Staff Perspective: Examining the Link Between Mild Traumatic Brain Injury and Insomnia
It is estimated that 1.7 million traumatic brain injuries occur on an annual basis in our country, and that approximately 80% of those are mild (Dietch & Furst, 2020).
The World Health Organization (WHO) Collaborating Centre for Neurotrauma Task Force on Mild Traumatic Brain Injury defines this condition as:
“an acute brain injury resulting from mechanical energy to the head from external physical forces” (p 1, Montgomery et al., 2022). A mild traumatic brain injury (MTBI) often results in one or more of the following symptoms:
- Change in mental status such as confusion or becoming disoriented
- Loss of consciousness for 30 minutes or less
- Post-traumatic amnesia for less than 24 hours
- Transient neurological abnormalities (e.g., problems with speech, headaches, vision problems or sensitivity to light, dizziness, or balance problems).
- Emotional difficulties such as anxiety, irritable or sadness
- Problems with sleep (e.g., sleep more or less, trouble fall asleep).
For the vast majority of individuals who experience a MTBI, particularly if they were healthy beforehand, will recover and return to normal activity (Montgomery et al., 2022). However, there are individuals who have symptoms persist beyond a year post incident. Although the reasons why symptoms of MTBI may persist are still investigating, one issue that stands out are sleep problems associated with MTBI. A recent study that conducted a systematic review and meta-analysis on available studies estimated that the prevalence rate for having an insomnia disorder post MTBI at 27% (Montgomery et al., 2022). The authors of the study also found that around 72% of individuals who had a MTBI reported having symptoms of insomnia. This result is not surprising due to the overlap between the symptoms of MTBI and insomnia.
MBTI and Insomnia Overlapping Symptoms:
Fatigue
Problems with attention
Problems with concentration
Problems with memory
Problems with mood (e.g., irritability)
Sleep problems like insomnia can develop either immediately following a MTBI or later during the course of recovery. The problem with insomnia is that it can hinder the recovery process from a MTBI, and unlikely to remit without treatment even if the symptoms of MTBI improve or fully resolve (Montgomery et al., 2022). As a result, it is important for clinicians working with individuals who have suffered from a MTBI to assess their sleep functioning. If patients are struggling with MTBI and insomnia, it is important to provide evidence-based treatment such as cognitive behavioral therapy for insomnia (CBT-I) to help improve their sleep functioning.
A common question that comes up during training and consultation regarding CBT-I, is what providers should do if a patient has a comorbid condition. Research examining CBT-I for patients with comorbid TBI has demonstrated positive effects for improving a patient’s sleep efficiency, decreasing both sleep onset latency (SOL) and wake after sleep onset (WASO), improving total sleep time, and improvements with symptoms of fatigue and mood (Ludwig et al., 2020). However, there are some things that are helpful to consider when doing CBT-I with patients who have had a TBI (Almklov et al., 2022).
Dealing with memory and recall issues
- Decreasing the amount of information covered in session.This may require adding additional sessions
- Allow for time to review materials and ask questions
- Provide brief and focused rationale for treatment components
- Use of cues or reminders to help with implementing interventions (e.g., completing sleep diaries, attending appointments, reminders for bedtime and waketime)
- Allow patients to record sessions, take pictures of white boards, or write notes to help review or remember content
- Consider use of technology such as apps or wearable devices to get information about sleep functioning if completing sleep diaries is too difficult
Stimulus control and sleep restriction challenges
- If getting out of bed during the night is problematic due to concerns about balance or other factors, consider utilizing counter control (e.g., sitting up in bed and engage in a non-stimulating activity such as reading a boring book)
- Instead of having the patient leave the bedroom, have a piece of furniture nearby the bed if possible to reduce the amount of distance they have to travel
- Consider using sleep compression therapy vs sleep restriction (i.e., gradually reducing time in bed by 15-30 minutes until patient reaches a sleep efficiency of 85% or higher)
- Emphasize that resting is not the same or as beneficial as consolidate sleep
- Limit napping if possible. If a nap is needed have a scheduled time limited nap (i.e., 30 minutes)
Sleep education
- If the patient did not have sleep problems prior to the MTBI, emphasize that the expectation about full recovery
- Address how physical, cognitive, and emotional issues can affect sleep through increased arousal
- Discuss how the interventions (e.g., relaxation skills, cognitive skills) in CBT-I can be utilized to address other problems in addition to improving sleep functioning (e.g., mood problems, stress management)
- If patients require rest breaks due to fatigue or pain, schedule for timed rest
Ultimately, it is important to know that problems with sleep functioning commonly occur after having a traumatic brain injury. As a result, it is critical for providers to not only assess patients for sleep difficulties, but to ensure that they are getting effective treatment for those sleep difficulties. Evidence suggests that we as providers can have confidence in using CBT-I to address Insomnia comorbid with MTBI. This blog also reviewed considerations that can help to implement CBT-I with patients who have MTBI.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Tim Rogers, Ph.D., is a Senior Military Internship Behavioral Health Psychologist and serves as the Associate Program Director for the Air Force Clinical Psychology Internship Program at Joint Base San Antonio-Lackland Texas.
