Luis F. Buenaver Ph.D., C.B.S.M., D.B.S.M. presents at the Johns Hopkins Department of PM&R’s Grand Rounds on October 15, 2019.
My name is Luis Buena. I might be speaking to you today about sleep disturbance and traumatic brain injury. Mm. So I have nothing to disclose no conflicts of interest. Here's an overview of what I'm going to be speaking to you about today. So first, I'm going to describe what is normal sleep. And then I'll give you a definition of insomnia. And I like to give you a little bit of an overview of sleep disturbance and traumatic brain injury, more specifically the prevalence of sleep disturbance and traumatic brain injury. And then I'll talk about uh what do you do about it? How do we treat it? And so I'll give a, a kind of a uh a little background in the path of physiologic and behavioral perspectives of insomnia and then discuss uh cognitive behavioral therapy for insomnia. So sleep is basically divided into rapid eye movement and non rapid eye movement sleep. We spend most of our time, approximately 80% of our time in non rapid eye movement, sleep and within non rapid eye movement sleep, it's subdivided into three different stages. Stages 12 and three. So stage one is the kind of the transition from wakefulness to sleep where your body starts to relax, people start to fall asleep. We spend approximately 5 to 10% of our total time as sleep. In stage one, stage two is late sleep, but it's sleep. Brain activity definitely slows down. It starts to stabilize and we spend the majority of our time as sleep. And stage two sleep, about 50% of our time, non rapid eye movement. Stage three is what we refer to as slow wave sleep, delta wave sleep. So your brain waves are slow, high amplitude delta waves. Typically during stage three, you have body and tissue restoration. And on average, people spend about 20% of their time asleep. In stage three, sleep, rapid eye movement sleep accounts for about 20% of our time as sleep. And during rem sleep, you can experience some hallucinations sometimes during sleep and weight transitions, secondary to arousals. Rem is usually associated with learning and memory consolidation. It's also characterized by atonia. So there's there's a loss of muscle tone. So you have the sleep paralysis and although you can dream in any stage of sleep, dreaming is most associated with rapid eye movement sleep. And so you have a to, you're not kind of acting out your dreams. Um There's a sleep disorder and behavior disorder which is um the prevalence is very low. But in Parkinson's patients, it's, it's uh almost like between 40 to 50% where the uh neurological centers involved in controlling uh kind of movement and so forth. Um There's kind of a degeneration and people kind of act out their dreams. Uh Rem sleep is also characterized by de synchronized fast frequency eeg sleep. And there's an increase in heart rate. There's also variability in heart and respiration, respiration rate and thermal thermal regulation is also disrupted. So here's a hypno gram. Here is what um what sleep should look like ideally. So as you can see, rem sleep is the red bars and people get most of their rapid eye movement sleep in the second half of the night. Deep sleep or stage three is kind of the darker blue bars and people get most of their slow wave deep sleep in the first half of the night. So typically, what happens is you progress through the different stages and that's referred to as a cycle. A cycle can last up to 90 minutes approximately. So, from when someone falls asleep until they enter their first stage of rapid eye movement, sleep typically that takes anywhere from 80 to 100 minutes with an average of about 90 minutes. And then, so when you go through the different stages, that's a cycle and people typically have several cycles throughout the night. So this is what sleep looks like in someone who has had a brain injury. So sleep is very fragmented. There's a lot of arousals looks much different than this. So what controls sleep. So there are two primary things that control sleep. Number one is sleep drive, how long you've been awake? So the longer that you're awake, the stronger your sleep propensity will be, the stronger your sleep drive will be. So it's analogous to saying appetite, right? So the longer you go without eating the hungrier you're going to be. Hm. The second thing that controls sleep is the circadian clock. So everyone has kind of a biological clock and within a 24 hour day, there's a specific window of time during which your body is physiologically primed to be asleep. So that means that what's kind of occurring internally is in the service of promoting sleep. So for example, cortisol levels are kind of decreasing, core body temperature is decreasing. Uh The the the alerting signal is turned off. Uh Melatonin is released kind of secreted and remains elevated for about seven hours. And that coupled with the intensity of your sleepiness help uh help you to sleep. Now, one thing that I'm not going to really talk too much about today is that sleep does change across the life span. Um So I like these images. So the rubber band for how long you've been awake. So the more so when you wake up, it's kind of flat, it's not very tight, but the longer that you're awake, you're kind of stretching the rubber band that, that pressure, that biological pressure to sleep continues to kind of build gradually throughout the day. And then the biological clock just kind of shows that there's a specific window of time within a 24 hour day during which your body is physiologically primed to be asleep. So let me define what insomnia is. So to diagnose insomnia, you usually use the international classification for sleep disorders version three and the DS M five. So briefly, insomnia is defined as difficulty falling asleep, difficulty staying asleep, early morning awakening, which we define or operationalize as waking up more than half an hour before your desired or intended wait time and then having difficulty returning to sleep, resistance to going to bed on an appropriate schedule and difficulty sleeping without parent or caregiver intervention. So this is the I CS D. So you don't need to meet all of the criteria in a uh one or all of them are a combination. The way we operationalize, difficulty falling asleep is if it takes you more than half an hour to fall asleep, and the way we operationalize, difficulty maintaining sleep is not including time to fall asleep, looking at your different awakenings throughout the course of your major sleep period. If you aggregate your time awake, does it exceed 30 minutes? And B is you look at daytime symptoms associated with sleep disturbance and these are the most common daytime symptoms. So feeling tired, attention, concentration or memory impairment or difficulties, impaired social family, vocational or academic performance. If you're very tired or unmotivated, anti social and then mood disturbance is common. So people are usually irritable. Sometimes there's depressed mood, daytime, sleepiness, behavioral problems, decreased motivation and proneness to making mistakes or having accidents, including an increased risk for motor vehicle accidents and then kind of being preoccupied and worried about your sleep or not satisfied