A 40-year-old man comes to the office due to sleep difficulties over the past 2 years. He regularly goes to bed at 11:00 PM but is unable to fall asleep until 12:30 AM. As bedtime approaches, he typically becomes tense, watches the clock, and worries about the prospect of another sleepless night. The patient eventually falls asleep and awakens by alarm at 6 AM in order to arrive at his office by 8 AM. During the day he feels fatigued and is concerned that his insomnia is negatively affecting his work performance. The patient does not take naps during the day. His wife has not noticed any snoring or unusual limb movements during sleep. His general health has been good and he takes no medication. He would like to exercise but feels too tired.
Which of the following is the most appropriate next step in management of this patient?

Question

A 40-year-old man comes to the office due to sleep difficulties over the past 2 years.  He regularly goes to bed at 11:00 PM but is unable to fall asleep until 12:30 AM.  As bedtime approaches, he typically becomes tense, watches the clock, and worries about the prospect of another sleepless night.  The patient eventually falls asleep and awakens by alarm at 6 AM in order to arrive at his office by 8 AM.  During the day he feels fatigued and is concerned that his insomnia is negatively affecting his work performance.  The patient does not take naps during the day.  His wife has not noticed any snoring or unusual limb movements during sleep.  His general health has been good and he takes no medication.  He would like to exercise but feels too tired.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98c6_8fc5_853d_ab2c80464660_MD0002_00 This patient has developed chronic insomnia that is perpetuated by his association of the bed and bedroom with the fear of not sleeping. His sleep environment has therefore become a conditioned stimulus for sleep difficulty. As bedtime approaches, he anticipates another sleepless night, resulting in increasing tension and arousal that makes it even less likely that he will fall asleep. Among the behavioral therapies for insomnia, stimulus control would be most useful as it disrupts the association of the bedroom with not sleeping. Components include going to bed only when sleepy, using the bedroom for sleep and sex only (not reading, watching television, eating), leaving bed if unable to fall asleep within 20 minutes and returning only when sleepy, and avoiding daytime naps. Patients should be advised not to watch the clock as this heightens tension and arousal. When consistently applied, these techniques help the patient learn to reassociate bedtime and the sleep environment with restful sleep. In combination with good sleep hygiene, stimulus control therapy is recommended as an initial treatment for insomnia and should be attempted before considering hypnotic medications. (Choice A) Daytime naps should be avoided as they contribute to insomnia. (Choice B) Patients who are unable to fall asleep after 20 minutes are advised to leave the bed and go to another room and engage in a relaxing activity. They should return to bed only when sleepy. (Choice C) Exercising regularly for at least 20 minutes is a component of good sleep hygiene but should be done >4-5 hours prior to bedtime. Exercising before bedtime can be activating and further disrupts sleep. (Choice E) Restricting time in bed to one's actual sleep hours (ie, sleep restriction therapy) is another behavioral strategy that is preferred for insomnia patients who tend to stay in bed longer in an attempt to make up for lost sleep (eg, a patient who stays in bed 9 hours but sleeps only 5 hours). Limiting one's time in bed improves sleep efficiency (ie, the percentage of time in bed that the patient is asleep) by consolidating sleep hours. The patient's time in bed should be increased by 15 to 30 minutes once sleep efficiency is >90%. Educational objective: The initial behavioral approaches to insomnia consist of sleep hygiene and stimulus control therapy. With stimulus control, patients learn to reassociate the bedroom environment with restful sleep by using the bedroom only for sleep or sexual activity and going to bed only when sleepy. __________ References: Non-pharmacological management of chronic insomnia (http://www.ncbi.nlm.nih.gov/pubmed/26760592) Insomnia: psychological and neurobiological aspects and non-pharmacological treatments. (http://www.ncbi.nlm.nih.gov/pubmed/24637973)

A 40-Year-Old Man Comes to the Office Due to Sleep