The Behavioral Health Specialist in Primary Care by Mary Ann Burg PhD MSW LCSW;Oliver Oyama PhD ABPP PA-C DFAAPA;

Author:Mary Ann Burg, PhD, MSW, LCSW;Oliver Oyama, PhD, ABPP, PA-C, DFAAPA;
Language: eng
Format: epub
Publisher: Springer Publishing Company, Inc.
Published: 2016-10-15T00:00:00+00:00

Source: Vaughn & D’Cruz (2011).

The American Academy of Sleep Medicine (AASM) has established indications for sleep study in insomnia patients based on scientific review of the literature by their Standards of Practice Committee (2003). Polysomnography (“sleep study,” see the following) is not recommended in the routine evaluation of all insomnia. It is, however, recommended in the face of suspected breathing disorders or periodic limb movements during sleep. It is also advocated for insomnia treatment failures, unexplained hypersomnolence (prolonged or excessive sleeping), excessive daytime sleepiness, and nonrestorative sleep, or in the face of violent/injurious arousals (AASM, 2003; Ramar & Olson, 2013). Although many patients with insomnia may misreport or misperceive the amount of sleep they are getting (Manconi et al., 2010), this alone is not sufficient cause for polysomnography prior to an intervention trial.

Polysomnography, commonly referred to as a “sleep study” is a diagnostic tool in sleep medicine in which comprehensive biophysiological recordings are taken during sleep. During a polysomnogram, a number of bodily functions are recorded, generally at night, although shift workers and individuals with certain other disorders (e.g., circadian rhythm disorders, narcolepsy) may be recorded during the daytime. Monitoring includes brain wave activity, heart rhythm, eye movements, muscle activity, nasal and oral airflow, breathing effort, and blood oxygenation. All of these parameters are used, in combination, to characterize an individual’s sleep or to diagnose or rule out many sleep disorders.

The symptoms of disorders of sleep and wakefulness overlap significantly with many medical conditions, the evaluation of which is likely to have taken place prior to the patient’s referral to a behavioral specialist. Sleep disorders that present with coexistent fatigue can represent diagnostic dilemmas in primary care as up to 20% of all patients presenting to a primary care office will complain of fatigue (Rosenthal, Majeroni, Pretorius, & Malik, 2008). The causes of fatigue are highly diverse, representing disease states involving virtually every organ system, some potentially serious and/or life-threatening. Extensive medical evaluation of such a broad complaint can be time consuming and costly. The dilemma may center on the extent of medical evaluation necessary for fatigue in a patient with disordered sleep. Routine initial workup for fatigue should include complete blood count (CBC), chemistry panel (CMP), thyroid function studies (TSH), erythrocyte sedimentation rate (ESR), human immunodeficiency virus (HIV) antibodies, and pregnancy test. Other additional testing has not been shown to be generally useful unless indicated by specific findings.

The referring clinician will likely have also taken a complete medication history due to the many medications that impact sleep and wakefulness through use or withdrawal (Table 7.3; Schweitzer, 2011). The behavioral clinician should also take care to evaluate for the presence of mood disorders and anxiety disorders in the course of a complete evaluation of sleep disturbance.

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