6:  PHYSICAL AND MEDICAL SOURCES OF INSOMNIA             [Rev 3-23-2018]

This is one of the general issues addressed in Step C

Many physical and medical problems can make it difficult to sleep, by disrupting the person’s calm and interrupting the person’s normal sleep patterns.

Some Possible Issues

Respiratory issues can lead to difficulty breathing and coughing. Nose and throat infections can cause pain and lead to problems breathing. People can be kept awake by gastric pain, heartburn or gas. Some women are awakened by hot flashes during menopause. Male prostate enlargement can lead to frequent awakenings. Urinary tract infections cause pain. Joint and muscle pain from a variety of causes can make sleep rare and fitful.

Chronic pain is especially difficult, as it both interferes with sleep and can be exacerbated by lack of sleep. Disorders involving chronic pain are often described by their primary focus (Wickwire and Smith, pp. 140-141), but pain may involve more than one focus at a time. Often the source is vague, and it may not be possible to identify it medically.

 

Treatment

A first step would seem to be to determine whether the patient…

  • Is aware of a physical or medical problem that interferes with sleeping
  • Is taking medications to manage a physical or medical problem. The medications may then interfere with sleep. See Section 7.
  • Is aware of any other physical or medical problems. These may be affecting sleep and the patient doesn’t know it.
  • Has had a medical examination since the insomnia began. If not, there could be a physical or medical process that is the source of the insomnia.

These issues can be phrased as questions and asked in turn. The patient’s answers can lead to construction of a list of possible sources of insomnia, that leads to an action plan for medical treatment.

It is often not clear whether to call a problem medical or physical. Examples would be overweight, leg cramps in the night, or menopause. Effective treatments – when they are possible – may not be medical but dietary, life style change, or change of sleep environment.

Most therapists are not trained to treat physical and medical disorders. However, gathering relevant information can be valuable, because the person’s physician may not be aware of some of it. It may be necessary to obtain a release and talk with the physician directly about a disorder and its implications.

It can help to work from symptoms and diagnoses at the same time, to focus in on possible medical sources. Ask the patient what the symptoms are and infer what they might be, based on the person’s diagnoses. Then use each (diagnosis, symptoms) to refine questions about the other.

Some of these disorders are discussed in Reite, Weissberg and Ruddy, Chapter 7. At this point, it seems best not to discuss them here, or even list them, especially if there are a lot of different disorders. The real information is not in the name of the diagnosis but in the effect the disorder has for a particular person.

Some might not typically be considered medical, but the treatment is medical:

On the other hand, it might pay to know that some disorders typically lead to insomnia, if the effect is consistent for a lot of people. There might be some comfort for a patient in knowing that he/she isn’t the only one with that reaction. There may also be some common effects on sleep that can be countered when you are aware of them.

Medical conditions can have effects on activity level, social contacts, attitudes and narcissistic focus, and those reactions can have implications for sleep. This is especially true when the person focuses on his/her disability, limitations and pain, possibly withdrawing from involvement with the world and other people.

In more serious conditions, limited activity and chronic pain can lead to anger and bitterness. All of these can impact the person’s sleep timing and amount of time spent in bed.

It can be helpful to pay close attention to the details of time in bed, naps, and any tendency to withdraw into fantasy and inactivity.