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Same sleep complaints, different etiology
- Sleep deprivation/restriction: lack of sleep opportunity
- Circadian rhythm and lifestyle mismatch
- Insomnia
- Comorbid mental health conditions
- Sleep disturbance due to physical conditions
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20%-35% Australians have sleep complaints: about half due to voluntary choices to limit sleep opportunity or poor sleep habits.
- “Have-to”
- ¤ Work pressure/demand
- ¤ Caring duties
- ¤ Travel
- “Love-to”
- ¤ “Going out”
- ¤ Electronic entertainment
- ¤ Social media
- ¤ Substance (e.g., alcohol)
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Adolescent behaviour that affected sleep regardless of chronotype (evening/morning)
- Video games: associated with later bedtime and shorter total sleep time during school and holidays
- Same as Online chat and social networking
- Time with family: Protective factor. Earlier bedtime and longer TST (not necessarily causal, could be better family structure, better parenting)
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Technology and sleep
- Light is important but other factors matter too
- Psychological mechanisms: eg. social media increases cognitive arousal and increases time onset latency
- Could also be displacing sleep (replacing sleep with games)
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When poor/insufficient sleep is a voluntary choice…
- Prioritizing sleep often means giving up something else
- Takes more than educating that “sleep is important”
- Motivation to prioritize sleep
- ¤ Cost-benefit: better performance, mood, relationship, health…
- ¤ Behavioural experiments: “try it for a week”
- Sustainable behavioural change
- ¤ Discuss collaboratively on specific steps: “how?”, logistics?
- ¤ Start small, make it achievable: e.g., “4 out of 7 nights is a good start”
- ¤ Savoring success: acknowledge benefits of adequate sleep along the way
- ¤ Family partner support
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Vulnerable population 1: Adolescents
- Cycles of terms and breaks: creates cycle of sleep restriction, recovery, restriction, long recovery
- Maturational processes: during adolescent, phase delays
- Also less homeostatic sleep drive so it is harder to fall asleep
- Early school time
- Cultural social interests and obligations
- Time-in-bed ~55min shorter (< 8 hrs) during school compared to holidays
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Impact on mental health & functioning
- Poor sleep linked cross-sectionally & prospectively with: ¤ Depression, anxiety, suicidal ideation (controlling for mood)
- Substance use
- Neurocognitive functioning, school performance
- Later school start: more sleep, better mood and daytime functioning.
- Potential solution to sleep restriction, implications for policy change
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Vulnerable population 2: Women
- Women have 2x more insomnia complaints than men
- Sleep disturbance universally experienced by most new mothers
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Pregnant women
- Late pregnancy: Chronic sleep disturbance/fragmentation
- Giving birth: Acute total/partial sleep deprivation
- Postpartum: Chronic sleep disruption /restriction (>3 months, sometimes 1-2 yrs)
- Increased napping after birth
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Mothers with unsettled infants
- Low sleep efficiency 65%
- Sleep onset latency almost 30min (close to clinical threshold)
- Very poor sleep quality as measured on pittsburgh sleep quality index
- High insomnia severity index
- Great variation between mothers
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Sleep and Perinatal Mental Health
- Self-report sleep, strong evidence for: Cross-sectional associations with poor mood
- Longitudinal risk factor for later mood problems
- Objective sleep and mood mixed findings: Overall weaker association,
- Some aspects matter more: continuity, variability, daytime naps
- Perceived sleep quality & daytime consequences important: More susceptible to guidance and change.
- Look out for high risk individuals (e.g., bipolar)
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Menopausal Transition
- Reasons for poor sleep not well understood
- Beyond anticipated age-related changes
- Hormonal changes inconclusive
- Undetected sleep disorders?
- Psychosocial changes during midlife and associated mental health conditions?
- Vasomotor symptoms: hot flushes
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Intraindividual variability matters
- No 2 nights’ sleep are the same, variability natural part of sleep/ wake cycles
- The degree of variability differ among individuals
- Adolescents: variable sleep between weekday and weekend
- Shiftwork: variable sleep across days on/off duty
- Insomnia: variable overall.
- Variable sleep patterns: poorer physical/mental health outcomes
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Insomnia symptoms
- Subjective complaint
- Initiation: more young adults
- Early awakening
- Maintenance
- Non-restorative
- Common: general population 30%
- More common in:
- Psychiatric patients: 50% ~ 85%
- Medical conditions (e.g., chronic pain ~ 65%)
- Older age: 40% among 60+
- Women: x2 more likely
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Insomnia disorder
- The most prevalent sleep disorder.
