A Case Study in Insomnia
“Anna,” a 42-year-old woman, is referred to the sleep disorders center with a complaint of chronic, severe insomnia affecting her daytime functioning. The single mother of three teenage boys, Anna first experienced insomnia eight years ago when bankruptcy threatened her small business. Although the business recovered a year later, Anna’s insomnia has remained almost unchanged over the next eight years.
Medication History: Anna has taken Temazepam, Zolpidem, and Zaleplon, as well as several antidepressants including Trazodone, Amitriptyline, and Mirtazapine. All have been unsuccessful. Although an initial benefit was derived from some of these medications, Anna gave up on each of them after a few weeks because of their side effects and/or lack of efficacy.
Social History: Anna feels she is just “hanging on by her fingernails,” and that looking after her business and her sons takes all of her energy. Her insomnia has forced her to give up her social life, including her fly-fishing hobby and gym workouts. She feels depleted and stressed all of the time. She has begun to drink four to five strong cups of coffee per day to keep awake and tries to catch a nap whenever possible.
Review of Sleep Pattern: Anna tries to go to bed around 11:00 PM. She usually falls asleep in less than 15 minutes, but occasionally it seems to take her hours to fall asleep. She wakes up three to four times per night, and at least one of these awakenings lasts two to three hours. Anna gets frustrated when she “sees the clock ticking away;” in response, she usually gets out of bed to work on the computer until she becomes sleepy, which often does not happen until around 5:30 AM — which is the time she should be getting up. At that time, Anna falls into a very deep sleep and may not awaken until 7:00 or 8:00 AM.
Physical Examination: Anna’s general physical evaluation found Anna to be healthy but suffering from excessive sleepiness, fatigue, and a lack of energy. A concomitant psychiatric interview revealed high stress levels, but no evidence of depression, anxiety, or other psychopathology. Anna was referred to a sleep center, where her screens for restless legs syndrome and possible respiratory disturbances were negative. An evaluation of her current lifestyle — designed to identify behaviors and thought patterns that might contribute to her insomnia — uncovered situational distress and a weak coping style.
Treatment: Anna was also recommended the following sleep hygiene improvements: decrease caffeine intake; avoid sleeping late in the morning at all costs; conceal the alarm clock to avoid checking the time during the night; and, when she is unable to sleep, to do some light reading rather than working. These measures did not provide adequate relief, however. Anna enrolled in a relaxation course (using meditation). She also completed two sessions of cognitive therapy in order to address her dysfunctional beliefs about sleep, which included “I have to give up everything enjoyable to get better sleep.”
Anna was also referred to an organization to help review her business practices. It was suggested that her business had grown enough to employ a full-time secretary. After she successfully hired this new staff person, Anna was advised to use the time gained to address her personal needs for exercise, social activities, and hobbies.
After six months, Anna’s sleep improved, and she reported that she now slept poorly only about two nights per week. An as-needed hypnotic was prescribed for her to use if her sleep was poor for two or more nights in a row, or if she anticipated being particularly stressed the following day.
Follow-up: One year later, Anna reported that her life was much improved. Her business was running much more smoothly and she felt that had more time to spend with her sons. She continued to practice good sleep habits and daily meditation and took the hypnotic when necessary, about twice per month. She was quite satisfied with these results. A second follow-up conducted five years after initial treatment showed she was sleeping normally without the use of hypnotics.
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