Review Articles
INSOMNIA: CASE STUDIES IN FAMILY PRACTICE
arousal and increased muscle tone. She has formed an association between the home bedroom environment and not sleeping. Her sleep environment has therefore become a conditioned stimulus for sleep difficulty. As bedtime approaches, she anticipates another sleepless night that results in increasing tension and arousal. The harder she tries to sleep, the less likely she will fall asleep. Patients with psychophysiological insomnia experience paradoxical improvement in sleep when outside their usual sleep environment or not carrying out bedtime routines. Psychophysiological insomnia is diagnosed only if the above learnt behaviours seem to have a dominant role in the insomnia and no other associated medical or psychiatric diseases to explain the insomnia.
How would you manage Puan Suraya’s sleep problem?
Puan Suraya has chronic insomnia, (defined as sleep difficulty experienced on 3 or more days/week for a period >1 month).
- The mainstay of management of chronic insomnia is behavioural therapy. The patient should be instructed to maintain a sleep diary. There are several behavioural strategies and one that may be effective in psychophysiological insomnia includes emphasis on maintaining good sleep hygiene, stress management (muscle relaxation techniques, meditation, guided imagery and biofeedback). Progressive muscle relaxation (Jacobson) at bedtime can be particularly beneficial in reducing cognitive and autonomic arousal at bedtime. Not all these measures need to be initiated at the same time.
- Stimulus control therapy. Of the behavioural therapies, Stimulus Control Therapy is particularly useful. (Table 3). The objective of stimulus control therapy is to help the patient learn to re-associate bedtime and the sleep environment with sleeping and correct learned maladaptive behaviour that disrupt sleep. Behavioural techniques take several weeks to learn and provide clinical benefit. Hypnotic use in chronic insomnia plays a limited role and is preferably restricted to short term use during the initial phases of therapy, when the patient is being taught behavioural measures. Intermediate-acting benzodiazepine e.g. lorazepam or other benzodiazepine-like hypnotics e. g. zolpidem, zopiclone may be prescribed for a period of about 2 to 3 weeks to relief the patient’s distress. Zolpidem can be taken on a PRN basis on difficult nights. When prescribing hypnotics, particularly the benzodiazepines, the risk of physical dependence should be borne in mind.
Cognitive behavioural therapy (CBT). Is aimed at identifying and changing maladaptive sleep habits, dysfunctional beliefs and unrealistic expectations that the patient has about her sleep and that may perpetuate her insomnia e.g. over-concern about total sleep duration, that ‘insomnia is dangerous’, ‘may lead to insanity’ etc. CBT aims to replace these views with more adaptive substitutes. The reassurance and discussion on these issues, clarifying misperceptions can be therapeutic.
Table 3. Stimulus control therapy
- Go to bed only when sleepy
- Do not use the bed for anything except sleep; i.e. do not read, watch TV, eat, or worry in bed.
- If unable to sleep within 20 minutes, get up and go to another room. Stay up as long as you wish and then return to the bedroom to sleep.
- If you still cannot fall asleep, repeat rule 3. Do this as often as is necessary throughout the night.
- Set the alarm and get up at the same time every morning regardless of how much sleep you got during the night. This will help your body acquire a consistent sleep rhythm.
- Do not nap during the day.
- Do not take recovery sleep to compensate for a previous bad night
CASE 3
Mrs Lee, a 62 years old widow who lives alone.
Mrs. Lee presents at the practice requesting for a prescription for diazepam (Valium). She is currently on diazepam 15 mg nocte to help her sleep and allay anxiety. A doctor she consulted after the death of her husband 5 years ago had started her on diazepam 5mg nocte but with time, she required increasing doses of the hypnotic. Her previous attempts to discontinue her medication had failed as it resulted in insomnia, anxiety, tremor, irritability, nightmares and hyperacusis (unpleasant loud distortion of noise) and tinnitus.
She has adjusted to her activities of daily living while on the above medication but does complain of poor memory. A GP she consulted recently after a fall had advised her to discontinue her diazepam in view of her perceived poor memory and tendency to falls.
Physical Exam: Normal. Gait and mobility unimpaired. BP 130/85 mmHg.
Mini Mental Status Exam: Normal
What are the likely consequences of long-term hypnotic (diazepam) therapy in Mrs Lee?
Diazepam is a long-acting benzodiazepine hypnotic with an elimination half-life of 20-80 hours. The most common side effect of benzodiazepines is CNS depression. Tolerance usually develops to this effect. Other side-effects associated with its use are disorientation, psychomotor impairment, aggression, excitement, confusion, and anterograde amnesia. Benzodiazepines have prominent hypnotic, anxiolytic, muscle relaxant and anticonvulsant properties. High does of diazepam are associated with an increased risk of falls and fractures in the elderly.