Worried About Insomnia?

Insomnia is probably the most prevalent symptom in psychiatry. The majority of mood scales used in psychiatric research contain insomnia questions because of the importance of this problem in a number of major psychiatric conditions.

Pharmacologic treatment for insomnia began with the use of sedative hypnotics. Barbiturates were first, and then came nonbarbiturate sedatives such as chloral hydrate, meprobamate, glutethimide, methyprylon, and methaqualone. Later came the modern era with benzodiazepines and, finally, nonbenzodiazepine hypnotic agents like zolpidem, zaleplon, and eszopiclone, as well as the melatonin receptor agonist ramelteon. Our profession also uses a variety of other agents “off label” to combat insomnia. We have various over-the-counter preparations and alternative medicine approaches, as well as a subspecialty of sleep medicine for patients who need specialist care.

I Googled insomnia and received about 80,300,000 hits. Here, I will present some ideas about insomnia but no solutions. Possibly together we can come up with useful strategies to help our patients, our colleagues, and even ourselves sleep better.

I know that we all see many patients, especially in our outpatient practices, with insomnia. We may give some of them diagnoses of GAD, dysthymic disorder, or adjustment disorder. Other descriptions are Type A personality or the worried well. Often these patients are educated and successful in their chosen professions. These patients pay attention to detail and worry about incomplete projects until the tasks are complete to their satisfaction. They then tend to find other things to worry about. These high achievers obtain promotions at work and are relied upon by less-organized family members. In fact, our worried patient rarely misses work and often has no need for an alarm clock in the morning except when he or she hasn’t slept. When under work or family stress, our patient will work harder, worry more, and lose more sleep. If catch-up sleep is obtained, then our patient is again more functional, but chronic sleep deprivation will wear down our patient’s ability to cope with stress.

Many of our baby boomer patients have the additional stress of dealing with a chronic medical illness. Heart disease, chronic pain, chronic GI conditions, or cancer add further stress, and chronic worry leads to chronic anxiety, insomnia, and finally depression. These patients then move from being independent to becoming dependent. As their depression worsens, these individuals will give up on following the physician’s recommendations, and their medical condition deteriorates, often together with worsening insomnia.

Clearly, worry is the culprit leading to insomnia. Although manageable worry motivates us to successfully complete tasks, worry above a certain threshold tends to overwhelm our ability to cope. Is it possible to achieve a state of equilibrium in which we have enough worry to be productive but not have it get so out of control that it leads to insomnia and depression?

Any suggestions?

Financial disclosure:Dr King had no relevant personal financial relationships to report.