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A sleep clinic within a general hospital psychiatry service
A Sleep Clinic Within a General Hospital Psychiatry Service Quentin R. Regestein, M.D. Peter Reich, M.D.
Division of Psychiatry, Department ofMedicine, Peter Bent Brigham Hospital, and the Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
Abstract: A sleep clinicwasfounded within a general hospital psychiatry service. A practical approach toward sleep problems included: flexible diagnostic investigations; descriptive, imprecise diagnostic categories; and symptomatic treatment measures. A summary of 100 consecutive patients with chronic insomnia is presented to illustrate this approach. Of36 treafment failures, most were due to incomplete treatment rather than irremediableproblems. Thegeneral psychiatry service may provide a favorable base for a sleep clinic.
Recent years have seen the rise of sleep clinics offering specialized diagnostic and therapeutic services to patients with sleep disturbances. Several well-known centers offer these services primarily on referral. Treatment outcome from such centers has been only anecdotally reported. This paper describes experience with one general hospital sleep clinic. We briefly review the clinic organization and approach, and then describe our work with a group of patients experiencing insomnia.
Clinic Organization and Approach As a pilot project, we have established a sleep clinic within a general hospital psychiatric service, under the direction of a psychiatrist with experience in sleep research. The approach is practical and eclectic, relying primarily on routine procedures available in every general hospital. In an attempt to lessen patient cost and inconvenience, we used a flexible rather than standardized program of laboratory testing, deferring firm diagnosis in some cases 112 ISSN 016~&334%3@020112-061$02.25
until after initial treatment trials. Various laboratory examinations can be obtained in the hospital through collaborative arrangements with departments of psychology, neurology, pulmonary medicine, endocrinology, and others. Patients are admitted to general medical beds when more prolonged investigations are needed. This report covers five years of experience in this sleep clinic. Utilization In spite of publicity at the time of the clinic’s opening and even after several mailings to the hospital staff, referrals from within the hospital were few during the first year. Announcements were also sent to the medical directors of 75 Boston area hospitals, but few referrals resulted from these. During the next two years, after further clinical and promotional efforts, self-referrals of patients suffering from chronic sleep disorders grew steadily to the present level of one to three per week.
Feasibility The fee schedule for. clinic patients was based on usual insurance benefits for outpatient psychiatric visits, for which third-party carriers accepted responsibility. Most laboratory tests were also covered, but some psychophysiological tests were charged to the patient directly. On this basis, the clinic fees supported the salary of the director but were insufficient to pay for space and overhead. However, patient flow could be accommodated in regular psychiatry offices. GaeraJHospital
Psychiatry 2, 112-117, 1980 @ Elsevier North Holland, Inc., 1980 52 Vanderbilt Ave., New York, NY 10017
Psychiatry Service Sleep Clinic
Clinical Experience During the past five years, approximately 400 adult patients were seen in the sleep clinic. Approximately 80% of the patients suffered from chronic insomnia, 15% complained of excessive daytime somnolence, and the remaining 5% complained of nightmares or behavioral disturbances during sleep. Thorough history and mental status examination, and when indicated, a medical evaluation, formed the core of each case study. Beyond this, our diagnostic evaluation did not follow an established routine. Laboratory investigations were applied only in cases of patients manifesting ambiguities in diagnosis and unresponsiveness to initial treatment. These included psychophysiological tests of arousal level, multiple sleep latency tests, nap records, video recordings, all-night polygraphic recordings, and endocrine-metabolic studies. Polygraphic studies were limited primarily to cases of suspected sleep apnea, nocturnal myoclonus, atypical narcolepsy, subwakefulness syndromes, investigation of impotence, intractable behavioral disorders occurring during sleep, chronic intractable insomnia of unusual severity, and as an added diagnostic study in cases of sleep disorders that were unresponsive to treatment. Polygraphic studies were carried out in about 10% of the total cases of all sleep disorders seen.
Patients In order to illustrate the clinical management of patients, we describe our experience with 100 consecutive patients who complained of chronic insomnia . The patients in this series were largely selfreferred and resided in the greater Boston area and surrounding parts of Massachusetts. The median age was 41, with a range from 18 to 79, the preponderance being between 25 and 50 years. The series included 45 men and 55 women, most of whom had been treated unsuccessfully by other physicians. Because we initially accepted results of recent medical evaluations, only 14 patients required physical examination. In 53 instances the patients were asked to keep logs of sleep habits. Psychometric testing was done in six cases, and all-night polygraphic recordings were required in another six. Seventy-three patients complained of fitful sleep with frequent wakenings. Most of the remaining complained of sleep onset insomnia. In 49 cases the insomnia had been present for more than five years.
