40: TREATMENT OVERVIEW [Rev 3-19-2019]
This section appears at the end of Step A and leads into later steps.
There are three parts to this section:
- A review of Step A and where we are now, in working with a patient
- A review of the conditions for sleep as a basis for making decisions about this patient
- An overview of next steps
40a. Review of Step A: Here’s where we are:
- We have collected some preliminary information about the person’s sleep issues in Section 1
- We believe that he or she has a problem with insomnia
- We have provided some initial information, but it wasn’t enough to resolve the person’s problem.
- We have reviewed the nature of sleep and the conditions for sleep in Section 4
40b. Conditions for Sleep
Several things need to come together to ensure good sleep:
- Circadian rhythm: a person should be in the circadian phase where sleep is programed to occur. Melatonin signals the beginning of sleep.
- The physiological need for sleep should be great. The person should be tired. Brain glucogen should be mostly converted to adenosine, and the physiological signals of exhaustion should be present.
- There should be an absence of emotionally energizing thoughts – rage, fear, excitement, guilt, and so on.
- Disruptions and interference from the sleep environment should be minimal.
These conditions were discussed in part (a) of Section 4, from the perspective of informing patients and allowing them to self-treat. Ideally, a person can manage all of these factors and sleep comes normally and naturally. However, many things can interfere. If you have gotten to this point with a patient, the information by itself apparently wasn’t sufficient for the patient.
Now we will use these same issues to identify conditions that may be sources of a patient’s insomnia and to select possible treatments.
CIRCADIAN RHYTHMS
Humans are predisposed to be awake and alert during the day and sleep at night. Ideally, a person’s life style is consistent with this pattern.
Some people may be on a consistent 24-hour cycle of sleep and wakefulness that differs from the earth’s cycle of day and night. Any consistent pattern can be circadian if it repeats in about a 24 hour cycle. For more, see Section 4b, # III.
Many things about a person’s life style can influence his/her circadian patterns, including
- Exposure to light and darkness. This triggers melatonin production and cessation, which is a major signal of sleep and wakefulness.
- Temperature changes that signal changes in the day-night cycle. These also trigger melatonin production and cessation
- Consistency and timing of work, which is a major organizer of life for most people.
- Consistency and timing of other activities, such as eating, parties, exercise, and hobbies.
When the person’s daily activities are regular and consistent, sleep is supported in its appropriate time and place. When the signals for sleep and wakefulness are not consistent, it may be necessary to compensate by adjusting the signals or strengthening some of them. This is the direction to be followed in making treatment suggestions.
PHYSIOLOGICAL PRESSURE TO SLEEP
Ideally, a person is sleepy at the time set aside to sleep. When this happens, sleep tends to come normally and naturally. Patterns of living call for activity and action throughout the day, and the person’s energy supplies are replaced by chemicals that signal time to sleep. See Section 4b #III for more.
Many things can undermine the need for sleep at bedtime, including
- Taking naps, which allow for rebuilding the supply of chemical energy and reduction of the fatigue hormone adenosine.
- A basically sedentary life style, which doesn’t use the person’s energy or create enough adenosine to pressure for sleep
When a person isn’t alert throughout the day and tired at night, sleep signals may need modification. Treatment suggestions often are directed toward increasing daytime alertness and evening fatigue.
COMFORT AND PREDICTABILITY OF THE ENVIRONMENT
An environment that is associated with sleeping, that includes normal cues for sleep, makes it easier to get to sleep and stay asleep. This might include the experience of calm, safety, peace and quiet.
A look at normal sleep architecture (Section 4b # VI) suggests that humans are programmed to get some deep sleep throughout the night, in order to rebuild physically, and frequent periods of alertness, in order to adjust their bodies and check for dangers.
During periods of light sleep, unusual lights, motion and sound can be perceived as signals of danger, leading to awakening. A strange, new or unpredictable environment can lead to sleep interruptions, possibly leading the person into full alertness.
INTERNAL PHYSICAL AND MENTAL CALM
Sleep has to “just happen”, because the person can let go of the day, the past and future, thoughts and ideas, and strong emotions. A mind that is clear is ready for sleep
Disruptions can come in many forms, including physical pain, emotional stress, excitement, anticipation of events, and so on. These disruptions can be alerting and energizing, as the person prepares to deal with them directly.
