Cognitive behavioral therapy for insomnia associated with traumatic brain injury: A single-case study

doi:10.1016/j.apmr.2003.11.036

Archives of Physical Medicine and Rehabilitation

Volume 85, Issue 8, August 2004, Pages 1298-1302

Presented in part at the Association of Professional Sleep Societies meeting, June 2002, Seattle WA.

https://doi.org/10.1016/j.apmr.2003.11.036 Get rights and content

Abstract

Ouellet M-C, Morin CM. Cognitive behavioral therapy for insomnia associated with traumatic brain injury: a single-case study. Arch Phys Med Rehabil 2004;85:1298–302.

Objective

To test the efficacy of a cognitive behavioral therapy (CBT) for insomnia with a patient with traumatic brain injury (TBI).

Design

Single-case study.

Setting

Outpatient rehabilitation center.

Participant

A man in his late thirties who sustained a moderate TBI in a motor vehicle crash and who developed insomnia. He complained of difficulties falling asleep and staying asleep, despite pharmacotherapy with zopiclone.

Interventions

Eight weekly individual CBT sessions. Treatment included stimulus control, sleep restriction, cognitive therapy, and sleep hygiene education.

Main outcome measures

Sleep diary and polysomnography data.

Results

Sleep onset decreased from 47 to 18 minutes, and nocturnal awakenings dropped from 85 to 28 minutes on average at posttreatment. Sleep efficiency also increased substantially (58% to 83%). Polysomnography evaluations corroborated the diary data by showing a decrease in total time awake (63.2 to 26.3min) and in the number of awakenings (21 to 7.5). The majority of gains were well maintained at 1- and 3-month follow-up assessments.

Conclusions

These preliminary results suggest that sleep disturbances after TBI can be alleviated with a nonpharmacologic intervention. CBT for post-TBI insomnia is a promising therapeutic avenue deserving more scientific and clinical attention.

Section snippets

Methods

The patient was a man in his late thirties with a high school education. He was married, lived with his wife and young children, and worked as a technician on an assembly line. His medical history was unremarkable until August 2000, when he was involved in a motor vehicle crash (MVC) and sustained a TBI of moderate severity. On arrival at the hospital, his Glasgow Coma Scale score was 13/15. No coma was observed but his posttraumatic amnesia lasted from 5 to 7 days. A computerized axial

Results

Fig 1, Fig 2, Fig 3, Fig 4 show that CBT induced substantial improvements in sleep parameters in our patient. Sleep onset latency, which averaged 47 minutes before treatment, dropped to 18 minutes, and time spent awake after sleep onset decreased from to 85 minutes to an average of 28 minutes posttreatment (fig 1). These values fell below the clinical criterion of 30 minutes that is used to determine the clinical significance of insomnia symptoms. Sleep efficiency was markedly increased, from

Discussion

These preliminary results suggest that sleep disturbances after TBI can be alleviated with a psychologic intervention. This study represents the first demonstration that CBT for post-TBI insomnia is a promising therapeutic avenue that deserves more scientific and clinical attention.

As for other patients with medical conditions, it may be assumed that patients with TBI would not benefit from a cognitive behavioral intervention for insomnia perhaps because of cognitive limitations or because a

Conclusions

Even though the present data are limited to 1 patient, we hope our results will stimulate interest in both the scientific and clinical realms in nonpharmacologic treatment options for insomnia in patients with TBI. CBT for insomnia involves simple procedures that could easily be implemented during rehabilitation by mental health professionals, either as a therapeutic or as a preventive tool. Improving patient’s ability to sleep may facilitate the rehabilitation process, as well as the patient’s