with your sleep quality. And again, you don't need to meet criteria for all of these daytime symptoms. You can have one or a combination of them. This is uh insomnia, diagnostic criteria for the diagnostic and statistical manual version five. So again, difficulty falling asleep, staying asleep and or early morning awakening. So one thing I didn't mention here is that to diagnose insomnia in terms of frequency and duration, you look at at least three nights per week or more for at least three months. So again, for the DS M, it's pretty consistent, you have difficulty with sleep initiation, sleep maintenance and or early morning awakening, uh clinically significant daytime symptoms uh such including the ones that I mentioned previously and you also have the same frequency and duration uh criteria. So at least three nights a week or more for at least three months, you have difficulty sleeping despite an adequate opportunity for sleep. So usually you look at sleep ability versus sleep opportunity, right? So if you are doing your residency and you don't have a lot of time, that's different because you may not have an opportunity to sleep, but if you have adequate opportunity for sleep and you still have trouble sleeping, that would be diagnostic clinically meaningful. And you also rule out that the trouble sleeping is not due to another sleep disorder or to a substance. So this is prevalence of insomnia. So trouble sleeping is pretty common. So overall prevalence of some sort of sleep disturbance can be anywhere from about 30 to 48% of the population. And then when you start, uh so that's kind of taking kind of a broad approach when you start funneling down. Uh So then when you start looking at um what's the prevalence for sleep disturbance? Uh that is that occurs at least three nights a week or more. So then that drops down to about 16 to 21% of the population and then moderate to extreme sleep disturbance about anywhere from 10 to 28%. So how about having an insomnia, symptom and a daytime symptom or daytime consequence? Then that's about 9 to 15% of the population. Then how many people are dissatisfied with their sleep quality or the quantity of their sleep that can range anywhere from about 18 to 18% of the population. And then for people that might meet full diagnostic criteria, that might be about 6% of the population. So the prevalence in primary care can range anywhere from 10% to 40% but only about 31 to 50% of people that have insomnia actually speak to their primary care provider about it. So unless you specifically ask your patient, they may not volunteer that information or it may not occur to them to mention it. Mhm. So here are some risk factors for sleep disorders. So older adults, there are sex differences. So sleep disturbance, insomnia in particular is more prevalent in females and males and we see this across the entire life span. So we know that there are sex differences, we don't know exactly why. So, stress is always a risk factor for most things and then having certain medical conditions or psychiatric conditions can elevate your risk for sleep disturbance. So, chronic pain. So you saw the prevalence of sleep disturbance in the general population. If you look at the prevalence of sleep disturbance and chronic pain population, it it's upwards of around 88%. Also having a mood disorder such as anxiety or depression, elevates your risk for insomnia and having insomnia elevates your risk for chronic pain and for a mood disorder for depressive symptoms, it can be anywhere from a four fold to 10 fold increase in risk. So let me talk a little bit about sleep disturbance in the context of traumatic brain injury. So sleep is controlled by different sleep promoting and weight promoting brain regions. TBI I tends to be associated with kind of diffuse exon injury. So therefore, it's not really surprising to have to kind of see high rates of sleep disturbances following a traumatic brain injury. So, the main thing is that sleep disturbance is very common in patients who have sustained a traumatic brain injury. So this paper uh by Mathias and Alvaro is a 2012 meta analysis of 21 studies published in sleep medicine. And they looked at just kind of general global reports of sleep disturbance. They also looked to see uh uh which patients met diagnostic criteria for a sleep disorder. And then they focused in on specific sleep problems such as difficulty initiating sleep, difficulty maintaining sleep, early morning awakening, chronic insufficiency. So the the results basically were that approximately 50% of people suffer from some sort of sleep disturbance following a traumatic brain injury. And about 25 to 29% of those persons had to diagnose sleep disorder. So basically, the rates were much higher than in the general population. Hm. So in this table, what I'm showing you are the rates of insomnia, sleep apnea, circadian rhythm, sleep disorders and narcolepsy in populations of traumatic brain injury relative to the general population. So as you can see, it's higher in TB I patients across the board. So let me show you a little data. So uh so I have a American Sleep Medicine Foundation pilot study. My coin investigators are Vani Rao Durga Roy, Una mccann, Claudia Campbell. And uh so in this pilot study, we've been doing it about 2.5 years. Now, we're wrapping up data collection this fall and this is only the baseline data now to be completely transparent. One of our inclusion criteria is having an insomnia severity index score of 10 or greater. Now, in the last 2.5 years of 45 people that have come in to our lab for a baseline visit. One only two people in the last 2.5 years have not met that inclusion criteria. So it's not something we've really had to worry about because it's so prevalent. So what you see here is these are just kind of a sampling of some of the measures we we looked at. So the insomnia severity index, um the average, the mean score is about 19.5, almost 20 which is consistent with moderate insomnia, the upward sleepiness scale. So that's that's six, that's not very high and the the effort. So daytime sleepiness is something that you would be more likely to see in patients who have obstructive sleep apnea. Mhm The Pittsburgh sleep quality index. So the clinical cut offs are five lower scores are better. So five or greater is consistent with sleep disturbance. So, on average in our population, it's about 13. So this is a small sample size, by the way, this is about 33 to 34 people. Um So the depressive, so anxiety symptoms were I think a six probably a little bit lower. So I think that's consistent with mild anxiety symptoms. And the P HQ nine was consistent with um moderate depressive symptoms. And then the PC L five for PTSD. Um So, so I don't really use that skill very often. I think that 33 is the cut off to meet uh DM five diagnostic criteria for PTSD. We're going to take a closer look at that kind of looking at the different domains. So as you can see, um sleep is correlated with anxiety and PTSD symptoms. So here's eeg sleep. So in this study, what was different is that we measured sleep in multiple ways. So we we use ambulatory sleep eeg monitoring. So we give people sleep profiler, which is this device. It's a little box with a headband, it has