A person who is experiencing any kind of energizing thoughts and feelings will find it difficult to relax to the point of sleep.
Treatment involves finding ways to put the disruptive thoughts and emotions aside.
40c. Continuing with Treatment from Here
In the present treatment, I am dividing possible sleep issues and their treatment into five ordered clusters or steps, labeled A – E.
- We have already considered startup issues. Sometimes, just looking at a problem carefully will be enough for the person to continue paying attention and possibly find a solution without further therapeutic attention. If you have gotten this far with a patient, that apparently hasn’t worked.
Here are the four remaining steps in treatment:
- In this step, we look at broad issues about the organization of the person’s life and the impact of that organization on circadian processes.
- Here the issues are a bit more specific, and there are a lot of them that can have an impact on the person’s overall ability to sleep. Generally, insomnia is seen as a side effect of some other issue; treat that other issue and the insomnia will resolve.
- In this step, we are treating the person’s insomnia directly. To conceptualize the problem, we organize sleep issues around the time of night that they are most often experienced, along with underlying issues of circadian rhythms, physiological fatigue, emotional problems and situational conditions.
- There are also some last resort issues and treatments.
Your choice of how to proceed will be determined by patient qualities and interests, in addition to patient symptoms and treatment availability.
Some patients would rather talk about symptoms than about possible causes. Maintaining patient involvement in the decision process is one reason not to collect a lot of data about possible causes at this point.
Patient awareness might also point toward the issues of Step D – a person can often describe the time of night that insomnia occurs. The danger here is that the real source of insomnia can be passed-by, by skipping over the more pervasive and often less obvious issues of Steps B and C.
Other patients may already have a theory about the source of insomnia and want to talk about that. “I have to deal with a lot of stress.” “This medication I have to take…” You may have to go where the patient wants to go for a while; and that could be very helpful. After all, he/she is the symptom expert and has already tried several treatments.
But the patient’s theory may be wrong. Clearly, he/she still has insomnia, despite knowledge of symptoms, theories about underlying causes, and prior attempted treatments. So, a systematic exploration may still be helpful.
STEP B
Here we look at broad ways that a person has arranged his/her life, to see whether they are consistent with sleeping well. A life-style that is disorganized or out-of-synch with the world around the person may lead to frequent insomnia.
People may not be aware of the principles of regularity, safety, and comfort that make for ease of sleeping, so this is a good place to look early on. It also makes sense to look at the issues of Step B before Step C, because there are fewer issues and they are relatively obvious. The place to begin here is with Section 38.
STEP C
Step C contains a number of broad categories of potential insomnia sources, organized by Section 43. Within each category are many specific possible sources. Many of them can affect sleep at different times of the night. If one of these is the cause of the person’ insomnia, you may be able to resolve the problem and move on to other therapeutic concerns; or the other problems may be resolved when the person is sleeping normally. Our propensity as psychotherapists is to look for psychological sources (anxiety, depression, trauma, etc.) first. But as Jacobs points out, patients may become anxious when they can’t sleep and blame the anxiety for their insomnia. They may also become depressed from lack of sleep or their inability to sleep more effectively. The same may be true for other issues.
Section 43 lists categories of sources of insomnia, to help you check them all. There are many components to each category. Go to the corresponding linked sections for details. This step is introduced by Section 43.
STEP D
If the general considerations of Steps B and C fail, the treatments of Step D are available for more direct control. These approaches are symptom-related and symptom-focused. The causes are more limited, and it pays to focus on symptoms to start. A person may complain initially that he or she..
- goes to sleep easily but wakes in the middle of the night and can’t get back to sleep for a long time
- has trouble going to sleep at night
- wakes early and can’t return to sleep
- some combination of these
Begin with this phase of treatment by going to Section 11.
STEP E
When other attempts at treatment have failed, try the approaches. In this step. Begin at Section 17, which provides an overview.
Links
- Section 38 organizes Step B: Broad Circadian Challenges
- Section 43 organizes general issues when insomnia is secondary to some other problem
- Section 11 introduces direct treatment of insomnia, when insomnia is primary
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