How to handle insomnia?

[jbomba]

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I get many patients (many of them cluster B) who come to me with complaints of insomnia. Sometimes this is an initial complaint other times it comes up months into treatment. More often than not they've tried all the usual suspects without luck (melatonin, trazodone, vistaril, and often doxepin). Sometimes it's a benzo they want which is a firm no. If they've accepted no benzo, they'll continually ask what else can I give them for sleep.

I understand borderlines have high co-morbidity of insomnia, which is also a significant risk factor for suicide. How do I treat their complaints seriously but without giving in to what they want and/or offer something novel?

 

[WisNeuro]

CBT-i, as long as medical reasons have been ruled out. Most other interventions are temporary at best.

 

[romanticscience]

I get many patients (many of them cluster B) who come to me with complaints of insomnia. Sometimes this is an initial complaint other times it comes up months into treatment. More often than not they've tried all the usual suspects without luck (melatonin, trazodone, vistaril, and often doxepin). Sometimes it's a benzo they want which is a firm no. If they've accepted no benzo, they'll continually ask what else can I give them for sleep.

I understand borderlines have high co-morbidity of insomnia, which is also a significant risk factor for suicide. How do I treat their complaints seriously but without giving in to what they want and/or offer something novel?

I do a thorough sleep-wake history, sometimes with a diary. Often, the situation is that of extreme circadian sleep phase advance. The person sleeps in because they have little self-control to wake-up to about noon. Then they complain that they cannot sleep at night. However, adding up their hours of sleep (3AM to 10AM), they are actually sleeping.

Sometimes they understand this and we try some sort of chronotherapy/sleep-restriction.

 

[Stagg737]

Agree with the above, especially with education on CBT-I. Clarification of the diagnosis is important too though. What's the etiology of the insomnia? Is it acute or chronic? Is it even insomnia or is it a circadian rhythm disorder? If the latter Melatonin or Ramelteon should be reconsidered. Did they take Melatonin 10 minutes before bedtime which can be anywhere between 7pm to 3am? Or did they have a consistent bedtime and took it 3-4 hours prior to this consistently for a month or more?

I understand borderlines have high co-morbidity of insomnia, which is also a significant risk factor for suicide. How do I treat their complaints seriously but without giving in to what they want and/or offer something novel?

I've done fairly well with treating insomnia, but when all else fails or I'm just uncomfortable with the remaining options they get a referral to sleep medicine. No shame in deferring to a specialist for high-risk patients when the first few lines of therapy fail.

 

[watto]

There was a nice advance article in Sleep that came out this week where Espie's group picked apart the Spielman 3 Ps and tried to hone in on what factors pushed people into different phases of insomnia. One takeaway, which I have always suspected and utilized in my CBT-I practice, is that if anxiety or worry are present and the predominant perpetuating factor, you need to address that early in the game. I have used entire first sessions on the topic. Then move on to time in bed awake restriction / stimulus control / etc. I imagine for BPD you might examine if there are dysfunctional attitudes and beliefs about sleep present (you can use Morin's checklist) and attack, attack, attack those from the outset.

 

[Stagg737]

There was a nice advance article in Sleep that came out this week where Espie's group picked apart the Spielman 3 Ps and tried to hone in on what factors pushed people into different phases of insomnia. One takeaway, which I have always suspected and utilized in my CBT-I practice, is that if anxiety or worry are present and the predominant perpetuating factor, you need to address that early in the game. I have used entire first sessions on the topic. Then move on to time in bed awake restriction / stimulus control / etc. I imagine for BPD you might examine if there are dysfunctional attitudes and beliefs about sleep present (you can use Morin's checklist) and attack, attack, attack those from the outset.

Do you have a link to that article? I'd be interested in reading it.

 

[watto]

Here is the abstract - you need to be a subscriber to get the PDF:

The natural history of insomnia: predisposing, precipitating, coping, and perpetuating factors over the early developmental course of insomnia

Abstract. While there is an extensive literature on predisposing, precipitating, coping, and perpetuating factors in those with chronic insomnia, very litt

academic.oup.com

 

[WisNeuro]

Also, please note that there really isn't a CBT-i lite. There has been some work done, semi-dismantling, that shows that the psychoed by itself doesn't lead to much amelioration. The behavioral intervention definitely key there.

 

[Sushirolls]

CBT-i
CBT-i
CBT-i

It is the gold standard, with a lot of evidence.

Thankfully I have a sleep medicine physician I can refer to who actually does it themselves, and is good at it. Rare to find a sleep physician who does it.

There is an app that is out there for folks to do CBTi, but it requires a prescription and costs money to gain access.

It's equally hard to find a psychologist who also does it, and does it routinely enough to be good at it. Some sleep medicine departments as they grow in size will hire their own therapist to do it but they often times are learning on the job or don't stick around.

Most patients usually just want a pill....

 

[Evidence Based]

CBT-I, wish I could give it to everybody! Definitely systems limitations on access though.
However, the VA CBT-I coach app is actually pretty good (especially for highly motivated folks) and can be a good first step: CBT-i Coach

 

[deleted1100659]

agree with the above posters but sometimes ill do stuff like trazodone. often times I have people who state they get 2 hours of sleep a night or something of that sort, but talking to them theres no sign of sleep deficit at all. Like a conversion disorder in the form of insomnia? maybe somatic sx disorder, lol

 

[watto]

Sleep state misperception, or varying levels of sleep reactivity.

Addendum: ACT usually works well for these cases.

 

[WisNeuro]

agree with the above posters but sometimes ill do stuff like trazodone. often times I have people who state they get 2 hours of sleep a night or something of that sort, but talking to them theres no sign of sleep deficit at all. Like a conversion disorder in the form of insomnia? maybe somatic sx disorder, lol

It's usually more that they just have really poor insight into their sleep and sleep patterns. That's where the initial education and logging in CBT-i can become pretty helpful right off the bat.

