43:  GENERAL ISSUES – STEP C                                        [Rev 3-18-2018]

This section follows Section 38 (Organization of Daily Life) and introduces Step C.

43a. How to Proceed

Once you have determined that the person has an issue with chronic insomnia, it is time to begin refining the diagnosis and considering some treatments.

A first choice might be whether to collect a lot of data and then begin treatment, or collect enough to believe that one particular treatment could help.

  • Clinics and other large programs commonly begin by collecting a lot of intake data, because the set-ups for data collection are consistent. A clerk or intake form can be used to start the process, and a clinician can follow-up later. This approach has the advantage of convenience. It also may provide information on the interactions of different sources of insomnia.
  • Another choice might be to try one treatment at a time, serially, or several at once. Either way, this has the advantage of following up on specific issues and ignoring –at least temporarily – others that seem less likely.

43b. A Collection of Possible Sleep Disruptors

Step C contains a number of broad categories of potential insomnia sources. 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 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, psychological issues can be the consequence of sleep loss. For example, patients may become anxious when they can’t sleep and blame the anxiety for their insomnia. They may become depressed from lack of sleep or their inability to sleep more effectively. The same may be true for other issues. Lack of sleep can degrade physical and mental performance, reduce alertness, contribute to accidents, and so on. In some cases, the most effective treatment for a range of problems may be for the person to improve his or her sleep.

Listed here are categories of sources of insomnia, to give you a wide range and remind you of some you might forget to ask about. There are many components to each category. Go to the corresponding linked sections for details.

The categories are not necessarily in order. Your best approach is probably to consider them as they arise in a general discussion of the person’s difficulty sleeping. Then go back to any you have missed as you see fit.

  • Many different medical disorders can lead to loss of sleep, because they affect a person’s comfort or alertness, or throw the person’s schedule off to the point that sleep is disrupted. Section 6 discusses this issue.
  • The problem may lie less in the person’s medical diagnosis than in medications that he/she is taking to treat it. See Section 7 for more on this.
  • Caffeine, alcohol, tobacco and recreational drugs all can have an impact of sleep See Section 8 for more.
  • Consideration of the Sleep Environment includes many factors, including light, noise, animals, and other people. See Section 5.
  • A person’s life stresses can have an impact on his/her comfort, energy level, sleep and general health. See Section 33 for more.
  • A person’s sleep may be chronically disrupted by special responsibilities – waking with a newborn; an elderly dependent who needs attention in the night; being on-call for work, or working long shifts.
  • Sleep can be affected by what you eat, how much you eat, and when you eat it. Diet is discussed in Section 9
  •  People who exercise regularly tend to sleep better than those who don’t; but it also depends on when they exercise. See Section 23
  • A person who naps during the day may not be able to sleep on a normal schedule. See Section 32
  • Sleep state misperception (Section 14), occurs when the person is convinced that he/she is not sleeping but really is getting an adequate amount.
  • Many psychological issues can have an impact on sleep, including anxiety, depression and post-traumatic stress. Some of these are discussed in Section 10.

43c. Kinds of Impact

Once you have identified one or more possible sources of a person’s insomnia, it might pay to speculate about the impact of each source on the various sleep issues discussed in Section 40:

  • Circadian rhythms
  • Physiological pressure to sleep
  • Comfort and predictability of the environment
  • Internal physical and mental calm

It is possible that a single source will be the person’s major problem. It is also possible that two or more disruptors will be contributing the person’s sleep difficulties at the same time.

One problem can lead to another. For example,

  1. Medical issues can lead to chronic pain, which leads to light sleep, multiple awakenings, and difficulty returning to sleep in the middle of the night. The person’s circadian cycle could be disrupted by that problem.
  2. Sleep disruption could then lead the person to need one or more naps during the day in order to “catch up”, further disrupting his or her circadian cycle.
  3. Multiple awakenings and naps and daytime pain could reduce the person’s ability to get sufficient exercise and engage in enough active brain and body work to build the physiological pressure to sleep.
  4. The person could develop a sleep-wake schedule that is out-of-synch with others in the immediate environment and common daily activities, further reducing his or her ability to maintain a normal circadian rhythm.
  5. Reduced contact with others could be a source of depression, along with the discouragement in not being able to be normal. This could further affect the person’s circadian cycle.

43d. Time of Impact

A common way of looking at insomnia considers the time of night in which it occurs:

  • Falling asleep
  • Waking too early
  • Interrupted sleep
  • Or some combination of these

The issues in Step C can have their impact in various times of night. However, it pays to keep track of when the person’s major problems occur, to gauge when an intervention has been successful.

It also pays to notice whether a particular intervention has helped all three kinds of insomnia for a person, or whether something else must be considered for adequate sleep to occur.

If resolving a person’s issues of Step C is not sufficient, you can move on to more direct approaches in Step D (Section 11).

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