three electrodes and they wear that at baseline post treatment and then three months follow up. They, they also use act. So an act graph is a wrist worn device. It looks like a fitness tracker and uh it's, it's uh FDA approved to measure sleep. It's widely used clinically and also um uh well, more in clinical research, these data here um look at the eeg sleep. So time in bed people spend roughly about eight hours in bed, their total sleep time is about five hours. So they're spending an excessive amount of time in bed relative to how much time they're actually sleeping. So their sleep efficiency is so to calculate sleep efficiency, that's a widely used metric in what we do both clinically and in terms of research. So sleep efficiency tells you how efficient is um is the person's sleep. So mathematically, you compute that by taking the total sleep time, dividing it by the time in bed and it gives you, it tells you of the time that they're spending in bed, what percentage of that time is being spent to sleep? So 66.5 is is low, the goal is to have people. So clinically, when you treat people, you want them to hit a sleep efficiency of 85% or greater sleep onset latency is a metric of approximately how long it takes people to fall asleep. And what we look at is over under 20 minutes. Ideally, we want our patients to be falling asleep within 20 minutes, wake after sleep onset, looks at um aggregated time awake across the different awakenings throughout the major sleep period. That does not include the time to fall asleep. So again, the cut off for that in terms of clinical meaningfulness is 30 minutes. So what you see here is that this population has chronic insufficient sleep, they're very inefficient sleepers. They spend long periods of time in bed, lying awake and their sleep is very fragmented. And this is the type of sleep that also uh so when we look at this, so this is the type of sleep that is also seen in chronic pain patients that then adversely affects your body's kind of endogenous pain, modulatory abilities. All right. And so this is just uh kind of looking at. So each row represents a patient that that the kind of the top row is looking at um people who sleep is more fragmented, the the the bottom half is people who sleep is less fragmented and then on the bottom is kind of clock time. And what you see is that that kind of in terms of circadian anchoring, kind of having consistent bedtime and wait times. These patients have a lot of variability in bedtime and wait times and not very much. Um And you can't really appreciate in this um figure too well, but they don't have very much deep sleep either. So, yeah. So uh so the these are patients who meet diagnostic criteria for. Um so, so, so mild to moderate TB I within the last five years, I have to be tomorrow day have a true chronic state of peru, right. Yeah. Um ok. So then, so sleep disturbance and number of TV is so um so there's likely an association, very likely an association between frequency of TBIS or how many number of traumatic brain injuries one person has had concussions and sleep disturbance. So in this study, 2013 study of 150 military personnel, so rates of insomnia were assessed by the insomnia severity index. They were higher in people who had a greater number of tbis. So 6% for no tbis, 20% for single tbis, 50% for multiple tbis. Now, uh regarding whether TB I severity is associated with sleep disturbance so that the findings are mixed. Um it's kind of unclear, some studies have reported a relationship, other studies have not reported a relationship. So there are a lot of risk factors for why someone would develop trouble sleeping following a head injury. I just kind of go through this list. So lack of daytime structure. So many times patients who have sustained a head injury when they're in the kind of the rehabilitation or healing stage, they, they, they're not as active as they were premorbidly. Uh There's a lot of daytime napping that can interfere with nighttime activity. They don't have a lot of structure to their days. So if you kind of think about, you know, when you're working, you really busy or whether you're in school or doing a residency or kind of a fellowship and then you have a break, you know, you may actually do nothing. You know, you may get up at the crack of noon and uh you know, watching TV, all day and movies and, and so your sleep schedule becomes deregulated pain is also a factor that increases someone's risk for sleep disturbance. And so many times people that have had a TBI now are experiencing pain, have increased pain. And so we know for a fact, as I mentioned, before the prevalence of sleep disturbance in chronic pain populations is upwards of around 88%. And pain can interfere with both sleep initiation, sleep maintenance. Um And then when your sleep is disrupted, it usually tends to be more fragmented, more shallow that affects your body's kind of natural ability to modulate pain and you become more pain sensitive. So alcohol and illicit drugs. So people try to, to cope, uh use a lot of different coping strategies to try to manage their sleep disturbance. And so they turn to a AAA number of different drugs or their substance abuse to begin with. Uh But I can tell you that I see even clinically, we have a lot of patients in our clinic. Um many of whom are also health professionals and know better. They kind of self medicate with alcohol. So using alcohol and substances is associated with fragmented sleep and poor sleep quality. And then there's over the counter sleep medication. So many people start taking things like TYN PM, Benadryl, et cetera. And so they can be ineffective but also cause side effects. So things you know, so you wake up, you're feeling lethargic dry mouth, it can uh impact cognition a little bit and then mood disorders. And so uh there's a high prevalence of mood disorders in TB I patients, right? So now let me talk. Uh let me start transitioning a little bit to um insomnia and uh talk a little bit about um how you manage insomnia in different populations. So first, let me kind of review the three patho physiologic process model. So these are the three patho physiologic processes that are hypothesized to drive insomnia. So, hyperarousal kind of chrono biologic dysregulation and homeostatic dysregulation. So I talked a little bit before about what controls sleep. So sleep drive that would be homeostatic dysregulation and your biological clock, which would be chrono biologic dysregulation. I'll talk a little bit more about that. So what is hyper arousal? So, hyper arousal is being in a physical and mental state that is incompatible with sleep. So that's usually having a lot of uh kind of psychophysiological arousal or cns arousal. So, how does that happen? Well, there would be a, there's a lot of different ways, right? So it could be kind of a genetic predisposition. Um It could be social environmental. So if you live in an area that there's a lot of uh kind of noise or chaos. So if you live, let's say, for example, in a part of the city where there's a lot of traffic or you hear a lot of kind of outside noise that could be disruptive um social if you have a bed partner who has a kind of a sleep disorder that or keeps odd hours, that could be disruptive. Um