Section 6 Insomnia
A 50-year-old woman presents with “insomnia.” She was always a good sleeper until she had her first child at age 33 years, when she started having difficulty initiating and maintaining sleep. Her primary care physician (PCP) started her on an antidepressant, fluoxetine, at age 35 years, which she still takes. Her sleep greatly improved when she started the SSRI, until the past 6 months, when she developed trouble staying asleep. Typically, she wakes up after 3 to 4 hours of sleep and is “wide awake,” sometimes for hours. She has no trouble falling asleep; in fact she falls asleep the minute her head hits the pillow. She feels very tired during the day but does not nap. Her periods have become irregular but she denies hot flashes or night sweats. She lives with her husband and two teenage daughters. Her home life seems calm and stable. She works in real estate part-time but denies stress or anxiety over the bad real estate market because her husband is “a good provider.” She states, “I have never been happier, never had less stress and bang, out of the blue, 6 months ago I start having sleep problems.” She denies racing thoughts but admits that in the middle of the night she can perseverate on not being able to return to sleep. She has become increasingly concerned that she is “wrecking” her health and she worries about this as she lies there trying to get back to sleep. She reports that she is often getting only 5 hours of sleep and most of her adult life she has needed 7 hours. Her past medical history indicates only a tonsillectomy at age 6 years. Her only medication is the SSRI. She has gained 20 lb in the past 2 years. She does admit that about 1 year ago her husband started complaining about her snoring. She saw her primary care physician (PCP) recently and states, “all my blood work came back normal.” On physical exam, you note she is overweight with a BMI of 30 and a neck circumference of 16 inches. Oropharyngeal exam shows Mallampati 4. There are no tonsils. The rest of the exam is unremarkable.
Worried About Having an Awful Disease
Upon further questioning, she reports that she is a struggling actress who works until 3 AM as a waitress and in the daytime often has to go to auditions or rehearsals. When asked about her daytime functioning, she states that she “feels great” and is “too busy to worry about being tired as long as I don’t have some awful disease.” She then adds, “If I am having a bad day, I just take a little extra Ritalin.”
A 33-year-old man presents to the sleep center with a long history of “insomnia.” He states that he has had problems falling asleep since childhood. He has seen many doctors, including more than one sleep physician, and he feels that he has “tried everything.” He has tried many medications, including prescription, OTC, and “herbal.” Most worked for awhile and then stopped working. You mention cognitive behavior therapy (CBT) as a possible treatment, and he claims to “know all about it.” He proceeds to tell you about his changes in “sleep hygiene” and how it has not helped his sleep at all. His primary care physician (PCP) has recently diagnosed depression.
Because it was having no effect on either his insomnia or his depression, the PCP stopped the trazodone and started him on a new medication for depression and referred him to the sleep center for help with the insomnia. He has taken this antidepressant every night for the past week. The PCP told the patient that he had recently attended a seminar on insomnia where an expert recommended this antidepressant because it “has no affect on sleep,” which he understood to mean that it would not treat his insomnia, but he has found that the new antidepressant has made his initiation insomnia even worse.
A 76-year-old woman who is a retired psychiatrist reports to the sleep center with a complaint of “early morning awakening.” She wakes each day at 4 AM and she does not want to start her day in the “cold dark.” She states that she wants your help in figuring out whether she has a “primary sleep disorder or depression.”
The Insomnia That Won’t Go Away
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