Behavioral sleep medicine

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Sleep clinic

Behavioral sleep medicine (BSM) is a field within sleep medicine that encompasses scientific inquiry and clinical treatment of sleep-related disorders, with a focus on the psychological, physiological, behavioral, cognitive, social, and cultural factors that affect sleep, as well as the impact of sleep on those factors. [1] [2] [3] [ page needed ] The clinical practice of BSM is an evidence-based behavioral health discipline that uses primarily non-pharmacological treatments [3] (that is, treatments that do not involve medications). BSM interventions are typically problem-focused and oriented towards specific sleep complaints, but can be integrated with other medical or mental health treatments (such as medical treatment of sleep apnea, psychotherapy for mood disorders). [4] The primary techniques used in BSM interventions involve education and systematic changes to the behaviors, thoughts, and environmental factors that initiate and maintain sleep-related difficulties. [3] [4]

Contents

The most common sleep disorders that can benefit from BSM include insomnia, [5] circadian rhythm sleep-wake disorders, [6] nightmare disorder, [7] childhood sleep disorders (for example bedwetting, bedtime difficulties), [8] parasomnias (such as sleepwalking, sleep eating), [9] sleep apnea-associated difficulties (such as difficulty using continuous positive airway pressure), [10] and hypersomnia-associated difficulties (for example daytime fatigue and sleepiness, psychosocial functioning). [11]

Scope

The clinical practice of behavioral sleep medicine applies behavioral and psychological treatment strategies to sleep disorders. [3] [12] BSM specialists provide clinical services including assessment and treatment of sleep disorders and co-occurring psychological symptoms and disorders, often in conjunction with pharmacotherapy and medical devices that may be prescribed by medical professionals. [12]

Most BSM treatments are based on behavioral therapy or cognitive behavioral therapy. [4] [ page needed ] Goals of BSM treatment include directly treating the sleep disorder (for example with cognitive behavioral therapy for insomnia [13] ), improving adherence to non-behavioral treatments (such as motivational enhancement for CPAP [14] ), and improving quality of life for people with chronic sleep disorders (for example, by using cognitive behavioral therapy for hypersomnia [11] ).

Training and certification

Behavioral sleep medicine is a clinical specialty practiced by individuals who are licensed health professionals, including psychologists, counselors, social workers, physicians, nurses, physical therapists, and other healthcare professionals. [15] Licensed BSM practitioners work in a variety of settings, including sleep clinics, hospitals, universities, outpatient mental health clinics, primary care, and private practice. [12] Some scientists conduct behavioral sleep medicine research but are not licensed health providers and do not directly provide clinical treatment. [1]

Training in behavioral sleep medicine varies. Training may be obtained during graduate clinical training, internship/residency, fellowship/postdoctoral training, or through continuing education courses. [16]

The Society of Behavioral Sleep Medicine has established a certification process whereby licensed health professionals who have met certain training requirements can earn the title of Diplomate in Behavioral Sleep Medicine (DBSM). Requirements include graduate course work, specialized clinical training, and passing a written exam. [15] This certification was previously known as Certification in Behavioral Sleep Medicine (CBSM).[ citation needed ]

Diagnosis

Assessment methods used in behavioral sleep medicine are similar to those used in sleep medicine as a whole. Methods include clinical interview, sleep diaries, standardized questionnaires, polysomnography, actigraphy, and multiple sleep latency test (MSLT).[ medical citation needed ]

The third edition of the International Classification of Sleep Disorders (ICSD-3) [17] [ page needed ] contains the diagnostic criteria for sleep disorders. Many of these disorders are also described in the diagnostic manual of the American Psychiatric Association, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). [18] [ page needed ]

Insomnia

Insomnia, which is the most common sleep disorder in the population as well as the most common disorder treated by BSM practitioners, is typically evaluated with a clinical interview and two weeks of sleep diaries. [13] The clinical interview examines topics such as sleep patterns, sleep history, psychiatric history, medications, substance use, and relevant medical, developmental, social, occupational, cultural, and environmental factors. [19] [20] [ page needed ] For young children, the clinical interview and sleep diaries would be completed primarily by a parent. [8]

