A 51-year-old attorney comes to the office due to sleep difficulties. She is a partner in a law firm and finds her job stressful but enjoyable. The patient goes to bed at 12:00 AM and has trouble initiating sleep. When she cannot sleep, she watches the clock, tosses and turns, and worries about being able to function the next day, eventually falling asleep around 3:00 AM before having to wake up at 7:00 AM for work. She reports feeling "exhausted" by 6:00 PM and takes a 20-minute "power nap." The patient's job requires long hours, and she usually eats dinner at 8:00 PM "when things settle down" at the office. The patient drinks several cups of coffee throughout the day but avoids caffeinated beverages after dinner. She has 1-2 alcoholic drinks when she goes out with colleagues in the evenings once or twice a week. She quit smoking 3 years ago but recently started smoking a pack a day again. She often wonders "what my life is all about" and tries not to dwell on these thoughts. She also has been more irritable lately and feels down at times but attributes this to "sleep deprivation." Which of the following is the most likely cause of the patient's symptoms?

Question

A 51-year-old attorney comes to the office due to sleep difficulties.  She is a partner in a law firm and finds her job stressful but enjoyable.  The patient goes to bed at 12:00 AM and has trouble initiating sleep.  When she cannot sleep, she watches the clock, tosses and turns, and worries about being able to function the next day, eventually falling asleep around 3:00 AM before having to wake up at 7:00 AM for work.  She reports feeling "exhausted" by 6:00 PM and takes a 20-minute "power nap."  The patient's job requires long hours, and she usually eats dinner at 8:00 PM "when things settle down" at the office.  The patient drinks several cups of coffee throughout the day but avoids caffeinated beverages after dinner.  She has 1-2 alcoholic drinks when she goes out with colleagues in the evenings once or twice a week.  She quit smoking 3 years ago but recently started smoking a pack a day again.  She often wonders "what my life is all about" and tries not to dwell on these thoughts.  She also has been more irritable lately and feels down at times but attributes this to "sleep deprivation."  Which of the following is the most likely cause of the patient's symptoms?

Quizplus · Accepted Answer

This patient has a number of habits (collectively referred to as sleep hygiene) that interfere with quality sleep and full daytime alertness. She takes a late afternoon nap, drinks caffeine until late (caffeinated beverages should generally be avoided after lunch), has started smoking again, works late hours, and eats a late dinner. When she is unable to fall asleep, she watches the clock, causing further arousal. These habits are inconsistent with a stable sleep pattern. This patient should be counseled regarding good sleep hygiene, including avoiding late afternoon naps, nicotine, caffeine, alcohol, and heavy meals in the evening. If she cannot fall asleep, she should not look at the clock but go to another room and do something relaxing until she feels drowsy enough to fall asleep. Other components of good sleep hygiene include adhering to a regular sleep schedule, avoiding use of electronic devices before bedtime, and maintaining a comfortably cool, dark, and quiet bedroom environment. (Choice A) Although adjustment disorders can present with sleep disturbance, there is no evidence of a particular psychosocial stressor preceding this patient's symptoms. (Choice B) Delayed sleep phase syndrome is characterized by the inability to fall asleep at "normal" bedtimes, difficulty waking in the morning, and excessive early daytime sleepiness. When allowed to set their own schedule (eg, on weekends), these patients have normal sleep quality and duration for age. In the absence of a history of sleeping normally when permitted to follow her own schedule, this patient's sleep disturbance is more likely the result of poor sleep hygiene. (Choice C) This patient does not experience chronic worries about multiple issues that are characteristic of generalized anxiety disorder. (Choice D) Although sleep disturbance is common in perimenopause, this patient does not report other symptoms of approaching menopause (eg, hot flashes, menstrual irregularities, vaginal dryness), making this diagnosis unlikely. (Choice E) Insomnia, irritability, feeling down at times, and thoughts about the purpose of life are consistent with dysthymia. However, this patient enjoys her work, socializes with coworkers, and has no other depressive symptoms (eg, anhedonia, guilt, loss of appetite, low self-esteem, hopelessness). It is more likely that the mood symptoms are a consequence and not the cause of her sleep disturbance. Educational objective: Poor sleep hygiene is a common cause of insomnia. Strategies to improve sleep hygiene include maintaining a regular sleep schedule and a quiet, dark, and comfortably cool bedroom; avoiding late afternoon naps and exposure to electronic devices before bedtime; and avoiding nicotine, caffeine, alcohol, and heavy meals in the evening. References: Nonpharmacologic management of chronic insomnia. (http://www.ncbi.nlm.nih.gov/pubmed/26760592)

A 51-Year-Old Attorney Comes to the Office Due to Sleep