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Brooke Harbor Health System

PMHNP Clinical Learning Environment

Condition Guide

Condition GuideAssessment, differential, treatment, and monitoring guidance.

Sleep-Wake Disorders

Sleep complaints require more than selecting a sedating medication. Define the sleep pattern, schedule, opportunity, environment, daytime consequences, psychiatric relationship, substances and medications, and possible breathing, movement, circadian, or neurologic disorders.

Use this when

Sleep timing, continuity, quality, behavior, or daytime alertness is affecting safety, function, diagnosis, or treatment planning.

Clarify first

Define the sleep opportunity, schedule, pattern, duration, daytime effect, environment, and difference between sleepiness and fatigue.
Review breathing, movement, circadian and neurologic features; mood; substances; medications; medical conditions; and safety-sensitive activities.

Act now

Name the clinical question, select the history, diary, examination, measurement, or consultation needed to answer it, and address modifiable risks.
Match the plan to the suspected sleep-wake process and assign ownership for testing, results, and reassessment.

Document and communicate

Record the sleep-wake pattern, daytime consequences, relevant contributors, safety findings, working explanation, planned evaluation, and follow-up responsibility.

Escalate or consult when

There is dangerous sleepiness, respiratory concern, altered consciousness, suspected nocturnal seizure, injury risk, severe sleep loss with psychiatric instability, or another concern that cannot be safely evaluated in the current setting.

Diagnostic Features

Name the sleep-wake disorder before treating the symptom

DSM-5-TR diagnosis requires adequate history of timing, opportunity, duration, daytime impact and exclusions; sleepiness, fatigue and insomnia are not interchangeable.

≥3 nights/week · ≥3 months

Insomnia disorder

Difficulty initiating or maintaining sleep or early awakening occurs despite adequate opportunity, causes significant daytime distress or impairment, and persists at least three nights weekly for at least three months.

≥3 months

Hypersomnolence disorder

Excessive sleepiness occurs despite a main sleep period of at least seven hours, with recurrent sleep lapses, prolonged nonrestorative sleep or difficulty becoming fully awake, at least three times weekly for three months.

Sleep attacks plus defining physiology

Narcolepsy

Recurrent irresistible sleep need, lapses or naps occur at least three times weekly for three months, plus cataplexy, hypocretin deficiency or characteristic REM findings under specified conditions.

Breathing-related disruption

Obstructive sleep apnea hypopnea

Polysomnographic obstructive events plus symptoms, comorbidity or event-frequency thresholds establish the disorder; questionnaires estimate risk but do not diagnose it.

Clock-schedule mismatch

Circadian rhythm sleep-wake disorders

A persistent or recurrent mismatch between the endogenous rhythm and required schedule causes insomnia, sleepiness or both with significant distress or impairment; subtype depends on timing pattern.

Stage, timing and recall matter

Parasomnias and restless legs syndrome

Non-REM arousal, nightmare, REM sleep behavior and restless legs diagnoses require their defining behaviors or sensations, frequency or impairment where specified, and exclusion of substances, medical causes and other sleep disorders.

Rating Scales & Screening

Measure the correct sleep domain

Use questionnaires to structure history and follow outcomes, then order specialty testing only when it answers a defined diagnostic question.

Insomnia Severity Index

Seven-item self-report measure for perceived insomnia severity, distress and interference.

Open VA/DoD insomnia tools ↗

Epworth Sleepiness Scale

Measures likelihood of dozing across situations; official licensing and use conditions apply.

Open official ESS information ↗

STOP-Bang

Eight-item obstructive sleep-apnea risk screen; high risk requires diagnostic evaluation rather than treatment based on the score alone.

Open STOP-Bang ↗

Consensus Sleep Diary

Daily timing and continuity data support insomnia and circadian formulation and reveal mismatch between estimates and patterns.

Open sleep diary resource ↗

Assessment

Start with the pattern and the clock

A focused sleep history distinguishes insufficient opportunity, insomnia, circadian mismatch, hypersomnolence, parasomnia, and sleep disrupted by another condition.

Insomnia

Clarify sleep opportunity, onset and maintenance difficulty, early awakening, duration, frequency, conditioned arousal, daytime impairment, schedule variability, naps, and compensatory behaviors.

Circadian disorders

Compare preferred and required sleep timing across workdays and free days. Ask about light exposure, shift work, travel, adolescence, routines, and timing of melatonin or other interventions.

Hypersomnolence and narcolepsy

Differentiate sleepiness from fatigue. Assess total sleep, sleep attacks, cataplexy, sleep paralysis, hallucinations around sleep, medications, substances, apnea, and safety-sensitive activities.

Parasomnias and movement

Characterize timing, recall, dream enactment, injury, confusion, restless legs symptoms, bed-partner observations, seizures, trauma, medications, and substance effects.

Tools & Testing

Choose measurement that answers the clinical question

Testing is targeted; not every sleep complaint requires polysomnography.

Sleep diary

Track bedtimes, estimated sleep, awakenings, rise time, naps, substances, medications, and daytime function for at least one representative interval.

Specialty testing

Refer for polysomnography, home apnea testing, multiple sleep latency testing, actigraphy, or neurologic evaluation when the suspected disorder and pretest conditions support it.

Treatment

Use behavioral and circadian treatment deliberately

Match the intervention to the diagnosed sleep-wake problem rather than treating all sleep complaints as insomnia.

CBT-I

First-line treatment for chronic insomnia includes stimulus control, sleep restriction or compression, cognitive and behavioral strategies, and relapse planning—not sleep-hygiene advice alone.

Circadian intervention

Precisely time light, darkness, schedule shifts, activity, and melatonin when indicated. Incorrect timing can move the sleep phase in the wrong direction.

Medication

If used, define the target, duration, reassessment plan, next-day risks, interactions, misuse potential, respiratory concerns, and how the medication fits with behavioral treatment.

Treat contributors

Address apnea, restless legs, pain, nocturia, hot flashes, substance use, medication effects, mood episodes, anxiety, trauma, and environmental barriers as clinically indicated.

Follow-Up

Measure sleep and daytime recovery

Follow the outcome that matters: safe, restorative sleep and improved function.

Track the target

Review sleep efficiency or timing when relevant, awakenings, daytime sleepiness, function, adherence, and the patient’s prioritized goal.

Reassess diagnosis

Persistent symptoms should prompt review of schedule, implementation, comorbidity, substances, medications, apnea or movement symptoms, and bipolar-spectrum activation.

Taper thoughtfully

Avoid abrupt discontinuation when withdrawal or rebound is possible. Create a patient-specific taper and monitor sleep, anxiety, autonomic symptoms, and safety.

Coordinate care

Clarify responsibilities among psychiatry, primary care, sleep medicine, neurology, pulmonology, behavioral sleep clinicians, and pharmacy.

Clinical Sources

Use current guidance and patient-specific evidence

These sources support clinical reasoning but do not replace a complete assessment, current prescribing information, local policy, consultation, or individualized shared decision-making.

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Last updated September 1, 2026