That we are not much sicker and much madder than we are is due exclusively to that
most blessed and blessing of all natural graces, sleep.
Imagine you can listen in to the chief complaint of each new sleep clinic patient. Not the complaint that the intake nurse writes on the chart, but what patients actually say when the doctor asks, "What's the problem?" or "What's bothering you?" One common complaint you'll hear is 'snoring'.
"I snore a lot."
"My wife won't sleep in the same room with me because of my snoring."
or (when the wife speaks first)
"My husband snores a lot."
About 40% of men and 20% of woman snore habitually, but usually snoring is not associated with any medical problem. In some people, though, snoring is associated with complaints suggesting sleep apnea.
[I snore and] "I stop breathing during sleep."
"My wife says [I snore and] stop breathing during sleep."
"John [snores,] stops breathing, then snorts and wakes up, then he goes back to sleep and it starts all over again."
For these patients I will usually order an overnight sleep study, to see how bad the apnea is and if treatment (e.g., with CPAP) is beneficial.
But perhaps the most common complaints you will hear concern falling (or staying) asleep - some form of insomnia.
"I can't get to sleep at night."
"I wake up and then can't fall asleep again."
"I haven't slept in a year."
This last was John Lane's complaint. The chart indicated he was 44, 5'10" and 163 lbs., referred by one of our internists for this very complaint. I knew he was greatly exaggerating, because without sleep a person will die and Mr. Lane was very much alive. In fact the reputed world record for going without sleep is just over 11 days. Most people are incapacitated if they go sleepless for 48 hours. Mr. Lane just wanted to make sure the doctors knew his insomnia was bad.
With any chief complaint the next step is to obtain a complete history. Below is a reconstruction of my first few minutes with Mr. Lane.
"What happens when you try to go to sleep, Mr. Lane?"
"I don't sleep, I don't fall asleep."
"For how long has this been happening?"
"Over a year, at least."
"You have to sleep some," I said, and reminded him of the world record.
"Oh, I fall asleep in bits and pieces, then I get up and can't go back to sleep."
"Exactly how much sleep do you think you get in a night."
he paused to answer. He had already told me he did not sleep in a year, now he was being pinned down to come up with some sensible response.
"I don't know, two, maybe three hours."
I doubled the time in my mind. He probably sleeps 6 hours a night, but has trouble falling and then staying asleep. A case of insomnia, pure and simple. But what type? And why?
"What kind of work do you do?"
"I'm a systems analyst for [company]. I spend a lot of time at the computer."
"Do you have people under you? Employees."
"I supervise about 6 people," he said.
"Any problems with your job?"
"How long have you been at [company]?"
"It's going on 8 years now."
"So you work a regular 8 hour day?"
"No night work?"
"No, unless I take work home with me."
I spent the next 15 minutes touching on his personal life. He divorced a year ago, but volunteered it was a positive move, and doubted this was the cause of his insomnia. He and his wife had "irreconcilable differences," as he put it. To put the divorce in perspective, he said trouble sleeping went back to college, only it had become worse the past year. His wife took their child, whom he visits once a week or so. He is dating "occasionally," and lives alone in a condominium. This too was "good" since his commute to work is now only about 10 minutes. Both parents are living and well, as are an older brother and younger sister; he sees his family "infrequently".
"What do you do with your spare time?"
"I'm a writer. I'm writing a novel."
"Oh? Anything published yet?"
In the community where I my practice, which includes a mixture of blue and white collar workers and many professionals, the usual answers to my 'spare time' (or 'retirement time') question are: 'fix things around the house'; 'golfing'; 'fishing'; 'watch TV'; 'watch the grandkids'; and/or 'read the newspaper.' Lane's answer was a surprise and intriguing, not least because I also write in my spare time.
"No, I'm still working on it. Some short stories, though."
"Where are they published?"
He named an obscure Ohio literary quarterly that had published two of his stories. He said they were about alienation in the work place, written from a human interest angle.
"What's your novel about?"
"I'd rather not talk about the plot. Brings bad luck to divulge the story before you're finished."
He wasn't being snotty or anything; he genuinely felt this way.
"OK. Do you stay up at night writing your novel? Is that why you can't fall asleep?"
He denied this, too. He reported feeling very sleepy about 10 p.m., getting into bed, and then just "laying there, awake," for over an hour. He thinks about his novel in order to fall asleep, then thinks about other things, hoping that will end the insomnia. He dozes off, then wakes up and can't return to sleep. It had been that way for over a year. Yet he managed to function on his job, evidently did well at his company, and his physical health was good. At the time of this visit he was taking only a single drug, for elevated cholesterol.
Based on length of his complaint the diagnosis was likely 'psychophysiologic insomnia', a type of chronic insomnia. Insomnia less than 3 weeks is transient or short term, and often due to acute medical conditions, change in shift work, jet lag, room temperature changes, or an acute stressful situation (preparing for a job interview or exam, for example), or taking new medication (e.g., stimulants, asthma medication).
