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07.04.2015

What are the treatment of insomnia, cancer fatigue - For You

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The library is an integral part of a project being developed by FAPESP - Fundacao de Amparo a Pesquisa do Estado de Sao Paulo, in partnership with BIREME - the Latin American and Caribbean Center on Health Sciences Information. The Project envisages the development of a common methodology for the preparation, storage, dissemination and evaluation of scientific literature in electronic format.
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The interface also provides access to the full text of articles via author index or subject index, or by a search form on article elements such as author names, words from title, subject, words from the full text and publication year. Primary care physicians tend to choose for pharmacological treatment of insomnia,9although Cognitive Behavioral Therapy for Insomnia (CBT-I) has been recognized as an effective alternative,7,10 causing a durable long-term improvement of the patient’s sleep, well beyond the termination of the treatment. Several models have been proposed to understand the development of chronic insomnia.14,15,16 Despite differences between the models, common aspects are a reciprocal interaction between nervous system arousal, cognitive and emotional activation, environmental aspects, dysfunctional cognitions and maladaptive behavior.
As the majority of insomniacs develop an irregular sleep pattern the first concern in CBT-I is to encourage patients to keep regular bedtimes and times of getting up. With that in mind a web-based system Somnio was developed for the evaluation, diagnosis and treatment of insomnia patients. From this group 62 patients completed at least 7 of the 8 CBT treatment sessions (20 males, 42 females, age between 18 and 72 years). The treatment plan consisted of 7 sessions with various components of CBT: sleep restriction, stimulus control, cognitive therapy, sleep hygiene and relaxation. The group of 5594 visitors who completed a detailed sleep profile questionnaire showed a large variability in sleep variables.
The sleep pattern in the apnea group without insomnia as comorbidity was different from the sleep pattern in the insomnia group.
Before they entered the therapy the patients were asked to complete a questionnaire to assess faulty beliefs and negative attitudes. To analyze the change in the sleep parameters over the consecutive 7 consults of the CBT-I a multivariate repeated measures analysis was performed with the sleep parameters Sleep latency, Wake after sleep onset (WASO), Total sleep time (TST), Sleep efficiency, Sleep quality and Feeling in the morning.
Insomniacs have different types of complaints and generally one of the complaints is predominant.
In the group of patients who completed the faulty beliefs and attitude questionnaire an interesting result was found.
Supportive contact of the consultant with the patients proved especially important to motivate them to adhere to the sleep restriction assignment. In this paper we showed that the prevalence of insomnia and comorbidities measured via internet is comparable to other studies.
The prevalence of insomnia is very high and sleep centers have not been able to offer effective treatment because CBT-I is difficult to offer. Understanding insomnia and how it can most effectively be treated continues to challenge psychiatrists and other clinicians. This column provides information on how and why insomnia develops, as well as on its treatment, focusing primarily on behavioral interventions. Behavioral treatments for insomnia can be very effective for many patients, but there are substantial challenges to clinicians desiring to use these treatments. Age is a factor in development of insomnia, but not because we need less sleep as we age or even that sleep drive and sleep depth are reduced with age. Personality traits may also play a significant contributory role in the development of insomnia, based on this model. A wide range of events and stimuli may precipitate an insomnia episode in susceptible individuals.
As a consequence of the development of insomnia, patients may make various changes in their habits and routines to try to compensate for their sleep loss and greater difficulties falling asleep.
Understanding how insomnia develops may provide opportunities to treat insomnia at early stages and prevent progression to chronic insomnia. Understanding how insomnia develops is also important when insomnia has become established as a chronic condition. Various behavioral therapies have demonstrated efficacy in the treatment of chronic insomnia.9 Research supports the hypothesis that non-pharmacologic therapies can be very effective in the treatment of insomnia, and an effort should be made to include behavioral therapies in the treatment of every patient with insomnia. Numerous specific behavioral therapies have been described in the past, including sleep restriction, relaxation therapies, and stimulus control therapy. Sleep restriction therapy was initially described by Spielman and colleagues10 and is based on an assumption that sleep deprivation will promote a stronger drive to fall and remain asleep. Operationally, sleep restriction involves an initial limitation of time in bed to an amount close to the number of hours that the insomnia patient reports having slept. Stimulus control therapy (SCT), originally described by Bootzin and colleagues,11 has become so widely utilized in the behavioral treatment of insomnia that many practitioners do not appreciate that it defines a specific and universal approach to the treatment of insomnia.
