How to Help Your Clients Get Better Sleep Bonus Video 1 10-Point Checklist for Getting Better Sleep with Rubin Naiman, PhD
How to Help Your Clients Get Better Sleep 2 10-Point Checklist for Getting Better Sleep with Rubin Naiman, PhD Dr. Naiman: We re going to talk about the top 10 questions you should ask to diagnose sleep issues. I want to begin by saying that it s really critical for every therapist to incorporate a concern about sleep issues into their practices, and that we should routinely ask about an individual s sleep, in the same way that we would ask about their mood, their feelings, their depression, relationship issues, stress and things like that. I like to begin with open-ended questions, an open-ended conversation around sleep and then seek specific clarifications as needed. So, the first question is: How s your sleep? With this question we re looking for a general sense of the individual s experience about their sleep as well as some specifics. We should routinely ask about an individual s sleep. We want to get a sense of how much time they re sleeping what we call total sleep time or TST in sleep medicine. We want to get a sense of how much time they re sleeping what we call total sleep time or TST. There s a normal range that could probably run anywhere from about six hours up to about nine hours, and even ten hours for some individuals. Around this question, we re also interested in issues about the quality of their sleep: Are they having trouble falling asleep? Are they having trouble staying asleep? Are they having trouble obtaining rejuvenating sleep? We re really looking for indicators of sleep onset insomnia, sleep maintenance insomnia, or poor-quality sleep. The second question, very much related to this, is a question about How is your energy throughout the day? We re looking here for something technically referred to as EDS, which stands for excessive daytime sleepiness. It s very common for people who don t sleep well to find that they re not sleepy during the day. It s very common for people who don t sleep well to be sleepy during the We re looking for indicators of sleep onset insomnia, sleep maintenance insomnia, or poor-quality sleep. day, but it s also common as we ll talk about in the moment to find that they re not sleepy during the day, and then we look for some daytime impact of their trouble sleeping at night.
How to Help Your Clients Get Better Sleep 3 With EDS, the focus is on excessive daytime sleepiness because it s actually normal for people to have some sleepiness during the day. We re all biologically programmed to nap, so getting sleepy after lunch, around two or three o clock is perfectly normal. It s perfectly normal, and actually necessary, for people to nap in the afternoon. But we re looking for sleepiness that oscillates pretty intensely through the day: somebody feeling sleepy after breakfast, before lunch, certainly in the afternoon, maybe falling asleep in the late afternoon or in the evening when watching television after dinner. One of the major causes of sleeplessness at night is not insufficient sleepiness, but excessive wakefulness. So, there are a couple of additional points related to the question, How s your energy throughout the day? One is the issue of napping. It s perfectly normal, and actually necessary, for people to nap in the afternoon. The only time we don t recommend napping is if somebody is having insomnia we don t want to reduce their sleep load through naps. A second point here is we want to ask also if people are sleepy during the day if they feel sudden periods of weakness or lax experiences in their muscles. What we re looking for here is an indication of something called cataplexy. Excessive daytime sleepiness, in addition to being a symptom of insomnia, is also a symptom of narcolepsy. This is not as common a disorder, but it s a sleep disorder that is widely missed, often misdiagnosed as depression. We re looking for indications of obstructive sleep apnea. If somebody is also expressing these reactions of sudden weakness in some or all of their muscles and sometimes a feeling like they re going to fall over, it s something worth tagging and worth addressing by recommending a sleep study. We want to know whether their bedroom is dark through the night, quiet, and cool. I should also add here that probably, more often than not, people with trouble sleeping at night with insomnia actually are not excessively sleepy during the day they turn out to be hyperaroused. In fact, one of the major causes of sleeplessness at night is not insufficient sleepiness, but excessive wakefulness. during the day. This hyperarousal, this excessive wakefulness, keeps them from sleeping well at night, but it also masks their sleepiness The lack of sleepiness during the day is not necessarily an indicator that they don t have a sleep disorder.
