SSD3377 - SECTION 4: INFORMATION THAT INDICATES INSOMNIA DISORDER
Section 4: Information that Indicates Insomnia Disorder
DSM-5 Code: G47.00
Prevalence = 10-30% (10% meet full criteria, 30% meet partial criteria)
- With non-sleep disorder mental comorbidity, including substance use disorders
- With other medical comorbidity
- With other sleep disorder
Can Insomnia Disorder legitimately be diagnosed by a Master’s level clinician? Yes, with caution.
Less serious problems with insomnia are often linked to increases in stress, anxiety or depression, significant life changes, or sudden changes to the client’s normal sleep schedule or routine. Because a sudden sleep schedule change is the most direct and uncomplicated cause of sleep disruption, it should be the first thing looked for in a sleep assessment.
There are several common events that can cause a sleep schedule disruption. Moving from a day shift at work to a night shift, or vice versa, is the most obvious example. However, less dramatic changes to a sleep schedule can lead to problems with falling asleep for some people, for instance when clocks move forward or backward one hour in the movement of daylight savings time, or beginning a new job or a new school that starts earlier in the day.
As will be described later in this course, there is a complex chemistry of sleep that operates on a somewhat regular schedule. When there is a disruption to that schedule – even one hour’s worth - it can interfere with the sleep inducing neurochemicals being released at the right time. This will make it more difficult for the person to fall asleep when they go to bed. People with less flexible sleep chemistry may require several weeks to adapt to the shift changes.
The birth of a child is another common event that can generate sleep schedule shifts. Because this event also occurs with new responsibilities, worries, fears and challenges, there is often a somewhat lengthy period of adjustment during which time sleep deprivation is the norm rather than the exception. This should not be overlooked or underestimated if a clinician is working with a couple at this phase of their relationship. At a time of heightened conflict, sleep deprivation can lead to decreases in the resources needed to manage that conflict, allowing the conflict to grow. This can lead to a cascading effect in terms of re-establishing a better regular sleep schedule.
There is psychological work involved in processing and adapting to new life challenges, work that is best accomplished by allocating time and energy to sorting through the changes by reflection and/or talking it through with other people. However, if a person avoids this process, or if daytime responsibilities don’t allow it, the need for that kind of processing work may push the client to ruminate when there are no longer any distractions to keep the client otherwise occupied: in bed, at night, with no other distractions. When this rumination process cannot be halted at bedtime, it can lead to temporary problems falling asleep, or waking up to ruminate in the middle of the night.
When any sleep disrupting events occurs, sleep may return to normal fairly quickly if the precipitating events are transient, if the person’s sleep chemistry possesses some degree of flexibility, and if the person does not start to become so worried about getting a good night’s sleep that it creates a self-fulfilling prophecy around having sleep problems. For many people, this is the case and the sleep problems do not become entrenched.
However, in the event of a new child coming into the family, or other longer lasting challenges, sleep insufficiency can become more entrenched, even for people with generally good neurochemistry for sleep. In fact, there are many people for whom a temporary case of insomnia becomes a longer-standing sleep disorder, even without such a dramatic precipitant as the birth of a child. Unfortunately, a person can become conditioned to having sleep problems. Bedtime, the routines leading up to bedtime, and even the physical space in which one sleeps can become associated with sleeplessness and can generate worry about not getting enough sleep.
Later sections in this course will address some of the approaches to modifying this kind of conditioning process. Since we are still looking at the assessment phase, for now, it is simply important to remember to ask the client questions that get a thorough overview of what created and sustains the problems falling asleep.
Question ‘a’ above is designed to elicit preliminary information from the client about what factors may be contributing to problems falling asleep and/or staying asleep. It is important to pay attention carefully to the clues that will be offered by the client’s responses, and to follow up with additional questions to reach some kind of clarity about the causes. This is differential diagnosis at its most basic level.
Some of the factors mentioned by the client may indicate the presence of the kinds of normal stresses and worries and/or changes to the client’s sleep schedule that can precipitate Insomnia Disorder. If the client indicates a recent change from day shift to night shift, combined with worries about being able to fall asleep pursuant to that shift change, it is highly likely that you are seeing insomnia. In such a case, the course of treatment will include some education about the complex chemistry of sleep in order to normalize the client’s experience and reduce the pressure from the sleep anxiety. At a later point in this course, additional approaches for Insomnia Disorder will also be introduced.
