WAKE UP
PROBLEM
to the
PhD Research
Why Sleep?
Epidemiological studies suggest insomnia symptoms occur in approximately 35%–50% of adults, with approximately 10% meeting diagnostic criteria for insomnia.
Insomnia is characterized by chronic difficulty with either falling asleep, staying asleep, or waking too early with associated daytime impairment(s) occurring 3 times/week for 3+ months.
"...disrupted sleep
is a public health
pandemic..."
World Health Organization, 2021
Globally Highly Prevalent
Disordered sleep and insomnia are highly prevalent, estimated to impact 30-60% of the world's population, and are on the increase.
Disease
Risk Factor
Sleep plays a critical role in physical and psychological well-being. Chronic sleep problems are linked to worsened health outcomes.
A persistent difficulty falling or staying asleep that impairs daily functioning is the most common type of insomnia.
Can't fall asleep!
Onset
Insomnia
Can't stay asleep!
Maintenance Insomnia
Chronicity of sleep problems over 3 months and level of impairment differentiates acute from chronic insomnia.
Sleep
Takes Out
the Trash
The image is credited to Laura Lewis, Boston University.
During sleep, the brain does its housekeeping.
The change in neural activity associated with sleep results in the flow of blood out of the brain, to be replaced by cerebrospinal fluid (CSF) that rhythmically removes the toxins associated with neuronal activity.
Disrupted sleep prevents the needed clean-up, resulting in a buildup of toxic proteins that appears to be associated with impaired brain function.
Research by Fultz et al., (2019) shows large rhythmic waves of CSF during deep sleep (blue) occurring immediately after waves of oxygenated blood (red) leave the brain.
IMPACT
of Chronic
Disordered sleep
Premature Death
Disordered sleep is a risk factor in 8 of the 10 leading causes of premature death or preventable diseases. It is associated with greater health care utilization.
Risk Injury
Disrupted sleep increases the risk of all types of accidents and injuries. The relationship between poor sleep and motor vehicle accidents is very strong.
Preventable Co-Morbid Diseases
Many of the physical disorders that are associated with disordered sleep are preventable and insomnia is frequently reported in psychiatric disorders.
Poor Health
Chronic insomnia is associated with a long period of difficulty falling or staying asleep and is associated with an increased risk of multiple health conditions including cardiovascular disease, Alzheimer’s and Parkinson's disease, cancer, diabetes, obesity, and pain.
DISRUPTED SLEEP
"...the canary in the psychiatric coal mine..."
Disordered sleep is endemic in all psychiatric disorders and is believed to have a bidirectional relationship. Insomnia is a risk factor for depression, anxiety, PTSD, and suicide.
Emerging research points to sleep as the trigger of psychiatric disorders.
Insomnia &
Psychiatric Disorders
Disrupted sleep is a presenting, predisposing, precipitating, perpetuating, and protective factor
in all types of psychiatric disorders.
Insomnia is the most common sleep disorder and is predictive of the new onset of depression, anxiety, alcohol
and substance use, nicotine dependence, recurrence of depression, and worst outcomes.
Disordered sleep during adolescence equates to an increased risk of depression in later life.
Difficulty falling asleep, early morning awakening, and hypersomnia are risk factors for suicidal behavior independent of psychiatric history, in adolescents and adults.
Insomnia & Depression
COMMON Pathophysiology
The striking association between insomnia and depression in so many studies suggests that insomnia is an early marker for the onset of depression, and the two may be linked by common pathophysiology.
Although the pathophysiological relationship is not known, the overlapping neural pathways that regulate sleep also regulate mood and anxiety.
It's unclear if the temporal association between insomnia and psychiatric disorders is an early manifestation or potential trigger.
The impact of insomnia is believed to be bi-directional, with the strongest causal pathway being disrupted sleep preceding psychiatric illness.
Disordered sleep is a more powerful predictor of suicide than a suicidal intent or plan.
Sleep Circuits for A: Wakefulness, B: Non-Rapid Eye Movement (NREM), C: Rapid Eye Movement (REM)
#1
Depression
Globally depression is the leading cause of disability and is strongly correlated to insomnia.
Increases Wellbeing
Untreated insomnia negatively impacts health and well-being resulting in reduced quality of life.
Reduces
Risk
Disordered sleep is a risk factor for all psychiatric disorders and death by suicide.
Improves
Mood
Chronic sleep problems make depression and anxiety more likely to start, persist, or return.
Treatment
Recommendations
Cognitive Behavioral Therapy is a type of structured evidence-based talk therapy (psychotherapy) that was developed for the treatment of depression.
With the support of a trained therapist, typically over 12 consecutive psychotherapy sessions, an awareness of the negative thoughts contributing to depression is made and new ways to view and challenge those thoughts are learned.
Multiple studies have shown the efficacy of CBT to treat depression and considering the prevalence of insomnia with depression, a modified version of CBT was developed to target disordered sleep.
CBT for insomnia (CBT-i) has become a first-line treatment for insomnia across the globe
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IMPORTANCE
Insomnia Treatment
For many insomnia is a new symptom after recovery from depression and anxiety.
In 94.6% of people, insomnia persists after depression symptoms have improved.
Approximately 80% of people who wake in the middle of the night can't resume sleep.
Adjunctive Treatments
Medications such antidepressants, anxiolytics, and sedatives can lead to improved sleep as a function of treating another psychiatric disorder such as depression or anxiety.
Behavioral Treatment
Cognitive impairment, lack of attention, memory, and focus associated with depression pose challenges to cognitive-based treatments.
Online treatments and Apps increasing reach but accessibility remains low.
Limited accessibility and availability to skilled clinicians, particularly in rural areas.
