Sleep Psychology Offers Options to Address Insomnia

According to the American Academy of Sleep Medicine, insomnia affects one out of every three adults in the U.S. More than 20 million Americans complain of chronic insomnia, which lasts at least one month—and can sometimes last for years.*

Practitioners in the emerging field of sleep medicine have discovered that a number of factors can contribute to insomnia, including physical problems, lifestyle choices, environmental influences, and psychological or psychiatric issues. In light of this, sleep disorder centers have come to recognize that psychologists can play an important role in helping to address this multifaceted condition.

Dr. Rosenblum and Rick Maki

review a patient’s polysomnogram.

Reflecting this trend, Minnesota Sleep Institute—which treats a wide variety of sleep disorders—recently added a sleep psychologist to their staff. "In the past several years, we've seen a steady rise in the number of patients presenting with insomnia and other complicated sleep issues," says regional director Richard Maki, RPSGT. "As a full-service sleep disorders center, we wanted to offer these patients a broad spectrum of treatment options. Given the complex nature of insomnia, we knew that bringing on a sleep psychologist to work hand-in-hand with our medical team would help us achieve that goal."

Filling that position is Mark Rosenblum, PsyD, LP. He initially learned about the field of sleep psychology while receiving his training in clinical neuropsychology and health psychology. Rosenblum completed his insomnia training through a preceptorship with Peter Hauri, PhD. A former director of the Mayo Clinic's insomnia program, Hauri is considered a pioneer in the field of sleep medicine.

"The more I heard about the field of sleep psychology, the more interested I became," says Rosenblum. "I saw the chance to be involved in an exciting area of practice that was still in the early stages of development."

Evaluating psychosocial factors

Rosenblum sees patients on referral from the center's physicians once they have ruled out the presence of other sleep disorders. Before meeting with Rosenblum, the patient fills out a sleep diary to record information on sleep patterns. Then, at his first session with the patient, Rosenblum reviews the diary and gathers a complete history of the patient's sleep problem. He also investigates the patient's sleep hygiene habits, which are behaviors that can promote or interfere with better sleep, such as activity level, nighttime rituals, and use of alcohol, caffeine or nicotine.

During this initial session, Rosenblum also may ask the patient to take one or more psychological assessments. These instruments help him determine the specific type of insomnia affecting the patient, measure psychosocial factors contributing to the condition, and provide information that guides treatment planning. At his second meeting with the patient, Rosenblum reviews the results of his evaluation, including test results, and discusses his treatment recommendations.

MBMD test sheds light on relevant issues

In his work with clinical neuropsychology and health psychology, Rosenblum had become familiar with the benefits of standardized psychological tests in helping to discern underlying factors that might be influencing a patient's condition. One of the instruments he had used previously and now finds advantageous in evaluating patients with insomnia is the MBMD™ (Millon™ Behavioral Medicine Diagnostic) test.

"The MBMD helps assess several areas that are very relevant to this patient population," Rosenblum says. "First, it helps measure negative health habits that can have a role in perpetuating insomnia. Second, it covers psychiatric factors such as anxiety and depression, which are both very common with insomnia patients. Third, it reports on the patient's coping style, which can give us valuable insight on concerns such as whether we need to help the person increase his or her hopefulness about treatment outcomes."

Rosenblum also likes the fact that the MBMD test is normed on a medical population. "With many patients, insomnia can be considered a chronic medical condition," he says. "In these cases, the MBMD gives us a good reference point to gauge how the patient will respond to treatment options."

In addition, Rosenblum notes that the MBMD assessment is easy to use, an important consideration for a busy practice. He administers the test by computer, which he finds to be a convenient option for both patients and staff. And, he likes the format of the Interpretive Report, which provides a graphic representation of results and a detailed analysis of the patient's strengths and weaknesses.

Measuring other key concerns

Depending on the patient, Rosenblum's selection of instruments also may include the QOLI® (Quality of Life Inventory) test. "This tool helps us evaluate factors such as patients' activity levels, how much enjoyment they experience, and other life satisfaction factors we may need to address in order to effectively treat the insomnia," he says.

With some patients, Rosenblum uses the BHI™ 2 (Battery for Health Improvement 2) test; or, if there are concerns about the patient's endurance due to the presence of other medical conditions, he may administer the shorter version of this measure, the BBHI™ 2 (Brief Battery for Health Improvement 2) test. "These assessments are useful to us because they include a focus on pain, which is a factor commonly associated with insomnia," he says.

Behavioral therapy provides effective alternative to medications

In developing treatment plans, Rosenblum factors in the information he has gathered through his interview, as well as the results from any tests he has given. The primary treatment approach he takes with patients is Cognitive Behavioral Therapy for Insomnia (CBT-I), a multicomponent technique that focuses on changing or modifying behaviors contributing to the patient's insomnia. The specific interventions, which vary depending on the patient's circumstances, may include cognitive therapy, sleep restriction, stimulus control, relaxation training, or sleep hygiene training. Typically, treatment involves one session weekly for one or two months.

Rosenblum notes that research has shown CBT-I to be as efficacious in treating insomnia as prescription medications. According the National Institute of Health: "Cognitive behavioral therapy for insomnia is as effective as prescription medications are for short-term treatment of chronic insomnia. Moreover, there are indications that the beneficial effects of CBT-I, in contrast to those produced by medications, may last well beyond termination of active treatment."**

"One benefit of prescription medications," says Rosenblum, "is that they are quick-acting and, therefore, may be the best option for certain individuals, such as a patient who is in the midst of an acute crisis." He points out, however, that there are potential downsides to drug therapy, such as risk for dependency and next-day grogginess. Patients using medications also may exhibit behaviors that are unusual for them, or engage in activities they don't recall later.

"CBT-I offers a treatment option that carries no known side effects," he says. "Plus, medications are simply treating the symptom, whereas CBT-I is teaching the patient better ways to manage sleep behaviors, promoting a lifestyle change that can have long-lasting positive effect.

Helping patients find relief

As director of Minnesota Sleep Institute's insomnia program, Rosenblum is enthusiastic about being at the forefront of an evolving sub-specialty. "I see the healthcare community paying increased attention to the importance of considering psychosocial factors when evaluating and treating insomnia—and the value psychologists can add to sleep disorder practices," he says. "It's very rewarding to realize the ways in which we can help patients find relief from a problem that may have negatively affected many aspects of their lives."

*A wellness booklet from the American Academy of Sleep Medicine"

**National Institute of Health 2005 State-of-the Science Conference Statement on Manifestation and Management of Chronic Insomnia in Adults

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