References:
Almklov, E. A., Rivera, G. L., & Orff, H. (2022). CBT-I in patients with a history of
traumatic brain injury. In Adapting Cognitive Behavioral Therapy for Insomnia (pp.
265-290). Academic Press. https://doi.org/10.1016/B978-0-12-822872-2.00009-8
Dietch, J. R., & Furst, A. J. (2020). Perspective: Cognitive behavioral therapy
for insomnia is a promising intervention for mild traumatic brain injury. Frontiers in
Neurology, 11, 1-8. https://doi.org/10.3389/fneur.2020.530273
Ludwig, R., Vaduvathiriyan, P., & Siengsukon, C. (2020). Does cognitive-behavioural
therapy improve sleep outcomes in individuals with traumatic brain injury: a scoping
review. Brain Injury, 34(12), 1569-1578.
https://doi.org/10.1080/02699052.2020.1831070
Montgomery, M. C., Baylan, S., & Gardani, M. (2022). Prevalence of insomnia
and insomnia symptoms following mild-traumatic brain injury: A systematic review and
meta-analysis. Sleep Medicine Reviews, 61, 1-23.
https://doi.org/10.1016/j.smrv.2021.101563
It is estimated that 1.7 million traumatic brain injuries occur on an annual basis in our country, and that approximately 80% of those are mild (Dietch & Furst, 2020).
The World Health Organization (WHO) Collaborating Centre for Neurotrauma Task Force on Mild Traumatic Brain Injury defines this condition as:
“an acute brain injury resulting from mechanical energy to the head from external physical forces” (p 1, Montgomery et al., 2022). A mild traumatic brain injury (MTBI) often results in one or more of the following symptoms:
- Change in mental status such as confusion or becoming disoriented
- Loss of consciousness for 30 minutes or less
- Post-traumatic amnesia for less than 24 hours
- Transient neurological abnormalities (e.g., problems with speech, headaches, vision problems or sensitivity to light, dizziness, or balance problems).
- Emotional difficulties such as anxiety, irritable or sadness
- Problems with sleep (e.g., sleep more or less, trouble fall asleep).
For the vast majority of individuals who experience a MTBI, particularly if they were healthy beforehand, will recover and return to normal activity (Montgomery et al., 2022). However, there are individuals who have symptoms persist beyond a year post incident. Although the reasons why symptoms of MTBI may persist are still investigating, one issue that stands out are sleep problems associated with MTBI. A recent study that conducted a systematic review and meta-analysis on available studies estimated that the prevalence rate for having an insomnia disorder post MTBI at 27% (Montgomery et al., 2022). The authors of the study also found that around 72% of individuals who had a MTBI reported having symptoms of insomnia. This result is not surprising due to the overlap between the symptoms of MTBI and insomnia.
| MBTI and Insomnia Overlapping Symptoms: |
|---|
| Fatigue |
| Problems with attention |
| Problems with concentration |
| Problems with memory |
| Problems with mood (e.g., irritability) |
Sleep problems like insomnia can develop either immediately following a MTBI or later during the course of recovery. The problem with insomnia is that it can hinder the recovery process from a MTBI, and unlikely to remit without treatment even if the symptoms of MTBI improve or fully resolve (Montgomery et al., 2022). As a result, it is important for clinicians working with individuals who have suffered from a MTBI to assess their sleep functioning. If patients are struggling with MTBI and insomnia, it is important to provide evidence-based treatment such as cognitive behavioral therapy for insomnia (CBT-I) to help improve their sleep functioning.
