1. Sleep in Patients Who Have
Undergone a Bone-Marrow
Transplant: Ways to Help
By Josh Tal, RPSGT
Research Assistant at Stanford’s Behavioral
Sleep Research Center
First Year PhD Student at Palo Alto
University

2. The Bone Marrow Transplant
Experience
 During the transplant:
 Patients undergo intensive monitoring and supportive
care, yet their requirements for deep uninterrupted
sleep often go unrecognized.
 Noises of monitors/pumps
 Need to use the bathroom
 Agitation/Stress
 Even healthy individuals could develop sleep
difficulties if they were woken up so frequently.

3. After the Transplant
 One study in Nature found that nearly 50% of bone
marrow transplant patients had sleeping issues and
fatigue one year after the transplant.
• Additionally, this study
showed that sleeping issues
do not decrease over time,
indicating it was no longer
an acute effect of the
transplant.

4. The Evolution of Insomnia
Insomnia
Insomnia Threshold
No Insomnia
Premorbid Acute Chronic
Insomnia Insomnia
Predisposing Factors
Precipitating Factors Adapted from Spielman et al., 2000.
Perpetuating Factors

5. Cognitive Irony
Worry about falling asleep leads
to worse sleep.
 It takes longer to fall asleep if you tell yourself to fall
asleep as fast as possible

6. Additional Issues:
 Facing a life-threatening illness.
 What happens next?
 Anxiety
 Depression
 Nightmares
 Avoidance of things that remind you of your past illness
 Relationships
 The whole experience before the transplant, during and
after is scary and it affects you.

7. Treatments

8. Sleeping Pills?
• How many of you take sleeping
pills?
• How do you feel before you take
them?
• How do you feel the next morning?
• How do/would you feel after years
of taking them?
• How would you feel if you decided
not to take them?
Adapted from Morin CM et al. JAMA 1999;281.

9. Cognitive Behavioral Therapy

10. Nonpharmacologic Treatment
TECHNIQUE AIM
Sleep hygiene Promote habits that help sleep; provide
rationale for subsequent instructions.
Stimulus control** Strengthen bed & bedroom as sleep stimulus
Sleep restriction Restrict time in bed to improve sleep depth &
consolidation
Relaxation training* Reduce arousal & decrease anxiety
Cognitive therapy Address thoughts and beliefs that interfere with
sleep.
Circadian rhythm Reset or reinforce biological rhythm
entrainment

11. Sleep Hygiene
 Regularize sleep / wake schedule
 Avoid stimulants and stimulating behavior
 Establish relaxing bedtime routine
 Provide a conducive sleep environment
 Limit daytime naps
 Reduce or eliminate alcohol and caffeine
 Obtain regular exercise earlier in the day
 Avoid clock watching

12. Clock Monitoring
 In both poor and good sleepers, compared to non-
monitoring, clock-monitoring leads to
 more pre-sleep worry and longer sleep onset latency in good
and poor sleepers
 more pre sleep worry
 For insomniacs, compared with digit monitoring, clock
monitoring leads to
 longer time to fall asleep
 more pre sleep worry
(Tang et al. 2007)

13. Stimulus Control
 Use bed for sleep, sex,
and sickness
 Go to bed only when
sleepy
 Get out of bed when
unable to sleep
 Wake up at a consistent
time
 Do not take daytime naps

14. Stimulus Control
 Stimulus control reduces sleep anticipatory anxiety
(Bootzin et al. 1999).
 What do you think about using electronics in bed?

15. Sleep Restriction
 Determine average time asleep
 Set time in bed = time asleep
 Consistent wake-up time
 No daytime naps
 If time asleep > 90% (85%) of time in bed then
increase time in bed (15-30 minutes)
 If time asleep < 80% of time in bed then
decrease time in bed (15-30 minutes)
Spielman AJ et al. SLEEP 1987;10.

16. Sleep Restriction

17. Cognitive Therapy
Adapted from Morin CM. J Psychosom Res 1999;46.

18. Circadian Rhythm Entrainment
 Light Therapy
 Morning light exposure for delayed sleep phase
 Evening light exposure for advanced sleep phase
 Behavioral Methods
 Establish regular wake-up time

19. Relaxation
Progressive muscle relaxation
Diaphragmatic breathing
Meditation and guided imagery
Biofeedback (EMG)

20. Nightmares:
 Coping with bad dreams can be difficult. Some people don’t like
relaxation before going to sleep, or are scared of letting go. If that is
you, try these preparation techniques instead:
 Prepare yourself in case you have bad dreams by thinking of a bad dream then think
of a different ending for it. Practice this new ending many times before going to
sleep.
 Before going to sleep prepare to re-orient yourself when you wake from a bad
dream.
 Remind yourself that you are at home, that you are safe. Imagine your street, buses,
local shops.
 Put a damp towel or a bowl of water by the bed to splash your face, place a special
object by the bed, such as a photograph, or a small soft toy.
 Practice imagining yourself waking up from a bad dream and reorienting yourself to
the present, to safety by splashing your face, touching special object, having a
bottle of rose or lavender essential oil to sniff, going to window to see surroundings.
 When you wake up from a bad dream- move your body if you can and reorient
yourself immediately (touching object, wetting face, going to the window, talk to
yourself in a reassuring way)

21. Thank you for having me!
 If you have any questions or concerns, email me at
jtal@stanford.edu.
 If you feel that you would like to see a behavior sleep
specialist, email me for a referral.
 Any last questions?