Treatment Modalities and the Perspectives
The treatment of patients complaining of insomnia should be individualized and should flow from the formulation of their cases. The underlying argument of this book has been that a multitude of processes may influence the potential for insomnia and that many of these factors may be operating simultaneously. Therefore, various treatment approaches may be indicated for any particular person. Of course, this is not unusual in clinical practice. For instance, hypertension may be addressed with a dietary program (e.g., salt restriction), weight loss, exercise, and assorted medications with different pharmacodynamic actions. The identification of multiple insomnia influences, however, does not necessarily require disparate and uncoordinated treatment programs. Often therapeutic strategies can incorporate goals crossing perspective boundaries.
All of us experience brief episodes of insomnia at some time in our lives. Usually, there are clear situational precipitants. Typically, the stimulus resolves or we adapt to the situation, so these brief insomnia episodes often do not come to clinical attention. However, people do sometimes seek help for their sleep while in the midst of some crisis. Perhaps an immediate cause can be addressed. Additionally, psychotherapeutic support and possibly the temporary use of a short-acting hypnotic may be beneficial. Sometimes this early treatment can help prevent longer-term sleep difficulty.
What is the ideal clinical setting for the evaluation and treatment of chronic insomnia? This, too, is dependent on the patient and the clinical circumstances. Ideally, the evaluator will be able to offer a comprehensive consideration of the broad range of processes (e.g., behaviors, enduring vulnerabilities, life circumstances, and disorders) potentially contributing to the patient’s sleep disturbance. Treatment options then may include such strategies as schedule modifications, behavior changes, the exposure to or avoidance of bright light at particular hours, substance restrictions, behavioral therapy and psychotherapeutic techniques, hypnotic medications, and direct attention to other contributory disorders (which may warrant further testing and treatments). The global treatment plan for insomnia may have the patient work with various practitioners to accomplish the therapeutic objectives. The overall insomnia evaluation and treatment may be coordinated and conducted by a single clinician, with considerable individualization in modalities and timing. Alternatively, chronic insomnia may be approached successfully with a highly structured generalized treatment program, such as that espoused by Charles Morin (1993). His insomnia program incorporates weekly group therapy sessions that emphasize particular themes each week. There is a strong cognitive-behavioral foundation, with a broad range of sleep-healthy recommendations.
Patient education always should be at the foundation of the clinical management of chronic insomnia. Patients should understand how their behaviors, vulnerabilities, situations, and disorders can affect their sleep and contribute to their insomnia. Patient insight into these processes will help motivate compliance with treatment recommendations, which otherwise might be met with more resistance. Knowledge about basic sleepregulation mechanisms may help patients face new circumstances with better solutions. Furthermore, explanation is reassuring, which inherently may be therapeutic.
Time and patience also are important ingredients in the management of chronic insomnia. Sometimes patients come in for help, demanding an instant solution to the sleep problems with which they have suffered for years. Rapid improvement in sleep sometimes is possible, but more commonly recovery is a longer-term process. The treatment plan may include immediate steps (e.g., evening coffee cessation, use of hypnotics) and approaches requiring longer periods for effective results (e.g., psychotherapy, use of antidepressants). Monitoring the outcome of different therapeutic manipulations can enhance the patient-clinician partnership as the successes or failures of various strategies are explored. The hypotheses of the formulation of a patient’s insomnia complaints may be confirmed, revised, or discarded. Ongoing clinical care allows continued feedback and modification of the treatment plan, as well as continued support and encouragement. Just as each of the perspectives of insomnia illuminates different aspects of a patient’s case and highlights factors that might influence the risk for that person’s sleep difficulty, the perspectives also suggest different, though complementary, treatment strategies. Often an identified problem directly leads to a treatment objective and plan. General therapeutic directions associated with the motivated behavior, dimensional, life-story, and disease perspectives are considered in the following four sections.
Source: David N. Neubauer, “Understanding Sleeplessness: Perspectives on Insomnia,” The Johns Hopkins University Press, Baltimore 2003
Republished by Health Care Programs