CBT, demonstrated to be effective in the treatment of depression, has also demonstrated efficacy in multiple research studies as a treatment for insomnia.12-14 Typically, CBT attempts to address maladaptive behaviors and thought patterns that plague insomniac patients.
Poor sleep hygiene, including habits such as the use of caffeine late in the day, clock watching, or the presence of excessive noise or light in the bedroom, may also have a detrimental affect on sleep.
Some patients may over-emphasize sleep hygiene, stopping caffeine intake altogether (rather than just in the evening) because they realize it is a stimulant. E-newsletter Opt-inSent no more than 2–3 times each month, our E-Newsletter brings you recent findings and commentary from the psychiatric literature.
Studies have been unable to unequivocally confirm the efficacy of this intervention for the treatment of insomnia76,87.
There is no data on the efficacy of sleep hygiene measures for the treatment of acute insomnia73,74,76,91. Sleep hygiene measures are often used as an adjunct to other therapeutic interventions73,74,76,91. If this is the case, it must be considered as a contraindication for prescribing CNS depressants. At these ages, the perception of the risks of the use of BZDs is lower in patients than practitioners117.
Since 2002, the Project is also supported by CNPq - Conselho Nacional de Desenvolvimento Cientifico e Tecnologico. Problems with the initiation or maintenance of sleep are associated with difficulties in daily functioning. This has led to the development of pharmacotherapy aimed at sedative as well as antianxiolitic actions. It is not surprising that pharmacotherapy is not an effective long-term solution for several of these components and their interaction. This is a time consuming procedure and worldwide the availability of therapists able to deliver CBT-I is scarce.
This paper reports on our experience with the internet based method and on the effectiveness of online CBT-I for a subgroup of 62 verified insomnia patients.


The overall improvement over the consecutive consults was tested with a repeated measures multivariate test. Interestingly the sleep pattern in the apnea group with comorbid insomnia was more similar to the sleep pattern of the insomnia group (Figure 1).
An overview of the answers on this questionnaire form the basis for the cognitive component of the CBT-I. This high prevalence is in agreement with what is found in the literature22,23 and may warrant more emphasis on the assessment of insomnia in apnea diagnosis.
This component is generally considered to be the most difficult technique to do, but it is also found to be one of the most effective ones.
The high percentage of comorbidity of insomnia in apnea patients should be of concern to the sleep centers to also focus on insomnia. In this paper we showed that with modern technology it is possible to offer the treatment cost-effectively. Erman is clinical professor in the Department of Psychiatry at the University of California, San Diego School of Medicine, is a staff scientist for the Scripps Research Institute Department of Neuropharmacology, and is the president of Pacific Sleep Medicine Services. Insomnia may be acute or chronic, but the majority of patients presenting for evaluation to treating physicians complain of chronic insomnia. The origins of chronic insomnia are usually much more complex, with contributions from predisposing, precipitating, and perpetuating factors. Clinicians must be educated in how to use behavioral treatment modalities, and must be able to identify which patients are most likely to benefit from their use. It also recognizes that chronic insomnia is maintained (unintentionally) by maladaptive coping strategies (perpetuating factors). The presence of concomitant medical illnesses is the largest contributing factor to increased rates of insomnia seen with increased age. Insomnia patients are often anxious, and may develop fixations about the amount and quality of sleep that they obtain and the impact they believe it will have on daytime function. The disruption of sleep seen in association with depression, anxiety disorders, bipolar disorder, obsessive-compulsive disorder, or psychotic disorders may interact with the personality traits of these patients to increase anxiety and concern about sleep.5,6 Social factors may also be contributory to this process. They may try to fall asleep at an earlier hour (ie, 8pm), not appreciating that their level of alertness at that hour, controlled by their circadian sleep rhythms, will prevent premature entry into sleep. As sleep becomes more elusive, efforts to fall asleep may become more intensified, as is the level of arousal and anxiety the continued failure to sleep generates. For example, using the Spielman model,2-4 if physicians and therapists recognize that premorbid traits predisposing to development of insomnia exist, they may be more aggressive in treating stress and instructing patients on avoidance of key stressors capable of provoking insomnia. Identification of elements that have contributed to the development of insomnia, and educating the patient about the roles that behavior and conditioning have played in this process, should help physicians and patients understand that behavioral therapies combined with pharmacologic interventions are useful treatment options. Some of the elements from these specific therapies may also be incorporated in a more global approach to the treatment of insomnia using cognitive-behavioral therapy (CBT). This restriction is based on assumption that most insomnia patients underestimate the amount of sleep that they have obtained. This technique requires a compliant patient, careful record keeping and record analysis by patient and therapist, and recognition that at least several weeks will be required before significant changes will be observed by the patient. SCT consists of a series of five instructions given to patients to strengthen their capacity to fall asleep at night and to improve their capacity to sleep on a regular basis in their own bedroom.
