Sleep Enhancement Programs
Types of Sleep Disorders
Among many factors that influence brain functioning and cognitive skills, sleep remains one so integral and yet so underestimated in terms of its regenerative and restorative effects on the brain, and by extension, our everyday functioning. Further, sleep deprivation brought on by clinical sleep disorders may prove to result in the onset, or exacerbate existing psychological and/or neurological disorders. Of course, the sleep disorder itself may be a manifestation of underlying psychological disturbance.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013), Insomnia Disorder is characterised by a predominant complaint of dissatisfaction with sleep quantity or quality. Insomnia can manifest at different stages of sleep as follows:
- Sleep onset insomnia: difficulty in initiating sleep at desired bedtime.
- Sleep maintenance insomnia: difficulty maintaining undisturbed sleep, involving frequent or prolonged awakening during the sleep period.
- Late insomnia: referring to early morning waking with an inability to fall back to sleep.
Such disturbance must also result in clinically significant distress or impairment in social, occupational or other integral areas of functioning. Insomnia therefore involves resulting daytime symptoms, such as fatigue, sleepiness, impaired cognitive functioning including attention, memory and motor skill performance, and mood disturbances such as irritability, anxiety and depression.
Insomnia can be triggered by major life stressors or chronic daily stress experienced by individuals predisposed to anxious or worry-prone cognitive styles. Disorder onset appears to be sustained and exacerbated by poor sleep habits, irregular sleep scheduling and a cycle of resulting stress over lack of sleep.
Breathing-related Sleep Disorders
Obstructive Sleep Apnea Hypopnea, the most common breathing-related sleep disorder, is characterised by repeated total or partial upper airway obstruction during sleep, according to the DSM-5 (2013). Given sleep disruptions due to airway obstruction, individuals with sleep apnea likely report clinically significant day-time disruptive symptoms of insomnia as abovementioned.
Children with sleep apnea often present with daytime symptoms including excessive sleepiness and behavioural issues characteristic of Attention-Deficit Hyperactivity disorder (ADHD) such as inattention, academic impairment, hyperactivity and internalising behaviours.
Further, comorbidities exist between sleep apnea and depression, with one-third of patients referred to sleep specialists reporting such depression symptoms.
Circadian Rhythm Sleep-Wake Disorders
Circadian Rhythm Sleep-Wake Disorders are characterised by persistent sleep disruption due to an alteration of the circadian system or a misalignment between the endogenous circadian rhythm and the sleep-wake schedule dictated by an individual’s physical environment or social/professional schedule (DSM-5, 2013). Such sleep disturbance must be accompanied by excessive sleepiness and/or insomnia, and subsequently cause clinically significant distress or impairment in social, occupational, and other important areas of functioning. Such disorders are often associated with a history of or demonstrate comorbidities with mental health disorders.
Of course, assessment is necessary to consider and determine sleep disorder aetiology to appropriately inform resulting treatment. As aforementioned, sleep disorders may be preceded by psychological disturbances that will require additional, specific treatment to address underlying issues. Likewise, poor lifestyle and sleep habits and scheduling that lead to clinical sleep disruptions may trigger or exacerbate psychological and/or neurological disorders, and thus also require sleep specific programs. For instance, chronic medical or psychiatric conditions such as ADHD and anxiety can both either precede or follow various types of Insomnia disorder.
Cognitive Behavioural Therapy
Cognitive Behavioural Therapy (CBT) is an effective treatment for sleep disorders such as insomnia in addition to CBT for other psychiatric disorders. Cognitive Behavioural Therapy (CBT) for Insomnia is a multimodal therapy consisting of both cognitive techniques and behavioural interventions that aim to simultaneously target maladaptive thoughts and beliefs concerning sleep and habits that appear to reinforce and prolong insomnia disorders.
The cognitive techniques involved serve to challenge incorrect or bad thoughts and attitudes about sleep that result in increased stress and arousal that further prevent sleep. For example some unhelpful thoughts that can reinforce poor sleep involve beliefs and anxiety that sleep is out of one’s control, and that sleep habits and schedules cannot be changed. Whilst the same negative thoughts may plague older children or adolescents, young children may also experience night-time fears such as imaginary monsters, or even more realistic dangers such as burglars. These fears can result in a child’s persistent bedtime refusal, or inability to sleep alone. CBT aims to address these thoughts by challenging the underlying logic and premises and utilising journaling of such thoughts to decrease worrying when it comes to sleep time.
