Adult Treatment Planner
37: Sleep Disturbance
SNOMED Terms
- Circadian rhythm sleep disorder due to alcohol
- Posttraumatic stress disorder
- Sleep terror disorder
Goals
- Restore restful sleep pattern.
- Feel refreshed and energetic during wakeful hours.
- Terminate anxiety-producing dreams that cause awakening.
- End abrupt awakening in terror and return to peaceful, restful sleep pattern.
- Restore restful sleep with reduction of sleepwalking incidents.
Behavioral Definitions
- Complains of difficulty falling asleep
- Complains of difficulty remaining asleep.
- Reports sleeping adequately, but not feeling refreshed or rested after waking.
- Exhibits daytime sleepiness or falling asleep too easily during daytime.
- Insomnia or hypersomnia complaints due to a reversal of the normal sleep-wake schedule.
- Reports distress resulting from repeated awakening with detailed recall of extremely frightening dreams
involving threats to self.
- Experiences abrupt awakening with a panicky scream followed by intense anxiety and autonomic arousal, no
detailed dream recall, and confusion or disorientation.
- Others report repeated incidents of sleepwalking accompanied by amnesia for the episode.
Diagnoses
- Primary Insomnia
- Primary Hypersomnia
- Circadian Rhythm Sleep Disorder
- Nightmare Disorder
- Sleep Terror Disorder
- Sleepwalking Disorder
- Posttraumatic Stress Disorder
- Major Depressive Disorder
- Dysthymic Disorder
Objectives and Interventions
- Describe the history and details of sleep pattern.
- Assess the exact nature of sleep pattern, including bedtime routine, activities associated with the
bed, activity level while awake, nutritional habits including stimulant use, napping practice,
actual sleep time, rhythm of time for being awake versus sleeping, and so on.
- Assign the client to keep a journal of sleep patterns, stressors, thoughts, feelings, and activities
associated with going to bed, and other relevant client-specific factors possibly associated with
sleep problems; process the material for details of the sleep-wake cycle.
- Share history of substance abuse or medication use.
- Assess the contribution of the client's medication or substance abuse to his/her sleep disorder;
refer him/her for chemical dependence treatment, if indicated (see Chemical Dependence chapter in
this Planner).
- Verbalize depressive or anxious feelings and share possible causes.
- Assess the role of depression or anxiety as the cause of the client's sleep disturbance (see
Depression or Anxiety chapters in this Planner).
- Keep physician appointment to assess organic contributions to sleep disorder and the need for psychotropic
medications.
- Refer the client to a physician to rule out physical or pharmacological causes for sleep disturbance
and to consider sleep lab studies and/or need for a prescription of psychotropic medications.
- Take psychotropic medication as prescribed to assess the effect on sleep.
- Monitor the client for psychotropic medication prescription compliance, effectiveness, and side
effects.
- Learn and implement stimulus control strategies to establish a consistent sleep-wake rhythm.
- Discuss with the client the rationale for stimulus control strategies to establish a consistent
sleep-wake cycle (see Behavioral Treatments for Insomnia by Bootzin and Nicassio).
- Teach the client stimulus control techniques (e.g., lie down to sleep only when sleepy; do not use
the bed for activities like T.V., reading, listening to music, but only for sleep or sexual
activity; get out of bed if sleep doesn't arrive soon after retiring; lie back down when sleepy; set
alarm to the same wake-up time every morning regardless of sleep time or quality; do not nap during
the day); assign consistent implementation.
- Instruct the client to move activities associated with arousal and activation from the bedtime
ritual to other times during the day (e.g., reading stimulating content, reviewing day's events,
planning for next day, watching disturbing television).
- Monitor the client's sleep patterns and compliance with stimulus control instructions; problem-solve
obstacles and reinforce successful, consistent implementation.
- Practice good sleep hygiene.
- Instruct the client in sleep hygiene practices such as restricting excessive liquid intake, spicy
late night snacks, or heavy evening meals; exercising regularly, but not within 3-4 hours of
bedtime; minimizing or avoiding caffeine, alcohol, tobacco, and stimulant intake (or assign "Sleep
Pattern Record" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
- Learn and implement calming skills for use at bedtime.
- Teach the client relaxation skills (e.g., progressive muscle, guided imagery, slow diaphragmatic
breathing); teach the client how to apply these skills to facilitate relaxation and sleep at
bedtime.
- Refer the client for or conduct biofeedback training to strengthen the client's successful
relaxation response.
- Identify, challenge, and replace self-talk associated with sleep disturbance with positive, realistic, and
reassuring self-talk.
- Explore the client's schema and self-talk that mediate his/her emotional responses counterproductive
to sleep (e.g., fears, worries of sleeplessness), challenge the biases; assist him/her in replacing
the distorted messages with reality-based alternatives and positive self-talk that will increase the
likelihood of establishing a sound sleep pattern.
- Assign the client a homework exercise in which he/she identifies targeted self-talk and creates
reality-based alternatives (or assign "Negative Thoughts Trigger Negative Feelings" in Adult
Psychotherapy Homework Planner, 2nd ed. by Jongsma); review and reinforce success, providing
corrective feedback toward improvement.
- Identify current stressors that may be interfering with sleep.
- Explore the client's current life circumstances for causes of stress and/or anxiety that may be
interfering with his/her sleep.
- Probe the client for the presence and nature of disturbing dreams and their relationship to his/her
life stress; if needed, assign him/her to keep a dream journal to be processed in future
appointments.
- Verbalize a plan to deal with stressors proactively.
- Assist the client in formulating a plan to modify his/her life situation to reduce stress and
anxiety; monitor the plan implementation, reinforcing success and redirecting for failure.
- Implement a thought-stopping technique to dismiss thoughts counterproductive to sleep.
- Assign the client to implement the thought-stopping technique on a daily basis and at night between
sessions (or assign "Making Use of the Thought-Stopping Technique" in Adult Psychotherapy Homework
Planner, 2nd ed. by Jongsma); review implementation, reinforcing success and redirecting for
failure.
- Discuss experiences of emotional traumas that may disturb sleep.
- Explore recent traumatic events that may be interfering with the client's sleep.
- Discuss fears regarding relinquishing control.
- Probe the client's fears related to letting go of control.
- Disclose fears of death that may contribute to sleep disturbance.
- Probe a fear of death that may contribute to the client's sleep disturbance.
- Share childhood traumatic experiences associated with sleep experience.
- Explore traumas of the client's childhood that surround the sleep experience.
- Probe the client for the presence and nature of disturbing dreams and explore their possible
relationship to present or past trauma.
- Reveal sexual abuse incidents that continue to be disturbing.
- Probe the client for the presence and nature of disturbing dreams and explore their possible
relationship to present or past trauma.
- Explore for possible sexual abuse to the client that has not been revealed (see Sexual Abuse chapter
in this Planner).
- Learn and implement relapse prevention practices.
- Discuss with the client the distinction between a lapse and relapse, associating a lapse with an
occasional and reversible slip into old habits and relapse with the decision to return to old habits
that risk sleep disturbance (e.g., poor sleep hygiene, poor stimulus control practices).
- Identify and rehearse with the client the management of future lapses.
- Instruct the client to routinely use strategies learned in therapy (e.g., good sleep hygiene and
stimulus control) to prevent relapse into habits associated with sleep disturbance.
- Develop a "coping card" or other reminder where relapse prevention practices are recorded for the
client's later use.
- Schedule periodic "maintenance sessions" to help the client maintain therapeutic gains.
Index