Chapter Eleven
Summary
Sleep disturbances are common complaints in many physician and therapist’s offices. The various forms of
insomnia include initial insomnia, or trouble falling asleep; middle insomnia, or intermittent awakening throughout
the night; or terminal insomnia or awakening about two hours before one’s normal wake time. These forms of insomnia
are common in both anxiety and depressive illness.
There are five distinct stages of sleep. Stages one and two are the light stages, but three, four and REM
provide the restorative stages needed to feel rested and alert during the day. Serotonin and norepinephrine are
necessary to obtain and maintain sleep. Patients with anxiety and/or depressive disorders experience depleted levels
of these neurotransmitters, and therefore, often have sleep problems. Some view stage five not as a distinct stage per
se, but as part of stage one when an individual progresses through the night. When a person cycles from one to stage
four and back to stage one, he/she experiences a distinct period of REM, and on each subsequent cycle of REM, it
increases in length throughout the night.
Evaluating sleep disturbances involves careful assessment, and the use of a sleep study. Various other causes
of sleep disturbance can include physical illness, and various other sleep disorders like Obstructive Sleep Apnea,
bruxism, restless leg syndrome, (RLS), periodic limb movement disorder or PLMD, and narcolepsy. Sleep studies
Specific Discussion Questions:
1. What are the various types of insomnia and how are they different?
2. Explain the stages of sleep and how poor sleep interferes with functioning.
3. What is measured in a typical sleep study and what types of conditions do they rule–out?
4. Explore some of the other physical and substance use disorders that interfere with sleep.
Possible True/False Questions:
1. In a study of more than 1,000 people, 43% reported problems with initial insomnia.
2. There are three distinct stages of sleep.
3. About 50% of our time is spent in stages 1 and 2.
4. Serotonin is necessary to help maintain sleep.
5. Patients with only terminal insomnia are more likely to have an affective disorder, as opposed to an anxiety
disorder.
6. Benzos are safe to use and may be used for months without any real concerns for tolerance.
7. Since Ambien has a shorter half life than Restoril, it is more likely to wear-off by morning.
8. Benedryl can be used to induce sleep in intermittent cases.
9. A typical dose of Sonata is 80 mg qhs.
10. Kava may be associated with liver damage in long-term usage.
11. Long-term usage of melatonin may worsen a patient’s depression.
12. GHB or Xyrem has been shown to improve Stage 3-4 sleep cycles.
13. Exposure to excessive light in the sleeping area, especially blue light from devices, may interfere with healthy
sleep.
14. Suvorexant is an orexin antagonist.
Multiple Choice Questions:
1. Which of the following is not considered a benzodiazepine:
a. Doral
b. Klonopin
c. ProSom
d. Sonata
2. A typical dose of Restoril would be about:
a. 2 mg.
b. 7.5 mg.
c. 15–30 mg.
d. 50mg.
3. For patients with only occasional problems with sleep, they should consider:
a. warm milk
b. an OTC sleep aide like Tylenol PM or Sominex
c. Benedryl
d. any of the above
4. In the study mentioned in the text, what percentage of the patients with middle of the night insomnia also
reported daytime fatigue?
a. 34%
b. 39%
c. 43%
d. 67%
5. We spend about ____% of our sleep time in stages three and four.
a. 10
b. 15
c. 40
d. None of these
6. A mask-like devise is used by patients with OSA. It is called a ______ machine.
a. splint
b. CPAP
c. EEG
d. None of these
7. Sleepwalking and night terror are typically seen in approximately what percentage of the child population.
a. 10%
b. 15%
c. 18%
d. 22%
8. Narcolepsy is typically treated with stimulants and often ________.
a. Prozac
b. Ambien
c. Provigil/ Nuvigil
d. Intermezzo
9. Which does not belong with the others:
a. Halcion
b. ProSom
c. Restoril
d. Ambien
10. Which of the following, while sedating, may actually interfere with sleep cycles in the short run?
a. antidepressants
b. benzodiazepines
c. Imidazopyridine
d. barbiturates
11. Which of the following is actually an orexin receptor antagonist?
a. Belsomra
b. Intermezzo
c. Requip
d. None of these
12. For patients who would rather not use a benzo or BRA to improve their sleep, which of the following may be
a good alternative for initial insomnia?
a. Zolpimist
b. trazodone
c. modafinil
d. Any of these
Alternative Class Assignments and Essay Questions:
1. Explore in class the various causes of sleep disturbances in clients.
2. Role-play a session with a client where you explain using the 11 helpful tips mentioned in the text. Are there
any you would add?
3. Divide the class into two groups: Group one will discuss the pros and cons of various “holistic remedies” in
the treatment of sleep disturbance. Group two will make a case for the use of medications.
4. So many patients abuse alcohol to assist them in falling asleep. Explore why this is not a solution in the long
Case 1 and 2 Vignette Discussion Questions:
1. What is the major pathology or diagnosis presented in each case?
2. Is there another disorder that may apply or should be ruled-out?
3. Do you agree with the medication suggestions made in each case?
Answer Key to Possible True/False and Multiple Choice Questions
Chapter Eleven
Multiple Choice Questions: