Psychiatry · Year 3 · from Psychiatry
Case 1: Chronic Insomnia Disorder
Patient Demographics
- Age: 52 years old
- Sex: Female
- Occupation: Accountant
Chief Complaint
"I haven't had a good night's sleep in over a year. I dread going to bed because I know I'll just lie there for hours."
History of Present Illness
The patient is a 52-year-old woman presenting with chronic sleep difficulties that began approximately 18 months ago during a stressful period at work (tax season with significant overtime). At that time, she began having difficulty falling asleep due to worry about work tasks. The work stress resolved, but the sleep problems persisted and gradually worsened.
Currently, she reports lying in bed for 1-2 hours before falling asleep. Once asleep, she wakes 2-3 times per night and has difficulty returning to sleep. She typically wakes at 4-5 AM and cannot fall back asleep despite not feeling rested. She estimates getting 4-5 hours of broken sleep per night. She feels exhausted during the day, has difficulty concentrating at work, and has made several errors on financial reports. She has become irritable with family and has reduced social activities due to fatigue.
Her sleep hygiene has deteriorated as she has tried to compensate for poor sleep: She goes to bed earlier hoping to sleep more (9 PM, though not sleepy). She watches TV in bed to "relax." She naps on weekends for 2-3 hours. She has 3-4 cups of coffee to stay alert, with her last cup around 4 PM. She checks the clock frequently when unable to sleep, which increases her anxiety.
She has developed significant anticipatory anxiety about sleep, describing her bed as "a torture chamber." She reports: "As soon as I get in bed, my mind starts racing about whether I'll be able to sleep."
Past Medical History
- Hypertension (controlled)
- No history of restless legs symptoms
- No snoring, witnessed apneas, or excessive daytime sleepiness suggesting sleep apnea
- Denies symptoms of depression (mood remains good, still enjoys activities when not tired)
Sleep Diary Summary (2-week average)
- Time in bed: 9:00 PM - 6:30 AM (9.5 hours)
- Sleep onset latency: 90 minutes
- Wake after sleep onset: 90 minutes (combined)
- Total sleep time: 5 hours
- Sleep efficiency: 53% (severely impaired; normal >85%)
Mental Status Examination
Appearance: Professional-appearing woman, appears fatigued, dark circles under eyes
Behavior: Cooperative, anxious when discussing sleep
Speech: Normal rate and rhythm
Mood: "Tired and frustrated"
Affect: Anxious, mildly dysphoric
Thought Process: Linear, ruminative about sleep
Thought Content:
- Preoccupation with sleep and consequences of insomnia
- Catastrophic beliefs: "If I don't sleep tonight, I won't be able to function tomorrow"
- No suicidal or homicidal ideation
- No psychotic symptoms
Cognition: Alert, oriented; concentration somewhat impaired
Insight: Good - recognizes behaviors may be contributing
Judgment: Good - seeking help appropriately
Screening Measures
Insomnia Severity Index (ISI): 22 (clinical insomnia, moderate severity; range 0-28)
Epworth Sleepiness Scale: 8 (normal range; consistent with fatigue rather than pathological sleepiness)
PHQ-9: 6 (mild symptoms, likely secondary to insomnia)
GAD-7: 10 (moderate anxiety, largely sleep-focused)
Diagnosis
Chronic Insomnia Disorder (F51.01)
DSM-5 Criteria Met: A. Predominant complaint of dissatisfaction with sleep quantity or quality with one or more:
- Difficulty initiating sleep: YES (90-minute sleep onset latency)
- Difficulty maintaining sleep: YES (multiple awakenings, 90 min WASO)
- Early morning awakening: YES (4-5 AM awakenings)
B. Sleep disturbance causes clinically significant distress or impairment: YES (work errors, irritability, social withdrawal)
C. Occurs at least 3 nights per week: YES (nightly)
D. Present for at least 3 months: YES (18 months)
E. Occurs despite adequate opportunity for sleep: YES (spends 9.5 hours in bed)
F. Not better explained by another sleep disorder: NO (no symptoms of apnea, RLS, etc.)
G. Not attributable to substance use: NO
H. Coexisting disorders do not adequately explain insomnia: YES (anxiety appears secondary to insomnia)
Perpetuating Factors Identified:
- Excessive time in bed
- Napping
- Late caffeine use
- Clock-watching
- Screen time in bed
- Conditioned arousal (bed associated with wakefulness)
- Catastrophic beliefs about sleep
Treatment Plan
First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)
Sleep Restriction Therapy:
- Current sleep efficiency: 53%
- Prescribed time in bed: 5.5 hours initially (matches approximate total sleep time)
- Window: 12:00 AM - 5:30 AM
- Do not go to bed until prescribed time, regardless of sleepiness
- Get out of bed at 5:30 AM regardless of sleep quality
- When sleep efficiency >85% for 5 days, add 15-30 minutes to time in bed
Stimulus Control Therapy:
- Use bed only for sleep and intimacy
- Go to bed only when sleepy
- If unable to sleep after ~20 minutes, get up and go to another room
- Return to bed only when sleepy
- No TV, phone, or reading in bed
- Maintain fixed wake time 7 days per week
- No daytime napping
Sleep Hygiene Education:
- Limit caffeine to morning only (before noon)
- Regular exercise (not within 4 hours of bedtime)
- Keep bedroom cool, dark, and quiet
- Avoid alcohol as sleep aid (disrupts sleep architecture)
Cognitive Therapy:
- Address catastrophic beliefs about consequences of poor sleep
- Develop more balanced thoughts: "One bad night won't ruin my day entirely"
- Reduce clock-watching (turn clock away from view)
- Paradoxical intention: Let go of "trying" to sleep
Pharmacotherapy:
- Not recommended as first-line for chronic insomnia
- If needed for temporary relief during initial CBT-I (sleep restriction can temporarily worsen fatigue):
- Low-dose trazodone 25-50 mg or
- Melatonin 0.5-3 mg, 1-2 hours before bed
- Avoid benzodiazepines and Z-drugs long-term (tolerance, dependence)
Follow-up:
- Weekly CBT-I sessions x 6-8 weeks
- Sleep diary review at each session
- Adjust time in bed based on sleep efficiency
- ISI repeated at end of treatment