"Sleep is the golden chain that connects health and body." – Thomas Dekker, 1625
"Without enough sleep we all become great 2-year-olds." – JoJo Jensen, Dirt Farmer Wisdom, 2002
“I love sleep. I would sleep all day if I could. "- Miley Cyrus, 2019
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Photo of the author David Engstrom
"data-medium-file =" https://ct.counseling.org/wp-content/uploads/2017/04/David-Engstrom-1-204×300.jpg "data-large-file =" https: // ct .counseling.org / wp-content / uploads / 2017/04 / David-Engstrom-1.jpg "load =" lazy "class =" alignleft wp-image-18056 "src =" https://ct.counseling.org /wp-content/uploads/2017/04/David-Engstrom-1-204×300.jpg "alt =" "width =" 150 "height =" 221 "/> For me to create the elusive connections between events, experiences and symptoms One of the most exciting parts of counseling in our clients' lives is that there may not be a clearer connection between mind and body than sleep.
How do you sleep? More importantly, do you know how your customers sleep? When we evaluate our clients' stories and experiences, sleep is an area of behavioral health that is easy to ignore or minimize. But sleep disorders are very common among Americans and are related to many mental and physical health problems later in life. A more comprehensive assessment can lead to important clues about the experience of early trauma and abuse.
Sarah: First assessment
As a counselor at a sleep disturbance hospital in Arizona, I saw "Sarah", a 30-year-old Spanish woman referred for severe insomnia. She reported having great difficulty falling asleep, and even after that, she often slept no more than three hours a night with frequent awakenings.
Sarah was married, had no children and worked as a university professor. She claimed that her marriage was "strong and supportive" and she was very fond of her professorial work. Two years earlier, she had been prescribed benzodiazepine sleeping pills, but they were no longer helping, and Sarah feared she would become addicted to them.
Sarah was in good physical health but was concerned that she had gained 35 pounds over five years. She had never seen a psychiatrist before. Her previous overnight visit to the Sleep Disorders Center in the hospital had revealed great difficulty in inducing and maintaining sleep. Polysomnographic results confirmed that it took her 82 minutes to fall asleep initially and that she experienced five awakenings of more than 20 minutes each during the night. Her total sleep time was 2.7 hours.
Her sleep problems had been around since high school or for about 15 years and were getting worse. She had severe daytime sleepiness, anxiety, and depression. Sarah said, "I can't go on like this."
Facts about sleep
Studies by the Centers for Disease Control and Prevention (CDC) show the following data on healthy sleep duration (with higher percentages indicating a healthier duration):
Geography: The prevalence of healthy sleep duration ranged from 56% in Hawaii to 72% in South Dakota.
Percentage of Healthy Sleep Duration by Race / Ethnicity: Native Hawaiian / Pacific Islander (54%); Black (54%); Other / mixed race (54%); American Indian / Alaskan Native (60%); Asian (63%); Hispanic (66%); White (67%)
Although the requirements vary slightly from person to person, most healthy adults need seven to nine hours of sleep per night in order to function optimally. Children and young people need more. Despite the notion that our need for sleep decreases with age, people over 65 still need at least seven hours of sleep each night. Interestingly, the average total length of night sleep decreased from about nine hours in 1910 to about seven hours in 2002.
Prevalence of sleep disorders
Sleep disorders are a common problem that affects at least 75% of Americans at some point in their life. Among the various sleep disorders, around 33% of all adults suffer from an insomnia disorder which, if left untreated, can have significant negative consequences. Individuals struggling with chronic insomnia often describe their condition as a "vicious cycle" of increasing efforts and desires to get back to sleep, with negative results.
A 2014 survey by the National Sleep Foundation found that 35% of American adults rated their sleep quality as “poor” or “just fair”. 45% of the respondents said that they had difficulty falling asleep at least one night a week (incipient insomnia). In addition, 53% had trouble staying asleep for at least one night the previous week (early awakening or insomnia while maintaining), and 23% had trouble staying asleep for five or more nights. Research suggests that sleep problems are worse in women, but increase with age in both sexes.