Common findings were the current use of psychoactive medications, feelings of depression, frequent crying spells, and irregular bedtimes and sleep habits. On mental status examination and review of personal history, it was determined that 79 of the patients manifested mental disorders (1), including 41 with depressive disorders, 19 with personality disturbances, eight with neuroses, seven with situational disturbances, two with psychoses, and two with chronic alcoholism. In general, the treatment approach was made specific to the clinical problem underlying the sleep disorder. The complaint of insomnia does not necessarily indicate diminished sleep time (2,3); therefore, we defined insomnia as the subjective complaint of inadequate sleep, even though insomnia patients may be underestimating sleep or may be suffering from frequent nocturnal awakenings, prolonged sleep latency, changed electroencephalographic configurations, or other sleep disturbances, rather than actual sleep loss (4,5). There was no standard diagnostic classification nor conventional means of treating insomnia upon which we could rely. Operationally our patients could be grouped according to their most prominent and treatable clinical features. Endogenous depression (37 patients). Patients with endogenous depressions manifested such symptoms as early morning awakening, crying spells, severity of disorder disproportionate to recent events, diurnal mood fluctuations, onset after age 40, appetite loss, change in bowel habits, anhedonia, and noise or crowd intolerance (6). Often these depressions were long standing. In each case, an adequate trial of antidepressant medication was instituted, along with supportive psychotherapy. Hypervigilance (27 patients). A long-standing symptom pattern, best described as hypervigilance, often appeared to be associated with the complaint of insomnia. This pattern included forced thinking and a sense of being hyperalert, with a perfusion of consciousness by thoughts upon retiring. “My body is tired but my mind is awake” is a typical description of this state. Such patients suffered initial insomnia but, once asleep, returned to sleep easily if awakened and sometimes slept late on weekends. Such patients were often introverted, pessimistic, introspective, highly sensitive to a variety of stimulations, including exercise, unable to 113
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stop ruminating about intense experiences, and occasionally obsessed with worries. Their insomnia had often led them to habits inimical to sleep, such as naps, irregular bedtimes, reading or working in the middle of the night, and the chronic use of sedation. Although hypervigilance often appeared to be a lifelong pattern, many of these patients responded to common-sense attention to their poor sleep habits (7), bedtime relaxation techniques, and brief supportive psychotherapy. Patient 2 exemplifies hypervigilance. He is a 36year-old securities analyst and long-distance runner who, increasingly for four years, lay awake “all wrought up” after retiring, especially after a large dinner. He turned the lights out at 9:00 PM, and rose at 5:30 AM for a morning run. Two or three times a month he resorted to diazepam, 10 mg at bedtime. He enjoyed a rewarding job and a good marriage. In the clinic he was sensitive, introspective, candid, ironically self-deprecatory, and obsessional. Treatment consisted of delaying bedtime until 1O:OOPM, discontinuing caffeine, shifting some caloric intake from supper to breakfast, taking warm malted milk at bedtime, which reportedly improves sleep (8), and pursuing Jacobson’s relaxation exercises after retiring (9). A sleep log thereafter revealed that he fell asleep easily with infrequent exceptions. Disruptive practices (13 patients). Some patients manifested disruptive practices sufficient to account for the insomnia. These patients also suffered initial insomnia but did not manifest hypervigilance patterns. Five of them were unemployed young men who led chaotic, purposeless lives that included widely irregular sleep schedules and the use of many psychotropic substances. Others kept irregular bedtimes (10) or had caffeine sensitivity (11). Most found it difficult to regulate their schedules and to withdraw from the use of stimulants or sedatives. An example of these is Patient2, a 40-year-old administrator who awoke two to ten times each night to urinate, eat snacks, weigh herself, and ruminate. Although she was of ideal weight, she feared weight gain and ate nothing during the day, but ingested 1200 to 4500 calories each night. She also took about four mugs of percolated coffee and two to five bottles of diet cola daily. She had undergone five years of psychotherapy for anxiety and marital difficulties. In consultation she was friendly and detail ridden, and smiled when discussing sad subjects.
