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Insomnia, circadian rhythm disorder, inadequate sleep hygiene and environmental disturbances.

“He would lie in the bed and finally, with daylight, he would go to sleep. After all, he said to himself, it is probably only insomnia. Many must have it.”- Ernest Hemingway, A Clean Well Lighted Place

The etiology of an acute or chronic sleep disturbance can be simple, straightforward and attributable to a recognizable cause or stressor in your life. However, at other times the source will be a mystery that will take time, perseverance and patience to unravel.

In clinic, in order to provide effective therapy and advice, it is important for me to determine if the presenting sleep issues are due to insomnia (of various causes), a circadian rhythm disorder or inadequate sleep hygiene and environmental disturbances.

In terms of insomnia, some questions that I ask my patients to consider include:

  • How long does it take you to fall asleep at night?

  • Do you awaken in the night, and if so, how long are you awake?

  • Do you awaken early and are unable to return to sleep?

  • When did this sleeplessness begin, and was there an identifiable precipitating event?

  • How do you sleep in other bedrooms at home, or when traveling?

  • What is going on when you are awake in bed and unable to sleep?

  • What awakens you in the night?

  • How much sleep do you do best with?

  • What time do you go to bed and get up?

  • Is there a variation in your sleep on the weekend?

When it comes to establishing if the sleep disturbance is due to a circadian rhythm disorder, it is helpful to think about the relevance of some of the following questions:

  • What time would you go to bed and get up if the world was on your schedule?

  • Do you work shifts such as swing or nights? Have you in the past?

  • Do you travel across time zones regularly?

  • Are you sleepy when you go to bed?

Lastly, clinically pertinent questions that can help determine if your sleep issues are due to inadequate sleep hygiene and environmental disturbances can include:

  • Do you spend time awake in bed reading, watching TV, completing projects, computer work or other activity?

  • How much does your bedtime vary over a week?

  • Is your bedroom quiet, dark, cool, comfortable?

  • Do household members, pets or anything else wake you from sleep?

Addressing the above questions will often help narrow down the factors that are contributing to your sleep issues and facilitate appropriate and achievable treatment and interventions.

There are a number of scales which can be used clinically to help determine the severity of your insomnia. They can also be used post-intervention to evaluate the effectiveness of any recommendations, treatment or lifestyle modifications.

Epworth Sleepiness Scale (ESS) was first developed to help assess the “daytime sleepiness” of patients.

Beliefs and Attitudes Scale is used to assess the role of cognitive thoughts on insomnia and is a medium often used to monitor improvement. Four main factors that emerge from the scale are the evident consequences of insomnia, feelings of worry or helplessness surrounding the insomnia, sleep expectations and the impact of medications.

Insomnia Severity Index (ISI) is a short questionnaire designed to assess the severity of both nighttime and daytime components of insomnia.

Stay tuned for more posts on sleep. I am focusing on this topic at the moment as many of my patients are currently experiencing difficulty and struggling to attain a restful nights sleep. I hope that the above helps to not only educate but to also provides some areas to delve into and investigate.


Thank you to Dr. Catherine Darley at the Institute of Naturopathic Sleep Medicine for the invaluable clinical assessment tools.

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