Dews daily, the last at dinnertime, and stated he had quit drinking energy drinks in the year prior. He also reported smoked cigarettes before bed. He reported his insomnia led to difficulties in the daytime, including difficulty focusing and emotional lability. The patient endorsed minimal symptoms of depression (BDI-II = 2). He stated at baseline evaluation that he was abstaining from drugs at present and attempting to abstain from alcohol. The patient reported smoking 10 to 20 cigarettes per day and drinking 6 beers once per week.
TREATMENT Table 1 illustrates session-by-session sleep diary parameters and treatment recommendations. The section that follows elaborates on behavioral and cognitive targets for intervention that were reviewed and expanded weekly. At the start of the treatment, the patient and the therapist reviewed the sleep diary (a sample of which is included in Figure 1), discussed CBT-I treatment principles, and began setting behavioral recommendations on the basis of information gathered during assessment. The patient and the therapist agreed on a collaboratively set goal for treatment to obtain 5 to 6 hours of “quality” sleep per night. The patient and the therapist discussed a model of insomnia in the context of his sleep diary and prior assessment, including a sleep drive that was reduced by napping, conditioned arousal from staying in bed, and the need to account for “lark” (morning-type) tendencies. The patient and the therapist also reviewed and discussed sleep hygiene issues (reducing late eating and exercise, no caffeine after noon, no smoking before bed). The rationale for stimulus control and sleep restriction was presented. After the first week of sleep diaries revealed a time in
bed of 6.6 hours and a total sleep time of 3.7 hours, the patient was counseled to adopt a sleep window of 5 hours of time in bed. In the remaining sessions, the patient and the therapist continued to identify and address sleep-incompatible behaviors, including going to sleep before tired, sleeping in and remaining in bed when not sleeping. Pre-bedtime worry was also addressed in numerous ongoing interventions. A thought record was introduced to the patient as a way of addressing sleep-disrupting cognitions, and common cognitive distortions (catastrophizing, probability estimation, emotional reasoning) were reviewed. The patient also agreed to schedule a daily worry time to minimize the likelihood of worrying in bed. Breath-focused meditation was also introduced as a way to address prebed arousal. As the patient continued to report short sleep duration even without napping, the possibility of hypomania was considered with the patient, though he denied any other related symptoms. The patient was educated on variability in sleep need and the possibility that his sleep need was shorter than that of others. The patient was generally compliant with all interventions. One exception of note was that he attended a sporting event, stayed up later than usual, and consumed alcohol (although he denied drinking to intoxication). This was addressed in the session, and the therapist reiterated the need for both stable sleep schedules and avoidance of alcohol from the perspective of sleep management. The patient was open to this feedback, and did not report further alcohol use for the duration of treatment. In addition, the patient reported he did not find the meditation strategies helpful, and chose to discontinue them. However, this was done in a discussion of other strategies that he preferred (eg, thought challenging).
POSTTREATMENT ASSESSMENT OF SLEEP AND PSYCHIATRIC SYMPTOMS At the conclusion of the treatment, the patient reported an average sleep efficiency of 73% on his last week of recorded sleep diaries, with decreased latency to fall asleep after incorporating pre-bedtime strategies. There was a 2-week
TABLE 1. Summary of Sleep Parameters and Treatment Recommendations Session No.
Average TST
Average TIB
Average SE, %
Average Bedtime
Average Rise Time
1
—*
—
—
—
—
2
3.7
6.6
51.1
00:20
07:14
3
2.9
4.6
62.3
1:00
5:34
4
3.1
4.6
53.6
1:00
6:34
5
2.9
4.6
61.2
1:00
5:38
6
2.4
3.9
60.8
1:47
5:44
7 8
— 3.4
— 4.6
70.0 73.0
— —
— —
Recommendations Baseline assessment of sleep and psychological symptoms Sleep window: 1:00–6:00 AM Out of bed if awake 10–15 min No caffeine after noon No heavy desserts before bed No cigarettes after dinner No modifications No bedtime earlier than 1:00 AM No napping Worry time 6:00 PM daily No modifications Sleep window: 2:00–6:00 AM Practice mindfulness 15–30 min before bedtime No modifications No modifications
*Dashes represent missing data. SE, sleep efficiency; TIB, time in bed; TST, total sleep time.
