NURS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology | Week 7

From negative changes in mood to problems concentrating, pain and sleep/wake disorders can have a tremendous impact on clients’ lives. When clients suffer from these disorders, they often seek medical care with the intent of receiving medications to manage symptoms. However, many of the medications used to treat pain and sleep/wake disorders may be addictive, making thorough client assessments and close follow-up care essential. To prescribe appropriate therapies with client safety in mind, you must understand not only the pathophysiology of these disorders, but also the pharmacologic agents used to treat them. NURS 6630:Week 7: Therapy for Clients With Pain and Sleep/Wake Disorders

This week, as you study therapies for individuals with pain and sleep/wake disorders, you examine the assessment and treatment of clients with these disorders. You also explore ethical and legal implications of these therapies.

Discussion: Sleep/Wake Disorders

It is not uncommon to experience a night or two of disrupted sleep when there is something major going on in your life. However, sleep/wake disorders are much more than an occasional night of disrupted sleep. A recent report from the Centers for Disease Control and Prevention estimated that between 50 and 70 million American have problems with sleep/wake disorders (CDC, 2015). Although the vast majority of Americans will visit their primary care provider for treatment of these disorders, many providers will refer patients for further evaluation. For this Discussion, you consider how you might assess and treat the individuals based on the provided client factors.

Learning Objectives

Students will:

• Assess client factors and history to develop personalized therapy plans for clients with sleep/wake disorders
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for sleep/wake disorders
• Evaluate efficacy of treatment plans for clients presenting for sleep/wake therapy
• Apply knowledge of providing care to adult and geriatric clients presenting for sleep/wake disorders

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

• Chapter 11, “Disorders of Sleep and Wakefulness and Their Treatment”

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

Review the following medications:

For insomnia

• alprazolam
• amitriptyline
• amoxapine
• clomipramine
• clonazepam
• desipramine
• diazepam
• doxepin
• flunitrazepam
• flurazepam
• hydroxyzine

• imipramine
• lorazepam
• nortriptyline
• ramelteon
• temazepam
• trazodone
• triazolam
• trimipramine
• zaleplon
• zolpidem

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: Going beyond the guidelines. British Journal of Psychiatry, 2(6), e16-e18. doi:10.1192/bjpo.bp.116.003707. Retrieved from http://bjpo.rcpsych.org/content/2/6/e16

To prepare for this Discussion:

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following case studies to review for this Discussion. To access the following case studies, click on the Case Studies tab on the Stahl Online website and select the appropriate volume and case number.

Case 1: Volume 2, Case #16: The woman who liked late-night TV

Case 2: Volume 2, Case #11: The figment of a man who looked upon the lady

Case 3: Volume 1, Case #5: The sleepy woman with anxiety

• Review this week’s Learning Resources and reflect on the insights they provide.
• Go to the Stahl Online website and examine the case study you were assigned.
• Take the pretest for the case study.
• Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
• Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).
• Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
• Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.
• Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
• Review the posttest for the case study.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

By Day 3

Post a response to the following:

• Provide the case number in the subject line of the Discussion.
• List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
• Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
• List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s sleep/wake therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
• If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
• Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues who were assigned to a different case than you. For example, if you were assigned to Case Study 1, respond to one colleague assigned to Case Study 2 and one colleague assigned to Case Study 3. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings. NURS 6630:Week 7: Therapy for Clients With Pain and Sleep/Wake Disorders

ADDITIONAL INFORMATION 

Therapy for Clients With Pain and Sleep/Wake Disorders

Introduction

Sleep and wake disorders are common among adults, and the causes of these sleep problems can be complex. The most common disorders are obstructive sleep apnea (OSA), insomnia, and narcolepsy. If you suspect that you or a loved one has a sleep disorder, it is important to seek medical attention as soon as possible. In this article I will discuss how mindfulness-based practices may help with pain management, sleep quality improvement, and treating these conditions in clients with chronic pain syndromes or other conditions that affect their ability to restful deep slumber.

Developing a perspective

In order to develop a perspective, the therapist and client must begin by exploring their own feelings about the client’s pain. They should also consider how they can benefit from that person’s experiences and what it means for them personally.

In addition to asking questions about your own understanding of mental health issues, you may find it useful to explore whether there are any negative stereotypes associated with having chronic pain or sleep/wake disorders (e.g., “You’re weak”). Try not to be judgmental about these types of thoughts; instead try questioning them further by asking yourself if these beliefs make sense in light of your knowledge about other people who suffer from similar conditions (e.g., “I’d never imagine myself as someone who would have trouble getting up at 6 am because they were injured while biking”).

Managing pain, sleep, and wake

Pain and sleep are not the same thing. They are both normal parts of life, but they’re not the same thing.

