Australian Doctor 1st April 2022 | Page 31

HOW TO TREAT 31

ausdoc . com . au 1 APRIL 2022

HOW TO TREAT 31

patients with confidence to start
throughout the night . This started
believes they are addictive .
The GP discusses CBTi treatment
The GP introduces the ‘ two-pro-
a gradual sedative – hypnotic with-
six months ago during a stressful
His partner reports that , when
and referral options , and Martin
cess model ’ of sleep regulation ,
drawal program . A range of CBTi
period at work while he was also
Martin does sleep , he rarely snores ,
decides on BBTi with his GP .
explaining the rationale of the two
programs — including psycholo-
worried about a family member ’ s
and has not noticed any pauses in
The GP explains the five-week
behavioural treatments : bedtime
gist administered , GP administered ,
health . Despite both these issues
his breathing .
timeline and advises Martin that he
restriction therapy and stimulus
nurse administered and online pro-
having resolved , his sleep has not
His examination is normal , and
will need to keep a sleep – wake diary
control therapy that utilise sleep
grams — were found to facilitate
12 63-67 sedative – hypnotic cessation . GPs can therefore refer patients with a history of sedative – hypnotic use for CBTi to treat insomnia and increase the effectiveness of a withdrawal program
7 , 12 , 68
.
CBTi is effective when a patient is taking sedative-hypnotic medicines and , most importantly , facilitates medication withdrawal .
for the duration of the treatment . The GP provides Martin with a one-week sleep – wake diary to complete before his first appointment ( see figure 4 ).
Session one
Martin returns for his first session one
pressure and circadian rhythm . These are introduced during this
39 , 69 session . Martin and the GP discuss the nature of sleep . After falling asleep at night , our bodies progress through five sleep cycles , each last-
CASE STUDY
Initial appointment
MARTIN , 35 , presents to his GP
returned to normal . He reports a ‘ racing mind ’ when trying to fall asleep and sometimes lies awake for
a BMI of 22kg / m2 is noted . Martin scores 10 / 32 on the sleep condition indicator , indicating probable insom-
week later . The GP provides an overview of the therapy program , and they discuss the main nocturnal and daytime symptoms of insomnia and
ing about 90 minutes . Most deep / restorative sleep occurs in the first 1-2 sleep cycles , and most light sleep and REM ( dreaming ) sleep occurs
complaining of difficulty fall-
hours during the night . He would
nia , and 6 / 24 on the Epworth sleepi-
the prevalence of chronic insomnia in
in the final three cycles . Brief awak-
ing asleep and long awakenings
rather avoid sleeping pills as he ness scale .
Australia .
enings are completely normal , with
all people experiencing these but many not remembering the next morning .
When we wake in the morning , it may be difficult to remember when we were awake and asleep
during the night , making it easy to underestimate the amount of time
spent asleep .
Martin receives a pamphlet about sleep hygiene with general
information about behaviours during
the day , in the evening and
while in bed that can help or harm our sleep .
The GP and Martin also review his sleep diary from the past week ( see figure 5 ). On average , Martin reports 64 minutes to fall asleep at the start of the night ( SOL ) and 116 minutes spent awake during the night ( wake after sleep onset : WASO ) after first falling asleep .
On average , Martin estimates he spends about six hours asleep each night ( total sleep time ) but spends nine hours in bed each night ( time in bed ). According to the ‘ rules ’ of bedtime restriction therapy , if either average SOL or WASO is 30 minutes or more , it indicates that time in bed should be restricted for the subsequent week to reduce the amount of time awake throughout the night . Because Martin ’ s SOL and WASO are both 30 minutes or more , it indicates that the amount of time he spends in bed should be reduced . His time in bed should be restricted to six hours for the subsequent week to reduce the amount of time awake throughout the night . This restriction is temporary and time in bed will be extended as his sleep improves .
Martin decides to go to bed at midnight and get out of bed at 6am for the next week .
Because Martin experiences sleep-onset difficulties , he is provided with stimulus control therapy instructions ( see table 3 ). He is instructed only to go to bed when feeling sleepy , and if he is not asleep within about 15 minutes , he should get out of bed and go to

5 another room until feeling sleepy again . Bedtime restriction therapy will guide the time spent in bed , and stimulus control therapy will be used if he is having trouble falling asleep at the new bedtime .

Feelings of daytime sleepiness , especially while driving and in the late afternoon , are discussed . Daytime sleepiness can increase during the first 1-2 weeks of bedtime restriction therapy when time in bed is reduced to its lowest point . Long naps are discouraged , but a short 10-20-minute ‘ power nap ’