Sleep Conditions, Disturbances and Disorders

By Kathy Sexton-Radek and Gina M. Graci

While nearly one-third of our life is spent in slumber, many individuals underestimate the value and function of sleep. It is estimated that one in eight adults will experience discomfort and report lower quality of life rating due to a poor night of sleep. Frequently, our conversations include subjective ratings of "how well or how poor" we slept the previous night because so much of our alertness, ability to concentrate, and ability to function revolves around the length and quality of sleep.

Poor sleep generally includes frequent awakenings, difficulty falling or staying asleep or an abbreviated sleep interval that is secondary to personal scheduling. Sleep disturbance may have a biological/psychological basis or may be attributed to external factors -- arousal stimulants (e.g., coffee, late night eating, pain, etc). Our personal experience of a sleep wake rhythm has determined starts (i.e., a bedtime) and stops (i.e., wake time) that influences our sleep interval and becomes a behavioral habit that our brain anticipates. In fact, a homeostatic balance between the degree of sleepiness we feel and our readiness to fall asleep (i.e., how close we are to our bedtime) determines sleep. The challenge is assisting clients to feel comfortable with allowing their body to relax and allow the sleep process to occur. Similar to our work in hypnosis, this comfort or relaxation state often entails helping the client to "give way" to their sleepiness and enter sleep (an altered state of consciousness). For some, personality style, stressors from life conditions and/or worry prevent the state of relaxation which precedes the initiation of sleep. For example, the onset of sleep is characterized by low muscle tone and body temperature, relaxation and low cognitive activity. For those patients that are unable to prevent worrisome thoughts (anxiety-provoking) or mentally stimulating thoughts or events, the ability to sleep may be delayed.

Sleep disturbances begin when an individual's sleep cycle and duration of the sleep cycle is continuously interrupted. Many factors (i.e., trauma, adapting to new sleep environments, etc.) inhibit the sleep cycle causing an individual to experience excessive daytime sleepiness, and difficulty falling or staying asleep. Recording the duration, frequency of awakenings, and quality of sleep are important to clinicians. Sleep Specialists often utilize self-report measures, sleep logs, as well as daytime recordings of activities to gain insight into how daytime and nighttime activities impact sleep. Sleep Specialists introduce healthy sleep habits and sleep education as part of their treatment plan. Cognitive Behavioral Therapy (CBT), a short-term therapy, is often used in the treatment of insomnia. The overarching goal of CBT is to align emotional/cognitive functioning with appropriate behavioral factors (proper sleep promoting behaviors) to enhance sleep. CBT focuses on the behaviors that upset the homeostatic balance of sleep and wake, along with therapeutically addressing the cognitive assumptions about one's sleep serve to rapidly correct a person's poor sleep. When problematic sleep occurs to an extensive degree or over a long period of time, the specific sleep symptom pattern is examined in terms of a Sleep Disorder diagnosis.

When sleep presents with more a steadfast disturbance such that the architecture of sleep is out of balance, it considered to be a sleep disorder. The International Classification of Sleep Disorders Manual, second edition by the American Sleep Disorders Association is the standard, worldwide reference. A diagnosis by a Board or Certified Sleep Specialist stipulates the necessary treatment based on the standard assessment practices used (e.g., an all night sleep study, daytime wake or nap study). CBT therapy, hypnotic medications, and/or changes in an individual's sleep schedule are some of the common sleep disorder treatments. Please note that only a Sleep Specialist should make changes to a patient's sleep schedule.

Hypnosis has been efficacious in the treatment of some sleep disorders, such as insomnia and other hyperarousal disorders. Hypnosis should always be used as an adjunct to psychotherapy in the treatment of sleep disorders. Hypnosis has been used successfully to alleviate insomnia, nightmares, night terrors, and sleep walking. Hypnotic strategies have been used to treat arousal disorders using 1-2 sessions of hypnotherapy focusing on relaxation and self-hypnosis at bedtime. A hypnotherapy session typically involves the steps of explaining the rationale, describing the varied approaches and theories, explaining the interaction between the therapist and client during hypnosis, induction, use of cognitive therapy-imagery that is personalized to the client and the summary of the treatment plan. At a minimum, clients should experience improvements of allowing themselves "to let go" and allow the sleep process to begin. The overarching goal of hypnosis treatment is to restore sleep duration and sleep quality.

There are two key questions that a clinician should ask patients. First, given the common expression of poor sleep, intake questions and beginning session status questions should query about the client's sleep quality. Second, ask the client how they think their sleep problem started, and what they feel will help them to achieve good sleep again. These two questions provide the clinician with rich clinical information to use in the formulation of treatment plans. Additional key points to include in the treatment of sleep disorders.

Additionally, CBT is an empirically validated treatment for Insomnia and many other sleep disturbances and disorders. The American Academy of Sleep Medicine (AASM) maintains a listing of Certified Sleep Specialists that can utilize CBT treatment in their clinical practices. Lastly, hypnosis and hypnotherapy should be used as a supplement to CBT in the treatment of insomnia. The educative aspects of the rationale and procedure of hypnosis provide the client with an understanding of heightening the client's awareness of sleep process,-particularly acknowledging and allowing sleepiness to occur. This educative component will serve to facilitate the relaxation state necessary to fall asleep.

In summary, we feel that the clinical implications of what is necessary to treat the common problems of sleep disturbance and sleep disorders strongly support the supplemental use of hypnotherapy. We have provided a bibliography of sources for further information; the reader is also encouraged to contact the authors at their email addresses.

Bibliography
Graci, G. M., & Sexton-Radek, K. (2006). Chapter 11: Treating Sleep Disorders Using Cognitive Behavior Therapy and Hypnosis. In: R.A. Chapman (Ed.), A Practitioner's Casebook: The Clinical Use of Hypnosis in Cognitive Behavioral Therapy. New York: Springer Press.

Morin, C.M. (2004). Insomnia Treatment: Taking a broader perspective on efficacy and cost-effectiveness issues. Sleep Medicine Reviews, 8(1), 3-6.

Espie, C.A., Inglis, S.J., Tessier, S., & Harvey, L. (2001). The clinical effectiveness of cognitive behavior therapy for Chronic Insomnia: Implicaiton and Evaluation of a Sleep Clinic in General Medical Practice. Behaviour Research and Therapy, 39(1), 45-60.

Kryger, M. H., Roth, T., Dement, W. C. (4th Ed.)(year). Principles and Practice of Sleep Medicine. New York: Elsevier Saunders.

Sateia, M.J., Doghramji, K., Hauri, P.J. & Morin , C.M. (2000). Evaluaiton of Chronic Insomnia. An American Academy of Sleep Medicine review, Sleep, 23(2), 243-308.

Sexton-Radek, K. & Graci, G. M. (2008). Combating Your Sleep. New York: Praeger Press.