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She was instructed to eat regular small daytime meals, and to give up caffeine and night eating, salt, and liquids during the three hours before bedtime. She trained her bladder by delaying urination for progressively longer periods each day, placed her scale in a poorly accessible place, and weighed herself once a week. Upon night awakening, she remained in bed doing relaxing meditation (12). On this regimen, she slept through the night and proved hard to arouse in the midst of sleep. When crises arose, a fitful sleep pattern temporarily recurred. Patient 3 is a 22-year-old medical student who slept well until his college years, when he frequently kept late study hours. In medical school he continued to study late into the night, took longer to fall asleep, and sought relief in chlordiazepoxide or chloral hydrate. Problems with his girlfriend caused him to consult a psychiatrist, whom he saw twice weekly for eight months. His grades fell, he became depressed, stayed up nightly brooding and listening to records, and slept little. Interviews revealed ambivalence about medical school and a pervasive bitterness. A sleep log revealed haphazard bedtimes occurring between 7:00 PM and 5:00 AM. Upon institution of a regular sleep schedule, dependable sleep returned within a week. His ambivalence, bitterness, and depression remained unchanged, however. The irregular schedule had caused his insomnia, although the depression impaired his motivation to keep a regular schedule, causing recrudescences of insomnia. Chronic deprivation (6 patients). Six patients manifested chronic deprivation in their histories and current lives and suffered insomnia primarily in deprived circumstances. Thus, for example, Patien t 4, a 20-year-old unemployed girl, slept fitfully except when with her boyfriend and when she lived in a halfway house for troubled youth. Her parents had told her to leave home shortly after her high school graduation. Sorrowful years followed, characterized by drifting, drug overdoses, and psychiatric hospitalizations, until she lived in a halfway house. Insomnia returned when she started in a local college and felt lonely and estranged from her drug-dealing roommate. Her insomnia evidently derived from a sense of loneliness and abandonment, since she slept well when not alone. Although there are many deprived individuals without insomnia, the patients in this group suffered much from anxiety, phobias, trauma, loss,
Psychiatry Service Sleep Clinic
loneliness, and the treatment of their disturbed sleep was carried out best when they were helped with their relationships.
Idiopathic childhood-onset insomnia (5 patients). These patients suffered severe, constant, intractable insomnia beginning in childhood. For example, Patient 5, a 34-year-old unemployed woman, had suffered fitful sleep since age 12 and severe daytime fatigue, which precluded working more than a few hours continuously. Ashamed of her unemployment, she sought help from various doctors who diagnosed anxiety but did not focus on her insomnia. She was mildly obsessional and well motivated. Results of physical examination and routine screening tests were normal. Psychometric testing revealed no major psychopathology. Two nights of polygraphic recording in the sleep laboratory showed five hours of sleep interrupted by seven or eight awakenings of three to 20 minutes each per night, and fairly normal distribution of sleep in Rapid Eye Movement (REM) and non-REM sleep. Three nights of polygraphic recording two years later showed six to seven hours of sleep per night, many awakenings, 20-30% of time spent in a drowsy state compared with a normal 5-lo%, no deep sleep, and high amplitude electromyographic activity. Attempts to deal with the problem over an eight-year period had consisted of numerous treatments, including individual and group psychotherapy, over-the-counter hypnotics, barbiturates, benzodiazepines, phenothiazines, amitriptyline, phenelzine, daytime stimulants, discontinuing all psychotropic substances, keeping a regular sleep schedule, electromyographic biofeedback, and consultation with another sleep clinic, all of which failed to gain her refreshing sleep. The patient is being followed supportively and still suffers insomnia.
Less common categories (12 patients). Other categories of insomnia problems were each seen in a few patients. Three patients were each relieved when a medication, including propranolol, alphamethyldopa, and a glucocorticoid, respectively, could be discontinued. Two elderly women had occasionally experienced fitful sleep in recent years and, somewhat worried, appeared at the clinic. They responded to periodic reassurance. Two other patients suffered neurologic conditions-cerebral degeneration in one case and a unique condition
associated with head movements during sleep and periodic total insomnia in the other (13). Insomnia in two patients presented as the only symptom of hyperthyroidism. Central sleep apnea, manicdepressive psychosis, and exacerbations of schizophrenia were associated with insomnia in one patient each.
Results of Treatment Thirty-three patients reported the return of regular, adequate sleep, 19 of whom owed their relief to antidepressants and seven of whom were hypervigilant patients who adopted regular sleep habits and did relaxation exercises on retiring. They had been seen an average of 4.3 times over a 22-week period. In addition, 31 patients reported improved sleep with occasional brief recurrences of insomnia, (e.g., Patients 1 and 2). The 36 patients remaining were unimproved (e.g., Patients 3, 4, and 5). Of these 36 treatment failures, however, 17 attended the clinic only once or twice and 12 did not adhere to prescriptions. Seven patients, who were not relieved despite their cooperation, suffered conditions that were poorly understood or for which there were currently no specific remedies. These included three patients with idiopathic insomnia, two with CNS disorders, one with psychosis, and one with central sleep apnea. Factors apparently related to noncompliance with the clinic program included living too far away, dislike of the treatment plan, anger that a psychiatrist was involved, disagreement among the patient’s doctors, insufficient rapport with the clinic staff, apparent lack of motivation, or language barriers.