Standardized questionnaires may be used to evaluate the severity of the sleep problem or assess for other possible sleep problems. Example questionnaires commonly used with adults include: Insomnia Severity Index, [21] Pittsburgh Sleep Quality Index, [22] Epworth Sleepiness Scale, [23] and STOP-Bang. [24] The Brief Infant Sleep Questionnaire [25] is commonly used to assess sleep/wake patterns in infants and small children. Questionnaires commonly used with children and their parents include: Children's Sleep Habits Questionnaire, [26] the Pediatric Sleep Questionnaire, [27] and the Children's Report of Sleep Patterns. [28] Questionnaires commonly used with adolescents include: The Adolescent Sleep Wake Scale [29] and the Adolescent Sleep Hygiene Scale. [29]

Overnight sleep studies (polysomnography) are not necessary or recommended to diagnose insomnia. [13] Polysomnography is used to rule out the presence of other disorders which may require medical treatment, such as sleep apnea, periodic limb movement disorder, and rapid eye movement sleep behavior disorder. An MSLT is used to rule out disorders of hypersomnolence such as narcolepsy.[ citation needed ]

Actigraphy is sometimes used to gain information about sleep timing and assess for possible circadian rhythm disorders. [13]

Other sleep concerns

Assessment of other sleep concerns follow similar procedures to those for assessing insomnia. By the time individuals are referred to a BSM specialist, they have often already seen a sleep medicine provider and completed any necessary testing such as polysomnography, MSLT, or actigraphy. In that case, the BSM provider conducts a clinical interview and administers questionnaires if needed. Individuals are often asked to track their sleep or sleep-related symptoms such as nightmares or sleepwalking episodes that are the focus of treatment.[ medical citation needed ]

Management

BSM practitioners provide evidence-based treatments developed for specific sleep disorders, [3] [4] including some that are published in clinical guidelines of organizations such as the American Academy of Sleep Medicine. [7] [13] [30] BSM interventions are typically brief (between one and eight sessions), structured, and cognitive-behavioral in nature, aiming to provide the education and skills for individuals to become more independent in managing their sleep disorder. [4]

Infants, children, and adolescents

The most common sleep complaints of parents of infants include requiring a parent or specific condition, like rocking, or bouncing, to fall asleep, and struggling to return to sleep during nighttime awakenings. Among toddlers and preschoolers, nighttime fears or resisting/stalling at bedtime (and therefore delaying sleep onset) are common, as well as bedtime co-sleeping with parents or siblings. In school-aged youth, problems with falling or staying asleep due to poor sleep hygiene are common. [8] [ page needed ]

Insufficient sleep (sleeping under the recommended 8–10 hours) is common in adolescence. The other most common sleep disorders of adolescence include insomnia and delayed sleep-wake phase disorder. High rates of insufficient sleep in adolescence are partially attributed to a mismatch between adolescent biology and school start times. [31] Because adolescents experience a natural shift in their circadian rhythm around puberty (with a preference for later bedtimes and wake times), the American Academy of Pediatrics recommends that high schools start no earlier than 8:30am. [32]

Evidence-based treatments for childhood behavioral sleep disorders vary by developmental level, but typically include heavy parental involvement. [33] Interventions generally focus on: [8]

Treatment with parents of infants emphasizes the implementation of safe sleeping practices in order to reduce the risk of sudden infant death syndrome. The recommends that infants 0–12 months of age sleep:[ medical citation needed ]

Adults

Evidence-based treatments used to treat adult sleep-related disorders include:

See also

Related Research Articles

<span class="mw-page-title-main">Sleep disorder</span> Medical disorder of the sleep patterns of a person

A sleep disorder, or somnipathy, is a medical disorder of an individual's sleep patterns. Some sleep disorders are severe enough to interfere with normal physical, mental, social and emotional functioning. Polysomnography and actigraphy are tests commonly ordered for diagnosing sleep disorders.