The improvements associated with CBT-I typically only emerge after 3-4 weeks, reducing treatment adherence rates further.
Insomnia often results in cognitive impairment, lack of attention, memory, and focus posing treatment challenges.
Low mood and disordered thought processes are common in psychiatric disorders as is insomnia, making treatment difficult.
The reemergence of old behavioral patterns following CBT-I is common and insomnia relapse is frequent.
Initial treatment stages lead to reduced total sleep time and followed by greater daytime sleepiness resulting in high dropout rates.
CBT-i requires persistence, perseverance, and commitment, and treatment discontinuation is common.
The recommended behavioral changes of sleep restriction often seem counterproductive, and result in low adherence rates.
Promising New Treatments
The distress and risks of under-treated insomnia and the limitations of cognitive-behavioral approaches warrant exploration of alternative treatments and delivery modalities.
Different approaches have been explored for the treatment of disordered sleep that focus on addressing the overthinking or inability to 'switch off' that many people with insomnia experience.
Mindfulness-based approaches have the benefit of providing a means to be aware of unwanted thoughts that may be contributing to depression and disordered sleep while supporting the urge to address the thoughts, to avoid or challenge them.
Stress & Anxiety Contributes to Inability to Fall Asleep.
Worry & Demands Associated With Early Rising.
Mindfulness
Stress Reduction
Jon Kabat-Zinn at the University of Massachusetts Medical School, Center for Mindfulness brought mindfulness meditation outside of traditional eastern practices.
Mindfulness has no religious connections it's an approach that teaches different ways to reduce stress and anxiety,
By learning to be aware and accepting of unwanted or distracting thoughts by learning to not respond to them facilitates sleep.
Therapeutic Application of
Mindfulness for Insomnia
Mindfulness has been shown to improve reduce stress, anxiety, depression, and pain and concurrently improve disordered sleep.
It's hard to sleep when you're in pain.
Mindfulness
Facilitates
Lower Pain
Effectively lowers pain and stress.
Better Sleep
Reduced pain better sleep.
For Everyone
Suitable for all insomniacs.
Mindfulness
Training
Takes Time
Distraction is all around. Focusing is difficult.
Facilitating
Mindfulness Practice
Findings ways to offer the benefits of mindfulness while overcoming the initial challenges of developing a mindfulness practice mindfulness and developing sustained attention and focus to benefit more readily from mindfulness.
Power
Virtual
Reality
of
The
Not just for gaming.
Visual System
The visual system is the highway that delivers information to the brain and appears to modulate cortical activity.
The information captured by each eye travels through its respective optic nerve arriving at the orbito-frontal region of the brain to then be combined at the optic chiasm to enable stereoscopic perception.
The information from the visual field is then relayed to the lateral geniculate nucleus (LGN) located in the hypothalamus and processed.
Image: Miquel Perello Nieto, CC BY-SA 4.0 via Wikimedia Commons
Brain Circuits
Using optic radiation, the LGN then sends the information to the right and left primary visual cortex, and the associated visual cortex located at the back of the brain just above the cerebellum.
A few axons (nerve cells) in the visual system connect to the superior colliculus in the mid-brain that controls eye movements.
The visual system is part of the central nervous system and outside of conscious control. VR uses the visual system to modulate brain circuits and facilitate focused attention.
Anyone Can Use VR
Therapeutic Applications of VR
PAIN
VR is extremely effective at providing pain relief during medical and is comparable to medication.
INJURY
Has been used to support rehabilitation following physical injury in clinic and at home.
FEAR
Used in the management of mood and anxiety disorders including phobias and PTSD.
Suitability of VR for Insomnia
S
SCALABLE
Different populations, and skill levels, supports rehabilitation in clinical settings and encourage at-home treatment adherence.
Treatment delivery has high acceptability and user engagement.
Enables entertaining, adaptive feedback, increasing motivation and improving outcomes.
Is an ecologically valid environment to explore factors that contribute to insomnia.
L
LOW-RISK
A meta-analysis on the safety of VR treatment reported significant low to large changes in outcome with low attrition rates.
The use of VR technology supports a safe and rapidly efficacious modality for the delivery of psychological treatment.
Evidence of VR's ability to address comorbid cognitive impairment and chronic pain as a secondary benefit.
E
EFFECTIVE
Four weeks of twice-weekly VR for insomnia resulted in significant reductions in anxiety and improvements in mood.
Patients in intensive care showed improvements in sleep quality using a VR meditation protocol, recommended addition to clinical care.
Faster sleep onset, fewer awakenings, lower heart rate during sleep, and less sleep fragmentation using VR relaxation vs control.
E
EQUIVALENT
Comparable efficacy for Phobia treatment has used VR exposure to gold standard in-vivo, may surpass once procedures improve.
A meta-analysis of VR for depression and PTSD reported greater symptom reductions compared to waitlist and control.
In a review of 285 VR studies, 54% focused on psychiatric disorders concluded the strongest evidence for the treatment of anxiety.
P
POTENTIAL
Has the potential to reduce insomnia associated with environmentally conditioned responses.
The objective impact of VR treatment in Parkinson's patients showed improvements to sleep quality and sleep-related biomarkers.
Merging VR and biometric devices enables improved treatment by behavioral modifications and learning to target individual symptoms.
Virtual Reality
VR for insomnia has the potential to help millions of people live longer, healthier, happier lives.
PhD Supervisors
I am fortunate and extremely grateful to have A/Prof Lisa Lampe, MBBS, PhD at the University of Newcastle an expert on anxiety and A/Prof Christopher Gordon, RN, PhD, at the Woolcock Institute experts on sleep as my PhD supervisors.