Discussion There are now about 34 sleep disorders clinics in the United States; most of them are less than five years old. Organizational and clinical approaches differ widely, as evidenced by diversity among the clinic directors, of whom there are presently about 15 psychiatrists, nine psychologists, eight neurologists, and two internists. Some movement toward standardization is gaining strength through the Association of Sleep Disorders Clinic. Our clinic grew out of a clinical practice rather than a sleep laboratory and thus approaches the patient primarily through the history and mental status examination rather than through standardized laboratory
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procedures. As a result, many fewer patients receive all-night polygraphic recordings than in most other sleep centers. The operational groupings we introduced in the presentation of our cases did not constitute a proposed system of classification for insomnia, but rather a temporary adaptation to the lack of official nosology. Our groupings reflect the practical clinical approach we have employed. The clinic was developed around a symptom rather than around a discipline or a physiological system; the symptom per se is treated by whatever means are practically available; and we did not necessarily address coincidental psychiatric disorder if insomnia was relieved. Despite this apparent treatment superficiality, our experience suggests that patients with severe chronic insomnia may often be relieved by a practical and low-cost approach. Our outcome will be difficult to judge until treatment outcomes of similar patients managed by a variety of therapeutic approaches are reported. Elsewhere we have reviewed the difficulties of formulating a widely acceptable diagnostic approach to insomnia (5). Until the pathophysiological mechanisms of insomnia are illuminated, our working categories will continue to be descriptive and operational (14). Such categories may, therefore, lack a single organizational principle, manifest disparate levels of abstraction, and overlap among one another. Patients with hypervigilant patterns, for instance, may evince behaviors that also characterize patients with disruptive habits, sleep-wake cycle disorders, or with endogenous depression. Such underlying causes for insomnia may themselves be interconnected, precluding diagnostic clarity at present. Since the reported patients were seen, a standardized classification for insomnia has been proposed for the International Classification of Diseases of the World Health Organization (15). Its publication may further progress toward codifying insomnia types. Our diagnoses, e.g., hypervigilance, were modeled after earlier versions of this schema, except that some categories (e.g., disruptive practices, deprivation) were associated with more than one of the proposed diagnoses. Some might have termed the delayed bedtimes of Patient 3 a sleep-wake cycle disorder (16). Furthermore, although polygraphic records objectively describe sleep, such records at present may not detect insomnia (17), correlate with complaints of insomnia (2, X3), or diagnose insomnia complaints (5). This had led some clinicians away from use of laboratory 116
records in diagnosing insomnia in sleep clinic patients (19). Struggling within the morass of conceptual ambiguities about insomnia, and guided by few objective tests or research studies on specific subtypes of insomnia, the clinician must, at present, proceed intuitively, sort out major from minor causes of insomnia in complex cases, and therapeutically attack the probable causes of insomnia in each case according to a preset plan. Such methods are facilitated by rapport fostered in psychiatric interviews and supported by the resources of a general hospital. Forty-four of our patients had previously seen psychiatrists. Of these, 23 had been treated in regular, long-term psychotherapy-all but two by psychiatrists. Six patients whose insomnia was alleviated by clinic treatment continued to see their psychotherapists. Some patients, e.g., Patient 2, continued to suffer anxiety after insomnia was relieved. Psychotherapy and the sleep clinic program seemed to focus on different aspects of distress. Despite diagnostic imprecision, our experience suggests that patients with severe chronic insomnia may be managed within the format of office interviews, without the routine use of costly laboratory investigations. This experience, plus that of others in treating hypersomnia (20), suggests that the majority of sleep disorders may be handled reasonably well by simple methods. Further clinical experience and comparisons among similar insomniac populations managed differently will be needed to resolve current disparities in diagnostic approach and therapeutic practices. In conclusion, we suggest that the diversity of medical and psychiatric causes for insomnia, the presence of hospital diagnostic facilities and wellformed consultative arrangements, the high proportion of psychopathology among insomnia patients, and the favorable outcome from a short-term practical psychiatric approach to insomnia as well as to other sleep problems, render the psychiatric service of a general hospital a favorable setting in which to base a sleep clinic.