Likewise, if the client has experienced a major upswing in stress, or a traumatic event or loss, a temporary period of sleeplessness might be anticipated as a normal response to the increased emotional challenge. In such a case, the clinician would engage in the typical tasks of helping the client process and adapt to the challenges, while also normalizing the client’s experience and introducing best practices approaches to managing the sleep disturbance.
Some factors that might be mentioned by the client, such as general discomfort in arms and legs or difficulties breathing, can indicate other, more serious kinds of sleep disorders with a medical etiology. It is helpful for the clinician to have some background knowledge about these other sleep disorders so that a successful referral to a sleep specialist can be implemented, using a combination of educational and motivational strategies. There will be additional information about these other kinds of sleep disorders later in this course.
The client may also describe additional factors that may be attributable to either psychological or medical causes, and this is where differential diagnosis becomes more difficult. This is the topic of the next part of this examination of the first question in the sleep assessment process.
Information that indicates insomnia from another mental health condition, including substance misuse
There are numerous mental health related contributors to increased difficulties in falling asleep. Most clinicians have had at least some training in looking for medical conditions that are considered primarily psychiatric problems. During the manic phase of a bi-polar disorder, for instance, clients will exhibit extreme sleeplessness, and clinicians with any degree of training should know to look for this. Therefore, when the client describes racing thoughts as one of the factors making it hard to fall asleep, the clinician must determine what this represents - the kind of rumination that occurs within a more normal response to a recent stress or trauma, or the beginning development of a manic phase associated with latent bi-polar disorder, precipitated by a stress or trauma.
The client may be unprepared to offer enough detail on their own to clarify this issue. It requires a little deeper digging on the part of the clinician, with sufficient follow-up questions to clarify which is more likely. If there is doubt, it is always preferable to initiate a referral to a trusted psychiatrist for further diagnostic work. The development of bi-polar disorder would have profound effects on a person’s sleep patterns.
Likewise, increased problems with sleep may be seen in many other psychiatric disorders, such as schizophrenia and other thought disorders, major depression, serious anxiety disorders, eating disorders, substance abuse disorders, and attention deficit disorders. In such cases, the insomnia is not considered the primary problem requiring treatment because it occurs pursuant to the other, primary disorder(s).
If a clinician conducts a thorough psychosocial assessment, other clues will appear that will help differentiate between Insomnia Disorder as the primary problem to be addressed in treatment and sleep problems pursuant to some kind of other psychiatric problem. In such cases, both the underlying psychiatric problem and the sleep disorder must be assessed and treated.
There are important reasons that this dual approach must be undertaken. Because sleep is so intrinsically restorative, it can help reduce some of the negative effects of certain psychiatric disturbances. Conversely, sleep insufficiency can contribute to increases in psychiatric symptoms for clients with certain diagnoses.
The interplay between 1) psychiatric symptoms that increase sleeplessness and 2) reductions in functioning due to sleeplessness can create a downward spiral for some clients, as their symptoms and their sleep decline in tandem. Successful treatment for some clients will necessarily include bringing symptoms under control with medication and therapy and re-establishing healthful sleep hygiene to reduce this interactive effect.
When writing the diagnosis in instances where the Insomnia Disorder is secondary to another psychiatric issue, the primary psychiatric problem should be listed first. The diagnosis of Insomnia Disorder should be listed below, with the specifier “With non-sleep disorder mental comorbidity.” Given that the psychiatric problem responsible for the sleep disturbance is noted prior to the related sleep disturbance, it is not necessary to clarify the specific mental disorder which is responsible for the sleep problems.
The exception to this understanding would be in circumstances where there are multiple diagnoses that precede the Insomnia Disorder, not all of which contribute to the sleep disturbance. In such cases, you may wish to record the specifier in a manner that clarifies which mental or psychiatric condition is responsible for the presence of the sleep disorder. This would be recorded in the following manner: “With non-sleep disorder mental comorbidity attributable to Generalized Anxiety Disorder.”
A thorough psychosocial assessment will always include asking the client information about the use of alcohol and other mind altering substances, as well as information about any prescription medications that are being used. For any client who presents with insomnia, it is important to connect information about substance use and the use of prescriptions medications with what is occurring with the client’s sleep.
Alcohol has complex effects on the sleep cycle that will be covered in more detail later in this course. Recreational drugs with stimulant effects, including cocaine, methamphetamines, and many street drugs, will have obvious and immediate effects on the client’s ability to fall and stay asleep, so it is important to gather complete and comprehensive information about any recreational drug use.
