Losing Sleep Over Losing Sleep (Part II)

In this discussion, I will describe two cases, the first of which involved a patient’s primary physician contacting me out of great concern for a patient with severe insomnia; the doctor expected the patient to need a psychiatric hospitalization. The threats to the patient’s sanity appeared so explicit, the primary physician contacted me during a holiday season to request an urgent meeting with the patient, and I was able to comply. As it turned out, the patient was a very weak emotional processor, and things worsened dramatically after losing all social support upon having moved to NM. As we delved into the psychiatric history, severe mental illness was present in one of the parents, and the patient’s presentation suggested the possibility of a manic episode. However, once we had the chance to unpack these elements, giving the patient an opportunity to express some feelings about the current lifestyle, we then were able to go directly to work on the psychophysiology of LSOLS and how with the use of modified sleep restriction the patient might start to see some improvements in short order.

When interacting with these patients, the most common instruction would be summarized as follows: “I know this idea is going to sound really odd, but to get better faster and make insomnia clear up faster, the single most important thing you need to do is ‘not give a damn about your sleep.’ I know intellectually this idea might make some sense to you, but emotionally it is probably difficult to digest. Nonetheless, once you can emotionally embrace the idea that you do not care whether or not you sleep, then the insomnia will start to rapidly subside. And, this instruction means that if you can’t get to sleep or you wake up and can’t return to sleep, you absolutely have to stop caring about it, stop thinking about it, and stop any planning behavior to try to control it. If instead you LET GO of all control of your sleep, then you will discover you are able to LET yourself sleep.” This patient’s insomnia literally resolved in 3 days, albeit she still needed a low dose prescription sleep aid for several more months to use as an occasional “security blanket.”

In another case, the problem was first managed through a phone intervention in a patient who was desperate to gain relief, but who was not quite sure how to proceed. The patient had experienced a traumatic event of a very unusual type, consisting of a very loud and intense shock to the body from a deafening noise. For a few months, this person attempted to self-medicate for the sleep problems while seeking care from other types of physicians, but none of them realized the patient had developed ASD or acute stress disorder. In fact, through our initial online intake evaluation and my phone call with this patient, it was clear from the outset the patient was in the midst of developing chronic post-traumatic stress disorder. I spoke with the patient on the phone for 30 minutes two days before a scheduled sleep study (we scheduled the sleep study initially, because other intake indicators and symptoms strongly suggested a case of severe OSA) and then on the night of the study, I again met with the patient that evening for an hour long encounter.

In both encounters (phone and in person), it was clear the patient was going through considerable emotional turmoil following the loud, shocking noise. Once this traumatic aspect of the problem was elaborated upon, including some brief education on the posttraumatic stress process, we were then able to start work on the modified sleep restriction approach, which was discussed using the nearly identical summary paraphrased above in the prior case. Again, the theme remains constant: the patient must learn and embrace the idea of “not caring” whether or not sleep occurs. Rather, it is the giving up of control over sleep that often leads most rapidly to reduction or cure of insomnia. 

What if the patient cannot embrace these ideas or feels incapable of doing so? The most appropriate step might be psychiatric hospitalization. Another step, of course, could be to prescribe another medication, but I remain very leery of this approach, because of the potential for a panicky patient in the throes of high distress levels to impulsively consider or engage in some form of self-destructive behavior. Recently I spoke with another patient who presented to the sleep center with a mild case of insomnia, yet a year earlier this same patient had suffered such severe distress due to insomnia, LSOLS and the agony of tapering off decades-long use of a hypnotic, the patient informed me suicide was considered at that time.

If you read or hear about the numerous media reports on suicides in active duty military or veterans, the headlines and stories are nearly identical: the patient kept returning to a physician whose only treatment recommendations were increasing dosages of the same drugs or different drugs, followed by increasing dosages of the new drug. The stories describe cases lasting months or years and which ended either with an obvious suicide (e.g. gunshot, hanging) or apparent accidental death by drug overdose.

In these dire circumstances, while it should be obvious, it is always imperative to clearly identify the underlying mental health process. In other words, though many mental health patients are more vulnerable to LSOLS, most likely due to impaired thinking or judgments, most mental health patients seeking treatment at a sleep center will probably understand treatment instructions such as modified sleep restriction and follow them successfully. However, among those with more serious mental disorders or greater intensity, it would likely prove counter-productive in attempting to put too much focus on LSOLS. For example, consider a bipolar patient experiencing even a low grade manic episode. Here, the answer would likely be stronger medications or professional observation or monitoring, whereas LSOLS treatments might yield no results or might worsen the insomnia. 

Losing sleep over losing sleep can be very serious, but most patients respond to education and modified versions of CBT-I. When the case is severe, however, professional intervention of the right kind is strongly encouraged and should be rapidly delivered.

To close, however, I want to leave you with one very positive point to consider in a sizeable proportion of these LSOLS patients. As we know from our research, many of these insomnia patients suffer co-occurring sleep-disordered breathing, and some suffer from very severe sleep apnea. While it may be difficult to picture exactly how such a patient would rapidly embrace a PAP therapy device, I can report from clinical experience, we have treated many insomniacs with what might be termed “rapid PAP induction” (meaning very frequent appts, PAP-NAPs, and retitrations in the early going: literally days or a couple weeks) after which they IMMEDIATELY experienced marked changes in their insomnia. Even more remarkably, in my opinion, these same patients literally saw problematic symptoms such as racing thoughts, ruminations, and even LSOLS disappear overnight, because they perceived the problems were solved with PAP. They also took rapid ownership of the concepts involved, that is, breathing disrupts brain waves, leading to arousals and awakenings and eventually insomnia. Therefore, treat the breathing and insomnia should go away.

Theoretically, then, it is conceivable that even very conservative treatments might nudge the LSOLS patient toward some noticeable degree of improvement. I have employed this approach with nasal dilator strips and seen surprisingly good results, all because the use of a simple breathing tool stopped the patient’s downward spiral. For the same reasons, teaching an LSOLS patient to sleep on the side or having a patient use a chinstrap without any other treatment could be just enough to move someone back from the brink.

I am hopeful that one day psychiatric hospitals and other residential mental health programs will incorporate sleep laboratories and related sleep medical services into their institutional environments, because doing so would go a long way towards relieving mental health patients of one of their most vexing problems—the lack of high quality restorative slumber.  In the meantime, if mental health professionals could learn specific skills to apply CBT-I principles, such as a modified sleep restriction program, many patients would be well served and undoubtedly some lives would be saved.


Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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