References 1. Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Ed.2. Washington, D.C., American Psychiatric Association, 1968 2. Carskadon MA, Dement WC, Mitler MM, et al: Self-reports versus sleep laboratory findings in 122 drug-free subjects with complaints of chronic insomnia. Am J Psychiatry 28:769-783, 1973
Psychiatry
3. Frankel BL, Coursey RD, Buchbinder R, et al: Recorded and reported sleep in chronic primary insomnia. Arch Gen Psychiatry 331615-623, 1976 4. Williams RL, Karacan I, Hursch CJ: Electroencephalography (EEG) of Human Sleep: Clinical Applications. New York, Wiley, 1974, pp 120-122 5. Regestein QR, Reich P: Current problems in the diagnosis and treatment of chronic insomnia. Perspect Biol Med 21:232-239, 1978 6. Bielski RJ, Friedel RO: Prediction of tricyclic antidepressant response. Arch Gen Psychiatry 33:1479-1489, 1976 7. Regestein QR: Treating insomnia: A practical guide for managing chronic sleeplessness, circa 1975. Compr Psychiatry 17:517-525, 1976 8. Brezinova V, Oswald I: Sleep after a bedtime beverage. Br Med J 2:431433, 1972 9. Jacobson E: Progressive Relaxation. Chicago, University of Chicago Press, 1931 10. Kripke DF, Cook B, Lewis OF: Sleep of night workers: EEG recordings. Psychophysiology 7~377384, 1971 11. Goldstein A, Warren R, Kaizer S: Psychotropic effects of caffeine in man. I. Individual differences in sensitivity to caffeine-induced wakefulness. J Pharmacol Exp Ther 149:156-159, 1965 12. Benson H, Rosner BA, Marzetta BR, et al: Decreased blood pressure in pharmacologically treated hypertensive patients who regularly elicited the relaxation response. Lancet 1:289-291, 1974
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13. Regestein QR, Hartmann E, Reich I’: A head movement disorder occurring in dreaming sleep. J Nerv Ment Dis X4:432436, 1977 14. Eisenberg L: The social imperatives of medical research. Science 198:1105-1110, 1977 15. Association of Sleep Disorders Centers. Diagnostic classification of sleep and arousal disorders. Sleep 2117-137, 1979 16. Weitzman FD, Pollak Cl’: Disorders of the circadian sleep-wake cycle. Med Times 107:83-94, 1979 17. Karacan I, Williams RL, Salis PJ, Hursch CJ: New approaches to the evaluation and treatment of insomnia. Psychosomatics 12:81-88, 1971 18. Schwarz BA, Guilband G, Fischgold H: Electroencephalographic studies of night sleep. I. Chronic “insomnia.” Presse Med 71:1474-1476, 1963 19. Soldatos CR, Kales A, Kales JD: Management of insomnia. Ann Rev Med 30:301-312, 1979 20. Guilleminault C, Dement WC: 235 cases of excessive daytime sleepiness. J Neurol Sci 31:13-27, 1977
Uzrect reprint requests to: Quentin R. Regestein, M.D. Division of Psychiatry Peter Bent Brigham Hospital 721 Huntington Avenue Boston, MA 02115
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Division of Psychiatry, Department ofMedicine, Peter Bent Brigham Hospital, and the Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
Abstract: A sleep clinicwasfounded within a general hospital psychiatry service. A practical approach toward sleep problems included: flexible diagnostic investigations; descriptive, imprecise diagnostic categories; and symptomatic treatment measures. A summary of 100 consecutive patients with chronic insomnia is presented to illustrate this approach. Of36 treafment failures, most were due to incomplete treatment rather than irremediableproblems. Thegeneral psychiatry service may provide a favorable base for a sleep clinic.
Recent years have seen the rise of sleep clinics offering specialized diagnostic and therapeutic services to patients with sleep disturbances. Several well-known centers offer these services primarily on referral. Treatment outcome from such centers has been only anecdotally reported. This paper describes experience with one general hospital sleep clinic. We briefly review the clinic organization and approach, and then describe our work with a group of patients experiencing insomnia.
Clinic Organization and Approach As a pilot project, we have established a sleep clinic within a general hospital psychiatric service, under the direction of a psychiatrist with experience in sleep research. The approach is practical and eclectic, relying primarily on routine procedures available in every general hospital. In an attempt to lessen patient cost and inconvenience, we used a flexible rather than standardized program of laboratory testing, deferring firm diagnosis in some cases 112 ISSN 016~&334%3@020112-061$02.25
until after initial treatment trials. Various laboratory examinations can be obtained in the hospital through collaborative arrangements with departments of psychology, neurology, pulmonary medicine, endocrinology, and others. Patients are admitted to general medical beds when more prolonged investigations are needed. This report covers five years of experience in this sleep clinic. Utilization In spite of publicity at the time of the clinic’s opening and even after several mailings to the hospital staff, referrals from within the hospital were few during the first year. Announcements were also sent to the medical directors of 75 Boston area hospitals, but few referrals resulted from these. During the next two years, after further clinical and promotional efforts, self-referrals of patients suffering from chronic sleep disorders grew steadily to the present level of one to three per week.
