1:  INITIAL ASSESSMENT FOR INSOMNIA

This begins the treatment for a person who appears to have sleeping issues. It appears in Step A and covers two issues – deciding whether to look at insomnia as a problem, and looking at some startup issues.

You can begin to question a person’s ability to sleep for different reasons. As with many issues, what a patient says is the best starting point. Usually people complain of not sleeping well or of symptoms that could be related to poor sleep. A person may appear tired or provide indirect evidence that he/she is not getting enough sleep. Whether to pursue the issue depends on the strength of evidence for insomnia and its apparent impact on the patient’s life.

This section begins with some general issues and questions that can help identify the patient’s sleep issues. Then it includes several related subtopics

  • Common symptoms
  • Some diagnostic questions
  • Preliminary sleep log
  • Symptom history
  • Insomnia and other issues
  • Misconceptions

1a: Common Symptoms

There are many possible symptoms of insomnia – some direct, some indirect. You probably won’t ask about them all. But the patient may mention some, and others may then be worth asking about.

Direct evidence includes poor sleep efficiency, defined as time asleep divided by time in bed, and expressed as a percentage. One signal of insomnia is a sleep efficiency of less than 85% (Morin, 4). Using this standard, a person who spends 9 hours a night in bed but is asleep for 7 of them would have a sleep efficiency of 7/9X(100%) = 78%, and would be considered to have insomnia. This in spite of getting what many would consider a full night’s sleep.

Other direct evidence (Reite, Weissberg and Ruddy, 46) comes from complaints of…

  • not getting enough sleep
  • not being able to sleep or get to sleep
  • waking too early
  • being unrefreshed by sleep
  • waking in the middle of the night and not being able to return to sleep

Other symptoms include

  • Diminished quality of life, including impaired concentration and memory, decreased ability to accomplish daily tasks, and decreased ability to enjoy interpersonal relationships.
  • Sleep onset anxiety and depression
  • Daytime sleepiness. May include a need to take naps.
  • Health-related concerns
  • Using sleep medications to get to sleep. This may come up in a routine listing of medications that the person uses.
  • Accidents or near-accidents because of drowsiness or poor concentration or coordination

One scale, the “Athens Insomnia Scale”, gives a numeric score for insomnia, based on a weighting of several of the issues discusses in this map. Another, the Epworth Sleepiness Scale (which you can find online), gives a numeric score for adequacy of sleep .

1b. Initial Attitude and Perception

Insomnia can be frustrating as well as debilitating. There is a real danger that a person will feel so out of control of his/her own body and life as to be both desperate for proper sleep and convinced that it isn’t possible. (see Morin, 139-140, 186). Some people believe that they have “…tried everything,” and must resign themselves to over-the-counter sleep remedies or a life of constant nighttime insomnia and daytime fatigue. Such fear and despair make the problem even worse. For these people, a first issue is to instill some confidence that the sources of insomnia can be identified and treatment is possible.

1c. Some Diagnostic Questions

It often pays to start with generalizations, because people make them and want to share their conclusions. Some opening questions could include…

  • Why does the person think that there is a sleep problem?
  • How much sleep does he/she get every night? (an estimate)
  • What does he/she do to get to sleep?
  • Is the problem more about getting to sleep, or waking too early, or waking in the night?

A question or two may get at the person’s idea about cause or origin. This sets the stage for considering it to be a problem that can be explored and possibly solved.

  • How long have you had this problem? Many people have clear ideas about this, and it can lead to information about a precipitating event or situation.
  • Any idea about how it started? Mostly, this is a variation of the previous question.
  • What gets in the way of changing it? This may be more difficult for a patient to answer, but asking the question sets the stage for further exploration and possible resolution of the current situation.

Questions about prior attempts at treatment can give information about sources of this person’s insomnia, as well as what doesn’t work. See Section 3 for more.

Some details might be helpful at this point. Your patient can probably give reasonable estimates about last night, so you can ask about that. Each of the following questions can be followed-up as you see the opportunity.