396
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2014 American Society of Addiction Medicine
Copyright © 2014 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
J Addict Med r Volume 8, Number 6, November/December 2014
Behavioral Treatment of Insomnia in Early Recovery
FIGURE 1. Sample sleep diary.
span between session 7 and the patient’s final session, although completed sleep diaries were available for only the first of these 2 weeks. However, the patient reported significantly improved sleep in the second week. His most recent night of sleep, recalled by completing sleep diary information in the session, yielded a sleep efficiency of 93%. Symptom measures indicated insomnia that was in a subclinical range (ISI = 7), and depression symptoms had remained low (BDI = 2). The patient noted that recording sleep in the diary and thought records were very helpful, though noted less success with mindfulness practice. The patient expressed satisfaction with treatment outcome.
COMMENTARY BY JOHN McQUAID, PHD Three key elements stand out in this case. First, the very low level of reported total sleep time is concerning. The therapist complied with standard procedures of not restricting sleep to less than 5 hours, but this may have been a case in which considering even greater restriction may have been warranted. However, the risks involved (possible activation of a manic episode or possible injury or accident because of daytime sleepiness) need to be weighed against treatment effectiveness. In the end, the patient reports benefit, and appears on the path to greater sleep efficiency. Thus, the choice to extend the length of treatment rather than to restrict sleep further seems like a reasonable compromise. Second, although substances in general were not a major factor, the history of substance dependence plays a role in the focus of treatment. Behavioral interventions as a whole provide an option for individuals who are concerned, for whatever reason, about the use of pharmacologic interventions. In this case, the patient was very enthusiastic about a nonpharmaco C
logic option. Also, although the veteran was denying use, his alcohol use in the context of a sporting event suggests that his sobriety could be vulnerable. It is possible that emphasizing the negative consequences of substance use on sleep in someone experiencing sleep disturbance could be an important motivating factor in care. Third, the case emphasizes the importance of multiple measures of outcome, including both objective and subjective reporting. Although sleep efficiency improved, it did not reach optimal levels until the last week (and that is by self-report, without the confirmation of sleep diary information completed prior to last session). However, the patient’s subjective experience of insomnia, as measured by the ISI, was clearly improved, and the patient expressed great satisfaction with the outcome. Overall, the patient showed meaningful improvement. Attending to patient satisfaction as well as measurable objective responses gives a more complete picture of treatment response.
COMMENTARY BY STEVEN L. BATKI, MD Sleep disturbances are common in patients with substance use disorders, and the relationship between these 2 problems is bidirectional: the effects of substance use are known to impair sleep, and insomnia is often a trigger for using substances in an attempt to improve sleep (Haario et al., 2013). This patient has a history of using a number of substances including caffeine, nicotine, alcohol, cannabis, and opioids. Because the use of each of these 5 substances may be associated with sleep disturbances, it is important to clearly assess the types, amounts, and frequency of use when beginning treatment of a sleep disorder. The initial assessment is key to understanding the potential effects of substance use and
2014 American Society of Addiction Medicine
Copyright © 2014 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
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should therefore include detailed questions addressing these variables. Whenever possible, the interview should be augmented with objective assessments such as urine drug testing and relevant blood tests such as mean cell volume and serum hepatic transaminases including AST, ALT, and GGT. As both intoxication and withdrawal have effects on sleep architecture, it is therefore important to simultaneously address substance use while treating the sleep disorder. Such treatment can consist of office-based motivational counseling, using, for example, the patient’s stated goals of reducing his sleep problems as a source of health-based motivation to become free or remain free of substance use. Although there is evidence for behavioral treatments for insomnia having efficacy in patients with substance use disorders, it is as yet unclear whether improvement of sleep can, in turn, assist in reducing or stopping substance use (Roth, 2009). However, it may be reasonable to assume that improving sleep could reduce the need to use certain types of substances, especially depressants such as alcohol. Finally, if behavioral treatment had proved ineffective in this patient, one could consider the use of medications with low abuse potential. There is a small but growing literature examining the use of pharmacologic treatment of sleep disorders in patients with substance use disorders (Kolla et al., 2011), pointing to the possible utility of generally safe and nonaddictive agents such as gabapentin (Brower et al., 2008), although always weighing carefully the risks of potential misuse. Given this patient’s history of cannabis and alcohol use disorder, it is of particular interest that in addition to possibly helping with sleep, gabapentin has been shown to have potential utility in the treatment of both alcohol (Mason et al., 2014) and cannabis use disorders (Mason et al., 2012).