Feasibility The fee schedule for. clinic patients was based on usual insurance benefits for outpatient psychiatric visits, for which third-party carriers accepted responsibility. Most laboratory tests were also covered, but some psychophysiological tests were charged to the patient directly. On this basis, the clinic fees supported the salary of the director but were insufficient to pay for space and overhead. However, patient flow could be accommodated in regular psychiatry offices. GaeraJHospital
Psychiatry 2, 112-117, 1980 @ Elsevier North Holland, Inc., 1980 52 Vanderbilt Ave., New York, NY 10017
Psychiatry Service Sleep Clinic
Clinical Experience During the past five years, approximately 400 adult patients were seen in the sleep clinic. Approximately 80% of the patients suffered from chronic insomnia, 15% complained of excessive daytime somnolence, and the remaining 5% complained of nightmares or behavioral disturbances during sleep. Thorough history and mental status examination, and when indicated, a medical evaluation, formed the core of each case study. Beyond this, our diagnostic evaluation did not follow an established routine. Laboratory investigations were applied only in cases of patients manifesting ambiguities in diagnosis and unresponsiveness to initial treatment. These included psychophysiological tests of arousal level, multiple sleep latency tests, nap records, video recordings, all-night polygraphic recordings, and endocrine-metabolic studies. Polygraphic studies were limited primarily to cases of suspected sleep apnea, nocturnal myoclonus, atypical narcolepsy, subwakefulness syndromes, investigation of impotence, intractable behavioral disorders occurring during sleep, chronic intractable insomnia of unusual severity, and as an added diagnostic study in cases of sleep disorders that were unresponsive to treatment. Polygraphic studies were carried out in about 10% of the total cases of all sleep disorders seen.
Patients In order to illustrate the clinical management of patients, we describe our experience with 100 consecutive patients who complained of chronic insomnia . The patients in this series were largely selfreferred and resided in the greater Boston area and surrounding parts of Massachusetts. The median age was 41, with a range from 18 to 79, the preponderance being between 25 and 50 years. The series included 45 men and 55 women, most of whom had been treated unsuccessfully by other physicians. Because we initially accepted results of recent medical evaluations, only 14 patients required physical examination. In 53 instances the patients were asked to keep logs of sleep habits. Psychometric testing was done in six cases, and all-night polygraphic recordings were required in another six. Seventy-three patients complained of fitful sleep with frequent wakenings. Most of the remaining complained of sleep onset insomnia. In 49 cases the insomnia had been present for more than five years.
Common findings were the current use of psychoactive medications, feelings of depression, frequent crying spells, and irregular bedtimes and sleep habits. On mental status examination and review of personal history, it was determined that 79 of the patients manifested mental disorders (1), including 41 with depressive disorders, 19 with personality disturbances, eight with neuroses, seven with situational disturbances, two with psychoses, and two with chronic alcoholism. In general, the treatment approach was made specific to the clinical problem underlying the sleep disorder. The complaint of insomnia does not necessarily indicate diminished sleep time (2,3); therefore, we defined insomnia as the subjective complaint of inadequate sleep, even though insomnia patients may be underestimating sleep or may be suffering from frequent nocturnal awakenings, prolonged sleep latency, changed electroencephalographic configurations, or other sleep disturbances, rather than actual sleep loss (4,5). There was no standard diagnostic classification nor conventional means of treating insomnia upon which we could rely. Operationally our patients could be grouped according to their most prominent and treatable clinical features. Endogenous depression (37 patients). Patients with endogenous depressions manifested such symptoms as early morning awakening, crying spells, severity of disorder disproportionate to recent events, diurnal mood fluctuations, onset after age 40, appetite loss, change in bowel habits, anhedonia, and noise or crowd intolerance (6). Often these depressions were long standing. In each case, an adequate trial of antidepressant medication was instituted, along with supportive psychotherapy. Hypervigilance (27 patients). A long-standing symptom pattern, best described as hypervigilance, often appeared to be associated with the complaint of insomnia. This pattern included forced thinking and a sense of being hyperalert, with a perfusion of consciousness by thoughts upon retiring. “My body is tired but my mind is awake” is a typical description of this state. Such patients suffered initial insomnia but, once asleep, returned to sleep easily if awakened and sometimes slept late on weekends. Such patients were often introverted, pessimistic, introspective, highly sensitive to a variety of stimulations, including exercise, unable to 113