These disturbances develop over long periods of time, become an entrenched part of the insomniac’s thought and behavior patterns, and exacerbate insomnia severity. Education in sleep hygiene is always beneficial to patients, even for those who feel they fully understand how to improve their sleep. For example, clinicians should discuss computer use with their patients; using a computer when one cannot sleep involves motor activity, cognitive activation, and light exposure, all of which will interfere with the capacity to fall asleep.
Many patients who report that they use caffeine to help them become more alert and functional in the morning are relieved when informed that caffeine in the morning and early afternoon may not impact nighttime sleep. The progress in the pharmacotherapy of insomnia over the last four decades have improved the hypnotic compounds in terms of a reduction of negative effects on the physiological sleep pattern and a reduction of side effects. Cognitive behavioral therapy for insomnia (CBT-I) consists of a combination of several techniques addressing the various aspects of the development of chronic insomnia. Some education about sleep and the role of the biological clock is essential to motivate the patients to change their habits. A promising alternative for the standard face-to-face delivery of the therapy is the internet. The 15 questions covered the major symptoms of insomnia, apnea, narcolepsy and limb movement disorders. For each session, the patients had to keep a diary of their sleep wake schedule and their subjective perception of sleep. In addition the improvement after the 7th consult was compared to the baseline values of the first week, using the non-parametric Wilcoxon signed rank test. In this sample except in the apnea group, in the other 3 sleep problem groups there were more women than men. This was tested by classifying the patients in three groups: initiating sleep, maintaining sleep or a combination of both symptoms on the basis of their initial sleep profile.
Encouragement and making the patients understand why a specific assignment was important to do are crucial for the motivation.
Employee and job attributes as predictors of absenteeism in a national sample of workers: the importance of health and dangerous conditions. Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. NIH State-of-the-Science Conference statement on manifestations and management of chronic insomnia in adults.
Cognitive Behavioral Therapy for Insomnia Enhances Depression Outcome in Patients with Comorbid Major Depressive Disorder and Insomnia. Insomnia: conceptual issues in the development, persistence, and treatment of sleep disorder in adults. Frequency of insomnia report in patients with obstructive sleep apnea hypopnea syndrome (OSAHS).
Controlled trial of internet-based treatment with telephone support for chronic back pain. Most insomnia can be related, at least in part, to comorbid medical and psychiatric conditions, which may play a role in any of these three contributory realms. Patients must be motivated to accept these treatments, especially since they may not experience immediate relief. These patients maintain a state of excessive arousal (out of context with their need for arousal in their sleep or relaxation environment) that interferes with their capacity to sleep. Thus, a person may be prone to insomnia due to trait characteristics, may experience a trenchant or short-term insomnia as a consequence of precipitating stresses, and may develop a persistent and chronic insomnia as a consequence of pathologic coping strategies and poor sleep hygiene.


Thought processes of this sort clearly contribute to the development of insomnia, and are excellent targets for cognitive therapy as part of an overall treatment program.
Parental demands, care-giving for a spouse or parent, or arousal related to a bed-partner’s sleep tendencies, schedule, or habits may all contribute to increased risk of developing insomnia.
Examples of disorders that could precipitate insomnia include arthritis flares, angina, prostatism, hyperthyroidism, and irritable bowel syndrome. The bed and bedroom, which ideally are associated with comfort, pleasure, and relaxation, become increasingly associated with pain, arousal, and anxiety. If stressors are neutralized or insomnia symptoms are quickly and effectively treated, patients may revert to their pre-morbid, non-insomniac state.