uh It could also be the, it, it could also be kind of personality. Uh So for example, if type a personality or someone, you know, if you're more kind of high anxiety or neuroticism. So there's a lot of reasons, but the most common way in which someone develops um becomes kind of hyper aroused is through the process of classical conditioning. So there's a term called conditioned arousal. So essentially what happens is one thing that people have insomnia have in common is that they spend an excessive amount of time lying in bed awake, not sleeping. And so uh what they do is they'll try to go to bed earlier, they'll try to sleep in because they want to give themselves the greatest opportunity possible in order to sleep. But uh the fact remains that they spend the majority of that time in bed actually awake. So uh they begin to engage in non sleep related activities in bed. So they start what, you know, they may be watching TV, they may be using their smartphone and they may be using a computer or a laptop, working entertainment, music, eating bills, working, et cetera. And so what those activities have in common is that they require you to be in a physical and mental state that is not conducive to falling asleep if you are simply just going to go to go to bed, and if this happens regularly over time, you kind of train yourself to be more alert, more awake and your brain more stimulated in bed. Um So chrono biologic disregulation. So that is more of an issue. So what I mentioned before, let me just kind of repeat that, that within a 24 hour day, there's usually a specific window of time when your body is more biologically primed to be asleep. So typically, this is a problem if there is a misalignment between when you want to go to sleep and when your body is biologically primed to be asleep. So this would be more of an issue and someone who has a circadian rhythm sleep disorder. So for example, if you're a night owl and uh but you have a job or obligations that require you to wake up early and be somewhere early. You know, maybe your natural bedtime is around one or 2 a.m. or even later and you're waking up anywhere between nine and 10. But because you have obligations that require you to get up earlier, you may need to wake up maybe between six and seven in the morning. So what happens is you're trying to force your body to go to sleep when biologically, it's wanting to be awake and then you're trying to force your body to be awake when kind of physiologically it wants to be asleep. So there's a lot of sleep inertia. And so in this case, people result to all sorts of things, they start, typically they start taking over the counter sleep aids. And that's one of the primary coping strategies. You see, homeostatic dysregulation is based on the observation that people who have insomnia typically have a weak sleep drive. So your propensity to sleep. So within a 24 hour day, the amount of sleep that your body can generate is limited, right? You can't generate kind of an infinite amount of sleep. In fact, total sleep time decreases across the life span as we get older. So what happens is, think of it this way, if you're going to a meal and you're snacking before the meal, you'll be less hungry. So similarly, people that have insomnia have trouble sleeping, end up, you know, they try to take naps, they spend long periods of time in bed. And even though they're not sleeping, you can still, um so if you kind of measure their sleep, using eeg, you can demonstrate that they had micro sleeps that they were kind of kind of drifting in, out of sleep or had very light sleep. And all of this kind of counts towards your kind of allotted quota for the day. So that by the time your bed time rolls around, you're not as sleepy as you otherwise would have been. Had you just kind of adhered to a specific kind of bed time and wait time and abstain from, from sleeping, but that's much easier said than done. So this is kind of the behavioral model of chronic insomnia. So, predisposing factors are all the factors that someone kind of brings to the table. Those are that could be like genetic risk. Again, that could be environmental, social personality. So everyone has a certain level of risk that you bring to the table. So, precipitating factors are the triggers the things that happen. So most of the time, though, not all of the time, something tends to happen, that kind of disrupts your sleep, right? It could be a major life event. Uh So, you know, getting a new job, losing a job, uh financial stress, end of a relationship, it could be a medical illness, it could be an injury, uh psychiatric condition. Uh So something typically triggers disrupted sleep. So the expectation is most people just assume that this ship will write itself. And, you know, because everyone has had personal experience with insomnia with a night or a few nights or a bout of insomnia at some point or another. And so what happens in the case of chronic insomnia is that the individual begins to notice, hey, my sleep is not getting better. You know, this is continuing. It's been a week, it's been two weeks, it's starting to impact my performance at work, my social life, I'm irritable all the time. And so then they start trying to take matters into their own hands and these are the perpetuating factors. So these are the coping strategies that people use to try to manage sleep disturbance. And as I mentioned, the most common coping strategy employed is spending an excessive amount of time in bed. So people will go to bed earlier, they'll try to sleep in all in the service of trying to give themselves the greatest opportunity possible to get sleep. Except the problem is they're not sleeping because again, what they're doing is they're training themselves to be a bad sleeper. And then, uh, people develop, you know, poor sleep habits. They may start using drugs or alcohol, uh, different over the counter sleep aids. Um, and then they train themselves to be more alert and awake in bed. So over time, what happens is that what may initially have triggered your sleep disturbance loses stimulus value, right? So it doesn't contribute as much. And so if you're looking for the factors that are accounting for the variances in your sleep disturbance, it doesn't contribute as much to your sleep disturbance as do the perpetuating factors. So now what's kind of maintaining perpetuating and exacerbating the sleep disturbance are the maladaptive coping strategies that the patient or the individual is using? So what do we do to treat people who have insomnia? We use cognitive behavioral therapy for insomnia. So C BT I for short. So C BT I is a first line treatment for adults with insomnia. So in July of 2016, the American College of Physicians published a kind of clinical practice guidelines that basically stated that for adults with insomnia, the first line of treatment should be C BT I because the lines of evidence are strong. So when you look at the treatment outcome research comparing C BT I head to head to FDA approved hypnotics such as Amun or Lunesta. What you find is it for acute insomnia? So less than we'll say six months in duration, C BT is as effective as pharmacotherapy with no side effects for chronic insomnia, which is a duration of greater than six months. CV is considered to be superior because the treatment effects are more durable. Meaning that you can see improvements in sleep metrics up to 24 months, post treatment and there's no side effects. Whereas typically with many kind of pharmacological agents, what you tend to see is that when you stop or discontinue, the medication symptoms tend to return. So it's also the first line treatment for chronic insomnia. And so there's a National Institute of Health State of the Science panel calls for a new look at treatments commonly used for chronic insomnia. American Academy of Sleep Medicine Practice parameters. 