Norwegian Directorate of Health: course for sleep problems

rainy

rainy

Senior Member (Voting Rights)
I just saw this «sleep well» course by the Norwegian Directorate of Health advertised on Facebook.

From a powerpoint on the Directorate of Health webpages it seems like the course consists of the typical sleep hygiene advice and relaxation techniques etc.

They also have a list of what they call «negative assumptions about sleep» which include things like:
  • I need 8 hours of sleep to feel rested and function well during the day
  • If I don't get enough sleep during the night, I need to regain the lost sleep by taking a nap or sleeping for longer the following night.
  • I am worried that long term sleep problems will have consequences for my physical health
  • If I am irritable, depressed or anxious during the day, it is mainly caused by not sleeping well during the night
  • When I am tired, lack energy, or just functioning poorly during the day, it is generally caused by not sleeping well during the night.
  • I can never predict if I will have a good or bad night's sleep
  • To stay awake and function well during the day, I am better served taking a sleeping tablet than having a night of bad sleep.

More from the presentation:

Attitudes about sleep.
  • Correct misconceptions about sleep.
    Realistic expectations for sleep and sleep length.
    Accept that sleep varies.
    Understand that sleep problems don't have to ruin the next day.
  • Try to let sleep take up a little less space in your life!

«Thought traps» that inhibit sleep:
  • Unrealistic expectations: I need at least seven hours to function the next day
  • Compulsive thoughts: I have to sleep tonight
  • Exaggerations: Every time I sleep poorly, I function poorly the following day
  • Catastrophizing: Insomnia is ruining my life
  • Overgeneralization: My sleep is always poor
  • Black and white thinking: Because I haven't managed to fall asleep yet, this is going to be a bad night
  • Predictions: It's going to take at least one hour before I fall asleep tonight. I just know it
  • Hopelessness: I will never sleep well

Challenge negative thoughts.
Thoughts that inhibit sleep: I always sleep badly.
Thoughts that promote sleep: Not every night is as bad. Some nights I sleep pretty well.
 
From an article in Psykologtidsskriftet, by Department Director of Directorate of Health. My bolding:

In addition to teaching and talking about sleep hygiene, the Sleep well courses consist of combinations of stimulus control, sleep restriction and relaxation techniques as well as identifying and changing inappropriate thoughts about one's own sleep. The participants fill in a sleep diary, carry out exercises and measures between each meeting, and have conversations in plenary. It is not a requirement that you carry out sleep restriction, but many wellness centers offer follow-up for individual sleep restriction in connection with the course.

Furthermore, it is true that the Sleep Well course has not been scientifically evaluated, but mapping of participants based on completion of the ISI (insomnia severity index) before and after the course shows that the participants have good results. The course program was developed for, and in collaboration with, wellness centres.
Click to expand...

Insomnia severity index
0- none, 1 - mild, 2 - moderate, 3 - severe, 4- very severe.
Rate the current (i.e. last 2 weeks) severity of your insomnia problems.

  1. Difficulty falling asleep
  2. Difficulty staying asleep
  3. Problems waking up too early
  4. How satisfied/dissatisfied are you with your current sleep pattern?
  5. How noticeable to others do you think your sleep problem is in terms of impairing the quality of your life?
  6. How worried/distressed are you about your current sleep problem?
  7. To what extent do you consider your sleep to interfere with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc) currently?

Doing the sleep well course you learned that thinking your sleep problems affect your mood, and that your sleep problems are the reason for your daytime fatigue and tiredness are negative thoughts. And if you have negative thoughts about your lack of sleep, then you are inhibiting your sleep. So you no longer say you are dissatisfied with your sleep. If you are irritable or tired during the day, maybe it's just a personality flaw?

If you have very severe insomnia, and answer 4 - very severe on the first three questions that are directly concerning the actual sleep, but 0 on the last four questions that concern how you feel about your sleep, you get a score of 12 - subthreshold insomnia.

If you don't want to catastrophize and sound dramatic, maybe you vote 2 - moderate on the first three, after all, maybe it could be worse, then you have a score of 6 - no clinically significant insomnia.

total score categories:
0-7 = no clinically significant insomnia
8-14 = Subthreshold insomnia
15-21 = Clinical insomnia (moderate severity)
22-28. = Clinical insomnia (Severe)


But you'd only have to say that you are a little bit less distressed about your current sleep problem, and your ISI score would improve after the course. And even if you actually become more distressed, because you realise that the Norwegian health care system will never help you, you might no longer feel comfortable telling a professional that, because you are fed up with your sleep problems being seen as a moral failure.

Yet another example of teaching people to stop complaining on questionnaires, and equating that with improvement in health. It is not at all shocking that the Norwegian health care system loves the Lightning Process: Giving normal, rational thoughts about your health a negative value. Saying the thoughts about your problem is the cause of your problem. Teaching you not to complain. Moral judgement, painfully simplistic approach and patronizing.
 