Chronic insomnia can be due to deep seated medical, neurologic, or psychological problems; part of another primary sleep disorder such as sleep apnea; or 'idiopathic,' of unknown origin.
Here is the NIH definition of insomnia.
Insomnia is the perception or complaint of inadequate or poor-quality sleep because of one or more of the following:
* difficulty falling asleep
* waking up frequently during the night with difficulty returning to sleep
* waking up too early in the morning
* unrefreshing sleep
Insomnia is not defined by the number of hours of sleep a person gets or how long it takes to fall asleep. Individuals vary normally in their need for, and their satisfaction with, sleep. Insomnia may cause problems during the day, such as tiredness, a lack of energy, difficulty concentrating, and irritability.
Insomnia can be classified as transient (short term), intermittent (on and off), and chronic (constant). Insomnia lasting from a single night to a few weeks is referred to as transient. If episodes of transient insomnia occur from time to time, the insomnia is said to be intermittent.
Insomnia is considered to be chronic if it occurs on most nights and lasts a month or more.
Chronic insomnia is far more complex than transient or intermittent insomnia. It often results from a combination of factors, including underlying physical or mental disorders.
When a patient comes in with sleep apnea-type complaints, the workup is fairly straightforward, ending (usually) with a sleep study. When the complaint is chronic insomnia, the workup is much more diffuse, and seldom requires a sleep study for diagnosis.
One of the most common causes of chronic insomnia is depression, and a psychiatrist often becomes involved. However, chronic insomnia is also associated with many common medical conditions, such as arthritis, kidney disease, heart failure, asthma, Parkinson's disease, and hyperthyroidism.
Chronic insomnia is also associated with specific sleep-related problems, including sleep apnea, narcolepsy, and restless legs syndrome. For example, insomnia symptoms were reported in 50% of patients with breathing problems during sleep, principally sleep apnea. Other common associations with chronic insomnia are abuse of caffeine and alcohol, heavy smoking before bedtime, excessive napping in the afternoon or evening, and irregular sleep/wake schedules.
Sometimes you find no cause, no reason, no association. Then the diagnosis is the unsatisfying �idiopathic� insomnia.
Clearly, you aren't going to get to first base figuring out insomnia without a detailed medical, social and sleep history. Treatment of insomnia can basically be divided into two broad categories:
Cognitive behavioral therapy. Basically, CBT attempts to uncover the root cause of insomnia and correct it thru changing behavior and/or the patient's perception of the problem. In many studies CBT is as effective as medication (or more so), but it is labor intensive and often not reimbursed by third party insurance; for these reasons, CBT is not widely practiced.
Medication. There are numerous drugs for sleep, and several ways to classify them. One useful classification for patients is below. In this classification 'FDA-approved' means that there are sufficient clinical studies to state the drug is effective for sleep. Trazodone, which is an anti-depressant in doses higher than used for sleep, was until recently the most widely used prescription sleep drug; it has never been FDA-approved "for sleep" simply because there are no well-done studies proving it's effectiveness for just this purpose. Other drugs, such as Seroquel and Remeron, are approved for specific psychiatric disorders but widely used by physicians to help people achieve sleep. Such 'off label' use of drugs for sleep is a common and widely accepted practice.
Drugs For Sleep
b) GENERIC, BY PRESCRIPTION
For more information on drugs, see Drugs for Sleep & Awake
Treatment is often complicated because so many patients have 'co-morbid' insomnia, i.e., another disease either causing or directly affecting the insomnia. The most common 'other disease' is a psychiatric disorder. It's estimated that up to 50% of chronic insomnia patients have an existing psychiatric diagnosis.
Deciding what treatment to use should be based on a complete and accurate history. It is also sometimes helpful to ask the patient to fill out a two-week sleep diary, with as much detail as feasible - when do you go to bed, when do you think you fall asleep, what time(s) do you awake at night, what time do you finally wake up, how do you feel then, what time do you take naps and for how long, each drink of caffeinated beverage you take, medications you take, and any unusual sleepiness during the day.
Mr. Lane had simply lived with his affliction until his internist asked, during an evaluation, "do you have any sleep related problems?"
"Well, yeah, now that you ask, I always have trouble falling asleep" he replied.
And that's how he was referred to me.
I spent 35 minutes with Mr. Lane on that first visit. I could not find evidence for any of the usual medical causes of insomnia. He did not smoke and drank alcohol infrequently.
I am always reluctant to diagnose psychological causes of sleep problems until I have eliminated everything else. I made a point of emphasizing physical disorders, to convince myself and Mr. Lane that there didn't seem to be any. The guy was healthy, and didn't claim any infirmities.