2006, basically stated that CBT should be the standard treatment for chronic primary insomnia for chronic insomnia. In older adults, standard treatment for chronic sedative hypnotic users and for secondary insomnia. Now, what's different, right? So that was in 2006, this was in 2016 and new diagnostic criteria got rid of the primary secondary insomnia. Now, the way it's kind of classified or conceptualized it's either chronic or acute. So, uh what's been also shown is that CV T I is effective, not only in patients that have insomnia, but it's also been shown to be effective in patients that have sleep disturbance who also present with a variety of different medical and psychiatric disorders, including um different psychiatric disorders, chronic pain cancer HIV. Um panic disorder, depression, alcohol. So TB I, so last I checked there are about three small studies exam at looking at C BT I in TB I patients, they show that it's effective. But one was a case study, one was a sample size of about 11 and another one, I think the sample size was around 30 but they all demonstrated effectiveness. And so, you know, hopefully our study will be kind of contributing to that body of literature as we have both objective and subjective measures of sleep as well as kind of neuropsychiatric outcomes. So what is C BT I? So it's considered to be a multi component treatment. This is kind of an example of what uh kind of a standard CV T I package might look like. So it's comprised of the the first three components are in bold because those are kind of the standard component components of AC BT I treatment. So stimulus control, sleep restriction and sleep hygiene and I'll kind of go over in detail what these are. So for stimulus control and sleep restriction, there's overwhelming empirical support for their efficacy. They can be standalone treatments. Sleep hygiene is typically used to supplement and enhance um overall treatment outcomes. And it's, it's uh but you know, but it's not using that alone. Um So the data doesn't support using that as a monotherapy, using that alone, it's usually used to kind of supplement um the core components. Now, relaxation therapy and cognitive therapy are usually included in this if it's clinically indicated, right? So one thing that people have in common have or people have insomnia have in common is that they have a lot of psycho physiological arousal. So when they've done imaging studies, comparing primary insomniacs to kind of good or normal sleepers, what you find is that at bedtime and kind of in general throughout the night, there's a lot of a lot more brain activation in the brains of primary insomniacs. And it's also common for people have insomnia to have a lot to have many sleep interfering thoughts at night that then can kind of trigger or kind of amplify that psychophysiological response. So, relaxation therapy is often included to give the person skills to manage that. And then um cognitive therapy can also be included if you have a patient who's having a lot of sleep interfering thoughts at night, that results in high levels of stress and anxiety. So bright light therapy, that would be used if you have someone who has a circadian rhythm sleep disorder and you want to advance a circa clock or delay it. So, cognitive behavioral therapy for insomnia targets the maintaining factors. It requires a lot of self monitoring on the part of the patient. So we ask people to kind of to track their sleep patterns and you also address compliance issues. So here's what? So uh on average, so what I tell people uh is that C BT I ranges anywhere from 6 to 8 sessions plus or minus two sessions in either direction that depends on the magnitude and direction of treatment response. The literature also suggests that there's no differences in the effectiveness of treatment, whether you come in weekly or every other week, about twice a month. However, if you wait more than two weeks in between appointments, you run the risk of diluting the effectiveness of treatment. So here's kind of what a standard CV T therapy schedule might look like. So the first, the first session, you know, you do kind of the assessment intake, um kind of give the patient sleep blocks to take home. They usually track their sleep patterns for about two weeks. Then when they come back, you go over sleep restriction and stimulus control and then you kind of send them home and then when they come back and you kind of look at compliance, were there any obstacles? How adherent were they, what were the problems? And then you usually introduce sleep hygiene session. Four, typically there's an upward titration of time in bed as a function of their sleep efficiency, you can actually titrate up or down, depending on how they're responding. Um, session five, again, you titrate time in bed, you can add relaxation training at that point. And then se session six, you also, again, tight time in bed and this can be up and down and I'll talk a little bit more about that and, and you type it up and down in increments of 15 minutes as a function of how they're responding. And at this point, you can introduce cognitive therapy and then session seven more of the same kind of um t trading time in bed and cognitive therapy. Part two, session eight. you do kind of lapse prevention and maintaining gains. So, treatment is systematic. It's data driven, meaning that we use the data from the sleep logs to kind of come up with a personalized treatment plan where we prescribe a bed time and a wake time. And then we use the data from the diaries throughout the course of treatment to get feedback on the patient's treatment response and we make adjustments as necessary. All right. So I'm not sure how well you could see the, the sleep diary. So getting started. So the first thing you want to do is kind of establish baseline sleep patterns. So the gold standard is using paper and pencil sleep logs. So, uh to self report sleep logs, but in populations who might have cognitive impairment or memory issues, you can use an act to watch and that's kind of the one that we use in our, in our studies uh across all our different studies. Now, clinically, um it's hard to get reimbursed for gray because insurance companies will tell you that they consider it kind of an experimental procedure. So they typically don't reimburse uh in research. However, it's, it's kind of uh it's standard use, it, it's used regularly used. Now, I can tell you that here at Johns Hopkins, the Behavioral Seat Medicine program, Michael Smith and I just developed an act service where clinicians can order act on their patients. But it's going to be kind