Assessment

Formal

Informal

Athens insomnia scale

observation

Epworth sleepiness scale

clinical interview
Symptom baseline checklist

Formal Assessment
Athens Insomnia Scale (AIS). Athens insomnia scale (AIS) was first introduced in the year
2000 by a group of researchers from Athens, Greece to assess the insomnia symptoms in patients
with sleep disorders.
It is measured by assessing eight factors (as tabulated below) amongst which first five factors are
related to nocturnal sleep and last three factors are related to daytime dysfunction. These are
rated on a 03 scale and the sleep is finally evaluated from the cumulative score of all factors and
reported as an individual's sleep outcome. Over the period of time, AIS is considered to be an
effective tool in sleep analysis, and it is validated in various countries based on the local
patients. A cut-off score of 6 on the AIS is used to establish the diagnosis of insomnia.
Scoring

Sleep factors

Athens insomnia scale

Sleep induction

0: No
problem

1: Slightly
delayed

2: Markedly
delayed

3: Very delayed or
did not sleep at all

Awakenings
during the night

0: No
problem

1: Minor
problem

2: Considerable
problem

3: Serious problem or
did not sleep at all

Final awakening

0: Not
earlier

1: A little earlier

2: Markedly
earlier

3: Much earlier or did

not sleep at all

Total sleep
duration

0: Sufficient

1: Slightly
insufficient

2: Markedly
insufficient

3: Very insufficient or
did not sleep at all

Sleep quality

0:
1: Slightly
Satisfactory unsatisfactory

2: Markedly
unsatisfactory

3: Very unsatisfactory
or did not sleep at all

Well-being during
the day

0: Normal

1: Slightly
decreased

2: Markedly
decreased

3: Very decreased

Functioning
capacity during
the day

0: Normal

1: Slightly
decreased

2: Markedly
decreased

3: Very decreased

Sleepiness during
the day

0: None

1: Mild

2: Considerable

3: Intense

Quantitative interpretation
Items
Sleep induction
Awaking during the nights
Final awaking
Total sleep duration
Sleep quality
Well-being during the day
Functioning capacity during the day
Sleepiness during the day
Total
Qualitative interpretation

scoring
2
2
3
2
1
2
1
1
14

Clients total scored was 14 which indicate that she has a severe problem of sleeping, she did
well scored in first 4 items which is related to duration of sleep, awaking during the nights, sleep
induction and final awaking and got less score in last four item which is related to our daily
social functioning.
Epworth sleepiness scale
The Epworth Sleepiness Scale (ESS) is a scale intended to measure daytime sleepiness that is
measured by use of a very short questionnaire. This can be helpful in diagnosing sleep disorders
The test is a list of eight situations in which you rate your tendency to become sleepy on a scale
of 0, no chance of dozing, to 3, high chance of dozing. When you finish the test, add up the
values of your responses. Your total score is based on a scale of 0 to 24. The scale estimates
whether you are experiencing excessive sleepiness that possibly requires medical attention. . It
was introduced in 1991 by Dr Murray Johns of Epworth Hospital in Melbourne, Australia.
Scoring
How likely are you to doze off or fall asleep in the following situations? You should rate your
chances of dozing off, not just feeling tired. Even if you have not done some of these things
recently try to determine how they would have affected you. For each situation, decide whether
or not you would have:
.No chance of dozing =0

Slight chance of dozing =1

Moderate chance of dozing =2
High chance of dozing =3
Score Interpretation:
0-7: It is unlikely that you are abnormally sleepy.
8-9: You have an average amount of daytime sleepiness.
10-15: You may be excessively sleepy depending on the situation. You may want to consider seeking
medical attention.
16-24: You are excessively sleepy and should consider seeking medical attention

