Behavioral+Health,+Sleep+Insomnia

We suggest your primary assessment involves asking targeted questions to assess sleep behaviors, factors that may prompt and maintain insomnia, and sleep hygiene. Brief, standardized self-report measures exist that can be appropriate for the primary care environment.
 * __Assessment:__**

The Insomnia Severity Index (ISI; Bastien, Vallieres, & Morin, 2001) uses seven items to measure sleep impairment. Using a cutoff score of 14, the ISI distinguish between those with and without insomnia, with a sensitivity of 94% and specificity of 94% (Smith & Trinder, 2001), and is considered a valid index of insomnia severity (Smith & Wegner, 2003).

The Epworth Sleepiness Scale (ESS; Johns, 1991) is a commonly used measure that has eight items measuring daytime sleepiness, regardless of the cause of that sleepiness (i.e., sleepiness may or may not be due to insomnia). The ESS has a 93.5% sensitivity and 100% specificity for detecting narcolepsy when using a cutoff score that is greater than 10 (Johns, 2000): however, it is not considered to be a valuable tool for distinguishing between individuals who do and do not meet criteria for insomnia (Sanford et at., 2006). For more information regarding ESS, click **__here__**.

__**A focused functional assessment of a sleep problem might focus on the following areas:**__

//History:// -When did you first start having difficulty with your sleep? -Did anything happen that started your sleep problem? -How many nights of the week do you have difficuly with your sleep?

//Sleep environment:// -Is your bedroom generally quiet and comfortable? -Is there anything that wake you up throughout the night, such as noises, pets, children?

//Pre-sleep behaviors:// -Do you take or use anything to help you fall asleep, including alcohol or sleepoing medication? -What time of day do you exercise? Do you use any tobacco? If so, what is the latest time you use tobacco before you got to bed? -How much caffeine, including coffee, tea, soda, do you consume? What is the latest time you have any caffeinated bevverages before getting into bed?

//In-bed behaviors//: -What time do you go to bed? How long does it take you to fall asleep once you are in bed? -How many times do you wake up througout the night? How long are you awak? What do you do when you wake up? Do you worry about not lseeping? -What time do you wake up? Is that before or after the time you set on your alarm? How many naps do you take during the day? For how long? -When you are awake in bed, do yo uwatch TV, read, or eat? -How long do you stay in bed when you are awake?

//Consequences:// -Do you feel rested or tired when you wake up? Does that change during the day? -Do you feel sleepy througout the day? -Have you fallen asleep in inappropriate places? Do you have difficulty concentrating? -What are some ways that your sleep affects your functioning? -Do you nap? If so, how long are your naps?

//Exclusions:// -Sleep apnea: Do you snore at night? Do yo uwake up with a headache? Has anyone told you that you gasp for air when you are sleeping? -Periodic limb movements: Has a bed partner ever told you that you kick them at night? Do your legs suddenly move and wake you up?

__**Treatment Recommendations**__

1) **//Belly Breathing://** Diaphragmatic breathing, abdominal breathing, belly breathing or deep breathing is breathing that is done by contracting the diaphragm, a muscle located horizontally between the chest cavity and stomach cavity. Air enters the lungs and the belly expands during this type of breathing. This deep breathing is marked by expansion of the abdomen rather than the chest when breathing. It is considered by some to be a healthier and fuller way to ingest oxygen , and is sometimes used as a therapy for hyperventilation, anxiety disorders and stuttering. To breathe diaphragmatically, or with the diaphragm, one must draw air into the lungs in a way which will expand the stomach and not the chest. It is best to perform these breaths as long, slow intakes of air – allowing the body to absorb all of the inhaled oxygen while simultaneously relaxing the breather. Deep breathing exercises are a form of relaxation, and therefore, when practiced regularly, lead to the relief or prevention of symptoms commonly associated with stress, which may include high blood pressure, headaches, stomach conditions, depression, anxiety, and others.For more information on Belly breathing, click __here__.

A sample exercise that can be done in the exam room:
A common diaphragmatic breathing exercise is as follows: 2) **//Sleep Efficiency://** To be continued....
 * 1) Sit or lie comfortably, with loose garments.
 * 2) Put one hand on your chest and one on your stomach.
 * 3) Slowly inhale through your nose or through pursed lips (to slow down the intake of breath).
 * 4) As you inhale, push your belly/ stomach out and feel your stomach expand with your hand.
 * 5) Slowly exhale through pursed lips to regulate the release of air while squeezing your belly/ tummy.
 * 6) Rest and repeat.