<span class="mw-page-title-main">Insomnia</span> Inability to fall or stay asleep

Insomnia, also known as sleeplessness, is a sleep disorder where people have trouble sleeping. They may have difficulty falling asleep, or staying asleep for as long as desired. Insomnia is typically followed by daytime sleepiness, low energy, irritability, and a depressed mood. It may result in an increased risk of motor vehicle collisions, as well as problems focusing and learning. Insomnia can be short term, lasting for days or weeks, or long term, lasting more than a month. The concept of the word insomnia has two possibilities: insomnia disorder and insomnia symptoms, and many abstracts of randomized controlled trials and systematic reviews often underreport on which of these two possibilities the word insomnia refers to.

<span class="mw-page-title-main">Delayed sleep phase disorder</span> Chronic mismatch between a persons normal daily rhythm, compared to other people and societal norms

Delayed sleep phase disorder (DSPD), more often known as delayed sleep phase syndrome and also as delayed sleep–wake phase disorder, is the delaying of a person's circadian rhythm compared to those of societal norms. The disorder affects the timing of biological rhythms including sleep, peak period of alertness, core body temperature, and hormonal cycles.

<span class="mw-page-title-main">Nightmare disorder</span> Medical condition

Nightmare disorder is a sleep disorder characterized by repeated intense nightmares that most often center on threats to physical safety and security. The nightmares usually occur during the REM stage of sleep, and the person who experiences the nightmares typically remembers them well upon waking. More specifically, nightmare disorder is a type of parasomnia, a subset of sleep disorders categorized by abnormal movement or behavior or verbal actions during sleep or shortly before or after. Other parasomnias include sleepwalking, sleep terrors, bedwetting, and sleep paralysis.

In chronotherapy, an attempt is made to move bedtime and rising time later and later each day, around the clock, until a person is sleeping on a normal schedule. This treatment can be used by people with delayed sleep phase disorder (DSPD), who generally cannot reset their circadian rhythm by moving their bedtime and rising time earlier. DSPD is a circadian rhythm sleep disorder, characterised by a mismatch between a person's internal biological clock and societal norms. Chronotherapy uses the human phase response to light or melatonin. The American Academy of Sleep Medicine has recommended chronotherapy for the treatment of circadian rhythm and sleep disorders.

Sexsomnia, also known as sleep sex, is a distinct form of parasomnia, or an abnormal activity that occurs while an individual is asleep. Sexsomnia is characterized by an individual engaging in sexual acts while in non-rapid eye movement (NREM) sleep. Sexual behaviors that result from sexsomnia are not to be mistaken with normal nocturnal sexual behaviors, which do not occur during NREM sleep. Sexual behaviors that are viewed as normal during sleep and are accompanied by extensive research and documentation include nocturnal emissions, nocturnal erections, and sleep orgasms.

Sleep hygiene is a behavioral and environmental practice developed in the late 1970s as a method to help people with mild to moderate insomnia. Clinicians assess the sleep hygiene of people with insomnia and other conditions, such as depression, and offer recommendations based on the assessment. Sleep hygiene recommendations include: establishing a regular sleep schedule; using naps with care; not exercising physically or mentally too close to bedtime; limiting worry; limiting exposure to light in the hours before sleep; getting out of bed if sleep does not come; not using bed for anything but sleep and sex; avoiding alcohol as well as nicotine, caffeine, and other stimulants in the hours before bedtime; and having a peaceful, comfortable and dark sleep environment. However, as of 2021, the empirical evidence for the effectiveness of sleep hygiene is "limited and inconclusive" for the general population and for the treatment of insomnia, despite being the oldest treatment for insomnia. A systematic review by the AASM concluded that clinicians should not prescribe sleep hygiene for insomnia due to the evidence of absence of its efficacy and potential delaying of adequate treatment, recommending instead that effective therapies such as CBT-i should be preferred.