Quantitative interpretation
situation
Sitting and reading

Chance of dozing
2

Watching TV

Sitting inactive in a public place e.g (a theater

or a meeting)
As a passenger in a car for an hour without a
break
Lying down to rest in the afternoon when
circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in

traffic
Total no of dozing

1
1

Qualitative interpretation
Clients did 2 score in first item which indicates she has moderate chance of dozing when she
was sitting and reading. and she scored 1mark in item no ( 2,3,4,5) item,0 marked in 6 item 1 in
7 item and she scored 2 in last item which indicate she has average amount of daytime
sleepiness.
Informal Assessment
Behavioral Observation. The client was wearing shalwar kamiz. She entered the room with a
slow pace. Tremors were observed in the client. She was tall and middle aged woman with poor
physical health. Her manner and attitude towards the therapist were respectful. She showed
compliance. Voice tone of the client was low. The hygienic condition of the client was
satisfactory. Rapport was easily established with the client. She was able to establish and
maintain eye contact. The client had insight about her problem. Her hands were continuously
shivering.
Clinical Interview. Clinical interview was conducted with the client in order to gather
information about the onset of the clients problem. What circumstances lead to the maintenance
of the problem and how much the client had insight and self motivation to solve the problem.
Detailed history of the client helped in better assessment and management. The questions that
comprise these interviews usually pertain to the nature, severity and duration of the symptoms. It
was done on the following basis. The client was educated till middle so in order to ease the client
the therapist made used of simple language that was understandable for the client during the
session. For the reassurance of the client the therapist paraphrase, rephrase and summarizes the
obtained information. Rapport was established with the client during interview sessions.
Symptoms baseline checklist

Base line chart: For the purpose of assessment of the clients problem, baseline chart of
symptoms was given to client. Through the base line chart the antecedents and contents of the
thought was assessed. Intensity, frequency and the behavior of the client on the thought was also
accessed through the baseline chart.
Subjective ratings by the client.
A subjective rating scale is a set of categories which is designed to elicit information
about different problems related to the client. It was set to rate the problematic areas of the client
on a 0 to 10 point scale. 0 as minimum and 10 as maximum severity of the problem
Table 1
Presenting problems and rating by the client
Presenting problems

Subjective ratings (0-10)

Irritability

8/10

Muscle pain

10/10

Difficulty in sleep

10/10

Aggressive behavior

9/10

Management plan
Short term goal
The management plan which would be going to followed.

Psycho education would be done with the client for the purpose to educate the client
regarding her problem and making her to realize the importance of being a social person
and taking interest in activities related to her life.
Sleep dairy would be given to client to monitoring the sleep pattern; basically it is a self
administered tool by which client note down her circadian rhythm of sleep for e.g. she
was mentioned the duration of falling asleep. She noted the duration when she woke up,
the time when she did exercise, and the activities measure which she performed before an
hour of bed. The purpose of this activity to identify the nature of sleep disturbance
Automatic thought stopping technique would be applied on client by the purpose to
change her negative thoughts about the specific events, and removing the problematic
recurrent thought patterns and replaced it by new one.

Sleep hygienic chart was given to client for the purpose of developing good sleep habits,
gave the instructions for maintaining better sleep included avoid caffeine and nicotine, no
clock watching again and again, use a sleep dairy, do exercise daily, eat right ,get up early
etc.
Diet plan chart was also given to client for the purpose to improving her health. Some
problems generate with the poor diet plan such as excessive weight gain, daytime
sleepiness, and stroke mood disturbance. To overcome these problems I suggested my
client to follow the diet plan chart.
Deep breathing would be practiced to make her relax and free from tensions.
Stimulus control therapy applied on client to breakdown her negative association of the
bed as a place of frustration and instructed to her no watching clock again and again and
to even remove the clock from bedroom. This technique provided the great effects to
eliminate the psycho physiological symptoms of the client.
Restrictive therapy is a procedure that supports the adherence to providing services
within the Positive Behavior Framework, whereby clients are required to focus on
preventing or minimizing the emergence of behavior of concern by eliminating restrictive
practices and supporting clients to enhance their quality of life.i suggested my client to
resist yourself to sleep during day and cutting your sleep short during certain night. By
this way her circadian rhythm cycle of sleeping would be maintained.
Progressive muscle relaxation training would be practiced to enable the client to calm and
relax the tired muscles. To relieve from the pain, the overall anxiety symptoms would be
slightly diminished to practice it daily.
Motivation building exercise will be done to increase motivation for the prevention of
relapse.