A common question that comes up during training and consultation regarding CBT-I, is what providers should do if a patient has a comorbid condition. Research examining CBT-I for patients with comorbid TBI has demonstrated positive effects for improving a patient’s sleep efficiency, decreasing both sleep onset latency (SOL) and wake after sleep onset (WASO), improving total sleep time, and improvements with symptoms of fatigue and mood (Ludwig et al., 2020). However, there are some things that are helpful to consider when doing CBT-I with patients who have had a TBI (Almklov et al., 2022).
Dealing with memory and recall issues
- Decreasing the amount of information covered in session.This may require adding additional sessions
- Allow for time to review materials and ask questions
- Provide brief and focused rationale for treatment components
- Use of cues or reminders to help with implementing interventions (e.g., completing sleep diaries, attending appointments, reminders for bedtime and waketime)
- Allow patients to record sessions, take pictures of white boards, or write notes to help review or remember content
- Consider use of technology such as apps or wearable devices to get information about sleep functioning if completing sleep diaries is too difficult
Stimulus control and sleep restriction challenges
- If getting out of bed during the night is problematic due to concerns about balance or other factors, consider utilizing counter control (e.g., sitting up in bed and engage in a non-stimulating activity such as reading a boring book)
- Instead of having the patient leave the bedroom, have a piece of furniture nearby the bed if possible to reduce the amount of distance they have to travel
- Consider using sleep compression therapy vs sleep restriction (i.e., gradually reducing time in bed by 15-30 minutes until patient reaches a sleep efficiency of 85% or higher)
- Emphasize that resting is not the same or as beneficial as consolidate sleep
- Limit napping if possible. If a nap is needed have a scheduled time limited nap (i.e., 30 minutes)
Sleep education
- If the patient did not have sleep problems prior to the MTBI, emphasize that the expectation about full recovery
- Address how physical, cognitive, and emotional issues can affect sleep through increased arousal
- Discuss how the interventions (e.g., relaxation skills, cognitive skills) in CBT-I can be utilized to address other problems in addition to improving sleep functioning (e.g., mood problems, stress management)
- If patients require rest breaks due to fatigue or pain, schedule for timed rest
Ultimately, it is important to know that problems with sleep functioning commonly occur after having a traumatic brain injury. As a result, it is critical for providers to not only assess patients for sleep difficulties, but to ensure that they are getting effective treatment for those sleep difficulties. Evidence suggests that we as providers can have confidence in using CBT-I to address Insomnia comorbid with MTBI. This blog also reviewed considerations that can help to implement CBT-I with patients who have MTBI.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Tim Rogers, Ph.D., is a Senior Military Internship Behavioral Health Psychologist and serves as the Associate Program Director for the Air Force Clinical Psychology Internship Program at Joint Base San Antonio-Lackland Texas.
References:
Almklov, E. A., Rivera, G. L., & Orff, H. (2022). CBT-I in patients with a history of
traumatic brain injury. In Adapting Cognitive Behavioral Therapy for Insomnia (pp.
265-290). Academic Press. https://doi.org/10.1016/B978-0-12-822872-2.00009-8
Dietch, J. R., & Furst, A. J. (2020). Perspective: Cognitive behavioral therapy
for insomnia is a promising intervention for mild traumatic brain injury. Frontiers in
Neurology, 11, 1-8. https://doi.org/10.3389/fneur.2020.530273
Ludwig, R., Vaduvathiriyan, P., & Siengsukon, C. (2020). Does cognitive-behavioural
therapy improve sleep outcomes in individuals with traumatic brain injury: a scoping
review. Brain Injury, 34(12), 1569-1578.
https://doi.org/10.1080/02699052.2020.1831070
Montgomery, M. C., Baylan, S., & Gardani, M. (2022). Prevalence of insomnia
and insomnia symptoms following mild-traumatic brain injury: A systematic review and
meta-analysis. Sleep Medicine Reviews, 61, 1-23.
https://doi.org/10.1016/j.smrv.2021.101563