Insomnia and Cancer: Causes and Treatments throughout the Continuum
Sarosh J. Motivala, PhD, Assistant Professor, Semel Institute for Neuroscience at the David Geffen School of Medicine at UCLA and health psychologist
This is a summary of a presentation on September 9, 2008.
Sleep difficulties can be very disruptive to well-being and many people talk about having insomnia. Insomnia is a misunderstood term with many misconceptions such as “people who rarely or never sleep.” This is not the case. A good working definition of insomnia is when “An individual person is unable to get the sleep that they need.” Sleep can be broken down into different components. Falling asleep (referred to as initiating sleep) can be difficult for some people. It is usually considered problematic if this process takes longer than 30 minutes. Others suffer from difficulty maintaining their sleep. Some people think that maintaining sleep means never waking up at night, but this is also a misconception. Most people wake up several time each night but go back to sleep relatively easily. Insomnia is associated with people who wake up and are unable to go back to sleep within 30 minutes. Poor sleep efficiency means that someone spends a low percentage of their time in bed actually sleeping. Good sleep efficiency means that someone is actually asleep for 85% of the time that they are in bed sleeping. Finally, sleep problems that cause significant impaired functioning or distress are important in defining insomnia. Some people sleep very little but have neither impairment nor distress─this does not constitute insomnia. Insomnia is a condition in which affected people are not able to get the sleep that they need.
Contributors and Perpetuators of Insomnia
Insomnia can be transient (less than one month), short-term (1-6 months) or chronic (greater than 6 months). The good news is that behavioral treatments work just as well for people who have had it for a short-term as for those who have had it for a long-term. Insomnia occurs in about 10-15% of the general population; these numbers are usually higher in women and older adults. About 30-50% of people actively undergoing cancer treatments have problems sleeping. About 20% of patients with cancer have full-blown insomnia; most studies have been conducted with breast and prostate cancer patients. Cancer survivors (23-44%) report having sleep problems five years after treatment and 20% meet the criteria for full-blown insomnia.
Individuals who are likely to develop insomnia include women, older adults and people with a personal or family history of insomnia. Psychiatric difficulties such as depression and anxiety are also associated with poor sleep. Women have higher rates of depression, higher pain symptoms and more menopausal night sweats that interrupt their sleep and may contribute to these difficulties.
Insomnia can be triggered by a variety of things. Stress and anxiety are significant contributors. Loss and pain are also problematic. Being admitted to the hospital can disrupt sleep as well. In addition, for people with cancer there are many treatment-related triggers, such as radiation therapy, which usually remits over time. Chemotherapy ─ especially related to nausea, vomiting and some of the anti-emetic (anti-nausea and vomiting) medications ─ is also a trigger. Estrogen deficiency (tamoxifen can produce vasomotor symptoms) can disrupt sleep. These symptoms may wake you up but the important variable is how long it takes to go back to sleep. Other medications can disturb sleep, such as steroids or opioids which are used for pain management. It is important to remember that insomnia is usually not caused by one single factor and, thus, interventions that target various aspects of the sleep problems are going to have stronger and longer lasting effects.
Insomnia is also perpetuated by specific activities that may be under your control. Poor sleep habits can all lead to more insomnia, including spending non-sleep time in bed, napping during the day and irregular sleep schedules. How one copes with stress, tension and loss can negatively impact and worsen already difficult sleep. Nighttime worries are one of the most common psychological concerns. Many people describe having “racing thoughts” which make it difficult to become calm and relaxed. Nighttime is not the best time to create your list of things to be done the next day or to begin developing strategies to resolve problems. These are activating mental states which do not promote sleep. When you are already sleep deprived they can cause more fatigue; when you have no energy to do things it can lead to shutting down and isolating yourself from your social network. Isolation can add to depression and this can make insomnia worse. Of course, the experience of feeling helpless and paralyzed about changing sleep patterns can also perpetuate an already difficult scenario. It is easy to see how you can develop a cycle of perpetuating sleeplessness!
Insomnia is impacted by your sleep habits, stress, mood, medications and pain. There are many interventions you can do to target all of these different triggers. You can improve your mood, stress and sleep habits and that may make enough difference to change your insomnia from an intolerable to an acceptable level of sleep. What is an acceptable amount of sleep? On average people report that they get about 7-8 hours of sleep but there is no set amount that is needed for everyone; each of you is unique and each of you has different needs at different times of your life. As we get older (over the age of 50) we tend to need less sleep and sleep amounts decrease to around 7- 7.5 hours per night. Sometimes older adults hang on to the belief that they need eight hours but that may not be true. A healthy sleeper can wake up 2-3 times per night; people with insomnia do not easily go back to sleep while a healthy sleeper returns to sleep quickly after waking.