In gathering information about substance use, it is important to remember to ask questions about the client’s use of tobacco products and caffeinated beverages – coffee, tea, sodas, sports and energy drinks. Even moderate amounts of nicotine from cigarettes, chewing tobacco, and snuff, or caffeine from commonly consumed drinks can contribute to difficulties falling and staying asleep. In gathering this information, it is important to have clarity on both the amounts of consumption and how close to bedtime the last consumption of the substance occurs.
Caffeine has a half-life of 5-7 hours and nicotine about 2 hours, so any caffeinated beverage within 10 hours of bedtime and any nicotine consumption within 4 hours of bedtime is going to leave about a quarter of a dose in a person’s bloodstream when they are trying to go to sleep. Having this knowledge allows a mental health clinician the opportunity to provide the client with some education about sleep hygiene in this area.
Information that indicates insomnia from a medical or physiological cause
There are other medical concerns – besides psychiatric problems – that can precipitate insomnia. It does not fall into a mental health clinician’s area of competence to either diagnosis these medical concerns or to treat them. However, in the real world of medical care in this country, clients do not always have a primary care physician to oversee their overall healthcare. Clients may first enter into the healthcare system by scheduling an appointment with a mental health clinician.
This reality places an additional burden on mental health clinicians in terms of differential diagnosis. It means that mental health clinicians should have some degree of awareness of those medical conditions that can contribute to sleep problems. This allows clinicians to educate and motivate their clients to seek proper medical care. Therefore, it is helpful to know – at the very least – what conditions are likely to be associated with insomnia.
As a general starting point, insomnia has been associated with the following medical conditions: diabetes mellitus; cardiovascular problems; gastrointestinal disorders; hyperthyroidism and other metabolic disorders; Parkinson’s disease and other neurological disorders; asthma and other obstructive breathing disorders; cancer; menopause. Additionally, it is important to gather information about medical conditions that cause physical discomfort, including chronic pain from injury or illness, acid reflux, headaches, to name just a few.
It is also advisable to ask your client if he/she has ever had an injury to his/her head that may have been serious enough to cause unconsciousness. Insomnia is one of the most frequent co-morbidities associated with traumatic brain injuries (Zeitzer et al., 2009) and must always be ruled out when a client presents with problems sleeping.
It is not the task of the mental health clinician to engage in medical diagnosis, but it is important to help the client rule out any medical causes of insomnia before simply engaging in treatment for Insomnia Disorder. A good starting point is to ask the client if he/she has had a recent physical and if the sleep problems have been reported to the physician in charge of that physical. If the client did address the sleep concerns and the physician ruled out any medical causes, then the clinician can proceed with approaches to address Insomnia Disorder in collaboration with whatever was recommended by the physician.
However, even when a client does mention sleep problems to a primary care physician, it may not trigger a sufficiently thorough investigation of the causes of the sleeplessness. Within a managed care driven medical system, physicians’ time is valuable and may be limited in terms of the amount of time spent in direct contact with patients. Combined with this, clients may not necessarily understand the potential impact of sleep problems and may minimize the issue.
In other cases, clients may be intimidated, shy, or passive in voicing their concerns, and/or they may be poorly prepared to direct the focus of their physician towards key problems. Even the most skilled and thorough physician must rely on the information given by the patient, and if that information is not passed forward, then the focus will shift elsewhere. These realities may all contribute to the issue of sleep being under-addressed between physicians and their patients.
In truth, mental health clinicians are often able to take a more leisurely and ongoing approach to gathering comprehensive assessment information, session by session, week by week. This allows for the clinician to dig a little deeper into all the contributors to the client’s difficulties, including sleep problems. If it is determined that the client has not addressed the sleep concerns with his/her PCP, or if the PCP did not explore the sleep problems to a satisfactory degree, the clinician can gently help the client to prepare for more successful interaction with his/her physician – in order to trigger the proper medical interventions.
If and when a medical condition that affects sleep has been correctly identified by a physician, the medical diagnosis should be noted in the diagnosis section of the client’s mental health record, using the following format: “E07.9, thyroid disorder, unspecified, by history.” This clarifies that the diagnosis has been made by another party, in this case a medical professional permitted to diagnose and treat medical problems.
