A 55-year-old woman comes to the office due to insomnia and fatigue that began shortly after her divorce was finalized a year ago. The patient used to sleep 7-8 hours without difficulty; however, over the past year she has had increasing difficulty falling asleep and started drinking 2-3 glasses of wine before bedtime to help. Despite falling asleep more quickly, she has recently started to regularly wake up around 3:00 AM. Her symptoms have progressively worsened and she now lies awake for several hours in the middle of the night, thinking and worrying about her future, but she rarely experiences anxiety during the day. She reports mild difficulty with concentration and no change in appetite. The patient experiences occasional brief sadness and loneliness. She has recently started showing up late for work and has stopped attending her weekly exercise class. Medical history includes hypothyroidism, treated with levothyroxine, and gastroesophageal reflux disease, diagnosed 3 months ago and treated with ranitidine. Temperature is 37.2 C (99 F), blood pressure is 140/90 mm Hg, pulse is 90/min, and respirations are 12/min. Physical examination shows a mild tremor but no other abnormalities. Laboratory results are as follows: Which of the following is the most likely diagnosis in this patient?

Question

A 55-year-old woman comes to the office due to insomnia and fatigue that began shortly after her divorce was finalized a year ago.  The patient used to sleep 7-8 hours without difficulty; however, over the past year she has had increasing difficulty falling asleep and started drinking 2-3 glasses of wine before bedtime to help.  Despite falling asleep more quickly, she has recently started to regularly wake up around 3:00 AM.  Her symptoms have progressively worsened and she now lies awake for several hours in the middle of the night, thinking and worrying about her future, but she rarely experiences anxiety during the day.  She reports mild difficulty with concentration and no change in appetite.  The patient experiences occasional brief sadness and loneliness.  She has recently started showing up late for work and has stopped attending her weekly exercise class.  Medical history includes hypothyroidism, treated with levothyroxine, and gastroesophageal reflux disease, diagnosed 3 months ago and treated with ranitidine.  Temperature is 37.2 C (99 F), blood pressure is 140/90 mm Hg, pulse is 90/min, and respirations are 12/min.  Physical examination shows a mild tremor but no other abnormalities.  Laboratory results are as follows:  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

The National Institute on Alcohol Abuse and Alcoholism has found evidence of negative health effects for women of all ages and men age ≥65 who consume >7 drinks in a week or >3 in a day (for men age <65, the cutoffs are >14 drinks in a week or >4 drinks in a day). This patient's alcohol consumption pattern (≥14 drinks per week), abnormal liver enzymes (aspartate aminotransferase/alanine aminotransferase ratio ≥2:1), macrocytosis, alcohol tolerance (ie, decreasing sedative effects of alcohol over time), and impaired functioning (eg, work tardiness) are consistent with a diagnosis of alcohol use disorder. This diagnosis is also supported by her history of gastroesophageal reflux disease and hypertension as well as a tremor on examination. Individuals with alcohol use disorder frequently seek primary care due to sleep disturbance and/or anxiety symptoms from mild withdrawal, as in this patient. These individuals may use alcohol to fall asleep, but as the blood alcohol level drops, CNS hyperarousal occurs and results in awakenings. (Choice A) Although this patient's alcohol use may have initially escalated in response to her divorce a year ago, adjustment disorder cannot be diagnosed in a patient whose symptoms have lasted >6 months after a stressor. (Choice C) There is insufficient evidence that this patient's insomnia and anxiety are a direct result of the physiological effects of a medical condition. Her normal TSH level indicates that her hypothyroidism is well controlled. (Choice D) Generalized anxiety disorder is characterized by pervasive and excessive worry about multiple issues and is typically seen in patients who report lifelong anxiety. It is less likely in this patient with signs/symptoms of alcohol abuse, no history of psychiatric illness, and circumscribed anxiety (ie, only worries at night when unable to sleep). (Choice E) Although this patient may have initially developed difficulty falling asleep in the context of a divorce, it developed into a classic pattern of alcohol-induced sleep disruption with the onset of heavy drinking. Insomnia disorder is diagnosed only when the sleep disturbance is not better explained by another disorder. (Choice F) A diagnosis of dysthymia would require a depressed mood for at least 2 years and substance-induced causes to be ruled out. Educational objective: Patients with unhealthy alcohol use are frequently seen in the primary care setting for insomnia and/or anxiety. These patients should be carefully screened for alcohol use disorder. Findings of increased liver enzymes and macrocytosis can also assist in screening. References: Screening for substance abuse in women's health: a public health imperative. (http://www.ncbi.nlm.nih.gov/pubmed/23631601) Screening for alcohol and drug use disorders among adults in primary care: a review. (http://www.ncbi.nlm.nih.gov/pubmed/22553426) Alcohol dependence and its relationship with insomnia and other sleep disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27706838)

A 55-Year-Old Woman Comes to the Office Due to Insomnia