of a fee for service procedure. So basically, we use the sleep logs to capture the data that we need. Um And then we calculate the sleep metrics of interest and go from there. So let me start off, let me talk about stimulus control. OK. So this is classical stimulus control theory. So stimulus control. Um so on the left side of the screen, what you want is you want a very strong association between sleep related cues and sleep. So being asleep and falling asleep quickly, that's ideal on the right side of the screen. What you have is what you typically see in people who have insomnia or difficulty sleeping is that they use the bed for many different non sleep related activities. And so if this happens regularly over time, what happens is you condition yourself to be a poor sleeper, you condition yourself to be more alert, more awake in bed, uh your brain to be more stimulated. So, on, on the right side, as you can see the odds of eliciting kind of a physiological and psychological response that's conducive to falling asleep goes down, you know. So in this, in this case, it's like one in nine. So what you want is a high probability of sleep related cues eliciting the desired physiological and psychological response that is sleep promoting. So um when someone comes in for stimulus control treatment, what you do is you have them limit everything that happens in bed to just sleep and intimacy and everything else ideally should occur outside of the bedroom and out of bed for sure. Um So, so one of my colleagues, actually a sleep fellow likes to use the example of bathrooms, right? So there's a very strong association between bathrooms and going to the bathroom, you're not going to go have your lunch or have a snack in the bathroom, right? And so then you start thinking about it. So my son just turned three years old. Uh at the end of the summer, he started pre K, but one of the requirements was that he had to be potty trained. So starting in May, we started on this task, potty training him. So every time he needed to use the bathroom, we'd rush him to a bathroom in the house. And if we were outside, we had a little port, a potty, I didn't let him go in the grass. I didn't let him go behind a tree. I'd rush him to a toilet. So it's starting at a very young age. You have that really strong association. If you need to go to the bathroom, you know, you first seek out a bathroom, obviously, if there's not, then you know, but in general, so the point is you want an equally strong association between sleep related cues and sleep. So here are kind of the typical instructions we give patients when we're doing stimulus control. So only use your bed for sleep. Intimacy is the only exception to the rule, don't go to bed until you're sleepy and whether and the next one if you're not asleep, if you're having trouble, if you're in bed and not sleeping, get out of bed. This applies both at the beginning of the night when you're going to bed and or if you happen to wake up in the middle of the night. So if you're in bed and unable to sleep, and we're gonna operationalize that as if it feels like it's taking 20 minutes or longer, right? Because we don't want you to look at the time because that's only going to stress you out, right? When you look at the time you start getting annoyed or, or stressed and you start counting down how much, how little sleep you have the opportunity for. So it makes you more anxious and it interferes with sleep onset. So we have them just estimate if you're dozing off, we tell people to just stay put, stay in bed sleep will come. So if they're having trouble sleeping, we have them get up, get out of bed, engage in a quiet sedentary activity. Nothing that's going to promote wakefulness alertness or get your brain stimulated. Absolutely no electronic use. Then they can return to bed when sleepy and then you repeat it as often as necessary throughout the night until a either it's time to get up or b they fall asleep. The hard part is getting up at the same time every day, regardless of how much sleep they obtained and no napping. And this is all in the service of addressing the first thing that controls sleep, which is your sleep drive, right? So intentionally, we want to increase the intensity of their sleepiness because we want them to feel sleep here at bed time. That's been demonstrated to both um facilitate sleep on set and to consolidate sleep and people spend more time in deep sleep. All right. So sleep restriction. So again, sleep restriction. So if you remember my pilot data that I showed you, uh those patients tend to spend about eight hours in bed but are sleeping about five hours. So their sleep efficiency is about like 65 or something or 66. So the aim is to match sleep opportunity to sleep ability, right. So not going to talk about this too much. But one of the most common questions is how much sleep should I be getting? And so what I can tell you is that looking at epidemiological research both in conducted in North America, Asia Europe is pretty consistent, adults average anywhere between 6 to 9 hours of sleep per night. And so when they've looked at the relationship of sleep duration and all cause mortality regularly, getting less than six hours or more than nine hours is, is associated with increased mortality. Such that, that figure looks like a U, right? So the lowest part of the mortality curve, the bottom part of the U is between 6 to 9 hours and the sweet spot is 7 to 8 hours. But I tell people's eyes are between 6 to 9, that's where you want to be. And so again, people have that kind of maladaptive thought where they're thinking, well, if I'm in bed, 10 hours, maybe I can sleep, you know, 678 hours, but then their sleep will be fragmented and shallow. So the idea again is to match sleep opportunity with sleep ability. Um And so kind of when you figure out time in bed, you know, you ask people, well, what time do you need to get up to start your day? Uh What time do you need to wake up? And then you kind of look at um the sleep blogs and look at their average total sleep time across the period of two weeks. And, and kind of a rule of thumb is you can take total sleep time and add 30 minutes to it and that, that's your time in bed right there. However, you don't want, you typically don't want to restrict less than 5.5 hours. And there are some contrary indications which I'll kind of talk about. Again. We have people keep a log review expectations. So, right, it may be contraindicating borderline personality disorder and epilepsy and I'll talk about that a little bit. So here's an example of a sleep log that we use in lab, right? So we have the paper and pencil, but we also have an Excel spreadsheet that has been customized. Um and we have people enter their data and then it also creates these figures for us and what you're looking at in this graph. So the top line is average time in bed, the bottom line is average total sleep time and this is from a patient that we saw in clinic. And so the baseline, as you can see, this person was spending about seven hours and 45 minutes to about eight hours and 15 minutes in bed, but was only averaging about a little over 4.5 to a little under 5.5 hours. So, as you can see, we restrict an opportunity for sleep. And