Our profession is responding to the challenge of a healthcare marketplace that increasingly clamors for more expertise to manage chronic conditions such as pain, IBS, headaches, anxiety and so forth, and demands accountability from practitioners. Sleep health services represent a key set of interventions well within our skill set as applied psychologists and readily adaptable to a variety of treatment settings.

Information about sleep abounds on the web, with numerous opportunities for all psychologists to become versed in the basics of sleep hygiene, insomnia treatment and circadian rhythms. Fellowships and training programs have been established around the country. We are immersed in a global, 24/7/365 world in which work-life boundaries are fluid, and demands are placed on people during what might have been traditional bedtimes. Electronic devices have proliferated, robbing people of sleep, illuminating their retina and stimulating their hypothalamus, all of which disrupts the circadian pacemaker. Nonetheless, we hear advertising messages about the brevity of life and that we should keep alert and conscious as much as possible in the 24-hour day. Have we figured out a way to eliminate the need to eat? I suspect we would have the same luck with sleep. Ironically, the sleep we do achieve may be deleteriously affected by the subtle but omnipresent “light fields” in which all urban dwellers reside. Such dispersed light pollution can suppress melatonin and fool the brain into thinking that we should be awake, active and cogitating. And more and more of us are living in the urban setting, replete with noise, fumes and activity, further impairing our ability to sleep in a consolidated, restorative fashion. It is in this environmental context that we can offer help to clients with insomnia, a widespread behavioral and public health issue in our society.  Please refer to Morin, Bootzin, Buysse, Edinger, Espie & Lichstein, 2006. Well informed psychologists can debunk many of the myths about sleep that bedevil clients and perpetuate their sleeplessness.

There remain pockets of mental health professionals who regard sleep as a clinical issue outside their purview best left to “medical” practitioners. Nonsense. Sleep is a complex set of behaviors which can be readily quantified, as any sleep study data set can attest. Sleep outcomes (e.g., sleep onset latency, reducing nocturnal awakenings, self-rated sleep quality) can be operationally defined in care plans to satisfy the utilization review or treatment audit process. Traditionally, relaxation therapies have been implemented as a way to manage anxiety and thus facilitate sleep. Hypnotherapy has also been invoked. But the sleep function itself is typically bypassed in the everyday work of clinicians. We perform consultations or treatments in traditional wake time periods during the 24-hour clock. Performance fatigue, a ubiquitous problem vexing over-the-road truck drivers, nuclear power plant operators, military sentinels, pilots, ER workers, law enforcement and shift workers, has been studied extensively because of the huge personal and public safety considerations at play. The mindset of our profession was to buy into traditional concepts of psychiatric impairment, where the focus was presumably on daytime functioning and sleep would just be a background process that would take care of itself. Sleep issues do not always remit spontaneously.  We now understand that there is a delicate interrelationship between how one functions during the day and night. The impact is bi-directional. Psychotherapy, behavior management, biofeedback, neuropsychological evaluations and so forth take place when a patient or client is presumably awake and alert, an assumption which may or may not be true. We have learned that the sleep-wake interface is more fluid and semi-permeable than first thought. We have all heard about dramatic cases of sleepwalking, sleepsex and sleepdriving. People have reportedly engaged in criminal behavior but later claim they were not cognizant or mindful of their actions. Micro-sleeping can occur during the middle of the day when a person is grossly sleep deprived. Sleep debt is cumulative, with insidious effects which cannot be rectified by one or two weekend nights of recovery sleep.

There is a large literature on the relationship between light and wellness, which overlaps chronobiology, mammalian physiology, biological psychology and so forth (Lewy, Sack, Miller & Hoban, 1987). These concepts have not been generally elaborated on in the context of the mental health intervention paradigm but most assuredly need to be. Fatigue induced by sleep debt influences neurocognitive performance, resulting in concentration deficits of an order of magnitude that needs to be considered in interpreting test results. How often does a psychologist identify the time of day of intake, testing or the chronotype of the individual?  Questions about sleep habits should be as routine as asking about chemical health, abuse victimization experiences and symptoms of depression and anxiety. Cumulative sleep debt can adversely influence a child or adult’s willingness to cooperate with an evaluation protocol or sustain effort in sessions.  Educators have long been savvy about the effects of sleep on classroom behavior and academic performance.