If they are limited to the 5 hours, for example, which they report they have been receiving, their sleep will be restricted. Although it is helpful for many patients, some of its components, such as getting up from bed and going to another room if unable to sleep, may increase levels of arousal and make it extremely hard for patients to be able to return to sleep when they return to their bedroom. These disturbances tend to develop no matter how the insomnia originally developed, and include behavioral and cognitive elements that interfere with the patient’s ability to relax and fall asleep.
CBT is designed to interrupt the self-fulfilling nature of these beliefs and behaviors, and provides patients with coping skills to prevent or minimize recurrence of sleep disturbances after treatment.
Core elements, such as attempting to maintain regular bedtime and awakening hours, may seem obvious, but linking these activities to the importance of strongly entrained circadian rhythms may provide an intellectual base that allows the patient to make a greater effort to maintain such a regular pattern.
Another common habit exhibited by insomniacs is a tendency to look at clocks when they have trouble sleeping. Others may report sleeping for 90–120 minutes over the course of the day, but have difficulty understanding that this reduces sleep drive at night, making entry into sleep and sustained sleep more difficult.
Long-term effectiveness of a short-term cognitive-behavioral group treatment for primary insomnia.
Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial.
As insomnia is one of the most prevalent psychological health problems affecting between 9% and 19% of the adult population, it also has a socioeconomic impact on society in general. The NIH concludes in their state-of- the-science conference in 20057 that such a combination of techniques can stay effective even after the termination of the treatment. The rationale of the sleep restriction technique is to increase sleep time by consolidating the fragmented sleep of insomniacs in one solid block and by reducing the time the patient is awake in bed. The advantage of CBT for insomnia over the internet is the fact that that the therapy can be followed at home, so that it is independent of location.
After each week this information was analyzed and a personalized treatment plan was proposed.
The improvement achieved after the 7th week was also compared to the desired improvement, specified in the first consult. The three groups were compared on the change in sleep parameters from baseline to the end of the treatment. This is comparable to the values found in some recent studies on online self-administered insomnia treatment.19,20 These effects were found even though the patient group in this study consisted of patients with various insomnia complaints. Practice Parameters for the psychological and behavioral treatment of insomnia: an update. Other etiologic theories are based on models of inadequate sleep drive, or cognitively driven excessive arousal that interferes with the capacity to fall asleep or stay asleep. They may nap in the daytime, not appreciating that their daytime hours of sleep will reduce sleep drive at bedtime, further interfering with their capacity to fall asleep at their desired hour. If interventions are not made until perpetuating elements have developed, the insomnia condition is more likely to become chronic. As a consequence, it is expected that sleep drive will be increased, leading to improved sleep efficiency during the limited number of hours in bed. Insomniacs will attempt to process the information provided by the clock in the middle of the night; this is always a negative phenomenon. Walsh and Engelhardt1 estimated the direct costs involved in the diagnosis and treatment of insomnia in 1995 in the USA as $14 billion. The most important techniques used are: sleep restriction, stimulus control, cognitive therapy, sleep hygiene and relaxation techniques. Patients were also encouraged to send their personal comments and questions that were handled confidentially by a CBT therapist. When the original complaints of the patients were taken into account the effect sizes increased to very high.
Among maladaptive thought patterns are trying too hard to fall asleep (which provokes greater arousal), pathologic anxiety generated by the immediate inability to fall asleep, and excessive worry about sleep loss and its possible next day consequences. A positive alternative would be sleeping through the night and awakening on one’s own or with a morning alarm. The Insomnia Answer: A Personalized Program for Identifying and Overcoming the Three Types of Insomnia. Indirect costs of insomnia may involve the loss of productivity and the occurrence of accidents. The AASM practice parameters17 support the efficacy of the techniques for the treatment of insomnia.
In the first consult each patient was asked to specify their desired sleep pattern by the end of the treatment.
Furthermore, many patients fail to understand the importance of engaging in relaxing activities in the hours before bedtime.
A combination of the techniques is more effective than applying the techniques separately. Stimulus control aims to restore the positive association between these aspects, so that the sleeping room is associated again with sleep instead of sleepiness. The values of the sleep parameters in the first consult was considered as baseline values.
The results in the present study shows effects of the treatment of a heterogeneous patient population comparable to real life situation. The promotion of a natural state of relaxation which encourages sleep in the hours before bedtime, along with avoiding physical activity or exercise in the evening hours, can help create an environment favorable for sleep.
Frequently these patients also believe that they should be able to manage their sleep problem without professional help.




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