<span class="mw-page-title-main">Mandibular advancement splint</span>

A mandibi splint or mandibi advancement splint is a prescription custom-made medical device worn in the mouth used to treat sleep-related breathing disorders including: obstructive sleep apnea (OSA), snoring, and TMJ disorders. These devices are also known as mandibular advancement devices, sleep apnea oral appliances, oral airway dilators, and sleep apnea mouth guards.

<span class="mw-page-title-main">Obstructive sleep apnea</span> Sleeping and breathing disorder

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep. These episodes are termed "apneas" with complete or near-complete cessation of breathing, or "hypopneas" when the reduction in breathing is partial. In either case, a fall in blood oxygen saturation, a disruption in sleep, or both, may result. A high frequency of apneas or hypopneas during sleep may interfere with the quality of sleep, which – in combination with disturbances in blood oxygenation – is thought to contribute to negative consequences to health and quality of life. The terms obstructive sleep apnea syndrome (OSAS) or obstructive sleep apnea–hypopnea syndrome (OSAHS) may be used to refer to OSA when it is associated with symptoms during the daytime.

Parasomnias are a category of sleep disorders that involve abnormal movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, sleeping, between sleep stages, or during arousal from sleep. Parasomnias are dissociated sleep states which are partial arousals during the transitions between wakefulness, NREM sleep, and REM sleep, and their combinations.

Circadian rhythm sleep disorders (CRSD), also known as circadian rhythm sleep-wake disorders (CRSWD), are a family of sleep disorders which affect the timing of sleep. CRSDs arise from a persistent pattern of sleep/wake disturbances that can be caused either by dysfunction in one's biological clock system, or by misalignment between one's endogenous oscillator and externally imposed cues. As a result of this mismatch, those affected by circadian rhythm sleep disorders have a tendency to fall asleep at unconventional time points in the day. These occurrences often lead to recurring instances of disturbed rest, where individuals affected by the disorder are unable to go to sleep and awaken at "normal" times for work, school, and other social obligations. Delayed sleep phase disorder, advanced sleep phase disorder, non-24-hour sleep–wake disorder and irregular sleep–wake rhythm disorder represents the four main types of CRSD.

<span class="mw-page-title-main">Sleep medicine</span> Medical specialty devoted to the diagnosis and therapy of sleep disturbances and disorders

Sleep medicine is a medical specialty or subspecialty devoted to the diagnosis and therapy of sleep disturbances and disorders. From the middle of the 20th century, research has provided increasing knowledge of, and answered many questions about, sleep–wake functioning. The rapidly evolving field has become a recognized medical subspecialty in some countries. Dental sleep medicine also qualifies for board certification in some countries. Properly organized, minimum 12-month, postgraduate training programs are still being defined in the United States. In some countries, the sleep researchers and the physicians who treat patients may be the same people.

Catathrenia or nocturnal groaning is a sleep-related breathing disorder, consisting of end-inspiratory apnea and expiratory groaning during sleep. The name originates from the Greek kata (below) and threnia, and it describes a rare condition characterized by monotonous, irregular groans while sleeping. Catathrenia begins with a deep inspiration. The person with catathrenia holds her or his breath against a closed glottis, similar to the Valsalva maneuver. Expiration can be slow and accompanied by sound caused by vibration of the vocal cords or a simple rapid exhalation. Despite a slower breathing rate, no oxygen desaturation usually occurs. The moaning sound is usually not noticed by the person producing the sound, but it can be extremely disturbing to sleep partners. It appears more often during expiration REM sleep than in NREM sleep.

Sleep deprivation, also known as sleep insufficiency or sleeplessness, is the condition of not having adequate duration and/or quality of sleep to support decent alertness, performance, and health. It can be either chronic or acute and may vary widely in severity.

Cognitive behavioral therapy for insomnia (CBT-I) is a technique for treating insomnia without medications. Insomnia is a common problem involving trouble falling asleep, staying asleep, or getting quality sleep. CBT-I aims to improve sleep habits and behaviors by identifying and changing the thoughts and the behaviors that affect the ability of a person to sleep or sleep well.