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Sleep disorders in traumatic brain injury
2021, Neurocirugia
El propósito de la revisión es recopilar la literatura actual más relevante sobre los mecanismos de sueño normal y los trastornos del sueño asociados al traumatismo craneoencefálico (TCE), discutir las afecciones más frecuentes y la evidencia sobre sus posibles tratamientos y futuras investigaciones.
Los trastornos del sueño son extremadamente prevalentes tras un TCE (30-84%). El insomnio y los trastornos del ritmo circadiano son los trastornos más frecuentes entre la población que ha sufrido TCE leve, mientras que los trastornos por hipersomnia son más frecuentes en poblaciones que han sufrido TCE moderado y grave. El síndrome de apneas obstructivas del sueño y el síndrome de piernas inquietas son también muy frecuentes en estos pacientes; y los pacientes expuestos a múltiples TCEs (veteranos de guerra) son especialmente susceptibles a sufrir trastornos del sueño. El tratamiento de estos trastornos requiere tener en cuenta las particularidades de estos pacientes.
Como conclusión, el diagnóstico y tratamiento de los trastornos del sueño debería convertirse en parte de la práctica clínica habitual, y dejar de ser anecdótico (como es hoy en día) en pacientes con TCE. Además, es necesario continuar realizando investigación que nos revele cuál es la mejor aproximación terapéutica en estos pacientes.
The purpose of the review is to collect the most relevant current literature on the mechanisms of normal sleep and sleep disorders associated with traumatic brain injury (TBI), to discuss the most frequent conditions and the evidence on their possible treatments and future research.
Sleep disorders are extremely prevalent after TBI (30-84%). Insomnia and circadian rhythm disorders are the most frequent disorders among the population that has suffered mild TBI, while hypersomnolence disorders are more frequent in populations that have suffered moderate and severe TBI. The syndrome of obstructive sleep apnea and restless leg syndrome are also very frequent in these patients; and patients exposed to multiple TBIs (war veterans) are especially susceptible to sleep disorders. The treatment of these disorders requires taking into account the particularities of these patients.
In conclusion, diagnosis and treatment of sleep disorders should become part of routine clinical practice and cease to be anecdotal (as it is today) in patients with TBI. In addition, it is necessary to continue carrying out research that reveals the best therapeutic approach to these patients.
Non-pharmacological treatment for insomnia following acquired brain injury: A systematic review
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Citation Excerpt :
All studies were prospective. A total of nine studies examined participants with TBI [12,13,26–32], six studies examined stroke [33–38] and one study combined participants with TBI or stroke [39]. The severity of TBI among participants ranged from mild to severe.
Insomnia symptoms following acquired brain injury are serious and common, associated with cognitive and emotional complaints. This systematic review aims to summarize and appraise the current knowledge regarding the efficacy of non-pharmacological treatments for insomnia after traumatic brain injury and stroke in adults. A systematic search in the electronic databases of Medline, PsycINFO and Embase was conducted on January 15, 2019. The search strategy included traumatic brain injury or stroke and a combination of keywords and Boolean operators to represent the concept of insomnia. Articles were restricted to those in English and study populations of human adults. A total of 4341 studies were found, of which 16 were included, representing seven different non-pharmacological treatments. While the quality and quantity of the studies does not allow for firm conclusions, the outcomes suggest that cognitive behavioural therapy improves insomnia and sleep quality. The results highlight the need for larger studies of better methodological quality on non-pharmacological interventions for insomnia following brain injury.
Traumatic Brain Injury
2020, Braddom's Physical Medicine and Rehabilitation