COMMENTARY BY NICHOLAS ROSENLICHT, MD This case demonstrates the importance of a flexible approach combined with the use of structured assessments. Patients will rarely find all aspects of CBT-I (or pharmacologic treatment) helpful or even palatable. This gentleman’s rejection of the meditation strategies was not and should not be seen as a major barrier to treatment. Allowing him to pick and choose a bit, while focusing on the core elements of the treatment such as improving sleep efficiency and distorted cognitions, can help foster a sense of competence and mastery over sleep problems—which is key to reducing distress over sleep problems. The use of the sleep diary and ISI, rather than relying on remote recollection of sleep time and quality, is also crucial. These instruments, especially when reviewed with the patient, highlight both objective and subjective gains made in treatment. Furthermore, they may relieve the sense of helplessness and distress so common with sleep problems, and can generalize to an overall sense of competency and mastery that can help in the recovery process. I frequently find, especially in reluctant patients, that the simple intervention of a sleep diary, collaboratively reviewed, can be a powerful tool in improving sleep and reducing distress. In this case, the ISI decreased from 18 to 7. Despite a relatively small increase in sleep time, an improvement in sleep efficiency and use of CBT-I techniques can
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result in a dramatic improvement in subjective sleep quality— the overarching goal of any sleep treatment. A final comment should be made regarding the observed pauses in his breathing during sleep as assessed via the STOP questionnaire. This warrants further evaluation, and a referral was placed for subsequent polysomnographic screening. However, proceeding with CBT-I in the presence of suspected obstructive sleep apnea (OSA) (especially with minimal daytime sleepiness, as this patient reports) is both clinically indicated and common practice for CBT-I dissemination within the Veterans Health Administration (Manber et al., 2012). In patients with comorbid insomnia and OSA, research suggests that administering CBT-I before any treatment for OSA helps to increase total sleep time and reduce sleep onset latency (Guilleminault et al., 2008). Furthermore, research suggests that CPAP adherence is poor with sleep maintenance insomnia complaints, which this patient reports (Wickwire et al., 2010). Thus, the acceptance of CPAP, and most importantly the CPAP mask, is likely to be more successful after distress over his sleep has diminished. REFERENCES Beck AT, Steer RA, Brown G. Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation, 1996. Brower KJ, Myra Kim H, Strobbe S, et al. A randomized double-blind pilot trial of gabapentin versus placebo to treat alcohol dependence and comorbid insomnia. Alcohol Clin Exp Res 2008;32:1429–1438. doi: ACER706 [pii] 10.1111/j.1530-0277.2008.00706.x Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008;108:812–821. doi:10.1097/ALN.0b013e31816d83e4 Guilleminault C, Davis K, Huynh NT. Prospective randomized study of patients with insomnia and mild sleep disordered breathing. Sleep 2008;31:1527–1533. Haario P, Rahkonen O, Laaksonen M, et al. Bidirectional associations between insomnia symptoms and unhealthy behaviours. J Sleep Res 2013;22:89–95. doi:10.1111/j.1365-2869.2012.01043.x Horne JA, Ostberg O. A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms. Int J Chronobiol 1976;4:97–110. Kolla BP, Mansukhani MP, Schneekloth T. Pharmacological treatment of insomnia in alcohol recovery: a systematic review. Alcohol Alcohol 2011;46:578–585. doi: 10.1093/alcalc/agr073 Manber R, Carney C, Edinger J, et al. Dissemination of CBTI to the non-sleep specialist: protocol development and training issues. J Clin Sleep Med 2012;8:209–218. doi: 10.5664/jcsm.1786 Mason BJ, Crean R, Goodell V, et al. A proof-of-concept randomized controlled study of gabapentin: effects on cannabis use, withdrawal and executive function deficits in cannabis-dependent adults. Neuropsychopharmacology 2012;37:1689–1698. doi: 10.1038/npp .2012.14 Mason BJ, Quello S, Goodell V, et al. Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Intern Med 2014;174:70– 77. doi: 10.1001/jamainternmed.2013.11950 Morin CM, Belleville G, Belanger L, et al. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep 2011;34:601–608. Roth T. Does effective management of sleep disorders reduce substance dependence? Drugs 2009;69(suppl 2):65–75. doi: 6 [pii] 10.2165/11531120000000000-00000 Walters AS. Toward a better definition of the restless legs syndrome. The International Restless Legs Syndrome Study Group. Mov Disord 1995;10:634– 642. doi: 10.1002/mds.870100517 Wickwire EM, Smith MT, Birnbaum S, et al. Sleep maintenance insomnia complaints predict poor CPAP adherence: a clinical case series. Sleep Med 2010;11:772–776. doi: 10.1016/j.sleep.2010.03.012. C
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