• Pain is a physical sensation that occurs in response to an injury or other stimulus. It’s often accompanied by other symptoms such as swelling and tenderness, which can make it difficult to treat effectively with traditional therapies like acupuncture or massage therapy.

• Sleep disorders can cause disruptions in your body’s natural rhythms—and this means you may have trouble falling asleep at night or staying asleep through the day when you need some restorative shut-eye! These issues could also lead you back into chronic pain once again if you don’t take steps toward treating them sooner rather than later (like seeing a doctor).

• Wakefulness refers specifically (as opposed to generally speaking) when someone becomes alert after being asleep without having been conscious during their slumber period; this might happen during times when there isn’t enough time left over before waking up again like when someone gets out of bed early because they have somewhere important planned for tomorrow morning.”

Setting realistic goals for pain relief, sleep, and wake

Setting realistic goals is the most important part of therapy for clients with pain and sleep/wake disorders. The goal should be specific, measurable, achievable, relevant and timely (SMART).

Here are some examples of SMART goals that can help you in your work:

• Pain relief – I will reduce my pain by 15% within the next month.

• Sleep improvement – I will get a better night’s sleep on average each week by 1 hour total over the next month.

• Wakeup time reduction – I will wake up 30 minutes earlier than usual during my weekdays so that I’m not rushing through morning routine as much as possible

Developing a self-management plan

A self-management plan can be an effective tool for managing pain and sleep/wake disorders. It’s important to set realistic goals, including how long you’ll need to stay in bed or the amount of sleep you’ll need each night. Create a self-management plan that includes how long it will take you to get out of bed each morning, what steps will help make this happen (such as turning off lights), and how often these activities should be repeated throughout your day.

You may also want a “go-to” activity for when things get tough—for example: I find writing down my pain symptoms helps me understand what’s going on better than just thinking about them during the day; so instead of having three different ideas floating around in my head all at once (like “I’m tired again”), they’re written down separately so I can focus on one thing at once instead!

Identifying cognitive and behavioral strategies for managing stress and pain

Self-management plans are essential to the success of treatment. They focus on identifying and addressing stressors, developing coping strategies for managing pain and sleep/wake disorders, creating a realistic plan for how you will manage these conditions during the day, setting goals for yourself that are achievable but challenging enough to be motivating.

A self-management plan should include:

• A list of your current issues so that you can prioritize them when planning your schedule

• Short-term goals (e.g., “I’ll eat more protein”) as well as long term ones (“I will see my doctor next week”) * Instructions on how to implement new habits or changes in lifestyle

Recognizing normal sleep patterns

Recognizing normal sleep patterns is the first step to understanding what type of therapy is necessary for your client.

• Sleep patterns vary widely by age, gender and culture. For example, babies generally need more sleep than adults do because they are growing so fast during their first years of life. This means that if a child is having trouble going to sleep at night or staying asleep during the day (because he or she wakes up frequently), it’s important that you consider whether there may be an underlying problem with his/her circadian rhythm—a natural cycle that regulates body functions like eating habits and sleeping patterns.*

• Seasonal changes can also affect how much someone sleeps each night: in springtime when flowers bloom outside our windows; in summer when temperatures rise above 100 degrees Fahrenheit (38 degrees Celsius); and fall after school lets out for winter break has ended.*

Implementing restorative practices for sleep and wake

One of the most important things you can do for your clients is to implement restorative practices in their day-to-day lives. These include:

• Sleep hygiene – making sure your clients go to bed at a reasonable time and get enough sleep each night.

• Time-in – spending time in the morning with yourself (reading, meditating) or practicing mindfulness (like yoga).

• Exercise – engaging in physical activity that doesn’t involve pain can help them feel better and reduce stress levels.

Applying mindfulness-based practices in daily life

Applying mindfulness-based practices in daily life can help you manage pain, sleep and wake.

Awareness of your breath is the first step to managing pain. Be mindful of how you breathe as it moves through your body, from the top of your head down through your chest and abdomen. Notice how this movement feels in different parts of your body; feel what happens when you focus on breathing at a particular spot (e.g., above or below the navel). As you observe this awareness over time, notice if there are any changes in how things feel as they change around you or within yourself—for example, if certain emotions arise during certain points during these observations (e.g., anxiety about something that happened earlier today).

You may also want to do an exercise called “mindful walking” where individuals walk slowly while being mindful about their thoughts and feelings as well as their physical actions: they will notice whether they are walking too fast/slowly/in circles etc.; they may pay more attention than usual toward what others around them might be doing (e.g., looking at watches); etcetera…

Conclusion

We hope this post has helped you understand how sleep and pain are connected, and how to use mindfulness practices as a tool for managing both. We know that these can be challenging issues for people who struggle with them on a regular basis, so we encourage you to talk more about your own experiences with these conditions and give yourself time to find the resources that work best for you.