Insomnia was regarded historically as an effect or downstream phenomenon, perhaps subsumed under the rubric of Major Depression, Anxiety or Adjustment Disorder. The Diagnostic and Statistical Manual of Mental Disorders (5^th ed.; DSM-5; American Psychiatric Association, 2013)  provides clear guidance on the classification of independent sleep disorders, including insomnia. The old dichotomy of primary vs. secondary insomnia has disappeared. Psychiatry has addressed insomnia with a range of anxiolytics, the benzodiazepines, Lunesta, Ambien, Trazodone, Remeron, melatonin agonists, diphenhydramine and atypical antipsychotics such as Seroquel. Ongoing use of sedative-hypnotics can be dicey, especially among the elderly and neurologically compromised individuals. Falls, memory deficits and amnesia for behavior can occur.  Clients are choosing numerous self-medication options, encompassing natural, herbal and OTC remedies.

The good news is that psychologists can reach into their tool box for empirically validated, evidence-based, best practice techniques of cognitive-behavioral psychotherapy to apply to insomnia and utilize insights into other sleep phenomena to reframe from what might hitherto be viewed as a conversion symptom or just a symptom of depression, anxiety or other psychiatric disorder. For example, individuals with inexplicable episodes of syncope or falls may in reality be manifesting signs of cataplexy found in narcolepsy. Grossly sleep deprived individuals may hallucinate or perceive visual phenomena at the outset of sleep or in the morning upon awakening. They are clearly not psychotic in the traditional sense.  Parents whose children experience night terrors are often terrified.  Education about parasomnias and pediatric sleep management can greatly allay their fears. Commonly used psychostimulants for ADHD can trigger insomnia and create a vicious cycle of sleep deprivation, causing irritability and lack of focus and fueling further pharmacologic management.  Basic techniques such as stimulus control, sleep restriction and the challenging of unfounded or irrational beliefs about sleep (e.g., the insistence that one needs 8 hours of sleep every night or that one can get by with 4 hours nightly) are germane to the psychological treatment process. Continuous Positive Airway Pressure (CPAP medical device) used by people diagnosed with obstructive or central sleep apnea or both, is a critical device to improve daytime energy and alertness and reduce long-term cardiovascular risk. However, compliance with CPAP has been problematic in that some people are reactive to having any device cover their nostrils or mouth while in bed. Some people may experience claustrophobia, sensory defensiveness or flashbacks to abusive experiences. Psychologists can provide valuable assistance to individuals struggling with CPAP masks through standard systematic desensitization protocols.

In a performance oriented world, improving sleep quality, and in many cases, sleep efficiency, are critical objectives. Generally speaking, people seeking help with sleep problems are motivated and appreciative of psychologists who have some knowledge and intervention skills in this area of practice. Even nightmares can be managed with a technique known as Imagery Rehearsal Training (IRT; Krakow, Kellner, Pathak & Lambert,1995) in which nightmare narratives are re-written and the revised imagery rehearsed, affording clients an opportunity to empower themselves, wresting control from the bad dreams and creating a less anxiety laden outcome.  Bedwetting in children is an example of a parasomnia which can be managed behaviorally. Hypersomnia is amenable to cognitive approaches that invite behavioral activation during the day. Of course, hypersomnia and depression often co-exist. Adolescents with delayed sleep phase syndrome benefit from low doses of melatonin up to 5 hours before their designated bedtime and exposure to bright light upon awakening. Elderly with advanced phase syndromes may benefit from bright light exposure in the evening, which permits them to stay awake longer after supper and utilize precious hours for more meaningful activities.

This article offers a cursory overview of a robust sub-specialty within the field of health psychology that has enormous implications for personal and public health, and whose applications augment the perceived and actual value of psychologists in primary care integrated settings, specialized sleep clinics and independent practice.

Dr. Michael DeSanctis is a licensed psychologist in the states of MN and WI. He has been in practice for over 30 years.  He is a Diplomate of the American Board of Professional Psychology in Counseling Psychology, and a Fellow of the American Academy of Counseling Psychology. He is listed in the National Register of Health Service Psychologists. Dr. DeSanctis is certified in behavior sleep medicine by the American Board of Sleep Medicine and is a member of the American Psychological Association, Minnesota Psychological Association and American Academy of Sleep Medicine. He currently maintains a consulting and private practice in St. Paul, MN.  Dr. DeSanctis is reachable at [email protected].

References

Morin, C.M., Bootzin, R., Buysse, D.J., Edinger, J.D., Espie, C. & Lichstein, K.L. Psychological and behavioral treatment for insomnia. Sleep, 2006, 29 (11), 1398-1414.

Lewy, A.J., Sack, R.L., Miller, S. & Hoban, T.M. (1987). Antidepressant and circadian phase-shifting effects of light. Science, 235, 352-354.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th ed.) Arlington, VA: American Psychiatric Publishing.

Krakow, B.J., Kellner, R., Pathak, D, & Lambert, L. Imagery rehearsal treatment for chronic nightmares. Behavior Research and Therapy, 1995, 33, 837-843.