If you are having trouble sleeping chances are you have been offered medication as a treatment. The most common medications are drugs which fall into a category called hypnotics. The newer ones include Lunesta (eszopiclone), Ambien (zolpidem tartrate) and Sonata (zaleplon). The benzodiazepines have been around for a long time and include drugs such as Ativan (lorazepam), Klonopin (clonazepam), Valium (diazepam), Xanax (alprazolam), Restoril (temazepam) and Halcion (triazolam). Most of the sleep studies that have looked at these medications have been very short term, only following people for 14 days. These treatments have not been studied for long term insomnia or in older adult populations. In studies that have compared how quickly someone falls asleep with medications vs. controls, the startling result is that participants fell asleep an average of only 5-10 minutes quicker with medications! When reviewing sleep records of drug trials analyzing the effects of benzodiazepines versus placebo treatments it was found that people got on average about one hour of extra sleep on benzodiazepines.
Drug-free Strategies that Improve Sleep
There is some evidence to suggest that 30 minutes per day of aerobic exercise can improve sleep. although there are only a few studies that document this and it is unclear about when this exercise should occur. There is some data to suggest that Tai Chi, an ancient form of calisthenics and meditative movements, may also improve sleep. It improves flexibility, balance and increases feelings of relaxation. Qi Gong, another ancient Chinese activity that affects energy and balance, is offered through the Center on a weekly basis and may also help facilitate sleep.
There is considerable data to suggest that cognitive-behavior therapy (CBT) is the gold standard for improving insomnia. Two studies published in the Journal of the American Medical Association in 1999 and in 2006 found that CBT is helpful for chronic insomnia. One study compared it against one of the newer prescription sleep medications; six months after the CBT intervention sleep continued to improve. Of note, it is usually a relatively short therapy of 6-10 visits. CBT uses a combination of behavioral techniques to influence sleep and behaviors associated with sleep.
Tracking Sleep
The first step in altering sleep is to first determine what is wrong with your sleep by tracking your sleep daily, using a journal. It is not enough to think that you will remember the impact. You need to assess where you are now (before) and then compare it after interventions (later) so that you can see what percentage improvement there was in your sleep pattern. The diary helps you increase your knowledge about your sleep patterns and identifies where problems lie as well as allowing you to track improvements. A sleep diary should be kept for a week at a time by creating a grid.
From this grid you can then calculate on a weekly basis the following:
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How long it takes you to fall asleep?
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How many times you wake up during the night?
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How long you stay awake when you wake up during the night?
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How much sleep did you get?
Improving your Sleep Environment
The next step is to work on improving your sleep environment. The environment that you sleep in plays a significant role in how well you sleep. Notice the noise, the lighting, the room temperature, the bedding, where your clock is and any bedmate issues. If your bedmate tends to snore, it may be important to have a discussion with him or her about what can be done, including sleeping in different bedrooms. Men have a tendency to snore more than women. One of the primary causes of snoring is being overweight; even being slightly overweight can cause snoring. Sleep apnea can also cause snoring and should be evaluated by a qualified expert. If you stare at the clock, then remove it or turn it around. It is not helpful to stare at it, watching time slip away.
Good Sleep Habits
The third step is to develop good sleep habits that condition our bodies to associate the bed with sleep. One of the first demonstrations of “classical conditioning” was done by Pavlov with dogs. He noticed that dogs would salivate autonomatically when he presented them with food. Next, he rang a bell each time he presented food. Over time, the dogs associated the bell with food, and the dogs began to salivate when Pavlov rang the bell. This illustrated that we can condition a fundamental response to something unrelated (the bell). Pavlov noticed that when he stopped presenting the food, but kept ringing the bell, eventually the dogs stopped salivating to the bell. How does this relate to sleep? Our bodies need to be conditioned to sleep when presented with a bed. In poor sleepers, the connection between the bed and sleep is weakened. The goal of improving sleep habits is to strengthen this connection.
There are three parts to this reconditioning: (1) linking being in bed with sleep, (2) linking Nighttime hours to sleep and (3) limiting Nighttime and the bedroom to non-stimulating activities.