uh and so the idea is that you, you want the trajectory of time in bed in total sleep time to converge across time. Because the space in between those two lines represents um time awake in bed. But looking at week one and week two, that's your baseline data. And you use that to kind of come up with a prescribed bedtime and prescribed wake time. This person had kind of a very good outcome. His total sleep time increased became a much more efficient sleeper. And when you decrease time awake in bed or sleep fragmentation, sleep tends to deepen and that's usually associated with increased perception of sleep quality. So, sleep restriction. So we use sleep debt to consolidate sleep, right? So we're increasing sleep propensity, your sleep drive. So the sleepier you are the deeper you're going to sleep and the fewer times you're gonna, you're gonna wake up. So here's an example, baseline insomnia. Here's someone that might go to bed at 11 o'clock. Uh average wake time is 7 a.m. but they're not getting out of bed till about 10 a.m. And and this is actually fairly common and and the shaded parts represents sleep and uh and and the parts that are not shaded represent time awake in bed. So what you want to do with sleep restriction is you look at average wake time um and that's gonna be that's your starting point. You look at average wake time and then you look at average total sleep time and you go back that many hours and that's what your, your, your bed time will be. So if they're averaging, you know, in this case, maybe, I don't know, it's like five hours of sleep, maybe you go back or less than five hours of sleep, maybe you go back to 2 a.m. But again, I want to stress, we don't, uh, we typically try not to restrict more than 5.5 hours. So then when they come in for treatment, what you do is you review the sleep log, you know, you talk about adherence compliance, you you kind of address any adherence issues, but in terms of um increasing opportunity for sleep, what you do is you look at the sleep efficiency. If it's between 85 to 89 you maintain the same prescribed sleep and wake schedule. If sleep efficiency exceeds 89% you increase opportunity for sleep by 15 minutes. So they go to bed 15 minutes earlier. If their sleep efficiency is less than 85% you decrease time in bed by 15 minutes. So they go to bed 15 minutes later, right? Sleep hygiene education. So I can tell you that there's little consensus on what sleep hygiene is. Um you know, the bulk of research comes from good sleepers and you know, may be necessary, but it's not sufficient to improve kind of chronic insomnia. And many studies treat sleep hygiene kind of as an active place, placebo for multi component C BT I. So here's what we do at Johns Hopkins. So sleep hygiene, we divide into dietary factors, environmental factors and kind of lifestyle, behavioral factors. So diet, dietary factors, we basically review meals. So you know, with meals, you don't want to go to bed hungry, but you don't want to overeat right before bed because that can disrupt sleep. So a light snack at bedtime is ok, but we advise against eating during the middle of the night, having little water is fine. So liquids. So even though your kidney function slows down while you're sleeping, if you're consuming too many fluids, close to bedtime, that's associated with middle of night awakenings, frequent urination. So, you know, you may want to encourage people to have most of their fluid consumption in the first half to three quarters of the day. So moderate to heavy alcohol use, close to bedtime is associated with frequent awakenings, intense dreams and it can suppress rapid eye movement sleep. So it may, you may pass out, it may facilitate falling asleep. But once it's metabolized, then sleep quality is decrease because of fragmented sleep, nicotine is a stimulant. So there's many people who smoke, often have a cigarette within 30 minutes of going to bed or close to bedtime. And also in our patients of those people that smoke, it's not uncommon to see patients have a cigarette during the middle of the night awakening and then the general thumb with medications is to encourage people to have a conversation with their prescribing providers about the side effect profiles associated with their medications and whether there are any implications for disrupting sleep. And then they may want to kind of think about a different time to take it environmental factors. So temperature, light and noise. So, um, you know, for, so for temperature typically, what's happening physiologically is your core body temperature is dropping, right? So that's very individual, right? So you don't want to be too hot, you don't want to be too cold naturally. What's happening is your core body temperature is dropping that facilitates sleep. There's some research on a technique called passive body heating which involves taking a hot shower anywhere from 2 to 3 hours before bedtime. So what that does is it artificially elevates your core body, your body temperature rather. And then when you get out, it drops very quickly to catch up to where it otherwise would have been. And so that quick drop in temperature can help to facilitate sleep onset. Light is probably I think the most important sleep hygiene factor because light is one of the factors that regulates sleep. So light helps to keep your circadian clock in sync with the night and day cycles of the earth and light can also impact endogenous melatonin. So the general rule of thumb with light is get plenty of light, particularly if possible, a natural light in the first half of the day before 12 noon. And at night, you want to keep the lights dim and soft. Exactly. And then, you know, you want to try to unplug from electronic devices, namely smartphones, computers about two hours before bedtime because typically your body starts secreting melatonin about two hours before bedtime. Your kind of regular bedtime and levels of melatonin stay elevated. So what Melatonin does is it sends this chemical message to your brain to suppress the alerting signal, which then can facilitate sleep. But bright light and blue and green wave length, light neutralize the effects of melatonin. And so the difference between a television and electronics is you can sit 6 ft from your TV, but you're not going to hold your phone or your computer, 6 ft from your face. So noise, so even noise that doesn't result in a Frank Frank awakening can still be associated with an arousal. So a disruption to the continuity or the depth of your sleep. So lifestyles I'm gonna kind of speed up as I had plenty of time. It now looks we're running out of time. So exercise is good um avoiding naps. But if you're going to take a nap, limiting it to 30 minutes or less consistency in bedtime and wake times of what you know. So people oftentimes worry close to bedtime. So there's a technique called planned worry where you give people an assignment to kind of identify a time distal to bed time where they kind of problem solve things that are on their mind, turn their clock around, avoid clock watching and reduce excessive time in bed. So I think most people here are probably familiar with relaxation training. So simply what I'll say about this is that the purpose of relaxation training