CBT in addition often involves one or more of the following behavioural interventions:
- Sleep hygiene education – This form of behavioural treatment consists of educating the patient and/or the patients’ parents on behaviours that assist with sleep, and behaviours that prevent sleep. For instance, techniques involve the avoidance of caffeine and nicotine, of daytime napping, and attempts to ‘force’ sleep. Behaviours such as exercise, and ensuring a dark and quiet bedroom are likewise encouraged. Whilst such behaviours may appear to be common knowledge, many of us are guilty of not following these basic recommendations that can easily and greatly improve our sleep quality.
- Stimulus control – Based on psychological principles of operant and classical conditioning, this behavioural intervention focuses on reducing unhelpful associations between sleep (in our bed) and non-sleep activities. Many people often read, watch television and even worry whilst lying in bed attempting to fall asleep. The mind therefore is conditioned to associate our bed with various other wakeful activities and not sleep itself. Treatment aims to strengthen the association between our bedtime environment and falling asleep. Techniques involve setting guidelines such as only going to bed when tired, using the bedroom and one’s bed only for sleeping, removing oneself from the bedroom if they are lying awake for more than 10-20 minutes and only making a return when they are sleepy again.
- Sleep restriction therapy – Once again, we often spend too much time lying awake in bed, and may even go to bed early only to lie awake the entire time. In order to improve the ratio of sleep to wakefulness during bedtime and wake-up time, this behavioural treatment aims to restrict wakefulness in the bed by imposing a strict schedule of when one should go to and leave the bed and bedroom. Over time people will find themselves sleeping longer, and such time restrictions can be broadened to increase sleep duration.
As a combination of the abovementioned techniques CBT is therefore a highly effective treatment for both adults and children with sleep disturbances (1, 2, 3, 4). Studies show the effects of CBT are equal to or superior to the use of hypnotic medications (5, 6), and unlike medication are maintained up to three year after treatment (7).
Neurofeedback training also benefits sleep disturbances in terms of increasing total sleep time, reducing the amount of waking during sleep and reducing the time it takes to fall asleep (8, 9, 10). Neurofeedback involves rewarding the individual for activating or suppressing certain brain waves that over time result in the desired pattern of brain activity to address target symptomology. For more information concerning the principles behind and administration of neurofeedback training please refer to our treatment page for ‘Neurofeedback’.
In terms of sleep disorders, the cognitive hyperarousal and stress associated with insomnia can be seen as fast brain oscillations and elevated beta and gamma frequencies at sleep onset. This hyperarousal of brain activity means that our sensory and cognitive processing is heightened rather than quietened as it would be in desired functioning, making it more difficult to fall and stay asleep. By conditioning a frequency range reflective of quiet but alert wakefulness, neurofeedback training targets key areas responsible for undesired arousal prior to sleep, and in result improves sleep time and quality.
Melatonin supplementation also appears effective in the treatment of sleep disorders in both children and adults. Melatonin is actually a natural hormone endogenously released by the body’s pineal gland. Secretion of melatonin by the pineal gland is regulated by our suprachiasmatic nucleus (SCN) that becomes active when exposed to daylight. The SCN actively delays the release of melatonin until it is night-time. These increased melatonin levels at night-time are what contributes to feelings of sleepiness and a reduction in alertness and arousal, until such levels drop at the sign of daylight. This is why it may be the case that even bright artificial indoor lighting can prove to be as strong as daylight and prevent the release of melatonin at bedtime.
Those with reduced melatonin levels or those with delayed or disrupted melatonin release can benefit from supplementation. Supplementing melatonin to exogenously improve levels and in result increase feelings of sleepiness has proved effective in improving sleep onset and reducing the time it takes to fall asleep in both adults and children (11, 12, 13, 14). Importantly, studies show that melatonin supplementation has not been found to produce any short-term or long-term adverse side effects (11, 12, 13, 14).