Traumatic brain injury (TBI), defined as a traumatic blow or jolt to the head, or penetrating trauma to the skull that injures the brain, is a worldwide epidemic that has a substantial impact on global health and function. In this chapter, we overview TBI epidemiology and health care costs as well as discuss the fundamental pathophysiology associated with primary and secondary injury. We discuss TBI across the injury severity spectrum and continuum of care and also in the context of other injury complex elements such as injury due to blast, hypoxic-ischemic brain injury, polytrauma, and shaken-baby syndrome. We discuss how TBI influences neurotransmission and the myriad of secondary symptoms, conditions, and complications that arise due to TBI. Key testing and medical management approaches are discussed, and the roles of rehabilitation team members across the continuum of care are outlined. Translational research perspectives, including biomarkers and imaging modalities, as well as community integration and TBI prevention strategies are discussed. This comprehensive overview of TBI provides up-to-date perspectives and the fundamental literature needed for rehabilitation clinicians to be knowledgeable and address TBI epidemiology, pathophysiology, secondary conditions, management, prognostication, outcome, community reintegration, and prevention. Pediatric perspectives on these areas as also provided.
Towards a better understanding of increased sleep duration in the chronic phase of moderate to severe traumatic brain injury: an actigraphy study
2019, Sleep Medicine
Most adults with moderate to severe traumatic brain injury (TBI) report persistent sleep-wake disturbances. Whether these complaints are either associated with abnormal sleep-wake patterns or can be explained by TBI-related characteristics is unclear. The present study aimed at characterising the subjective and objective sleep-wake patterns in TBI adults by taking into consideration the influence of TBI severity, common comorbidities and psychoactive medication.
Overall, 34 adults with moderate-severe TBI (one to four years post-injury) were compared to 34 controls. Sleepiness, fatigue, sleep quality, mood, and pain were assessed with questionnaires. A seven day sleep diary and actigraphy was used to document sleep and wake patterns.
Compared to controls, TBI participants reported more sleepiness and fatigue, as well as poorer sleep quality. On actigraphy, they had earlier bedtime and longer time spent in bed, but equivalent sleep efficiency during the nighttime episode compared to controls. TBI participants also took more naps and accumulated more time asleep over the 24 h period than controls. These group differences were accentuated when only TBI adults using psychoactive medication were included. More comorbidities, more severe injuries and longer hospital stay were positively correlated with fatigue, sleepiness and sleep duration.
Our results showed that despite complaints regarding sleep and diurnal functioning, TBI survivors have very marginal changes in their objective sleep-wake schedules. Prolonged time spent in bed may reflect an attempt to increase their sleep duration in response to fatigue and sleepiness. TBI adults who use psychoactive medication are those with more evident changes in their sleep-wake schedules.
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2019, Handbook of Sleep Disorders in Medical Conditions
Traumatic brain injury (TBI) can affect multiple domains of functioning, including physical health, psychological health, cognition, and socio-occupational life. Sleep–wake disturbances are among the most common consequences of TBI. They can be present even years postinjury, and they interact with other conditions linked to the brain injury such as cognitive deficits, psychopathology, pain, and chronic fatigue. Sleep–wake disturbances thus affect recovery, the rehabilitation process, and the person’s capacity return to premorbid functioning. This chapter will present a brief overview of TBI, followed by sections on sleep–wake disturbances in the acute and chronic phase, pathophysiology, and potential impact of sleep–wake disturbances on TBI recovery. Then, the three main types of sleep–wake disturbances will be discussed, in terms of epidemiology, assessment, and treatment: insomnia, excessive daytime sleepiness and associated disorders, and circadian sleep–wake rhythm disorders.
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^☆: Supported by the Fonds de la Recherché en Santé du Québec.

¹: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

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ArticlesCognitive behavioral therapy for insomnia associated with traumatic brain injury: A single-case study1☆,

Abstract

Objective

Design

Setting

Participant

Interventions

Main outcome measures

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusions

Arch Phys Med Rehabil

Clin Psychol Rev

J Behav Ther Exp Psychiatry

Am J Med

Behav Ther

J Psychosom Res

Clin Psychol Rev

Sleep complaints in chronic postconcussion syndrome

Percept Mot Skills

Temporally related changes of sleep complaints in traumatic brain injured patients

J Neurol Neurosurg Psychiatry

Nonpharmacological interventions for insomniaa meta-analysis of treatment efficacy

Am J Psychiatry

Articles
Cognitive behavioral therapy for insomnia associated with traumatic brain injury: A single-case study¹☆,