Each of us can carry out a self-assessment of his sleep deprivation, which is also called "sleep guilt". You are likely to have trouble sleeping if you are 1) sleepy or drowsy during the day, 2) need an alarm clock to wake you up frequently, and 3) fall asleep very quickly (less than five minutes) when you go to bed.
Insomnia is not a disease; it's a symptom. It can be 1) related to medical problems, 2) related to mental health problems, 3) lifestyle reasons, 4) caused by poor sleeping habits, or 5) any combination of the above.
Sleep deprivation can have many effects, both physically and psychologically. In the short term, it can lead to stress, somatic problems, cognitive difficulties, anxiety and depression. Long-term effects can include cardiovascular disease, obesity, diabetes, cancer, and even early death.
Hypnotic drugs are often used to treat insomnia, but many patients prefer non-drug approaches to avoid addiction and tolerance.
Assessment of sleep disorders
The self-administered Pittsburgh Sleep Quality Index rates seven components of sleep based on customer self-reports. This widely used tool has been shown to reliably detect clinical levels of sleep disorders in adults over a wide range of ages. Areas examined include subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disorders, use of sleep medication, and daytime dysfunctions.
On a more practical level, I've found that it can be helpful for customers to keep a simple "sleep log" for two weeks to identify sleep problems. I have customer record:
The time when they go to bed
Medication taken (if available)
Estimated time to sleep (start)
Estimated number of awakenings in sleep
Wake-up time
Estimated total sleep time
Sleep quality (on a scale of 0-10)
Daytime vigilance (scale 0-10)
Degree of concern about sleep (scale 0-10)
Sarah: Sleep assessment
Sarah was given material for self-monitoring of sleep over a period of 14 days. The results clearly showed many awakenings during the night, short sleep times, and severe daytime sleepiness. These results were confirmed by polysomnographic data. The evaluation results indicated the diagnosis of insomnia disorder (780.52 / 307.42), Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
Assessment of the childhood trauma
The systematic assessment of childhood trauma has evolved since the CDC and Kaiser Permanente's original investigation into adverse childhood experiences (ACEs) in the mid-1990s.
ACEs are divided into three different subgroups: abuse (physical, emotional, sexual); Neglect (physical, emotional); and household disorders (mental illness, imprisoned relative, abusive parents, substance addiction, divorce). These 10 areas can be broken down into a structured interview with questions such as "Before your 18th birthday, did you often or very often have the feeling that you did not have enough to eat?" Had to wear dirty clothes? Didn't anyone have you to protect? That your parents were too drunk or too high to take you to the doctor when you need to? Was a household member depressed or mentally ill or did a household member attempt suicide before your 18th birthday? “These questions can easily be included in a routine clinical interview.
In a large study, 61% of adults had at least one ACE and 16% had four or more types of ACEs. Women and members of multiple racial / ethnic groups were at greater risk of developing four or more ACEs. Exposure to ACEs has been linked to an increased risk of many life-span health problems.
As a counterpoint, Jack Shonkoff, pediatrician and director of the Center for the Developing Child at Harvard University, states, "There are people with high ACE scores who are remarkably well." Resilience, he says , builds up over the course of life, and close relationships are key. This implies that the ACE score for a person is not a static number, but more dynamic, as personality traits and life experiences can change the effects of ACEs.
Effects of childhood trauma and abuse on sleep
In a large population-based study from 2011, Emily Greenfield et al. found that three classes of abuse history were highly associated with a higher risk of global sleep pathology:
1) Frequent physical and emotional abuse with sexual abuse
2) Frequent physical and emotional abuse without sexual abuse
3) Occasional physical and emotional abuse with sexual abuse
The most extreme class of abuse – frequent physical and emotional abuse with sexual abuse – was associated with poorer self-reported sleep in many measured components, including subjective sleep quality, major sleep disorders and increased use of sleep medication.