On the initial assessment form, there should be a section for writing out the diagnostic impressions and therapeutic recommendations in a long-hand format. This section usually immediately follows the diagnoses written in numeric format. This section is where information about the diagnosing physician would be recorded: “Client has been diagnosed with an unspecified thyroid disorder by Dr. Jane H. Doctor, endocrinologist.”
Following this information, a description of the connection to the Insomnia Disorder can be recorded: “This thyroid condition contributes to sleep difficulties leading to a diagnosis of Insomnia Disorder comorbid with Thyroid Disorder, unspecified, by history, for which the client is seeking treatment.” This thorough description establishes a trail of information that allows other parties to have a better understanding of the patient’s condition and the rationale for the treatment plan set up to address the problems.
In addition to medical conditions, there are also numerous prescription medications that can interfere with sleep, including antidepressants, heart and blood pressure medications, medications for ADHD, allergy medications, and steroids (Mayo), as well as thyroid medication for clients with hypothyroidism. Additionally, any medication with a diuretic effect will cause an increase in urination that may require the client to get up in the middle of the night to go to the bathroom.
When establishing a diagnosis for Insomnia Disorder related to the use of a medication, such as a medication to treat thyroid disorder, the diagnostic record would need to indicate the presence of the medication that is responsible for the sleep problem. This would be written as follows: “Z79.899 Other long term (current) drug therapy, by history.” The medication contributing to the sleep problems would then be recorded in the diagnostic impressions section. “Client is experiencing sleep problems related to the long-term use of Synthroid to treat Thyroid Disorder, under the supervision of Dr. Jane H. Doctor, endocrinologist.”
If the sleep disturbance is related to the Thyroid Disorder, then the diagnostic impressions section would clarify that the disorder is the contributing factor to the sleep disturbance. If the medication to treat the Thyroid Disorder is primarily responsible for the sleep disturbance, then this will be noted in the diagnostic impressions section. If it is unclear as to the primary contributor to the development of the sleep disturbance, then this should be noted in the diagnostic impressions section. Clinicians must present the most accurate picture possible of the contributors to the problem.
It is also important to remember to gather information about the client’s use of non-prescription medications and nutritional supplements. The client may assume that because these substances come without a prescription, they are not worth mentioning during healthcare discussions. Many over the counter medications contain caffeine (Excedrin, Midol), alcohol (NyQuil or Dayquil), and/or stimulants (antihistamines like Sudafed) that can make it difficult for a client to fall asleep and stay asleep. Likewise, there are nutritional supplements whose stimulant properties can interfere with a good night’s sleep, the most common of which would include green tea, which is high in caffeine, and Ginseng and Guarana, which may cause mild to moderate insomnia. (Boozer et al, 2001) (MedLine Plus)
It is not absolutely essential for the mental health clinician to know every medication or supplement that may affect a client’s sleep, but it is important to verify that the client has had detailed discussions with his/her physician about side-effects of all medications and all nutritional supplements. Where this discussion has not occurred, it may be useful for the mental health clinician to perform some research about the medications and/or supplements in question in order to prepare the client for more thorough conversations with his/her prescribing physician.
Along a similar vein, there are also some dietary considerations that can affect sleep. In addition to asking clients about their consumption of caffeinated beverages, it is also helpful to note other aspects of their diet. There are a surprising number of food items that you would not expect to contain caffeine, but which have enough caffeine to affect sleep.
First, many decaffeinated coffees can have up to 1/5 of the caffeine of regular coffee. Many flavors of soda are caffeinated, beyond the usual suspects Coke and Mountain Dew, including root beers, orange sodas, and lemon-lime drinks. Chocolate and any food item containing chocolate will possess caffeine, and the darker the chocolate the greater the amount of caffeine. Additionally, food makers are marketing an ever increasing array of products that are fortified with caffeine, including oatmeal, sunflower seeds, gum, and even breath mints! An uneducated consumer of these products may not be able to piece together the correlation between a change in eating habits and the development of Insomnia Disorder.
Insomnia may also result from what is not in food. In order for the body’s chemistry to function smoothly, there must be maintained a delicate balance of many vitamins and minerals in a person’s diet. If a client presents with insomnia in conjunction with a diet that is extreme in some manner or another, it is always helpful to do some further investigation. For example, a diet that is severely restricted in the intake of sodium – albeit rare in a country of highly salted processed food – can lead to the development of insomnia from the effects of sodium insufficiency. Along a similar vein, bulimia can also lead to sleep disturbance from imbalances between the various key electrolytes (sodium/calcium/potassium) that results from the process of purging.