An orexin receptor antagonist, or orexin antagonist, is a drug that inhibits the effect of orexin by acting as a receptor antagonist of one or both of the orexin receptors, OX1 and OX2. Medical applications include treatment of sleep disorders such as insomnia.

<span class="mw-page-title-main">Pittsburgh Sleep Quality Index</span>

The Pittsburgh Sleep Quality Index (PSQI) is a self-report questionnaire that assesses sleep quality over a 1-month time interval. The measure consists of 19 individual items, creating 7 components that produce one global score, and takes 5–10 minutes to complete. Developed by researchers at the University of Pittsburgh, the PSQI is intended to be a standardized sleep questionnaire for clinicians and researchers to use with ease and is used for multiple populations. The questionnaire has been used in many settings, including research and clinical activities, and has been used in the diagnosis of sleep disorders. Clinical studies have found the PSQI to be reliable and valid in the assessment of sleep problems to some degree, but more so with self-reported sleep problems and depression-related symptoms than actigraphic measures.

Sleep disorder is a common repercussion of traumatic brain injury (TBI). It occurs in 30%-70% of patients with TBI. TBI can be distinguished into two categories, primary and secondary damage. Primary damage includes injuries of white matter, focal contusion, cerebral edema and hematomas, mostly occurring at the moment of the trauma. Secondary damage involves the damage of neurotransmitter release, inflammatory responses, mitochondrial dysfunctions and gene activation, occurring minutes to days following the trauma. Patients with sleeping disorders following TBI specifically develop insomnia, sleep apnea, narcolepsy, periodic limb movement disorder and hypersomnia. Furthermore, circadian sleep-wake disorders can occur after TBI.

Confusional arousals are classified as “partial awakenings in which the state of consciousness remains impaired for several minutes without any accompanying major behavioural disorders or severe autonomic responses”. Complete or partial amnesia of the episodes may be present.

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  40. ↑ Aloia, Mark S.; Arnedt, J. Todd; Riggs, Raine L.; Hecht, Jacki; Borrelli, Belinda (2004). "Clinical management of poor adherence to CPAP: motivational enhancement". Behavioral Sleep Medicine. 2 (4): 205–222. doi:10.1207/s15402010bsm0204_3. ISSN   1540-2002. PMID   15600056. S2CID   30892416.
  41. ↑ Drakatos, Panagis; Marples, Lucy; Muza, Rexford; Higgins, Sean; Gildeh, Nadia; Macavei, Raluca; Dongol, Eptehal M.; Nesbitt, Alexander; Rosenzweig, Ivana; Lyons, Elaine; d'Ancona, Grainne (January 2019). "NREM parasomnias: a treatment approach based upon a retrospective case series of 512 patients". Sleep Medicine. 53: 181–188. doi:10.1016/j.sleep.2018.03.021. ISSN   1389-9457. PMC   6558250 . PMID   29753639.
  42. ↑ Hauri, Peter J.; Silber, Michael H.; Boeve, Bradley F. (2007-06-15). "The Treatment of Parasomnias with Hypnosis: a 5-Year Follow-Up Study". Journal of Clinical Sleep Medicine. 3 (4): 369–373. doi:10.5664/jcsm.26858. ISSN   1550-9389. PMC   1978312 . PMID   17694725.
  43. ↑ Baron, Kelly Glazer; Duffecy, Jennifer; Reid, Kathryn; Begale, Mark; Caccamo, Lauren (2018-01-10). "Technology-Assisted Behavioral Intervention to Extend Sleep Duration: Development and Design of the Sleep Bunny Mobile App". JMIR Mental Health. 5 (1): e3. doi: 10.2196/mental.8634 . ISSN   2368-7959. PMC   5784182 . PMID   29321122.
  44. ↑ Henst, Rob H. P.; Pienaar, Paula R.; Roden, Laura C.; Rae, Dale E. (December 2019). "The effects of sleep extension on cardiometabolic risk factors: A systematic review". Journal of Sleep Research. 28 (6): e12865. doi: 10.1111/jsr.12865 . ISSN   1365-2869. PMID   31166059. S2CID   174818171.
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