Adults who – independent of sexual abuse – reported frequent experiences with physical and emotional abuse in childhood, had a particularly high risk for global sleep pathology. Regardless of their experiences of sexual abuse, respondents who reported frequent experiences of physical and emotional abuse were over 200% more likely than respondents who reported no abuse to have clinically relevant levels of sleep pathology.
In 2018, Ryan Brindle et al. concluded that “childhood trauma can affect sleep health in adulthood. These results are in line with the growing body of evidence linking childhood trauma to unhealthy outcomes later in life. “In addition, trauma exposure had no impact on sleep health after age 18 and throughout life, suggesting that trauma experienced at a younger age is a more important factor.
Sarah: Trauma assessment
When collecting Sarah's story during the first few sessions, she reluctantly revealed that between the ages of 11 and 15 she had been repeatedly molested by her mother's living boyfriend. He and Sarah were apparently dependent on alcohol and other drugs on the grounds that he was "drunk most of the time". She recalled that these events took place "about twice a month" and consisted of mutual (subtly forced) sexual touching and caressing, including occasional oral sex but not having intercourse. Sarah never revealed this to her mother. Sarah's ACEs score was five. This finding indicated a second working diagnosis of trauma and stress-related disorder in the DSM-5.
Possible mechanisms
In theory and research there is a fairly clear connection between chronic stress and an increased production of the hormone cortisol, which in turn can accelerate inflammation in the body. This can be a factor that can help explain the trauma-sleep connection.
Stress: When discussing trauma and sleep in children, Avi Sadeh (1996) suggested that stress is one of the most powerful causes of sleep disorders. This can include significant life changes / events or threats that require physiological, behavioral and psychological resources to maintain “psychophysiological balance and well-being”.
Cortisol: Cortisol is produced by the adrenal glands, and a high level of physical or psychological stress leads to an increase in cortisol secretion. In a study by Nancy Nicolson et al. (2010) emotional and sexual abuse were most closely linked to elevated cortisol levels. Child abuse is also linked to increased cortisol.
In patients with stress and insomnia, the cortisol level remains above normal, especially during sleep. With persistently higher cortisol levels, these individuals remain in a hyperarousal state even during sleep, which affects the overall quality and rest of their sleep. Chronic “short sleepers” (those who sleep five to six hours a night) have a higher level of nocturnal cortisol secretion compared to “normal sleepers” (those who sleep seven to eight hours a night).
Inflammation: Research by Janet Mullington et al. (2010) suggest that long-term inflammation may be the most common factor in many chronic diseases. Social threats and stressors can drive the development of sleep disorders in humans and contribute to the dysregulation of inflammatory and antiviral responses.
It is assumed that trauma-induced insomnia is a direct result of two interacting variables: physiological hyperarousal and self-destructive cognitive activity.
Sarah's treatment
Given that Sarah suffered from an insomnia disorder as well as trauma and stress-related disorder, it was important to determine which problem should be the initial focus of treatment. If we had expected her traumatic history to keep the insomnia alive, maybe there would have been a reason to help her deal with the trauma first. On the flip side, there was justification for initially treating her insomnia as her insomnia had a huge impact on her mood, focus, and daytime alertness.
Based on the information about Sarah's sleep pattern and traumatic history, several evidence-based approaches were used in combination over 11 weekly sessions.
It has been shown that both body scan and breath awareness improve relaxation before sleep. They direct the mental focus to the current state of the body and breath. The body scan consists of observing and hearing what body sensations are communicating at the moment. It's about noticing areas of tension in the body and asking these areas to release the tightness.
Breath awareness can consist of slowly accepting the inhalation through the nose, deliberately stopping for a moment and then slowly letting the breath out of the mouth. This regulates the tempo of the nervous system and offers the opportunity to mindfully experience the feeling of letting go of what no longer serves the body. Sarah was given audio to practice these techniques on a daily basis.