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To link the bed with sleep you should not use your bed for anything except sleep or sex. Do not read, watch television, surf the web or talk on the phone while in bed. Of course, if you have NO sleep problems and do these things it is fine to continue these activities BUT if you do have sleep difficulties you must avoid these activities in the bed.
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The next strategy is to link nighttime hours with sleep. Avoid napping during the day or early evening. If you cannot avoid taking a nap, do it in the early afternoon at the same time each day for about 30-45 minutes. Try to be consistent. Aim for a consistent bedtime, but lie down only when sleepy.
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If you are not sleepy do not get into bed; go to another room and do something that is not stimulating. Nighttime activities and the bedroom must be as non-stimulating as possible. Do not try to work, pay bills or make a “to do list” for tomorrow, don’t clean, don’t organize, don’t start projects. Essentially you want to do something that is as useless as possible. Finally, get out of bed at the same time each morning. The recurrent theme is consistency.
Mental activity also prevents us from falling asleep. Other brain areas can override sleeping so don’t set up competition. One of the most common types of mental activation is worrying, which can feel like racing thoughts, and can lead to emotions such as anxiety, irritation, anger and hopelessness; this makes sleep difficult. Sometimes the worrying can take the form of worrying about not sleeping. Common things that we say to ourselves about not sleeping are: “I really need my sleep,” “I won’t be able to function tomorrow morning,” “I’m going to be really worn out tomorrow,” and “Will I ever sleep like I used to?” These thoughts will not help you get to sleep but rather create the same set of emotions as other worries. It is important to develop a strategy for dealing with Nighttime worries. Fast, stop-gap techniques generally involve a form of distraction and relaxation. You may be able to teach yourself the technique of “thought stopping.” The first part of “thought stopping” is to have an awareness which often begins with a question, “What am I thinking about right now?” followed by the question, “Am I worrying?” Once this awareness is achieved you must remind yourself that this is not the time to worry and then remind yourself that you are not going to think about this at this time. This usually must be done repetitively until the thought is stopped. Another method that can be used to stop mental activity is a breathing technique, such as a simple slow diaphragmatic breath. These types of breaths make your abdomen rise as you inhale rather than being only in your chest. Do this for just a couple of minutes. It helps create relaxation. Simple imagery of a relaxing happy scene or place can also change your mental activation from racing thoughts to a relaxed place. Before your bedtime, take a few minutes to create a few of these relaxing images and write them down on an index card to keep next to your bed. They can be of a vacation spot, a childhood home, a fantasy or a dream location. Refer to your cards at night as needed to help derail and retrain your mind to a calm place that is less upsetting and activating.
Resources for Sleep
While these suggestions may be enough for some people to retrain their sleep, some of you may need the help of a qualified therapist or other clinician. Some additional resources that may be helpful are:
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UCLA Sleep Disorders Center - 310 206-8005
Summary
Remember, sleep is not willed, we cannot make it occur. We can only clear our external and internal environment to encourage sleep to occur. I hope these behavioral techniques provide some tools to do this.
Editor’s Note: Depression can play a major role in sleep difficulties and treatments for depression can include both therapeutic interventions involving cognitive behavior therapy as well as anti-depressant medications.
The Simms/Mann -- UCLA Center for Integrative Oncology offers a variety of programs that may be helpful to individuals who are trying to assess and treat their sleep difficulties such as:
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Evaluation of medications by a psychiatrist to determine if they are useful for sleep or if there are better ones, including evaluating depression. This is a new program that began June, 2008. After seeing a clinician such as our oncology social workers or health psychologists you may receive a referral to a psychiatrist housed in the Center. (This program is covered by many insurance companies).
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Qi Gong has similarities to Tai Chi and consists of exercises that help people counteract the effects of stress, anxiety and anger. The breathing exercises can help people calm down and restore their energy. This group is offered every Wednesday from 10am-12pm.
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Meditation: Inner healing uses a variety of techniques to learn the relaxation response and promote inner peace and well being. Breathing techniques and guided imagery are taught during this group program.
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Mind/Body Approaches to Coping with Cancer is a workshop that teaches both relaxation techniques and some of the cognitive behavioral strategies discussed in this lecture to reframe how one talks to oneself, and thus, how one feels.
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Educational session with an Integrative Medicine physician to facilitate health and wellness and can assist in identifying strategies that may help to promote sleep and well-being (fee for service).
For information or appointments call 310 794-6644.
For reprint authorization, contact SimmsMannCenter@mednet.ucla.edu.