Insomnia and Anxiety (Series in Anxiety and Related Disorders) (38 page)

While not all will respond dramatically to IRT, this treatment does offer benefit

to many who are able to adhere to it.

Is it Time for a Sleep Specialist Consultation?

A major goal of this text is that of providing practitioners guidance in the use of

psychological/behavioral strategies for the management of insomnia and other

sleep-related complaints common among patients with anxiety disorders. Inasmuch

as the range of strategies discussed herein are all evidence-based, these techniques

collectively should provide the mental health practitioner a sizable armamentarium

of approaches for managing patients presenting with comorbid anxiety and sleep-

related complaints. Nonetheless, the problems discussed represent only a subset of

the myriad forms of sleep disturbances that may present as primary or comorbid

sleep disorders. Many people with such conditions require and benefit from one or

more consultations with a sleep specialist. Hence, it is useful to consider the types

of sleep problems and circumstances that would warrant a sleep specialty referral.

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9 Other Issues in Managing the Sleep of Those with Anxiety

Various people with primary sleep disorders present with symptoms that can be

confused with symptoms of an anxiety or insomnia disorders. For example, some

with sleep-disordered breathing (e.g., sleep apnea) report awakening gasping for

breath. Since it is not uncommon for such people to report feeling anxious and sens-

ing rapid heart rate upon such awakenings, it is easy to misinterpret such symptoms

as indicative of nocturnal panic. Furthermore, many people with sleep apnea or nar-

colepsy may present complaining of poor quality or fragmented nocturnal sleep that

they view as contributory to their daytime sleepiness. In some of the more persuasive

patients of this type, there is a risk of attributing the noted daytime symptoms to

the purported insomnia problem. Other people who suffer from restless legs syndrome

may present primarily with sleep onset complaints resulting from their feeling restless

and fidgety when in bed at night. While it may seem reasonable to assume that the

person is suffering from sleep-related performance anxiety and conditional arousal to

the bed and bedroom, such symptoms may actually have a neurologic basis. Finally,

some people who report that they often awaken screaming with a pronounced sense

of fear may be easily misdiagnosed as having nocturnal panic or a nightmare disorder

when, in fact, they suffer from a condition known as night terrors.

It is important to be able to identify those with such disorders since these indi-

viduals most often require the attention of a certified sleep specialist for proper

management. Those with suspected sleep apnea and narcolepsy as well as many

individuals who suffer from night terrors require specific forms of diagnostic sleep

monitoring that are conducted mainly in a sleep disorders center. Such diagnostic

testing is essential in such cases to correctly diagnose these conditions and gauge

their severities. Moreover, sleep specialists present in such centers are much more

likely to understand the specific treatment needs of these patients than are general

practitioners. Although those with restless legs syndrome usually do not require

specialized diagnostic sleep monitoring, they often are difficult to manage and

benefit from the knowledge of a sleep specialist to arrive at the most proper and

effective management strategy. Because the types of patients mentioned should be

considered for referral to a sleep specialist, it is useful to have a ready reference that

can be used to help identify those with one or more of these conditions. Thus,

Table 9.2, which lists the defining symptoms of each of these disorders, is provided

as a reference guide to aid in the identification of those who should be considered

for a sleep specialty consultation.

Of course, reliance on the information in this table will not result in identifica-

tion of all those who may warrant the diagnostic or treatment services a sleep

specialist can offer. In some instances, people may present with difficult to discern

occult primary sleep disorders. Many such cases may have such occult conditions

as a cause of or in addition to their more obvious insomnia symptoms. They may

present the previously described cognitive and behavioral targets that make them

appropriate candidates for a trial of the evidence-based insomnia therapy strategies

discussed herein. However, when patients show a poor or marginal response to a

trial of the cognitive and behavioral techniques described in this text, they may

merit referral to a sleep specialist for further diagnostic evaluation. This is particu-

larly the case when treatment adherence appears good and significant sleep/wake

References

145

symptoms persist. In fact, current practice parameters of the American Academy of

Sleep Medicine suggest that referral for a diagnostic sleep laboratory study should

be considered for insomnia patients when they fail their first line treatment (Littner

et al., 2003). Many such cases sufferer from underlying subtle, albeit clinically

significant, sleep-disordered breathing, or other medical/neurological sleep-specific

disorders than can only be detected via sleep monitoring. Thus, assuming treatment

adherence is satisfactory, nonresponse to the insomnia therapies described in this

text also may serve as adequate rationale for sleep specialist consultation.

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