 

[Monocles]

Most of the times it's something to do with poor sleep hygiene.

My usual spiel is asking about bedtime routines (devices, tv in bedroom, cell phones, bright lights, etc), daytime/afternoon naps, caffeine/energy drinks too late in the evening, and improper use of melatonin (standing is actually better than PRN).

95% of the time with some behavioural management the insomnia is solved within 2-3 office visits.

Then again insomnia is super easy to treat in kids and teens compared to grown-ups so... ¯\_(ツ)_/¯

 

[clausewitz2]

Most of the times it's something to do with poor sleep hygiene.

My usual spiel is asking about bedtime routines (devices, tv in bedroom, cell phones, bright lights, etc), daytime/afternoon naps, caffeine/energy drinks too late in the evening, and improper use of melatonin (standing is actually better than PRN).

95% of the time with some behavioural management the insomnia is solved within 2-3 office visits.

Then again insomnia is super easy to treat in kids and teens compared to grown-ups so... ¯\_(ツ)_/¯

In adults at least there are several studies suggesting 'sleep hygiene' counseling alone is ineffective at improving sleep. It's a conversation to have but it's rarely the end of things.

 

[hamstergang]

Then again insomnia is super easy to treat in kids and teens compared to grown-ups so... ¯\_(ツ)_/¯

What is your secret for getting parents to actually stop their teens from napping, keeping them off their phones at night, and getting them out of their beds for their virtual schooling? I haven't found any of this to be easy, let alone super easy.

 

[Stagg737]

CBT-I, wish I could give it to everybody! Definitely systems limitations on access though.
However, the VA CBT-I coach app is actually pretty good (especially for highly motivated folks) and can be a good first step: CBT-i Coach

Agree with CBT-I Coach. I've had a few attendings or senior residents say they think it's pretty useless without actual therapy but I disagree. I've had some patients do really well with it. Particularly those who have done individual therapy previously (specifically CBT, duh) and are motivated to actually implement the app appropriately

agree with the above posters but sometimes ill do stuff like trazodone. often times I have people who state they get 2 hours of sleep a night or something of that sort, but talking to them theres no sign of sleep deficit at all. Like a conversion disorder in the form of insomnia? maybe somatic sx disorder, lol

This is where clarification of insomnia type becomes so important. 2 hours of sleep/night for less than a week when they look awful and I usually believe them or at least that they're not far off. Longer than that in a person who doesn't look like the walking dead and I'm asking more questions. I'll also channel @clausewitz2 with these patients and say a sleep diary is essential here. If they're legit getting 2-3 hours, I do a pretty deep diagnostic dive and basically re-evaluate them to look for various causes. I also usually refer them to sleep medicine fairly quickly. If it's more like 4-6 hours (usually the case) then I treat them like most of my "typical" insomnia patients. If they're getting adequate hours and still feeling sleep was really poor or fatigued all day, I'm assessing for OSA and likely referring for a sleep study/specialist as paradoxical insomnia is not something I'm particularly well-versed with.

 

[Monocles]

What is your secret for getting parents to actually stop their teens from napping, keeping them off their phones at night, and getting them out of their beds for their virtual schooling? I haven't found any of this to be easy, let alone super easy.

Parents are powerless. 😉 The trick is to talk with the teens and think like an economist (aka frame things in terms of incentives and gains that THEY care about)

For instance, I have tons of teens who are into e-sports and will stay up till 2am playing rainbow 6 or whatever to "practice". I call them out on it and compare it to physical sports like football, etc and say that you don't find football players out practicing at 2 am in the morning, and importance of sleep, eating healthy, hygiene etc because it'll improve their mental acuity and APMs if they're not tired and struggling to stay awake.

Teens can be surprisingly cooperative when you build enough rapport with them and get even the tiniest buy in 😀, whereas I find that oftentimes it's the parents who are most resistant to change in terms of family schedules and screen routines, etc

(Maybe I'm just biased and cynical against grown-ups, ha)

 

[calvnandhobbs68]

Parents are powerless. 😉 The trick is to talk with the teens and think like an economist (aka frame things in terms of incentives and gains that THEY care about)

For instance, I have tons of teens who are into e-sports and will stay up till 2am playing rainbow 6 or whatever to "practice". I call them out on it and compare it to physical sports like football, etc and say that you don't find football players out practicing at 2 am in the morning, and importance of sleep, eating healthy, hygiene etc because it'll improve their mental acuity and APMs if they're not tired and struggling to stay awake.

Teens can be surprisingly cooperative when you build enough rapport with them and get even the tiniest buy in 😀, whereas I find that oftentimes it's the parents who are most resistant to change in terms of family schedules and screen routines, etc

(Maybe I'm just biased and cynical against grown-ups, ha)

Nice I'm gonna actually use this.

 

[birchswing]

We had a "cool" guidance counselor in middle school. I could kind of see through him and could tell the teachers didn't like him, even though the kids did. He was really big into scuba diving, and he would regale of his adventures. He sold a book in the front office with scuba diving adventures, which I could tell annoyed the teachers.

I was not interested (in him or scuba diving or any of it). All I can remember from the stories was that he went under water and then came back up.

Anyhow, I remember during one of these stories—in the midst of the exciting underwater part—he stopped and asked the class, "Do you know what you can't do if you want to go scuba diving?"

I had no idea where this was going.

But I was shocked at how many of the boys who were so admiring of his Jack London like fantasy stories were eagerly raising their hands and all knew the answer.

"Drugs."

You can't use drugs if you want to be a scuba diver.

It really seemed to hit home with a lot of the students.

Personally I think he was high most of the time.