How to Help Your Clients Get Better Sleep 4 The third question, a very important question, is again an open-ended one: Do you snore? Or do you know if you snore? We know that there s been a dramatic increase in couples sleeping apart. Some people will deny snoring because of course they re asleep when they snore. Do you know if you snore? taps into questions about the people sleeping with them or people in their home. About half of the population snores, and this is called primary snoring. But we want to ask also if it s loud and if it s associated with pauses in breathing or choking. What we re looking for here are indications of obstructive sleep apnea, which is a very serious disorder that affects probably between 20 and 30 million American adults, most of it still undiagnosed and untreated. If somebody is snoring, we want to follow that up with the question, again, about EDS: if they re snoring, they re excessively sleepy during the day, and they can t explain it, they might say, Well, I m a good sleeper I m sleeping seven/eight hours a night. There are many medications used as sleeping pills. But if they re also excessively sleepy and they have other indicators like depression, headache, secondary impotence, hypertension, then this raises a red flag about the possibility of sleep apnea we definitely want to refer them to a sleep specialist or back to their physician for polysomnography, which is an overnight sleep study. We re especially interested in the relationship between alcohol and sleep.. By the way, I should add that polysomnography, overnight sleep studies, are not indicated for ordinary insomnia. There are some circumstances where we might suspect leg kicks or things like that, that would require polysomnography, but typically, doing that kind of overnight study doesn t yield any information that s helpful in treating insomnia. Question number four: Is your bedroom conducive to sleep? This is a rather straightforward question. We want to know whether their bedroom is dark through the night, quiet, and cool we like bedrooms to be no warmer than 68 degrees Fahrenheit. We want to know if they re clock-watching at night if they have illuminated digital clocks. We also want to know if they feel safe in their bedroom psychologically safe. Many individuals will develop negative associations with their bedrooms as children. They were sent there as punishment, Many commonly used drugs can have a direct impact on sleep.
How to Help Your Clients Get Better Sleep 5 Caffeine has a relatively long half-life that can be impacting not only energy during the day but sleep at night. sometimes sent to bed as punishment, and of course there are situations where people were abused in their bed. We can see these long-term sort of classically conditioned negative associations with the bed that need to be assessed. So, Is your bedroom conducive to sleep? Also, related to that, are questions about their bed partner: Are you getting along with your bed partner? It s hard to sleep well next to somebody that you have tension with. Do you sleep with your bed partner? We are concerned about that we know that there s been a dramatic increase in couples sleeping apart, and this is associated with increased risk for separation and divorce. Question number five: Do you use medication alcohol, marijuana or other kinds of supplements to sleep? We want to know if they re trying to bolster their sleep by taking something to sleep by swallowing something to sleep. This is important for a number of reasons. One is, if they re reporting good sleep, is it truly good sleep or is it really about a knockout from these substances? People who don t sleep well develop a negative association with their bed. There are many medications that are now used as sleeping pills: there are the classic, standard sleeping pills, but there are also tricyclic antidepressants, benzodiazepines and other drugs that are used to promote sleep. We simply want to obtain information here. We re especially interested in the relationship in their lives between alcohol and sleep. We know that more than half of adult alcoholics report starting to drink as adolescents because they were unable to sleep, and that s something we want to look into. In recent decades, there has been a dramatic decrease in psychotherapists showing interest in the dreams of their clients and this needs to be reversed. The question about marijuana or cannabis is an openended one. Our situation today with growing legalization of this substance around the country is raising lots and lots of questions. Most of the research we have about the relationship of marijuana to sleep is dated and we also today have so many hybrid varieties, some of which may promote sleep, some of which may inhibit sleep, so we re just gathering information here really just for our own benefit. Question number six is open-ended again: How is your health? What we re concerned with here are medical conditions that may impact sleep: conditions associated with pain, for example, or stiffness or other forms of discomfort. We re also concerned with the impact of other medications on sleep. More and more Americans are using prescription medications and the probability of doing so increases as the population ages.
