11:  TREATING INSOMNIA AS A DIRECT FOCUS            [Rev 3-19-2019]

This is the organizing section for Step D. It often follows Step C, when the issues addressed there have failed to resolved the patient’s insomnia. With some people, it may be a natural place to begin.

11a. Primary insomnia

Here it is assumed that you have already asked about all the problems raised in Parts B and C, and have dealt with them as needed. In those cases, we were dealing with secondary insomnia. We can think of secondary insomnia as occurring any time that loss of sleep is a consequence or by-product of medical or psychological issues, medications, or general life style. If that other disorder could be managed differently, the person’s ability to sleep should improve. Step C included:

 

Once we get this far with a patient, it appears that previous approaches were at least partly ineffective. The patient’s difficulties sleeping may not be solely a consequence of some other condition. At this point, we move on to treat the person’s insomnia as primary.

 

11b. Common experience of insomnia

General symptoms of insomnia were discussed in Section 1. Here we want to focus in on the patient’s experience of insomnia at the point of trying to sleep, regardless of time of night. It may include being…

  • Agitated, tossing and turning
  • Obsessing, often about an emotionally charged issue
  • Physically tense and unable to relax
  • Otherwise uncomfortable

These symptoms don’t directly suggest effective management strategies. For that, we need to go through several steps.

  1. We first combine the person’s symptoms with the time of night that insomnia occurs. That helps clarify the symptom picture.
  2. We try to infer the underlying source of the insomnia – the determiner of sleep that is being disrupted. Four major categories of sleep issues can be used to sort out likely problems.
  3. Then we look at the person’s prior activities, experiences and expectations to seek out things that could be affecting the four categories.
  4. We work with the patient to select a treatment plan with a reasonable probability of dealing with the identified disruptors.
  5. If our plan is ineffective or only partly effective, we re-analyze and try something else.

11c. Sources of sleep and insomnia

Although each treatment proposed will have many possible contingencies and effects, it can be helpful to keep in mind four major sources of good sleep and insomnia. An analysis of the person’s situation can suggest which of these we should focus on, in order to choose a treatment intervention. Section 40 listed them as

  • Circadian rhythms and sleep timing
  • Physiological pressure to sleep at bedtime
  • Comfort and predictability of the sleep environment
  • Internal physical and mental calm versus agitation or excitement

11d. Timing of sleep issues

We now divide sleep issues into three major categories of insomnia, based on time of night that they ordinarily occur:

  • Falling Asleep
  • Early Awakening
  • Interrupted Sleep

The four broad sources of insomnia listed in part 11b above and described in Section 40 can affect a person at any time of night. However, each source may appear to function differently at different times. As we refine our treatment approach, we will consider time of night as a major way to classify insomnia.

11e. Antecedents of sleep issues

One of the reasons people fail to treat insomnia effectively is that they conceptualize the problem as occurring after they get into bed, and ignore all the events and activities leading up to it. However, quality and depth of sleep are dependent on many different events and behaviors that occur throughout a person’s day. Whether the person has a good night’s sleep has already been largely determined by earlier choices, proximate and remote. We can categorize them – roughly – as

  • Overall week, all month, life-style
  • All day
  • Afternoon and evening (assuming bedtime is at night)
  • Getting ready for bed
  • Being in bed

Many of the treatments proposed in the literature address the broader timing picture. They may also treat more than one of the patient’s experiences and underlying sources of insomnia. Because of this, it has not been clear in previous discussions of insomnia which treatment should be suggested for a given patient.

Part of a therapist’s task is to explain the connection between events in bed and the broader picture, preliminary to suggesting a treatment. That is the purpose of this and subsequent sections, namely, to make connections between type of insomnia, probable underlying issue, likely behavior leading to it, and possible treatments.

11f. Gathering data

SLEEP RECORD

Follow this link to a written sleep record that you can give to a patient to help collect relevant information.

SLEEP LOG

Once these data have been collected, we can enter the patient’s answers into a table or spreadsheet to get some summary results. This is commonly referred-to as a sleep log.

An example sleep log follows the sleep record at the above link.

When it is filled out, the sleep log organizes information useful in answering the questions of this section.

11g. Further Articulation of Issues

More about understanding and treating insomnia at each part of the night will be discussed in three choice-sections. Details of treatment then follow from the type of insomnia and probable source. The sections are

Problems falling asleep          Section 46

Waking early                           Section 47

Interrupted sleep                     Section 48