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stop ruminating about intense experiences, and occasionally obsessed with worries. Their insomnia had often led them to habits inimical to sleep, such as naps, irregular bedtimes, reading or working in the middle of the night, and the chronic use of sedation. Although hypervigilance often appeared to be a lifelong pattern, many of these patients responded to common-sense attention to their poor sleep habits (7), bedtime relaxation techniques, and brief supportive psychotherapy. Patient 2 exemplifies hypervigilance. He is a 36year-old securities analyst and long-distance runner who, increasingly for four years, lay awake “all wrought up” after retiring, especially after a large dinner. He turned the lights out at 9:00 PM, and rose at 5:30 AM for a morning run. Two or three times a month he resorted to diazepam, 10 mg at bedtime. He enjoyed a rewarding job and a good marriage. In the clinic he was sensitive, introspective, candid, ironically self-deprecatory, and obsessional. Treatment consisted of delaying bedtime until 1O:OOPM, discontinuing caffeine, shifting some caloric intake from supper to breakfast, taking warm malted milk at bedtime, which reportedly improves sleep (8), and pursuing Jacobson’s relaxation exercises after retiring (9). A sleep log thereafter revealed that he fell asleep easily with infrequent exceptions. Disruptive practices (13 patients). Some patients manifested disruptive practices sufficient to account for the insomnia. These patients also suffered initial insomnia but did not manifest hypervigilance patterns. Five of them were unemployed young men who led chaotic, purposeless lives that included widely irregular sleep schedules and the use of many psychotropic substances. Others kept irregular bedtimes (10) or had caffeine sensitivity (11). Most found it difficult to regulate their schedules and to withdraw from the use of stimulants or sedatives. An example of these is Patient2, a 40-year-old administrator who awoke two to ten times each night to urinate, eat snacks, weigh herself, and ruminate. Although she was of ideal weight, she feared weight gain and ate nothing during the day, but ingested 1200 to 4500 calories each night. She also took about four mugs of percolated coffee and two to five bottles of diet cola daily. She had undergone five years of psychotherapy for anxiety and marital difficulties. In consultation she was friendly and detail ridden, and smiled when discussing sad subjects.
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She was instructed to eat regular small daytime meals, and to give up caffeine and night eating, salt, and liquids during the three hours before bedtime. She trained her bladder by delaying urination for progressively longer periods each day, placed her scale in a poorly accessible place, and weighed herself once a week. Upon night awakening, she remained in bed doing relaxing meditation (12). On this regimen, she slept through the night and proved hard to arouse in the midst of sleep. When crises arose, a fitful sleep pattern temporarily recurred. Patient 3 is a 22-year-old medical student who slept well until his college years, when he frequently kept late study hours. In medical school he continued to study late into the night, took longer to fall asleep, and sought relief in chlordiazepoxide or chloral hydrate. Problems with his girlfriend caused him to consult a psychiatrist, whom he saw twice weekly for eight months. His grades fell, he became depressed, stayed up nightly brooding and listening to records, and slept little. Interviews revealed ambivalence about medical school and a pervasive bitterness. A sleep log revealed haphazard bedtimes occurring between 7:00 PM and 5:00 AM. Upon institution of a regular sleep schedule, dependable sleep returned within a week. His ambivalence, bitterness, and depression remained unchanged, however. The irregular schedule had caused his insomnia, although the depression impaired his motivation to keep a regular schedule, causing recrudescences of insomnia. Chronic deprivation (6 patients). Six patients manifested chronic deprivation in their histories and current lives and suffered insomnia primarily in deprived circumstances. Thus, for example, Patien t 4, a 20-year-old unemployed girl, slept fitfully except when with her boyfriend and when she lived in a halfway house for troubled youth. Her parents had told her to leave home shortly after her high school graduation. Sorrowful years followed, characterized by drifting, drug overdoses, and psychiatric hospitalizations, until she lived in a halfway house. Insomnia returned when she started in a local college and felt lonely and estranged from her drug-dealing roommate. Her insomnia evidently derived from a sense of loneliness and abandonment, since she slept well when not alone. Although there are many deprived individuals without insomnia, the patients in this group suffered much from anxiety, phobias, trauma, loss,
Psychiatry Service Sleep Clinic
loneliness, and the treatment of their disturbed sleep was carried out best when they were helped with their relationships.
Idiopathic childhood-onset insomnia (5 patients). These patients suffered severe, constant, intractable insomnia beginning in childhood. For example, Patient 5, a 34-year-old unemployed woman, had suffered fitful sleep since age 12 and severe daytime fatigue, which precluded working more than a few hours continuously. Ashamed of her unemployment, she sought help from various doctors who diagnosed anxiety but did not focus on her insomnia. She was mildly obsessional and well motivated. Results of physical examination and routine screening tests were normal. Psychometric testing revealed no major psychopathology. Two nights of polygraphic recording in the sleep laboratory showed five hours of sleep interrupted by seven or eight awakenings of three to 20 minutes each per night, and fairly normal distribution of sleep in Rapid Eye Movement (REM) and non-REM sleep. Three nights of polygraphic recording two years later showed six to seven hours of sleep per night, many awakenings, 20-30% of time spent in a drowsy state compared with a normal 5-lo%, no deep sleep, and high amplitude electromyographic activity. Attempts to deal with the problem over an eight-year period had consisted of numerous treatments, including individual and group psychotherapy, over-the-counter hypnotics, barbiturates, benzodiazepines, phenothiazines, amitriptyline, phenelzine, daytime stimulants, discontinuing all psychotropic substances, keeping a regular sleep schedule, electromyographic biofeedback, and consultation with another sleep clinic, all of which failed to gain her refreshing sleep. The patient is being followed supportively and still suffers insomnia.