is to elicit a physiological relaxation response. And with the goal of helping place the individual in a physical state and possibly mental state, that is more conducive to falling asleep. That the most commonly used techniques are abdominal breathing or diaphragmatic breathing, progressed to most relaxation and guided imagery. There's research behind these, you know, you ask people, what do you like to do for relaxation? They might say, well, I like to have a beer and watch a ball game or watch a movie and that sounds lovely, right? But we conceptualize that as entertainment and not as relaxation, right? Because what you're looking at is the likelihood of eliciting a physiological relaxation response. Um I think most people here are also familiar with cognitive therapy. So I'll just quickly say so many people uh have sleep interfering thoughts, right? And so we know that thoughts, emotions and behaviors are all interrelated and that uh thoughts influence emotional states and behaviors. And so the the the the idea is that maladaptive thoughts result in emotional states that can then trigger a stress response, a fight or flight response and also result in. And when that happens, that then again results in a physical mental state that is incompatible with sleep. So we do a lot of cognitive restructuring. There's a workbook that I recommend to my patients called Mind Over Mood. You can order it on Amazon. It's about $14. You can check it out at the library. And I think it's a really good workbook and it's pretty much this just cognitive therapy. So words of wisdom, sleep will get worse before it gets better. You want them to commit to the process, not going to be cured in one night. You know, it's skill acquisition, which I'm sure you use in C BT telling people that, you know, just like if you're learning a new language or a new skill, it doesn't happen in one day, set long term goals. So short term pain for long term gain and set appropriate expectations, you know, so not every night of sleep is good. It's normal for people to awaken throughout the night. So oftentimes people have insomnia have this misperception that good sleepers get fabulous sleep 365 nights a year. So you have to kind of help them understand that. That's not the case. People don't, it's normal to wake up. Um So what are some of the cautions? So you don't want to restrict too much because it, it could increase daytime sleepiness, which can then increase risk for a motor vehicle accident or accidents um sleep deprivation can lower seizure threshold. So you have to be cautious with epilepsy patients and it can trigger a manic episode in some vulnerable patients. So, bipolar type one. So something to be mindful about and in about 15% of patients, relaxation therapy can have this kind of paradoxical response uh where people feel anxious instead of relaxed. So lastly when to refer. So if you suspect sleep apnea, so if someone has excessive daytime sleepiness, if there's witnessed, Aines, if there's wake up gasping for breath or choking, um if they're not responsive to standard insomnia treatments, then you may want to refer to to a sleep clinic or for a sleep study. And so this is an app that's available. This is free to download. This was developed by Stanford and the VA Medical Center. It's developed for veterans. It's free. It's usually used as an adjunct to therapy and it's a standalone educational tool. So these are the four take home messages that you can give your patients reduce time in bed. Get up at the same time every day, don't go to bed. You don't go to bed unless you're sleepy and don't stay in bed unless you're asleep. Thank you. Yes. Uh In your, in your research on brain injury, population control for the typical medication. A lot of our patients are on that probably themselves. So, so we're so, so the answer to your question is we're not, it's, it's a very small. It's just a, it's a foundation grant, it's a small study. So what we're doing is we're just tracking and we'll look at that statistically, but we're not really doing anything for it in terms of manipulating that. But we just applied for a larger kind of Bari grant. And this is really going to be a more of a big scale study kind of replicating what we're doing right now. But right now, we're just kind of observing that treat men who the cheap disturbance in the physiological are maybe common to a variety of people. So uh do anything typically different locations for TB I related insomnia or. So that's a really good question. Uh It's pretty standard, it's pretty much the same, which is nice, right? So maybe when you're doing some of the C BT and psychoeducational training that might be tailored more to the specific disease. But so one thing we're doing in this pilot study, right is so patients are keeping self report sleep logs we have and they're using a Fitbit. And so we want to look at the correlations of um degree of agreement in between those three ways of measuring sleep patterns. But essentially, as far as the core components, they stay basically the same, right? So in a, in a TB I population or someone who has mild cognitive impairment, you might, the concern might be um how are we going to be able to identify sleep patterns if, uh, if you suspect cognitive impairment or memory issues. And so that's when you can use like, or, you know, we want to see if a Fitbit is equally as effective. But, uh, but generally the treatment stays the same. One of the problems we have in rehab populations is with stimulus control that the bed is the base of operations. Um, or they're, they're spending their entire life on a couch or in a recliner, that's where they sleep, that's where they eat, that's where they watch TV. What do you do with patients who got that kind of, so that, that's a really challenging, um, situation. So in the example that you're giving me is that primarily because of kind of medical limitations? Ok. Yeah, maybe. Right. So, so that, that's, that's difficult, right? So, um, so it, in a case where someone is spending more of their time like on a sofa or a bed, then it's hard to do kind of traditional like stimulus control, right? So then you might be, you might be doing things such as, so if they have like a wheelchair or a recliner or, you know, so if you, if it's possible to kind of designate a certain areas like this is where you're gonna sleep will occur and here's where you're going to hang out and watch TV, and so forth to the degree that you can make kind of a distinction or delineate that then you can do something along those lines. Now, they're not going to be able to get out of bed when they're unable to sleep. Right. So, you might kind of limit time in bed. You might be mindful of having them not do like electronics or television where they sleep of kind of light intensity noise levels. So there's other things that you can try, but those are really challenging cases in your sample with TV. I patients have uh run into any issues with seizures. So, not so far. No, I mean, fortunately no, we haven't. But, you know, but it's a pretty small sample size and, you know, most of these people aren't like fresh out of their injury. Well, thank you very much for having me. I really appreciate it. Thank you. Yeah, you very much.