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These questionaires are so incredibly biased on the premise that cause is worry that they don't even seem to bother to try and separate the concerns apart. Its no wonder the studies based on this garbage keep coming back with positive improvements simply by telling their patients to worry less.

What is probably worse is the fact we can actually measure sleep quantity and quality in a fairly non invasive way, even a basic smart watch can do a reasonable job of that. Its really not hard to see if a patient is genuinely having trouble sleeping and if your interventions changed that in any significant way. But why use a nice objective cheap measure when a good biased questionnaire can be used?!
 
NTNU is planning a study on the effect of this course on sleep quality and quality of life, starting fall 2022.

In the promotional video to get participants for the study they say:

Short term, sleep medication can work well, but the effect usually disappears after a couple of weeks of use. Treatment without medicine has a bigger potential for working long term agaist sleeplessness. More than 80% of those who undergo this treatment experience better sleep and function better during the day.
Click to expand...

Isn’t this promoting an expectation bias?

The control group is on a waiting list.
 
I am worried that long term sleep problems will have consequences for my physical health

WTF is wrong with having that concern? IIRC, chronically poor quality sleep is well known to be associated with, and probably (partly) causal of, lower quality physical health.

Society has been bombarded for years with advice from medicos about getting sufficient good quality sleep, but now apparently that was all wrong, or irrelevant, or just inconvenient to this version of psycho-behavioural fairy tale.

Furthermore, it is true that the Sleep Well course has not been scientifically evaluated,

But we at Sleep Well don't care. We know we are right, and so don't even need to properly evaluate our program.
 
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I listened to a webinar which was aimed at health professionals training in this course. The webinar was by the Directorate of Health, with a psychologist who has worked at St. Olavs Hospital at the Sleep Clinic, and at the Pain Clinic. The Pain Clinic at St. Olavs Hospital take referrals to diagnose patients with ME, and my experiences with them have been completely awful.


Some of the main principles of the insomnia treatment they talk about, except for gaslighting and blaming the patients, are sleep restriction - basically making the patient more sleepy so they are more likely to fall asleep, and sleep hygiene habits like avoiding bed except for when sleeping.

You have to wake up the same time everyday, regardless of when you fell asleep or wether this means you will only get 4 hours of sleep. And you should not sleep more than usual the following night to catch up the sleep you missed. Preferably no sleep during the day, except for short power naps if you absolutely have to.

Someone at the webinar asked how they should approach sleep restriction if someone has fatigue problems, and what about ME patients, is it good for ME patients to sleep a lot?

«Fatigue, CFS/ME is a difficult topic I think, because I am no expert on those diagnoses. It often clashes with the advice we give, if they have advice about spending a lot of time resting and sleeping. So you have to discuss with each client if they are willing to try this treatment method or not. I have talked to some doctors who think that sleep restriction and CBT for insomnia are not contrary to treatment advice for CFS/ME. But often they have gotten advice to rest when they can, and sleep when they can, so that is contrary. So each person has to chose if they wish to try this treatment, with the risk that they could become more tired from it. But the point of this treatment is in fact that you should become more sleepy and tired, so that could be difficult for many. But I am not familiar with any other reason why they should’t do it, or that it shouldn’t be adviced to try it.»

It’s upsetting, but not surprising, that someone that has worked at a clinic that diagnoses ME patients, doesn’t know that ME isn’t the same as being «tired», doesn’t know about PEM, doesn’t know that many ME patients have severe problems with sleep.
 
There were so many parallels between the way they are treating insomnia patients and the way ME patients are treated.

They talked about how there are factors that trigger insomnia (illness, crisis, side effects of medications) and then there are factors that maintain insomnia, which is worry, and patients having misconceptions about sleep.

They mentioned that many insomnia patients were upset when they came to the sleep clinic that insomnia was considered a psychological illness, and patients felt like insomnia shouldn’t be placed in psychiatry. But then the professionals would have a talk with the patient about how the head and the body are connected.

A big topic was how much of the truth of the danger of too little sleep do we share with the patients? Have to find the balance between not giving them health anxiety, but still giving them enough motivation to actually do the treatment. Patients are apparently one of two categories: overly concerned and anxious about their health, or unmotivated and need a kick up the backside.

(The idiom kick up the backside was used in the webinar. It’s very common in Norwegian, meaning to motivate someone who are lazy. I found it inappropriate to use about people struggeling with their health).
 
The underlying problem is that these courses are designed to help healthy people who experience sleep problems. Sleep is vital for health and modern society is not good for it so they probably do help many people.

We, though, have damaged bodies. Sleep hygiene is not the answer to narcolepsy and it is not the answer to ME. Unfortunately this simple, easily understood fact seems beyond the understanding of too many doctors.
 
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