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The DSM-V (20103) devotes an entire domain to Sleep-Wake Disorders. Specifically identified is Insomnia Disorder (G47.00), Hypersomnolence Disorder (G47.10), Narcolepsy, Obstructive Sleep Apnea-Hypopnea (G47.33), Central Sleep Apnea, Sleep-Related Hypoventilation, Circadian Rhythm Sleep-Wake Disorder, Non-Rapids Eye Movement Sleep Arousal Disorders, Nightmare Disorder (F51.5), Rapid Eye Movement Sleep Behavior Disorders (G47.52), Restless Leg Syndrome (G25.81), Substance Medication Induced Sleep Disorder, and various unspecified categories. Following is a discussion regarding the major types of drug interventions available for sleep disorders. Additionally, contained in a review of the addiction potential of these medications. Also covered below are the complexities that sleeping medications bring to the counseling environment. In closing, a discussion associated with the incorporation of this information into my clinical practice.
Major Drug Types & Addiction Potential
The addiction potential of medication is an important component of the decision-making process associated with pharmaceutical interventions as the intention of the prescriber is to help not harm their patient. Best practice for sleep disorder treatment is behavioral therapy (Matheson & Hainer, 2017). Preston and Johns (2011) assert medicinal interventions should be reserved for patients whos sleep disturbance is due to recent environmental causes rather than a chronic condition. Matheson and Hainer (2017) identified the following as regularly recommended medications, Benzodiazepines, Z-drugs, Melatonin antagonists, Tricyclics, Orexin receptor antagonists, Antipsychotics, and Anticonvulsants. For this paper, the focus will be on the most frequently prescribed medications, Benzodiazepines, z-drugs, and Melatonin.
Benzodiazepines
Benzodiazepines are a schedule IV drug as there is a high risk of addiction, withdrawal, and can cause rebound sleep issues with an increase in anxiety Matheson and Hainer (2017). When used, Benzodiazepines may be used in patients suffering from the inability to fall asleep but should be avoided when the insomnia is present in the middle of the night or is represented by early waking (Preston & Johns, 2011). The latent sleep disturbance is indicative of a depressive cause making a benzodiazepine contraindicated.
Z-drugs
The z-drugs (zaleplon, zolpidem, and eszopiclone) are the most commonly prescribed medication for sleep disorders (Matheson & Hainer, 2017). Although highly prescribed the z-drugs are also classified as a schedule IV due to abuse potential. Preston and Johnson (2011) assert Zolpidems addiction potential renders it a high risk for SUD individuals suffering from insomnia.
Melatonin
Melatonin is a natural hormone made in the pineal gland that participates in sleep regulation. Therefore, when an individual is deficient in Melatonin, sleep disorders can arise (Matheson & Hainer, 2017). Matheson and Hainer (2017) assert controlled-release melatonin are effective, lacks addictive properties, and is available over the counter. As an over the counter medication, Melatonin is not regulated by the FDA, so consumer research is recommended for a quality product (Perry, Alexander, Liskow, & DeVane, 2007). Perry et al (2007) assert naturally secreted Melatonin reduces as an individual age making Melatonin use in the elderly beneficial. Melatonin also provides drowsiness but does not impair psychomotor activity (Perry et al., 2007).
Malingering
Adetunji, Basil, Mathews, Williams, Osinowo, & Oladinni (2006) define malingering as the intentional production of false or grossly exaggerated physical or psychological symptoms (p. 68). Malingering is enacted by a patient to achieve a benefit (e.g. presenting with a painful presentation to obtain pain medication for the purpose of diversion). Despite a providers suspicion of malingering behavior, a thorough exam must occur (Adetunji et al., 2006). Psychiatrists are fearful of legal action and lose of a therapeutic alliance when encountering a patient who they feel might be malingering.
Malingering can be identified by inconsistency in the patients story or presenting behaviors. Observing a patient for this abnormal behavior, peculiar presentations, and inconsistent stories is essential in identifying a malingering client (Adetunji et al., 2006). Adetunji et al. (2006) recommend the use of psychometric tests to determine if a patient is presenting with malingering behaviors. These tests include the Minnesota Multiphasic Personality Inventory, Structured Interview of Reported Symptoms, Miller Forensic Assessment of Symptoms Test, The Victoria Symptom Validity Test, Personality Inventory for Youth, Structured Inventory of Malingered Symptomatology, Test of Memory Malingering, Rey Auditory Verbal Learning Test, and Wisconsin Card Sorting Test.
An epithetic nonthreatening approach should be used when conversations regarding malingering behavior is necessary. Exploration of causation for the malingering behavior should be explored. Adetunji et al. (2006) encourage practitioners to have a strong knowledge base of signs and symptoms specific to psychological diagnostic criteria, always assume the patient is being truthful until proven otherwise, and tactfully offer the client a nonthreatening way out of the situation.
Journal Review
The Journal Detection and Management of Malingering in a Clinical Setting (Adetunji et al., 2006) offers readers a wealth of information associated with how identification and approach individuals suspected of malingering. I will easily be able to incorporate this knowledge into my clinical approach. I am particularly appreciative for the assessment tools suggested by the authors as it provides an empirical tool to assist in solidifying a counselors suspicions. Lastly, I appreciated the suggestion regarding how to approach the crucial conversation in a nonthreatening and productive manner.
References
- Adetunji, B. A., Basil, B., Mathews, M., Williams, A., Osinowo, T., & Oladinni, O. (2006). Detection and Management of Malingering in a Clinical Setting. Primary Psychiatry, 13(1), 6169. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=psyh&AN=2006-01601-016&site=eds-live&scope=site
- Diagnostic and statistical manual of mental disorders: DSM-5. (2013). Washington, D.C.: American Psychiatric Publishing.
- Matheson, E., & Hainer, B. L. (2017). Insomnia: Pharmacologic Therapy. American Family Physician, 96(1), 2935. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=28671376&site=eds-live&scope=site
- Preston, J., & Johnson, J. (2011). Clinical psychopharmacology made ridiculously simple (7th ed.).Miami, FL: MedMaster, Inc.
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