It is always important to factor in the client’s age when asking questions related to sleep and sleep problems. While older adults actually need just as much sleep as younger adults, there are age driven changes that contribute to sleep difficulties as people grow older. Among other causes of sleep decline as a person ages, there is a gradual decrease in the release of a chemical called melatonin that supports falling asleep. (Waldhauser et al, 1998) Additionally, there is a reduction in the plasticity of the tissues of the bladder, leading to increased nighttime urination and more sleep interruption.
For women of a certain age, there are also hormonal changes that contribute to noticeable alterations in body temperature. The resulting hot flashes can cause the woman to awake in a pool of perspiration. While uncomfortable, this can be considered a somewhat common event for a woman past 40-45 years old. If this same event occurs in a much younger woman in the absence of an illness that causes a temporary temperature increase, it may indicate a more serious problem, necessitating a referral to a physician for assessment.
In each of these instances where the main contributors to insomnia are medically driven, it becomes the task of the clinician to facilitate a referral for appropriate assessment and treatment by a qualified medical specialist. Because there are so many potential causes of sleep disturbance from areas related to medical practice, it is important for clinicians to help the client find a practitioner who is prepared to conduct a sufficiently thorough assessment.
Most intake forms at physicians’ offices now ask patients to provide a comprehensive list of all medications and all supplements that they take. However, patients may not realize that the multiple cups of caffeine laden green tea - or cans of energy drinks – that they are ingesting fall under the category of supplements. In such instances, the most important medical issues responsible for sleep disturbance may be overlooked - until they are uncovered in the course of addressing the depression and anxiety that accompanies the presence of an Insomnia Disorder.
Once the patient’s physician establishes the connection between these contributors to sleep problems and Insomnia Disorder, this information may be recorded as noted above: “Insomnia Disorder with Medical Comorbidity, by history.” In the diagnostic impressions section, the clinician can clarify the supplement responsible for the sleep disturbance: “Client is experiencing sleep problems related to the excessive use of Ginseng and green tea supplements, which is currently being addressed in consultation with the client’s primary care physician.
As will be noted later in this course, sleep disturbances may take several weeks to be corrected even after the withdrawal of any substance that may be responsible for the creation of insomnia. There is a complicated chemistry of sleep, and once this chemistry is disrupted, a return to a sleep cycle homeostasis does not occur immediately.
Moreover, this does not even take into account the psychological effects that can occur if a person experiences disruptions to their normal sleep cycle. If a person begins to worry about whether or not they will be able to fall asleep within a reasonable time frame, that worry can generate neurochemical changes that contribute to the development of a sleep disturbance. This will require different kinds of treatment interventions.
Information that indicates insomnia from other kinds of sleep disorders
In addition to Insomnia Disorder, there are other sleep conditions that may interfere with a good night’s sleep. A number of these may create disruptions to a client’s normal sleep cycle in ways that contribute to the development of Insomnia Disorder. Some of these disorders are relatively rare and unlikely to show up in the practice of most mental health clinicians. Narcolepsy, for instance, has a prevalence rate of only 0.05%, while REM Sleep Behavior Disorder has a prevalence rate of only 0.3-0.5%. These disorders will be addressed at a later point in this course.
As we have noted here are also two sleep disturbances that are more common and more likely to be present in clients who show up for treatment for anxiety, depression and other mental health related concerns: Restless Legs Syndrome and Sleep Apnea Hypopnea. Both of these sleep disturbances may create significant disturbances to a client’s normal sleep cycle and generate problems that are diagnosable as Insomnia Disorder.
Should a clinician encounter either these more common, or any of the rarer kinds of sleep disorders, and should Insomnia Disorder be present concurrently with, or as a result of, these other sleep disturbances, then the final specifier for Insomnia Disorder would be utilized: “Insomnia Disorder with other sleep disorder.”
Because these other disorders will typically require diagnosis from a sleep specialist, this diagnosis would almost always include the “by history” specifier. Further clarification, including the name of the sleep specialist issuing the diagnosis would then be noted in the Diagnostic Impressions section of the assessment form.
Because the next sections of this course will address each of the other sleep disorders in turn, this will conclude this section on Insomnia Disorder. Intervention approaches for Insomnia Disorder and for milder sleep problems will be addressed in a later section.