Long term goal

Short term goal would be continued

Family should be educated
Practices the taught skills and activities to avoid relapse

Therapy blue print would be taught to client to check the outcome of treatment. It helped the
client easily to identify the evidence based programs that help the client to reach their full
potential.
Summary of therapeutic intervention
Rapport building .It was built with the client. It was important to gain the trust of the client. It
played a significant role in order to facilitate and gain correct information from the client for the
correct diagnosis and then selection of the right management plan. Rapport was established by
the therapist by actively listening to what the client said, showing empathetic attitude and

repeated the clients sentences with active nodding to show that the therapist was concerned
about her problem and wants to help the client to solve the issue.
Psychoeducation.client was psycho educated about her problem to make her aware and to
develop better insight into her problems. She was uneducated so that why easy way used to teach
her or to tell her about different techniques regarding sleep issue. She was advised to take proper
sleep at night. And dont use nicotine and caffeine before an hour of sleep. Educate her about
sleep hygiene and told best way to improve her sleep. She was also advised to maintain her
interest level by doing different activities and interest can also be maintained by sharing her
thoughts to others to get better solution of her problem. She was encouraged to continue her
session and the rehearsal of taught skills, because these would be helpful in maintaining a
positive flow of life.
Sleep dairy. Sleep dairy would be administered in the initial session to see her sleep patterns at
night; it was suggested to the client to note every time of sleep. Every activity performed before
sleeping would be noted .how much time she spend on her bed? After awaking last time from the
bed all duration would be measured and client would be mentioned in her dairy. It played great
role to resolve her sleeping problem. She showed her dairy to therapist and therapist tried to
solve the issues to looking her week dairy where she note the timing of sleeping and the measure
the duration of awakening.
The purpose behind this activity was to develop the insight about the problem and make the
client engage to note down her daily routine and try to resolve her issue by changing the sleeping
habits whether she had orientation of time.
Automatic thought stopping chart. The basis of this technique is that you consciously issue the
command to your client to say, stop when she experience repeated negative, unnecessary, or
distorted thoughts. Then replace the negative thought with something more positive and realistic.
I suggested my client whenever she feel distress and the negative automatic thought would be
running on your mind then you should be say stop verbally and replace your thought with your
positive alternative thoughts. For this way her motivation level will be increased and she can survive
good and healthy life. And she would be able to resolve her issues by her own way.
Sleep hygienic chart. This chart would be administered on client. And psycho educate about sleep
hygiene. Asked the client to follow the instructions carefully, take care of your body, and do physical
exercise regularly to maintain her hygiene to overcome your body pain issue, to relax your mood.
Taught her to take her sleep properly and dont disturb her routine of sleeping otherwise same issues
would be still remained which causes bad effects on her life. And advised her to make her bedroom
neat and clean and try to do pleasurable activity like listening soft music, reading books etc to
improve the clients sleeping habits.

Restrictive therapy. is a therapy in which therapist suggest to client to restrict their behavior which
is making caused by created some maladaptive pattern of others behaviors. Like I suggested my
client to dont need to go for a sleep during the day. You should go to your bed at that time whenever
you feel too much tired and sleepy. Because of that association would not be developed due to
unconditional response of the behavior.
Stimulus control therapy. My client develop "bad habits" when faced with a chronic insomnia, such
as frequently watching the clock and "counting down" the time remaining before needing to start
their day, or spending extended periods of time in bed without sleeping, or worrying about the
consequences of having a bad night of sleep then I applied stimulus control therapy on her to break
her negative association of the bed as place of frustration. Like I suggested my client to dont need to

