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.
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–abuse disorders that interfere with sleep.
5. What types of medications are used to treat sleep disturbance and why are some faster acting than others?
6. Are holistic remedies like kava safe to use?
7. Can sleep medications be habit forming? Please explain.
8. Why are barbiturates no longer used to treat sleep problems?
9. How can sedating antidepressants be used to induce sleep?
10. Explain how Valerian interferes with drug clearance in the liver.
Possible True/False Questions:
1. In a study of more than 1,000 people, 56% 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 100 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 sleep cycles.
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. 25 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. 25
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. Risperdol
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
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
run.
5. How would you educate patients on the various side effects of sleep and sedating medications?
6. Explore how counseling and psychotherapy play a role in reducing anxiety and improving sleep.
7. What is the difference between a melatonin agonist like ramelteon and an extended release formula of
melatonin like Cicadin?
8. Explain how sedating antidepressants like trazodone are a good choice for depressed patients with sleep
maintenance issues.
Read the Case Vignette in this chapter and answer the following questions:
Case Vignette Discussion Questions:
1. What is the major pathology or diagnosis presented in the case?
2. Is there another disorder that may apply or should be ruled-out?
3. Do you agree with the medication suggestions made in this case?
4. Any other medications that might be considered…what is the rationale?
5. If you were asked to follow-up on this case as the treating therapist, would you offer any additional
suggestions or approaches?
Chapter Eleven
Answer Key
True/False Questions:
Multiple Choice Questions: