Description:
This 2-day workshop provides training in the assessment and treatment of deployment related sleep disturbance with a focus on Cognitive Behavioral Therapy for Insomnia (CBT-I), an evidence-based approach to treating sleep problems. It covers the rates and types of sleep problems identified in the military population, highlights current research findings on this topic, and reviews clinical strategies and interventions. The instructors teach skills for using Stimulus Control and Sleep Restriction to treat insomnia, and Imagery Rehearsal Therapy to address nightmares. Military case examples are incorporated to illustrate key concepts and techniques. Participants are expected to do role-plays in class to practice CBT-I techniques, and they must attend both days.
Learning Objectives:
1. Describe the prevalence and kinds of sleep problems experienced by military personnel during and after deployment.
2. Identify types of insomnia and the symptoms associated with such sleep disturbance.
3. Recognize the role of sleep disturbance in PTSD and TBI.
4. Examine different components of Cognitive-Behavioral Therapy for Insomnia (CBT-I).
5. Develop skills for using Stimulus Control and Sleep Restriction to treat insomnia in military personnel.
6. Develop skills for using Imagery Rehearsal Therapy to treat nightmares in military personnel.
Rough outline of current 2-day CBT-I workshop:
1. Sleep and Insomnia Basics
a) Why do we sleep – Current Theories
- Inactivity, Energy Conservation, Brain Plasticity and Restorative Theories
b) How Sleep is Regulated
- Homeostatic and Circadian Processes
- Sleep Architecture
- Circadian Rhythms – Zeitgebers and alignment
c) Terms and Abbreviations
d) The Impact and Nature of Insomnia
- DSM-IV and ICSD Criteria
- DSM-V criteria
- Diagnostic Considerations
2. The Etiology of Insomnia
a) Predisposing factors
b) Precipitating factors
c) Perpetuating factors
d) Role of hyperarousal
- Physiological
- Emotional
- Cognitive
e) Role of conditioning
f) Integrative model of insomnia
3. War and sleep – not always compatible
a) Research on military sleep disturbance
- MHAT-V
- MHAT-VI
- PDHRA
- Annual incidence rates of insomnia by service
- Millennium cohort study
b) Sleep disturbance after deployment – sleep hygiene/education
c) Sleep disturbance and PTSD
- Positive and negative predictive power of sleep problems for PTSD
- Sleep complaints often remain post successful PTSD treatment
- Residual Insomnia
- Insomnia with PTSD should be treated as independent entity
- SOL, sleep maintenance problems, and nightmares in PTSD
d) Sleep disturbance and TBI
- Study from Israel (1991) – sleep complaints in TBI pts
- Study from Tripler (2009) – sleep/wake disturbances in mTBI pts
- TBI related polysomnographic changes in sleep
- CBT-I in TBI pts
4. Assessment of Sleep Disturbances
a) Assessment Goals
b) Case Conceptualization
c) Assessment Measures
- Retrospective
- Prospective
d) Differential Diagnosis
- RLS and PLMS
- OSA
- Parasomnias
- Other Medical and Psychiatric Conditions
e) Measuring Sleepiness
f) Assessing Dysfunctional Cognitions
5. Cognitive Behavioral Therapy for Insomnia
a) Components
- Educational
- Behavioral
- Cognitive
- Medication
b) Treatment strategies
- Sleep hygiene
- Relaxation therapies
- Stimulus control
- Sleep restriction
- Cognitive strategies
c) Steps
- Manage circadian misalignment
- Melatonin
- Light therapy
d) Sleep hygiene
e) Relaxation therapies
f) Behavioral strategies
- Stimulus control
- Steps
Avoid sleep-incompatible activities
Avoid sleeping outside of bed
Go to bed only when sleepy
Get out of bed if can’t sleep
Maintain regular sleep schedule
Takes about 3-4 weeks to establish new patterns of conditioning
- Sleep restriction
- Steps
Determine average sleep time with sleep logs
Limit time in bed to average sleep time
Continue with sleep logs
If sleep efficiency is greater than 85-90% continue to increase Time in Bed by 15-30 minutes
If sleep efficiency drops below 80% reduce Time in Bed by 15-30 minutes
Takes about 4-6 weeks
Assess barriers and use caution with certain pts (epilepsy, manic)
- Cognitive strategies
- Approaches
Cognitive restructuring
Paradoxical intention
Cognitive control: set aside worry time
- Role of cognitive arousal in insomnia
- Cognitive factors at play in insomnia
- Sample dysfunctional beliefs/thoughts
g) Case Conceptualization wrap-up
7. Imagery Rehearsal Therapy (IRT) for nightmares
a) Background and theory: nightmares become unhelpful habit, thoughts near bedtime are processed in dreams
b) Therapy
- Session 1: introduce treatment
- Session 2: identify reoccurring nightmare, write out script, teach PMR
- Session 3: change dream and write new script, then rehearse before bed
- Session 4: review changes to dream and successes
c) Research support for IRT
d) Use of Prazosin with IRT
e) Treatment Failure options
8. Sleep Management During Deployment
a) Sleep Management Techniques overview
b) Performance Degradation Signs
c) Overcoming Degradation