Insomnia cognitive behavioral therapy (CBT-I) is a structured program that allows unhelpful thoughts and behaviors that cause or worsen sleep problems to be replaced with habits that promote healthy sleep. CBT-I helps overcome the underlying causes of sleep problems. The customer must keep a detailed sleep diary for one to two weeks. The “cognitive” part of CBT-I teaches clients to recognize and change beliefs that affect their ability to sleep. This type of therapy can help control or eliminate negative thoughts and worries that are keeping clients awake.
Sarah recorded her unhelpful automatic thoughts and beliefs about her sleep. These included: "Not sleeping well ruins my life"; "I have to fall asleep now"; "I will never get over this sleep problem." and "I worry that I have lost control of my sleeping skills." The A-B-C-D-E system (activation of event, conviction, consequence, disputation, new effect) was explained to her and she was instructed to dispute and replace unhelpful thoughts and beliefs. She managed to describe and challenge these thoughts.
Acceptance and attachment therapy (ACT) is a newer form of psychotherapy that focuses on mindfulness and acceptance in clients with trauma histories. The underlying theory of ACT is that post-traumatic disorder results from trying to avoid a past experience at all costs. One goal of treatment with ACT is therefore to develop a more acceptable and more mindful attitude towards stressful memories and negative realizations rather than avoiding them.
Sarah was first introduced to mindfulness in order to reconnect with the present moment. This formed the basis for greater exposure to avoided thoughts and emotions. By practicing mindfulness daily for 10 weeks, Sarah became aware of painful thoughts that were affecting her sleep and mood. Defusion strategies helped Sarah learn to recognize these thoughts as "righteous thoughts." Defusion is the separation of an emotional stimulus from the unwanted emotional response as part of a therapeutic process (remember, this is similar to "defusing" a bomb). Unlike strategies that are cognitive in nature, the goal is not to challenge thoughts, but rather to recognize when thoughts are not helpful, to break away from them and move forward. It is not necessary to determine whether the thoughts are true or false.
An essential difference between these two approaches is how unhelpful thoughts are dealt with. In classic CBT therapy, clients are encouraged to deny these thoughts and replace them with more helpful ones. In ACT, clients learn to recognize and accept their thoughts, but to stay away from them, as is common in mindfulness practices.
Result of Sarah's treatment
After our 11 joint sessions, Sarah reported the following:
Although the average sleep onset time had decreased only slightly (82 minutes pretreatment to 68 minutes after treatment), their total sleep time had increased from 2.7 hours to 5.3 hours per night, and their number of awakenings decreased from average five a night to one or two a night. She also reported significantly less depression and much more vigilance during the day. She was able to work again as a full-time university professor.
Summary and takeaways
I have reviewed some important research into a possible link between child abuse and insomnia in adults. A case study will help clarify methods for identifying and treating these problems.
Working with people with insomnia for the past 10 years or more, I have come to realize that a) many clients who suffer from insomnia have no history of (or at least do not disclose) child abuse or neglect Clients who have been mistreated as children in the past, some have no apparent sleep problems. Regardless of these outliers, it is clear that sleep patterns should be studied carefully, and it would be good clinical practice to always inquire about your clients' sleep patterns.
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David Engstrom lives in Scottsdale, Arizona and is a key faculty member in the Clinical Mental Health Advisory Program at the University of Phoenix. A consultant and health psychologist, he is a diplomat for the American Mental Health Counselors Association for Integrated Health Care. He specializes in weight management, insomnia and pain management and is a medical staff at Honor Health Scottsdale Medical Center. Contact him at [email protected].
Knowledge-sharing articles developed from sessions presented at American Counseling Association conferences.
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Opinions and statements in articles appearing on CT Online should not be assumed to reflect the opinions of the editors or guidelines of the American Counseling Association.
