Mary-Catherine Segota, Psy D

“I can’t sleep!” How many times is that said in the office? Probably more than you can count, with a national average rate of 1 in 4 patients seen in primary care offices reporting sleep disturbance. However, it may surprise you to hear that sleep difficulties often go unreported in typical office visits unless specifically asked about. Sleep is a critical part of biological functioning, and lack thereof can lead to a host of medical and psychological problems. What is often missed is the tremendous effect of sleep problems on mood, and the effect mood has on sleep, often leading to misdiagnoses of each.

According to the American Academy of Sleep Medicine, 30-50% of adults report brief symptoms of insomnia, while 15-20% have short-term insomnia lasting less than 3 months, and 10% have chronic insomnia disorders that occur at least 3 times per week for at least 3 months. The most commonly reported issues are insomnia, restless leg, and obstructive sleep apnea (OSA), and the most commonly diagnosed sleep disorders include these as well as narcolepsy, and circadian rhythm disorders.

According to NIH, insomnia can worsen health problems or raise the risk of developing conditions such as: asthma, chronic pain, decreased immune response, heart problems, high blood pressure, metabolic syndrome, diabetes, becoming overweight, obesity, pregnancy complications, and substance use disorders. Additionally, insomnia in older adults increases the risk of cognitive decline and dementia (NIH 2019). When compared to someone who sleeps between 7 and 9 hours per night, a person who sleeps on average less than 6 hours per night has a 13 percent higher mortality risk, and a person who sleeps between 6 and 7 hours per night has a 7 percent higher mortality risk (NIH 2017). Causes of death in these cases include car accidents, strokes, cancer, and cardiovascular disease. Because of sleep deprivation, patients can experience microsleep, that is falling asleep for a few to several seconds without realizing it, which leads to dangerousness while driving or operating machinery, causing injury.

When looking at the biological mechanisms that are affected by sleep deprivation, we see the critical impact. Sleep deprivation leads to problems in immune system functioning, respiratory system, cardiovascular system, endocrine system, and central nervous system. It causes impaired production of antibodies and cytokines, making it harder to fight off illness such as the common cold or flu, making recovery slower, and causing worsening of chronic lung conditions. It reduces Leptin and raises Ghrelin, leading to increased appetite and decreased sense of fulness. It causes tiredness which leads to decreased exercise, and reduced release of insulin after eating which leads to high blood sugar levels. It lowers the body’s tolerance to glucose, and is associated with insulin resistance. It affects hormone production (specifically testosterone production and human growth hormone production).

Sleep difficulties also greatly impact the brain and the mind, and complicates the presentation of symptoms typically associated with psychological conditions. This can lead to overdiagnosis of psychological conditions and under diagnosis of sleep conditions. Even in the short term, lack of sleep can negatively affect mood, energy, work or school performance, memory, concentration, decision-making, and safety. Chronic insomnia affects the central nervous system functioning. It disrupts how the body sends and processes information. It affects the ability to retain newly learned information, makes concentration and learning more difficult, decreases coordination, affects decision-making processes and creativity, and increases the risk of accidents. It also negatively affects mental abilities and emotional states, increasing impatience, and causing more mood swings. Extended sleep deprivation can cause auditory and visual hallucinations, can trigger mania in people who have bipolar disorder, and can cause impulsive behavior, as well as anxiety, depression, or suicidal thoughts. Approximately 90% of people with depression have sleep complaints of insomnia, hypersomnia, sleep disordered breathing, or restless leg syndrome. This means that primary mood diagnoses typically include sleep related difficulties, but also that sleep difficulties can cause mood symptoms which lead to psychological diagnoses.

Risk Factors

The NIH lists these risk factors for insomnia as: age (more likely to have insomnia as you age), family history and genetics, environment (shift work, night work, and jet lag, nighttime noise or light and uncomfortably high or low temperatures), stress (worry or worrying about not getting enough sleep), gender (more women than men have insomnia) possibly due to hormonal changes, pregnancy, and menopause. Multiple sources of sleep restriction have been identified including binge-watching TV, playing video games, reading, watching sports, stressful events such as natural disasters and violence, as well as war, events such as 9/11, or pandemics.

Assessment

Due to the relationship between sleep and mood, a detailed interview is critical. When assessing patients, it is important to assess sleep quantity, sleep quality, sleep onset, ease in waking, and daytime fatigue. When assessing the related mood symptoms, it is important to assess the sequence of symptom occurrence, the intensity, and duration. Did a significant life stressor, or change in shift work occur prior to the sleep difficulties? At what point did the patient begin to experience the shift in mood? After the stressor? Or after the prolonged sleep disruption? Are you seeing nighttime panic disorder, or is actually untreated sleep apnea triggering anxiety? Targeted and detailed questioning helps the diagnostician identify the primary (mood/sleep) vs secondary (mood/sleep) issues.

Treatment

While specific medical interventions may be required for the treatment of specific sleep disorders (CPAP, Bipap, medication), good sleep hygiene is critical to addressing issues of

insomnia and maintaining good sleep. Targets in good sleep hygiene include maintaining a consistent sleep/wake schedule (even on the weekends and during vacations), avoiding naps, setting a bed time that allows at least 7-8 hours of sleep, going to bed sleepy, and having a relaxing bedtime routine (reading, meditating bath). Additional targets include using the bed only for sleep and sex, making a comfortable sleep environment (quiet and relaxing, with a comfortable temperature), turning off electronics at least 30 minutes before bedtime, and limiting light exposure in the evening. Other behaviors include avoiding large meals before bedtime, exercising regularly, maintaining a healthy diet, reducing fluids before bedtime, avoiding alcohol in the evenings, avoiding caffeine after 2 pm in the daytime, and doing a quiet activity without electronics or much light exposure if sleep onset does not occur within 20 minutes.

Sleep Psychology

Mental health professionals trained in the specialty of sleep psychology evaluate and treat sleep disorders. They address behavioral, psychological and physiological factors that underlie normal and disordered sleep, by applying evidence‐based psychological approaches to the prevention and treatment of sleep disorders. They are trained in normal and disordered sleep, sleep physiology, the effects of sleep medications on the brain, sleep cycles, sleep changes related to age, sleep deprivation, sleep regulation, cognitive, behavioral and non‐medication interventions for sleep disorders, treatment monitoring, sleep measurement procedures and methods, and standard medical and medication‐related therapies for sleep disorders. The specialty of sleep psychology addresses the behavioral, psychological and physiological factors involved with the full range of sleep disorders for all ages and diverse populations, including: sleep disorders, insomnias. hypersomnia, narcolepsy, sleep‐Related Breathing Disorders, sleep Cycle Disorders, parasomnias (e.g., nightmares, bedwetting, sleep walking, sleep terrors, etc.), Sleep‐Related Movement Disorders (e.g., periodic limb movement disorder, teeth grinding, etc.), sleep medication dependence, adherence to sleep specific medical procedures (e.g., positive airway pressure therapy for sleep apnea), and sleep in the context of related medical and psychological illnesses. Partnering with a mental health professional who specializes in sleep psychology, will help address both the biological and psychological comorbidities related to sleep disruption and ensure optimal outcomes for your patients.

With a doctorate in clinical psychology and over 20 years of experience in the field, Dr. Mary-Catherine Segota has conducted university-based behavioral medicine research, acted as a consultant to professionals and organizations, and worked with a diverse number of psychological and medical conditions. By identifying unique needs, the source of distress, and what’s perpetuating the problem, she will help develop the tools to overcome seemingly insurmountable circumstances. Visit www.CounselingResourceServices.com