- Cheng, S. K., & Dizon, J. (2012). Computerised cognitive behavioural therapy for insomnia: A systematic review and meta-analysis. Psychotherapy and Psychosomatics, 81(4), 206-216. doi:10.1159/000335379
- Irwin, M. R., Cole, J. C., & Nicassio, P. M. (2006). Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychology, 25(1), 3-14. doi:10.1037/0278-6220.127.116.11
- Okajima, I., Komada, Y., & Inoue, Y. (2011). A meta-analysis on the treatment effectiveness of cognitive behavioral therapy for primary insomnia. Sleep and Biological Rhythms, 9(1), 24-34. doi:10.1111/j.1479-8425.2010.00481.x
- Smith, M. T., Smith, M. S., Perlis, M. L., Park, A., Pennington, J., Giles, D. E., & Buysse, D. J. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159(1), 5-11. doi:10.1176/appi.ajp.159.1.5
- Nakajima, S., kajima, I., Nakamura, M., Usui, A., Nishida, S., Hayashida, K., & Inoue, Y. (2011). effects of cognitive behavioral therapy for stress-induced sleep disturbance and hyperarousal. Sleep Medicine, 12, S6-S6. doi:10.1016/S1389-9457(11)70019-3
- Mitchell, M. D., Gehrman, P., Perlis, M., & Umscheid, C. A. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: A systematic review. BMC Family Practice, 13(1), 40-40. doi:10.1186/1471-2296-13-40
- Carney CE, Edinger JD. (2010) Mutimodal cognitive behavior therapy. In: Sateia MJ, Buysse DJ, eds. Insomnia: Diagnosis and Treatment. London, England: Informa Healthcare, 342-351
- Cortoos, A., De Valck, E., Arns, M., Breteler, M. H. M., & Cluydts, R. (2010). An exploratory study on the effects of tele-neurofeedback and tele-biofeedback on objective and subjective sleep in patients with primary insomnia. Applied Psychophysiology and Biofeedback, 35(2), 125-134. doi:10.1007/s10484-009-9116-z
- Schabus, M., Griessenberger, H., Heib, D., Lechinger, J., & Hoedlmoser, K. (2013). Non-pharmacological treatment of primary insomnia using sensorimotor-rhythm neurofeedback. Sleep Medicine, 14, e260-e261. doi:10.1016/j.sleep.2013.11.634
- Schabus, M., Griessenberger, H., Koerner, D., Gnjezda, M., Heib, D., & Hoedlmoser, K. (2015). SMR neurofeedback for improving sleep and memory – two studies in primary insomnia. Sleep Medicine, 16, S12-S12. doi:10.1016/j.sleep.2015.02.027
- Xie, Z., Chen, F., Li, W. A., Geng, X., Li, C., Meng, X., . . . Yu, F. (2017). A review of sleep disorders and melatonin. Neurological Research, 39(6), 559-565. doi:10.1080/01616412.2017.1315864
- Carr, R., Wasdell, M. B., Hamilton, D., Weiss, M. D., Freeman, R. D., Tai, J., . . . Jan, J. E. (2007). Long‐term effectiveness outcome of melatonin therapy in children with treatment‐resistant circadian rhythm sleep disorders. Journal of Pineal Research, 43(4), 351-359. doi:10.1111/j.1600-079X.2007.00485.x
- Zwart, T. C., Smits, M. G., Egberts, T. C. G., Rademaker, C. M. A., & van Geijlswijk, I. M. (2018). Long-term melatonin therapy for adolescents and young adults with chronic sleep onset insomnia and late melatonin onset: Evaluation of sleep quality, chronotype, and lifestyle factors compared to age-related randomly selected population cohorts. Healthcare (Basel, Switzerland), 6(1), 23. doi:10.3390/healthcare6010023
- van Maanen, A., Meijer, A. M., Smits, M. G., van der Heijden, K. B., & Oort, F. J. (2017). Effects of melatonin and bright light treatment in childhood chronic sleep onset insomnia with late melatonin onset: A randomised controlled study. Sleep, 40(2) doi:10.1093/sleep/zsw038