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INSOMNIA: CASE STUDIES IN FAMILY PRACTICE

• self-limiting disorder, often resolving once the patient comes to terms and copes with the stressor. The course is usually transient lasting from a few days to less than 2 weeks. However, the sleep difficulty may last up to 3 months. Mr. Tan has had no previous sleep problems and the onset of his sleep problem after a major stressful event makes adjustment sleep disorder the likely diagnosis.


• Inadequate sleep hygiene (consumption of coffee and alcohol at bedtime, stress at bedtime) may contribute to his sleep difficulty. Table 2 lists the sleep hygiene measures that may promote sleep.
  
• Coffee (caffeine) is a CNS stimulant that may delay sleep onset with increases in awakenings and decreases in total sleep time. Alcohol is commonly self-prescribed to initiate sleep but is associated with sleep maintenance difficulties once ethanol is metabolized.

Periodic limb movements of sleep (PLMS) needs to be excluded in this patient. They are involuntary movements of the legs, occurring every 20-40 seconds, consisting of dorsifexion of the ankle, flaring of the toes and sometimes with flexion of the knee. The movements resemble a pathologic plantar response. Diagnosis of PLMS can be confirmed by polysomnographic evaluation. The leg movements are often accompanied by repetitive, brief arousals from sleep that the patient is often not aware of. The disruption to sleep may result in non-refreshing sleep and daytime fatigue. In the majority of patients, no underlying cause is found but sometimes it may be associated with anaemia, uraemia, liver disease, peripheral neuropathy, and the restless legs syndrome.

Table 2. General sleep hygiene measures

How do you manage Mr. Tan?
Management of Mr Tan’s sleep problem would involve:

• Exploring current psychosocial stresses, grief symptoms, coping skills, and symptoms of depression. Consider grief counselling if appropriate.
• Patient education: explain what adjustment sleep disorder is and advice on good sleep hygiene. (Table 2)
• Since the patient is unable to tolerate a tricyclic antidepressant, consider an intermediate-acting benzodiazepine (e.g. lorazepam) that may be prescribed for a period of about 2 weeks to relief his sleep difficulty while behavioural measures and counselling are considered. A non-benzodiazepine hypnotic e.g. zolpidem is an alternative. The presence of depressive symptoms may warrant the use of a selective serotonin inhibitor (SSRI). However, some SSRIs can aggravate insomnia. Therefore, daytime dosing of SSRIs is advisable.
• His sleep-related limb movements may require investigations by objective sleep laboratory testing (polysomnography) especially if there is later development of non-refreshing sleep or daytime sleepiness.   
• Follow up is necessary to see if the insomnia takes a chronic course (chronic psychophysiological insomnia).

CASE 2
Puan Suraya, a 40 -year-old lady with difficulty falling asleep.

Puan Suraya, a 40 year old schoolteacher complains of inability to sleep well for more than 2 years. She regularly goes to bed at 10 pm but is unable to sleep until 1 am. She experiences about 3-5 awakenings every night and with each awakening requires about 30 minutes to fall asleep again. Suraya, also experiences daytime fatigue and is unable to concentrate in her work. She does not take naps during the day. She does not snore and has no usual limb movements during sleep (history from husband). Her general health has been good. She vaguely recalls being involved in a stressful family property dispute just prior to onset of her sleep difficulty.     

As bedtime approaches, she becomes very tense and worries about the prospect of another sleepless night. “Sleep has become a real frustration. Every night, when I lie in bed, I have to try very hard to sleep. I keep watching the clock”. 

She does not take any sleeping pills and has no symptoms of depression. There is no marital conflict. On further questioning, she surprising admits that she sleeps well while on vacations and relatives houses.

 
What type of insomnia is Puan Suraya suffering from?

Puan Suraya has psychophysiological insomnia sometimes referred to as ‘learnt insomnia’ or ‘behavioural insomnia’. It usually follows a stressful life event though the patient may not always be able recall the event. The precipitating event resolves but the insomnia that was experienced during the period of psychosocial stress remains and takes a chronic course. In psychophysiological insomnia, the patient has learnt sleep-preventing associations where bedtime and home sleep environment result in agitation,

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