How to Help Your Clients Get Better Sleep 6 Many commonly used drugs can have a direct impact on sleep so we want to evaluate this, maybe do a Web search and look for sleep side effects of their medications. Question number seven: Do you use caffeine or energy drinks or sugary foods or any kind of stimulants to stay awake? These questions and issues around sleep are intimately bound up with lifestyle questions. What we re looking for here are habits that may be masking excessive daytime sleepiness. We asked earlier about their sleepiness, their energy during the day, and what we want to know here is if that energy or if their sleepiness is masked in any way by food or substances. We also know that caffeine, for example, has a relatively long half-life and some of the ingredients in energy drinks also have a long half-life that can be impacting not only their energy during the day but their sleep at night. Question number eight focuses in on what we call sleep phrase disorders and we want to ask: Is your bedtime routinely advanced or delayed or irregular. What we re looking for here is an indication of the quality of their circadian rhythms. We know, for example, that in our world, adolescents tend to have a markedly delayed bedtime: the clock on the wall says it is 10 o clock it is bedtime and the clock inside their head might say it is only 6 o clock. Even if we force them to go to bed, they won t sleep. That s a delayed sleep phase their brain their body doesn t believe sleep onset comes until later, and of course that would also delay sleep offset. If we look at the other end of the aging population people who are aging in their sixties and seventies and eighties, we commonly see an advanced sleep phase, meaning that the clock inside their brain believes it is bedtime long before the clock on the wall says it is bedtime. These are two conditions that can actually be relatively well managed by using by manipulating the applications of light and darkness and also melatonin. Both of these conditions are often associated with complaints of insomnia. Question number nine: we want to ask, Do you find it easier to sleep in places other than your bed. What s behind this question is a search for what we call conditioned insomnia. It s very common that people who don t sleep well end up spending a lot of time in their beds awake tossing, turning and in an agitated state of mind, trying to sleep. What happens then is that they develop a classically conditioned association, a negative association, with their bed. People with long-term insomnia, for example, will commonly think or say that they hate their bedrooms that they hate their beds, and they will have an easier time falling asleep in a chair watching television, or falling asleep on the couch, or sleeping in a hotel or motel away from home. This gives us an indication that there might be some conditioned insomnia going on that needs to be treated, and we do have good treatment protocols for this. Last but not least, question number ten is: How is your dream life?
How to Help Your Clients Get Better Sleep 7 This is a question that has implications not only for the quality of their sleep, but also for psychotherapy. It turns out in recent decades, there has been a dramatic decrease in psychotherapists showing interest in the dreams of their clients or their patients, and this is something that needs to be reversed. We re also concerned about dream recall. There are many medications for many forms of insomnia that limit the recollection of dreams or limit the amount of time we re dreaming. A very critical corollary to this question is one about a condition called RBD or REM sleep behavior disorder. This is a medical condition that has been increasing in prevalence in recent years actually since the introduction of Prozac because SSRIs can increase this condition. RBD refers to a situation where people are acting out their dreams. Normally, when we re in REM sleep, we experience an inhibition of our voluntary muscles we simply can t move in REM sleep it s called sleep paralysis. When this breaks down, there s an acting out of the dream, and more often than not, this acting out is violent. This is a condition that should be evaluated by a physician, particularly by a neurologist. It dramatically increases the risk for future occurrence of neurological disorders like Lewy Body Syndrome or Parkinson s Syndrome. Just with this review of 10 basic questions, you probably get a sense that these questions and issues around sleep are intimately bound up with lifestyle questions. And it s easy to see how they have implications not only for the quality of the night/the nights that our clients or patients have, but also for the quality of their days. Again, I want to stress how critical it is that we evaluate sleep as a part of ordinary psychotherapy evaluations.