What bothered me was how he glibly discounted his divorce, book writing and job as having anything to do with his insomnia. Either he was putting up a good front or he genuinely didn't make any connection. But when I eliminated all the usual causes, all I was left with were 'other', 'psychological', and 'idiopathic'. And they all had a common implication: 'difficult to treat'.
I explained my thinking and said, "The cause is simply not evident at this point, and I don't think an overnight sleep study is going to be helpful. I recommend you keep a detailed sleep diary for about 2 weeks, and then return to see me. I explained what he should record in the diary, including an estimate of the number of hours he slept each 24 hour period. .
He returned two weeks later. Here is a page from his sleep diary.
6 a.m. woke up - feel OK
7:30 a.m - at work [no naps noted during day]
5:30 p.m. - home
6:30 p.m. - finished supper
9:40 - to bed
10:40 - have read for one hour - not sleeping; to br
11 p.m. - back to bed
1 a.m. - ?dozed; don't feel as i've slept
3 a.m. - up to bathroom
6 a.m. - up (also got up at 5 a.m.)
tot. sleep @5 hrs.
His estimated sleep time on Oct 20 was 5 hours. Other sleep estimates in the two-week diary ranged from 3 to 5 hours. (Hardly 'no sleep', and even if accurate, enough to allow him to function as well as he did.)
We talked some more. I told him I didn't think there was any physical ailment to explain his difficulty sleeping, that it was related to psycholgical factors, most likely adjustment issues relating to his divorce. He didn't deny this but instead raised his eyebrows as if to say, "that's an intellectually interesting observation you are making, doctor." Mr. Lane seemed well defended, and needed help beyond what I felt capable of providing. I thought he would benefit from anti-depressant medication, but didn't want to prescibe it without psychiatric backup. I asked if he would consider seeing a psychiatrist, "to help me get you on some medication. I will continue to follow you as needed, but want to get a psychiatrist's opinion." He agreed, and I sensed he felt some relief that this was being suggested to him, that he didn't have to come up with the idea on his own.
I saw him a month later, with the psychiatrist's consult in the chart.
Patient: John Lane
Mr. Lane is a 44 year old caucasian male referred by Dr. L. Martin because of insomnia. Per the request there are no evident physical or medical problems inhibiting sleep. Patient is dressed neatly, makes eye contact. Affect rather flat, tone modulated, thought pattern is well organized. No evidence of psychotic thinking.
Gives history of difficulty sleeping since college. He married at age 23, divorced at 27, due to "she was not faithful." States his first wife also abused cocaine. No children from that marriage. Re-married age 30, divorced 15 months ago; has one child (boy), age 10 (wife has custody). Per divorce settlement, he visits child weekly.
Works as computer programmer/systems analyst at [company], has been with them 9 years. Has "good salary" and denies financial concerns. Says he likes his work, is considered middle management within firm.
Denies tobacco, drinks alcohol only socially. Denies any drug abuse, current or by history. Denies any childhood traumatic events. States he did not partake of any cocaine use during first marriage. No history of suicide attempts. Admits to some decrease in appetite, "maybe I've lost a few pounds."
He is baffled by his insomnia, states it is much worse than when younger. Saw Dr. M. to find out about it. Denies stressors, but admits to "occasional feelings of lonliness and sadness," says he would like to find another woman; has dated a few times since his divorce. He writes as an avocation, but would not share his current project. Apparently nothing substantive published. Regarding divorce, job, visitation of son, writing avocation, denies any are reason for insomnia.
Discussed temporal change of sleeping habits and divorce. He admitted there could be an association but "I don't see it." Asked re: previous psychotherapy, he admitted a few visits he and his wife made to to Dr. K--- to try to save marriage. States visits were "no help." ?Why did you divorce. "We just quit getting along." Seems guarded in his answers. Responses at times seem evasive. Gives interviewer impression of protecting some "secret" (?required by divorce settlement). Denies there were sexual, financial problems.
I pointed out that the only things to consistently relate to insomnia seemed to be -- divorce, living alone, lonliness and possible depression, that all "medical" causes seem to be ruled out. Patient offered no affirmation of this assessment, but agreed to try medication.
Thank you for asking me to see Mr. Lane.
J. T. Rosenszweig., M.D.
The consultation confirmed what I suspected all along: some type of depression, perhaps the commonest cause of insomnia. I continued to follow Mr. Lane for a few months, using the medication prescribed by Dr. Rosenszweig. Celexa is specifically for depression, and Remeron for sleep. The combination helped, but I knew it would take more than just medication, and hoped Mr. Lane would continue to follow up with Dr. R.
On his last visit to me he was up to 40 mg of Celexa and still taking Remeron. He was sleeping better, clearly due to the medication. I advised Mr. Lane I had little more to offer, and asked him to continue with the psychiatrist. There was a lot more to his case, I knew - the nature of his two divorces, what his writing was about, why he seemed to have so much denial - but these issues were best left to his psychiatrist. For my part, I am glad he was able to get the help he needed.