go to your bed unless you have no sleepiness.you should go to your bed at that time whenever you
feel too much tired and sleepy. So because of that your association would be made by providing a
stimulus. The purpose of this therapy to enhance the sleeping pattern and improve her duration of
sleeping.
Deep breathing. The client had a problem of irratibility, irritation and restlessness so the deep
breathing was practiced because in this state the level of oxygen disrupts and through this technique
oxygen levels becomes balance in the body. This was practiced for the purpose of relaxation.
The client was instructed to take a deep long breath through nose. Held it will in and slowly release it
through mouth. it was useful for the client and she reported that she got relaxed after doing deep
breath. Through this technique she can also feel and relax.
Progressive muscle relaxation training. Progressive muscle training therapy is helpful in relaxing
and calming the tensed muscle or when there is a pain in any part of the body. The client was asked
to tense up her particular muscles tensed for 5 seconds and then slowly relax that muscle for 5
seconds. These techniques help the clients to resolves her body twitching pain and calm her tired
muscles. During the whole activity the client took interested, she actively listen the instruction and
practiced it with full attention.
Outcome
The key symptoms of the client were lack of interest in daily activities.irratibility, difficulty in sleep,
body pain, and anxiety. For these problems psycho education was given to client, sleep hygienic
chart, diet plan, stimulus control therapy, restriction therapy would be administered on her for
improving her sleep. Progressive muscle relaxation training and deep breathing was applied to
resolve her anxiety and body pain issues. Motivate her to resolve her issues by her own way. The
total number of session with the client were 12 and through the implementation of different
techniques and activities the client showed great improvement in her problematic areas.post

subjective ratings were taken from the clients, on the basis of subjective ratings for the symptoms
were 60%.
Table 2

Presenting problems and rating by the client

Presenting problems

Subjective ratings (0-10)

Irritability

6/10

Muscle pain

5/10

Difficulty in sleep

6/10

Aggressive behavior

4/10

The above table showed that the intensity of the problems was reduced on great level. The
overall outcome of therapeutic interventions was 60%.
Session Table

Session

Timings

Work

45 minutes

Repo build
Identify and explore the
problems,pre rating the
problems

60 minutes

Clinical interview, behavioral

observation was deducted
scale
History taking.

40 minutes

Subjective rating scale

Epworth sleepiness scale
Deep breathing

50 minutes

Psychos educate.
Sleep dairy, daily activity
chart

50 minutes

Athens insomnia scale.

Biofeedback
6

55 minutes

Thought stopping chart and

sleep hygienic chart

50 minutes

Make diet plan and apply

stimulus control therapy
Try to enhance self confidence

40 minutes
Sleep restriction therapy
Progressive muscle relaxation
therapy.

45 minutes

Coping strategies and feed

back of the previous session
would be taken.

40 minutes

Re checking the subjective rating

scale of the client s anxiety and
applied relaxation exercise

11

45 minutes

Take biofeedback from all

previous session. Termination

12

40 minutes

Therapy blue prints, follow up

10

Session report:
Session 1

Dated

18, oct.2016
In the first session the purpose was to build rapport and tried to explore the problem so the report
was build on the principle of motivational interview to enhance clients motivation towards
therapy, at first the client was feeling a little bit hesitation during the session but slowly she
would be agreed to discuss her problems openly without feeling any hesitation.
Session 2:

In session 2 clinical interview, behavioral observation would be taken. For taking clinical
interview the goal of session was to gather information the onset of the clients problem that
what circumstances lead to maintenance of the problem and how much time client suffer to
develop the insight of problems. Detailed history would be taken to help us to evaluate the
problem, making assessment, and better management. The questions that comprise these
interviews usually pertain to the nature, severity and duration of the symptoms. It was done on
the following basis. The client was not too much educated; she studied till middle so in order to
ease the client therapist made used of simple language that was understandable for the client.
Rapport was established in initial session.

Psycho education
Sleep dairy
Sleep hygienic chart
Automatic thought stopping
Diet plan
Deep breathing
Stimulus control therapy

 Restrictive sleep therapy

Progressive muscle relaxation therapy
Long term goal
Continuation of short term goal
Practices the toughed skills and activities
Follow-up session

Session plan
Session 1

Clinical observation, rapports build

Session 2

History taking, symptoms rating scale

Session 3

Administer Epworth sleepness scale (ESS), deep breathing

Session 4

Psycho educate to her related problems, daily activity chart, routine dairy
Session 5

Administer Athens insomnia scale (AIS), make rest dairy

Session 6

Make automatic thought stopping chart, sleep hygienic chart

Session 7

Make diet plan. and apply stimulus control therapy,

Session 8:

Sleep restriction therapy, progressive muscle relaxation therapy

Session 9

Coping statement strategy, distraction technique

Session 10

Work through previous session and take feedback, behavioral skill traning

Session 11

Termination phase, motivation building exercise towards therapy.

Session 12

Feed back from all learned skills, Follow up

Appendices