Family

Physicians
guide

Insomnia in Primary Health Care Setting

Short notes on clinical cases

First Case:
Fatima, a 40 year old school teacher complains of inability to sleep well for
more than 2 years. She regularly goes to bed at 10 pm but is unable to sleep
until 1 am. She experiences about 3-5 awakenings every night and with each
awakening requires about 30 minutes to fall asleep again. Fatima also
experiences daytime fatigue and is unable to concentrate in her work.
She does not take naps during the day. She does not snore and has no usual
limb movements during sleep (history from husband). Her general health has
been good. She vaguely recalls being involved in a stressful marital problems
dispute just prior to onset of her sleep difficulty.
As bedtime approaches, she becomes very tense and worries about the
prospect of another sleepless night. “Sleep has become a real frustration. Every
night, when I lie in bed, I have to try very hard to sleep. I keep watching the
clock”. She does not take any sleeping pills and has no symptoms of depression.
There is no marital conflict. On further questioning, she surprising admits that
she sleeps well while on vacations and relatives' houses.
What is your provisional diagnosis? why?
Chronic insomnia, according to DSM-5-TR by using insomnia assessment tool
Insomnia last for more than 3 months, causing the following:
Dissatisfaction with sleep quality or quantity associated with one or more of the
following:
• Difficulty initiating sleep.
• Difficulty maintaining sleep (frequent awakenings or problems returning
to sleep after awakening).
• Early morning awakening with inability to return to sleep.
Disturbance causes clinically significant distress or impairment (social,
occupational, educational, academic, behavioral, or other important areas of
functioning).
Frequency of at least three nights per week

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-What are your recommendations / health educations methods as a primary
health physician?
The mainstay of management of chronic insomnia in primary care setting is
brief behavioral therapy. It is an accessible and effective management strategy.
Brief Cognitive behavioral therapy (CBT): consist of 5 components:
• Sleep hygiene: room, temperature, lightening etc. (As described in detail
previously).
• Sleep restriction: “bedroom is only for sleep and sex”
• Relaxation strategies: prayer, yoga, music
• Stimulus control therapy: awakening/sleep hours
• Behavioral therapy: sleep restriction and stimulus control strategies

In addition to drug treatment: Adjuvant use of drugs in insomnia may be

appropriate for a limited duration. Melatonin (2 mg extended-release
formulation), diazepam, antidepressants.

-What are the indications of referral?

Referral to a sleep specialist for further evaluation should be considered in
patients with insomnia who have a possible comorbid sleep disorder, do not
respond to brief behavioral therapy, or have persistent and distressing
symptoms.

Second Case:
Nadia is a 45-year-old woman presents with difficulty falling asleep and staying
asleep.
The problem started after ISIS crises and the forced departure from her home
2 months previously. she is unable to fall sleep until at least an hour after going
to bed. she has no previous sleep problems. She consumes 4 cups of coffee
during the day and lately smokes at night to aid sleep.
-What is the major cause of her sleeping problem (risky behavior) ?
risky behavior: coffee, smoking, stress.

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- What is your provisional diagnosis? why?
Acute insomnia, according to DSM-5-TR by using insomnia assessment tool
Insomnia last for less than 3 months, causing the following:
Dissatisfaction with sleep quality or quantity associated with one or more of the
following:
• Difficulty initiating sleep
• Difficulty maintaining sleep (frequent awakenings or problems returning
to sleep after awakening)
• Early morning awakening with inability to return to sleep.
Disturbance causes clinically significant distress or impairment (social,
occupational, educational, academic, behavioral, or other important areas of
functioning).
Frequency of at least three nights per week
-What type of drug treatment would recommend?
A short course of a hypnotic drug: diazepam, melatonin.
Antidepressants, sedating antipsychotics, and antihistamines can be prescribed
for the treatment of insomnia in this case.
- What will you advice the patient regarding follow up?
Follow up should be of short duration, up to four weeks to prevent progression.
How would your health educate the patient regarding her situation?
A-Wake up at the same time everyday
Stop consuming caffeine 4-6 hours before bedtime, and minimize total day
intake. Caffeine is a stimulant and may disrupt sleep
Nicotine is also a stimulant, avoid cigarette smoking especially near bedtime
and upon night awakenings
Avoid taking alcohol in late evening to facilitate sleep onset, alcohol may cause
awakening later in the night

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5 years later, Nadia presents at the practice requesting for a prescription for
diazepam (Valium). She is currently on diazepam 15 mg nocte to help her sleep
and allay anxiety. A doctor she consulted after the ISIS crises and the departure
from home 5 years ago had started her on diazepam 5mg nocte but with time,
she required increasing doses of the hypnotic. Her previous attempts to
discontinue her medication had failed as it resulted in insomnia, anxiety, tremor,
irritability, nightmares and hyperacusis (unpleasant loud distortion of noise) and
tinnitus. She has adjusted to her activities of daily living while on the above
medication but does complain of poor memory. A GP she consulted recently
had advised her to discontinue her diazepam in view of her perceived poor
memory and tendency to falls.
Physical Exam: Normal. Gait and mobility unimpaired. BP 130/85 mmHg.
Mini Mental Status Exam: Normal

-What is the cause of her sleeping problems this time?

Complication of diazepam treatment
- What drug treatment would you recommend?
Diazepam must be discontinued very gradually
Adjunctive use of sedating tricyclic antidepressants
-How would you educate the patient as a primary health care physician?
Behavioral measures can be considered (the same as previous case)
Follow up should be within 2 weeks
- What is your action regarding patients with loss to follow up?
Active follow up should be ensured, as a primary health physician contact with
patients and families is crucial part of the daily work, especially patients with
chronic diseases.

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Third Case:
Layla is a 45 year old female presented with difficulty of falling asleep, early
awake, frequent awake at night. she also has difficulty in concentration, fatigue,
tiredness, and reduced work performance. she started her new job recently and
feel her heart is racing most of the time (as she says I fear from failing at my job
that's why my heart can’t calm down). While taking history She does not take
naps during the day. She does not snore and has no usual limb movements
during sleep, she has weight loss despite of feel hungry and eating more, hair
loss also frequent bowel motion.
Social history: she is single mother to two young teenage boys. By examination
I noticed enlarged thyroid, elevated BP, tachycardia, normal spo2
The lab shows: low TSH, elevated T3 T4

-What is your provisional diagnosis? Acute insomnia due to hyperthyroidism

-when would you refer the patient?
Referral to a specialist for further evaluation if patients start to develop
complications of hyperthyroidism, also it should be considered in patients with
insomnia who have a possible comorbid sleep disorder, do not respond to brief
behavioral therapy or have persistent and distressing symptoms.
- How would you health educate the patient?
compliance to treatment
-Follow up within two weeks
-Behavioral therapy

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NO MORE INSOMNIA SLEEP HEALTHY

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