SSD3377 - SECTION 3: A BRIEF OVERVIEW OF PERFORMING A PRELIMINARY SLEEP ASSESSMENT
Section 3: A Brief Overview of Performing a Preliminary Sleep Assessment
Estimates by the National Institute of Health suggest that approximately 30% of adults across the world suffer some kind of sleep disturbance. (NIH) This means that approximately 3 out of every 10 adults we see will likely have problems with their sleep. Importantly for mental health clinicians, approximately 40% of the people who present with sleep problems such as insomnia also present with co-morbid psychiatric problems, the most common of which is depression.
For this reason, it is very important for mental health clinicians to include questions about clients’ sleep patterns in every psychosocial assessment and to have a basic foundation of knowledge for assessing sleep problems, including differentiating the possible sources of sleep disturbances. Just based upon data on the prevalence of sleep problems, mental health clinicians are most likely to encounter what is called Insomnia Disorder.
This consists of difficulties falling asleep or staying asleep for reasons not related to some sort of underlying medical or physical condition. This kind of sleep problem can often be handled as part of the counseling process, using the information available in this course. In such a case, a referral to a sleep specialist or to a medical provider for some other underlying problem would not necessarily be needed. The prevalence rate for this is estimated to be between 10 (full criteria are met) and 30% (partial criteria are met) of the adult population.
There are also two other sleep disturbances that are relatively more common in clients who show up for treatment for anxiety, depression and other mental health related concerns: Restless Legs Syndrome and Sleep Apnea Hypopnea. There are somewhat more complex physiological factors that generate these sleep disturbances, which will be covered in more detail in a later chapter. The prevalence rate for Restless Legs Syndrome is estimated to be 5.5% of the population, while Sleep Apnea – in its two most common manifestations - is estimated to affect between 3.9 and 7.9% of the adult population.
Additionally, there are two other sleep disturbances affecting 1% or more of the adult population that may affect clients’ ability to get a good night’s sleep on a regular basis: Nightmare Disorder (prevalence = 5.1%) and Non-REM Sleep Arousal Disorder, which manifests itself as sleepwalking type (prevalence = 3.6%) or sleep terror type (prevalence = 1%). These disorders will also be covered in later chapters.
There are other factors outside of the area of competence for mental health clinicians that may lead to the creation of difficulties with sleep. One of the great challenges for mental health clinicians in performing a thorough assessment is differentiating mental health problems with a primarily psychological origin – like Insomnia Disorder - from signs and symptoms related to some kind of medical or physical problem.
For problems with a medical origin, we must be prepared to make an appropriate referral. This means we must: 1) know enough to assess a sleep disturbance with a medical cause and 2) be able to educate and motivate the client to seek out whatever services might be indicated. The more thoroughly and clearly the clinician can educate the client, the easier it will be to generate motivation in the client for making good healthcare decisions.
In later sections, there will be some examination of the more common sleep problems that have a medical or physiological origin. The focus of this section, though, will be the presentation of a framework for assessing sleep problems, including some typical questions that might be asked as part of this assessment process and commentary of what information the questions are designed to elicit. Clinicians who wish to do so may also consider developing a brief sleep questionnaire to gather the same information, but it would still be useful to go over the client’s responses in person in order to expand upon the information that has been provided.
Questions to ask in a preliminary sleep assessment
- How well do you sleep and how many hours of sleep do you typically get each night?
If the client reports troubles with sleep or getting less than 6 hours or more than 8 hours, it is probably useful to continue the sleep assessment to get more details.
- Do you ever have any difficulties falling asleep and/or staying asleep?
If yes, a) what tends to make it difficult for you to fall and/or stay asleep?
Be on the lookout for the following: i) Racing thoughts; ii) Worries about not sleeping; iii) Fear or dread; iv) Generalized anxiety or worry; v) Problems with body temperature or waking up in a sweat; vi) Aches and pains; vii) heart pounding or beating fast; viii) General discomfort in the arms or legs, with a desire to move around; ix) Hard time breathing or a feeling of suffocating while lying down
b) How long do you typically spend tossing and turning before you finally fall asleep or how early do you wake up without being able to get back to sleep?
c) How long has this been the case?
d) Is there anything different you do on nights when it is particularly hard to fall asleep/stay asleep?
e) Did anything unusual or different happen right before you started having this problem?
f) Were there any changes to your sleep schedule or sleep routine prior to developing this problem?
g) Have you recently been diagnosed with any medical problems?
h) Are you currently taking any prescription or over the counter medications?
i) Are you currently taking any nutritional supplements?
j) Have you ever had an injury to your head where you lost consciousness?
k) Are you a i) smoker, ii) coffee drinker
l) If you drink alcohol, how much are you drinking in the evening and how long before bedtime is your last drink?
m) Do you take any other substances that might be interfering with your sleep?
- Do feel refreshed when you wake up from a full night’s sleep and are you able to go through the day without becoming excessively sleepy?
If no, a) How long has this been the case?
b) Have there been any recent changes to your sleep schedule?
c) Have you even woken up gasping for air?
d) Has anyone ever told you that you stopped breathing when you were asleep?
e) Has anyone ever told you that you are prone to snoring?
f) Do you find it especially hard to sleep when you have a head cold?
g) Do you even have morning headaches?
h) Has anyone ever told you that you move your legs or arms a lot when you are sleeping or trying to go to sleep, or that you act out your dreams by moving or talking?
i) At times when you are sitting or lying down, do you ever have a feeling of creeping, crawling, aching, pulling, searing, tingling, bubbling, or crawling in your arms or legs that creates an urge to move around in order to relieve the discomfort?
j) Has your weight increased recently?
k) Have there been any changes to your mood, with an increase in anxiety and/or depression?
l) Has there been any change to your blood pressure?
m) Have you noticed any decline in your sex drive?
The symptoms described by “h” and “i” above are oriented towards determining the possible presence of Restless Leg Syndrome, while c-g are oriented towards uncovering possible Sleep Apnea. If your client describes a restless feeling in his/her arms or legs when trying to sleep, Restless Legs Syndrome must be considered. If your client reports a feeling of suffocating or having a hard time breathing when lying down, then Sleep Apnea may be present. There will be more detail on these sleep problems later in this course, and some of the questions to follow will help in the process of uncovering these sleep disorders.
The next sections of this course will address all of the diagnostic categories noted in the DSM-5 under the heading of Sleep-Wake Disorders.