  • What time did you go to bed?
  • What were you doing before that?
  • How long did it take you to get to sleep? Was it hard to do?
  • What time did you wake this morning? What woke you? Did you try to go back to sleep? How long did you say in bed before getting up?
  • Did you wake in the night? How many times? Did you go right back to sleep?
  • What about taking naps yesterday or today?
  • Do you do anything special to get to sleep? Medication, glass of wine, sleeping pill, etc.? How effective is it?
  • How much energy do you have when you get up? Throughout the day?
  • Was this a typical night for you?

1d. Other Sleep and Sleepiness Issues

This review currently does not consider some other important sleep-related problems at present. These include

  • Hypersomnia – when the person has excessive sleepiness not directly related to insomnia (First and Tasman, 459-460)
  • Narcolepsy – with excessive daytime sleepiness and inappropriate attacks of sleep (First and Tasman, 460-461)
  • Parasomnias – disturbances of behavior or physiology during sleep, including sleepwalking (First and Tasman, 466-469)

 

1e. A preliminary Sleep Log

The idea here is just to get some baseline information at the start of treatment, without asking too much of patients before they are committed to the work.

 

 

 

 

 

 

A chart like this provides an opportunity to discuss some issues in therapy, including

  • Consistency of time going to bed, and lack of it.
  • Reasons for not getting up at the same time every day, value of consistent wake time
  • How long between going to bed and going to sleep, and what interferes with making that time very short.
  • Number of times up in the average night, why awakening, how long to get back to sleep, what interferes with falling back to sleep.

This in turn can lead to directions to explore regarding the patient’s sleep issues. You can also ask about how long the person stays in bed after waking in the morning.

1f: Symptom History

If you determine that the person does have insomnia, many questions arise, such as:

  • When did the problem start? This may help locate sources of the insomnia. It can also help decide if it is transient, brief, or chronic. Section 2 uses this information.
  • Have there been other times when you went through similar problems? This can help identify vulnerabilities and provide a start to the issues of Parts B and C.
  • How have you handled it in the past, and how effective was that? This can help both with diagnosis and treatment. More on this in Section 4.
  • Are you doing anything to sleep better now? How is it working? Are there any side effects of the treatment you are using? This also leads to Section 4.

Understanding precipitating factors can be helpful in the patient’s realizing that his/her insomnia has a history and reasons. There may also be issues and conditions that perpetuate the problem. These may be different from the precipitating factors and require separate understanding and treatment (Morin, 87).

1g. Interaction of Insomnia with Other Issues

Insomnia has many possible causes, and we will want to sort them out for each patient. Poor sleep can also be a source of other symptoms and disorders, including depression, anxiety, poor attention, and compromised immune reactions (First and Tasman, 453; Morin, 29).

Because of this, it is not always clear where to begin, and your judgment will be needed to make choices. However, it is often possible to treat two different issues simultaneously (e.g.: insomnia and anxiety), because they do affect each other, and because we are more interested in helping the person deal with life than with purity of diagnosis.

1h. Misconceptions and Other Diagnostic Complications

Patients may not have it right. If a patient is living with false perceptions or expectations, these need to be dealt with before treating insomnia. (Morin, 126-144). Otherwise, treatment may be misdirected, or at least inefficient. In fact, the patient’s prior treatment may have been based on misunderstandings – it wasn’t effective, or the problem would have been solved.

Faulty beliefs and attitudes can also increase a person’s level of arousal, contributing to the difficulty sleeping.

Common misconceptions include thinking that…

  • it is normal to lose sleep, and that chronic sleep has little impact on daily life.
  • insomnia is virtuous “I only got three hours of sleep, and I feel fine!” Actually, lack of sleep can be dangerous, contributing to poor judgment, nodding off, and accidents (Hauri and Linde, 157-158)
  • they must get a normal amount of sleep each night or they are going to be in trouble. Although most adults need between seven and eight hours of sleep on average, some people need more, some need less. And small variations are usually not a problem.
  • Waking in the night is a serious problem. Almost all adults wake one or several times a night. It might be a problem if the person has difficulty returning to sleep and loses sleep because of it.
  • loss of sleep for one night or a few nights is a sign of a serious insomnia problem. It might be, but it might not. See Section 2.
  • they can compensate by going to bed earlier or staying in bed after awakening

See Section 42 for more about this.