- DSM-5 criteria:
- Subjective complaints of sleep difficulty, no specific cut-off, but generally-
- Sleep initiation: sleep onset latency > 20-30min
- Sleep maintenance: wake after sleep onset > 20-30min
- Early awakening: 30 min before schedule, total sleep time < 6.5hrs
- Duration over 3 times/wk, persist for over 3 months
- Despite adequate sleep opportunity: not just sleep disturbance/restriction
- Daytime distress and impairment
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Insomnia is a persistent condition
- 388 adults with insomnia complaints, 3-year naturalistic follow-up (Morin, 2009)
- ¤ 3/4 persisted after 1 year
- ¤ half persisted after 3 years (baseline severity, women, elderly)
- ¤ 54% remission but 27% relapsed
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The Classic Diathesis-Stress Response Model
- Predisposing factors: vulnerabilities, genetics
- Precipitating factors: trigger, acute major event (death, break up), illness, chronic pain
- Perpetuating factors: maladaptive coping with poor sleep
- Three factor model
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From Acute to Chronic - Conditioned Hyperarousal
- They start associating bed with arousal (stress) that has been conditioned even after changing thoughts and behaviours
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CBT for Insomnia (CBT-I) is commonly multi-component
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Sleep Hygiene
- Goal: removing obstacles and creating optimal environment. Making it a habit helps keep sleep on track.
- No caffeine after 2pm
- No smoke
- Alcohol- helps initiate but wakes you up later
- No full/empty stomach
- Exercise: 30min 3x/week, not too much or too late
- Sound/light/temperature/mattress/pillow
- But, sleep hygiene alone is usually not enough
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Stimulus control
- First line treatment for sleep initiation and maintenance
- One of the most tested, produces reliable clinical results in monotherapy
- Behavioural principles to break conditioning between bed and not sleeping.
- ¤ Go to sleep only when sleepy but not before scheduled bedtime
- ¤ Avoid sleep-incompatible behaviours
- ¤ Get up if can’t sleep within 15 (?) min
- ¤ Go to another room, do something quiet till sleepy
- ¤ Repeat as many times as required
- ¤ Avoid daytime naps
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Bed Restriction and Sleep Scheduling
- Goal: increase sleep efficiency, consolidate broken sleep
- Greater sleep efficiency by reducing time in sleep
- Ascertain actual sleep time (diary/log)
- Delay bedtime: TIB ≈ actual sleep time
- Increase time in bed 15-30 min when sleep efficiency is greater than 85%
- Decrease time in bed by 15-30min when sleep efficiency is less than 80%
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Cognitive Reconstruction
- Goal: manage cognitive processes that interfere with sleep, build a healthy relationship with sleep.
- Dysfunctional Beliefs and Attitudes about Sleep
- Realistic expectations
- ¤ Revise attributions about the causes of insomnia
- ¤ Don’t blame sleeplessness for all daytime impairments
- ¤ Don’t catastrophize after a poor night’s sleep
- ¤ Don’t focus too much on fixing sleep
- Dealing with bedtime worries and rumination
- ¤ Constructive worry and effective problem solving
- ¤ Skills for coping with excessive thoughts and racing mind
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Relaxation
- Target bedtime arousal, best suited for sleep onset problems
- Abdominal breathing
- Progressive muscle relaxation
- Guided imagery
- Biofeedback
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Managing Daytime Behaviours & Sleepiness
- Healthy attitudes towards sleepiness
- ¤ Do not blame/dwell on the night before
- ¤ Sleepiness means more sleep later
- ¤ You might not feel 100%, and it is okay!
- Adjust, pace, and make use of sleepy days
- ¤ Do not stop doing everything or try to do too much
- ¤ Take short and frequent breaks
- ¤ Schedule small activities that are not demanding
- ¤ Alternate physical and mental activities
- ¤ Do not check how sleepy you are.
- Some practical tips
- ¤ Bright light, fresh air, short walks
- ¤ Power nap limited to 15~20 minutes
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The Attention-Intention-Effort Pathway
- Sleep is a natural process.
- It is automatic and passive: prolonged wakefulness induces sleep
- Controlled regulation disrupts automated system and increases arousal
- Selective Attention: scanning mode, vigilant. Become conscious of sleep
- Explicit intention: planning mode. Go from automatic to manual. This is a responsive mental state
- Sleep effort: performing mode. Proactive behavioural state. Emotionally driven
Theoretical platform for reducing sleep effort and control through the use of mindfulness and acceptance
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Treatment efficacy
- CBT-I vs medication
- Short-term: comparable
- Long-term: Superior, well maintained at up to 1 year
- Meta-analyses: CBT-I works for insomnia with/without comorbid physical/ mental health conditions
- They're not necessarily sleeping more, but better quality
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