Sleep Problems...Symptom or Disorder?

Are sleep problems a symptom or an independent disorder? They can be both! Sleep challenges are a component of many disorders. Indeed, the Diagnostic and Statistical Manual-5th addition (DSM-V) lists disturbed sleep as a symptom of depression, anxiety, and PTSD. Although sleep problems are not an explicit symptom of disorders such as OCD, ADHD, and autism, clients with these diagnoses frequently report that their sleep is poor. If low-quality sleep is a symptom, will treating depression, anxiety, or PTSD also fix sleep? In many cases, sleep problems persist even after other symptoms have been successfully relieved. Does it make sense to start with addressing sleep or addressing the other disorder? This is a great question, and we will strive to address it in this blog post.  

Sometimes insomnia is truly the only issue that someone needs to address. Many people simply suffer with trouble falling asleep and staying asleep or waking up too early, thinking this is how everyone sleeps or perhaps that they are just a “bad sleeper.” Sleep medications are often more easily accessed than therapy, so many people start with a prescription, perhaps from their primary care physician. Medication can be a good short-term option, but many people find that benefits wear off over many nights or that they have intolerable side effects such as daytime drowsiness or sleep driving or eating. Often individuals don’t consider seeing a psychologist for sleep problems, but Cognitive Behavioral Therapy for Insomnia (CBT-I) is actually the recommended first-line treatment for insomnia from the American Academy of Sleep Medicine, rather than medication. If sleep is a problem, it does NOT have to be this way. The majority of clients note significant improvement in sleep after only 6 sessions, and many find they are able to stop taking sleep medication. Although everyone has a rough night of sleep sometimes, if this is happening at least 3 nights per week for at least 3 months, it is appropriate to seek help.

On the other hand, many clients coming to us do struggle with insomnia but also other disorders such as anxiety, depression, ADHD, and OCD. What should we address first? Client goals are always the central consideration whenever we make decisions about treatment. Ultimately, clients come to us because something isn’t working in their lives, and they need it to be different. Usually there may be several things, but when we ask what one thing they would change immediately with a magic wand, there is a clear answer. Jamie in Birmingham may say that sleep is a problem, but he thinks it might improve if his ADHD were better managed. He is struggling so much with focus and organization at work that he needs to deal with those challenges before anything else. Quinn in Huntsville may share that she doesn’t  get to sleep as early as she would like, but it’s because she can’t relax until her bedding and décor are arranged “just right” because of her OCD. Ashley in Mobile shares that her PTSD is much improved after completing Prolonged Exposure Therapy. She hoped her insomnia would improve by treating her PTSD but, unfortunately, she still is wide awake as soon as she gets in bed despite feeling sleepy all day. Bill in Montgomery indicates that he knows he needs to work on his Generalized Anxiety Disorder, but his sleep problems are absolutely his biggest concern right now.  Jamal in Florence has struggled with insomnia, nightmares, irritability, and feeling on guard all the time ever since his home was destroyed by a severe tornado. He has been encouraged to seek therapy for PTSD but does not feel up for working directly on his trauma right now. He does feel willing and ready to work on his sleep. This is a great place to start, as he will get some relief for his sleep challenges and may also then feel ready to address his trauma. Availability may also be a consideration in clients’ decision-making about therapy priorities. By focusing on therapies that offer measurable results in a reasonable timeframe, we strive to get people seen for whatever their need in a timely manner. However, we do find that our current wait times for our CBT-Insomnia small groups are shorter than our wait times for individual sessions. Thus, treatment for insomnia may be available sooner than treatment for OCD, ADHD, or anxiety. Because of this shorter wait, many people may elect to go ahead and address their sleep problems in small groups while waiting to start individual therapy for another need.

People often ask if treatment for insomnia will work even if they have other diagnoses. Fortunately, CBT-I is a robust treatment that has been proven effective across a variety of co-occurring challenges such as depression, anxiety disorders, PTSD, OCD, ADHD, and chronic pain. It has also been found to be equally effective both in person and via video telehealth. Sleep issues may present slightly differently across various disorders. Individuals with depression may sleep too much or spend long periods lying in bed unable to sleep. They may feel as though there is no good reason to get out of bed. Likewise, someone suffering with chronic back pain or migraine headaches may spend a lot of time resting in bed in hopes of relieving pain.  Someone with anxiety may struggle to sleep due to their mind racing with all kinds of worries. A person with PTSD may want to sleep but check their outdoor cameras repeatedly to make sure their home is safe. They may also dread having nightmares if they sleep. Individuals with OCD may hope to sleep but have lengthy rituals to relieve uncomfortable obsessions, which limit time available for sleep. One commonality across all of these disorders is that bedtime has become associated with unpleasant things other than sleep, peace, and relaxation. CBT-I aims to break that association and make the bed a peaceful place again.

We have worked with several clients who experienced improvements in other symptoms as a result of insomnia treatment. Components of CBT-I such as getting out of bed at a regular time and increasing daytime activity improve mood along with sleep. Skills taught in CBT-I such as scheduled worry time, relaxation training, and cognitive restructuring may help with anxiety as well as sleep. Upward offers a free 15-minute consultation call to help decide if working with us is right for you. Our comprehensive intake evaluations also focus on identifying goals and engaging in shared decision-making to determine the right plan for your care.