Too stressed to sleep
Sleep. We need it. We crave it. It’s important for our health and well-being. Yet, 40 million Americans have a sleep disorder according to the National Center on Sleep Disorders Research. Sleep disorders include insomnia, sleep apnea, narcolepsy and restless leg syndrome.
“More than 50 percent of my patients struggle with sleep,” says Illinois psychologist Nancy Molitor, PhD. “Sometimes patients won’t bring it up because it’s not the primary reason they are seeing me. What they don’t realize is that there is a connection between sleep and their moods and overall health.”
Insufficient sleep not only affects our moods, it can contribute to poor decision making and how we function daily. Lack of sleep over a prolonged period can increase the risk of high blood pressure, heart problems, depression and other health conditions.
How exactly does a psychologist like Molitor help people with sleep issues? APA asked Molitor to walk us through a typical treatment situation.
Real life scenario: Psychologists helping with behavior change
A middle aged woman with existing health issues was referred to Molitor by her physician. The woman had sleep issues and anxiety which was exacerbating an existing gastrointestinal health condition, Crohn’s disease.
Why would a physician refer a patient to a psychologist?
Molitor: Many of my patients are referred to me by physicians because they recognize patients are having a difficult time managing a health condition. Insomnia tends to be a common problem. Physicians don’t have the time or capacity to treat the psychological issues that can contribute to sleep problems. In the case of this middle aged woman, her physician said the insomnia was making it harder to manage her health conditions and medication was not helping.
What happens during an initial consultation with a psychologist?
Molitor: Typically with physician referrals, the patients call me first to schedule an initial appointment. I usually spend a few minutes asking them about what is happening. In the first session, I focus on building a rapport and helping to lessen any anxiety the person may feel about seeing a psychologist. I always ask about their medical history, if they are taking any medications and what type of treatment their physician prescribed for any health conditions. I also gather information about what’s going on in their lives including any changes at work or home. And, I ask people to complete a form that includes all their health information.
What happened with this particular patient in the first visit?
Molitor: In the case of this middle age woman, since her physician referred her for sleep problems, we spent time talking about her sleep ritual and daily habits. We also talked about how she felt physically and what she thought contributed to her other health issues and the sudden flare up of her Crohn’s disease.
We also looked at her lifestyle and habits like eating, types of beverages she consumed, exercise and other daily activities. We even factored in any medications she took and how the side effects of some prescriptions affected her sleep. We also talked about work and home.
What did you learn about this patient?
She went to bed early because she felt so anxious and hoped falling asleep would lessen any anxiety. However, she got only four or five hours of sleep because she lay awake at night thinking the next day would be bad. She tossed and turned for a few hours. Got up, paced around the house, even turned on lights. Sometimes she ate in the middle of the night. But, she did not eat too much because her stomach hurt. Then she tried to go back to sleep. Some days, she took an afternoon nap since she was up at night.
This patient mentioned she was under stress for many months. She lost her job and was on disability. Additionally, her spouse was unemployed and her daughter and grandchild moved back home. She worried about finding work and paying the bills. Being at home all day with her spouse, daughter and grandchild put a strain on family relationships. And, she admitted to feeling unhappy in some of her relationships.
So, now we got to the root of what contributed to her anxiety and lack of sleep. The ruminations — constant, negative thoughts — trouble sleeping, weight loss and sudden flare up of her Crohn’s disease were all symptoms of situational issues at home, in her relationships and being unemployed.
How did you help this patient?
Molitor: I took a collaborative approach. We reviewed the patient’s situation together and broke it down into manageable chunks. We focused on what she could work on and how to approach each problem. Part of this involved retraining herself to do things differently. With this particular patient, the immediate need was to tackle her insomnia and change her sleep architecture. Initially, we focused on making a plan for just one week. That plan included avoiding naps. Going to bed at night when she felt tired instead of early to try to avoid her anxiety.
Not turning on lights when she woke up during the night and not looking at the clock. Instead, I instructed her to relax her mind and tell herself that it was OK to go back to sleep. I also provided her with deep breathing and visualization exercises to help her relax.
If she did not get back to sleep after a while, then got up, went into another room to sit for a bit without turning on lights, the TV or reading a book. It might take a few times. She needed to retrain her brain to understand that the bed is not a bad thing. It’s for sleep.
What happened with this patient?
When this patient returned the following week, she was like a different person. She was smiling and not as tired looking. She followed the plan and did the relaxation exercises. She also cut back on her junk food consumption and did not weigh herself for six days. She confessed to weighing herself before coming to our session just to check on her weight. Turned out she gained one pound.
The patient wanted to continue working with me. So, we set up a plan to continue dealing with the insomnia and address other areas like her anxiety, how she responded to stressful situations and relationship issues.
This patient was so emblematic of what I often see in people. There is so much going on, especially if a patient is managing a chronic illness. It usually takes a while to get to the root of what is behind the anxiety and stress that may be contributing to sleep problems and exacerbating existing health conditions.
This particular patient learned how to identify what she can control and how to handle stressful situations and relationship issues.
I always want patients to feel in charge. My role is to help them with their current health and life situations. I help them recognize how they’re responding to challenges, how it affects them emotionally and physically, and what they can do to improve their situation.
What does research say about psychotherapy and sleep problems?
Research shows that cognitive behavioral therapy (CBT) is effective in treating sleep problems such as insomnia. According to a sleep study published in JAMA Internal Medicine, CBT is an effective treatment for people suffering from insomnia, more so than medication.
Psychologists communicating with your physicians
It’s common practice for psychologists to keep in touch with a patient’s physician, especially if the doctor made the referral to the psychologist.
“I always make sure that patients feel comfortable with me communicating with their physicians,” says Nancy Molitor, PhD. “After the first visit, I call the internist to confirm that the patient came in and I relay an initial assessment. And, I continue to keep the physician posted throughout the course of treatment.”
Some physicians prefer that psychologists use secure email to provide patient information. This is a standard confidential means to deliver private health information and is in compliance with patient privacy laws. The Privacy Rule under the Health Insurance Portability and Accountability Act (HIPAA) increases your privacy rights and protections — for example by giving your psychologist the option to protect psychotherapy notes from insurance company access. Many state laws provide additional protections.
All members of APA adhere to a Code of Ethics that requires reasonable efforts to maintain patient confidentiality. To learn more about practicing psychologists visit the APA Help Center.
- Why sleep is important and what happens when you don't get enough
- Sleep and Sleep Disorders, CDC
- National Center on Sleep Disorder Research
- Sleep Fact sheet NHLBI (PDF, 1.8MB)
- NHLBI Guide to Health Sleep (PDF, 436KB)
- Gregg D. Jacobs, PhD; Edward F. Pace-Schott, MA; Robert Stickgold, PhD; Michael W. Otto, PhD, Cognitive Behavior Therapy and Pharmacotherapy for Insomnia: A Randomized Controlled Trial and Direct Comparison, JAMA Internal Medicine. 2004;164(17):1888-1896. doi:10.1001/archinte.164.17.1888.