Less common categories (12 patients). Other categories of insomnia problems were each seen in a few patients. Three patients were each relieved when a medication, including propranolol, alphamethyldopa, and a glucocorticoid, respectively, could be discontinued. Two elderly women had occasionally experienced fitful sleep in recent years and, somewhat worried, appeared at the clinic. They responded to periodic reassurance. Two other patients suffered neurologic conditions-cerebral degeneration in one case and a unique condition
associated with head movements during sleep and periodic total insomnia in the other (13). Insomnia in two patients presented as the only symptom of hyperthyroidism. Central sleep apnea, manicdepressive psychosis, and exacerbations of schizophrenia were associated with insomnia in one patient each.
Results of Treatment Thirty-three patients reported the return of regular, adequate sleep, 19 of whom owed their relief to antidepressants and seven of whom were hypervigilant patients who adopted regular sleep habits and did relaxation exercises on retiring. They had been seen an average of 4.3 times over a 22-week period. In addition, 31 patients reported improved sleep with occasional brief recurrences of insomnia, (e.g., Patients 1 and 2). The 36 patients remaining were unimproved (e.g., Patients 3, 4, and 5). Of these 36 treatment failures, however, 17 attended the clinic only once or twice and 12 did not adhere to prescriptions. Seven patients, who were not relieved despite their cooperation, suffered conditions that were poorly understood or for which there were currently no specific remedies. These included three patients with idiopathic insomnia, two with CNS disorders, one with psychosis, and one with central sleep apnea. Factors apparently related to noncompliance with the clinic program included living too far away, dislike of the treatment plan, anger that a psychiatrist was involved, disagreement among the patient’s doctors, insufficient rapport with the clinic staff, apparent lack of motivation, or language barriers.
Discussion There are now about 34 sleep disorders clinics in the United States; most of them are less than five years old. Organizational and clinical approaches differ widely, as evidenced by diversity among the clinic directors, of whom there are presently about 15 psychiatrists, nine psychologists, eight neurologists, and two internists. Some movement toward standardization is gaining strength through the Association of Sleep Disorders Clinic. Our clinic grew out of a clinical practice rather than a sleep laboratory and thus approaches the patient primarily through the history and mental status examination rather than through standardized laboratory
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procedures. As a result, many fewer patients receive all-night polygraphic recordings than in most other sleep centers. The operational groupings we introduced in the presentation of our cases did not constitute a proposed system of classification for insomnia, but rather a temporary adaptation to the lack of official nosology. Our groupings reflect the practical clinical approach we have employed. The clinic was developed around a symptom rather than around a discipline or a physiological system; the symptom per se is treated by whatever means are practically available; and we did not necessarily address coincidental psychiatric disorder if insomnia was relieved. Despite this apparent treatment superficiality, our experience suggests that patients with severe chronic insomnia may often be relieved by a practical and low-cost approach. Our outcome will be difficult to judge until treatment outcomes of similar patients managed by a variety of therapeutic approaches are reported. Elsewhere we have reviewed the difficulties of formulating a widely acceptable diagnostic approach to insomnia (5). Until the pathophysiological mechanisms of insomnia are illuminated, our working categories will continue to be descriptive and operational (14). Such categories may, therefore, lack a single organizational principle, manifest disparate levels of abstraction, and overlap among one another. Patients with hypervigilant patterns, for instance, may evince behaviors that also characterize patients with disruptive habits, sleep-wake cycle disorders, or with endogenous depression. Such underlying causes for insomnia may themselves be interconnected, precluding diagnostic clarity at present. Since the reported patients were seen, a standardized classification for insomnia has been proposed for the International Classification of Diseases of the World Health Organization (15). Its publication may further progress toward codifying insomnia types. Our diagnoses, e.g., hypervigilance, were modeled after earlier versions of this schema, except that some categories (e.g., disruptive practices, deprivation) were associated with more than one of the proposed diagnoses. Some might have termed the delayed bedtimes of Patient 3 a sleep-wake cycle disorder (16). Furthermore, although polygraphic records objectively describe sleep, such records at present may not detect insomnia (17), correlate with complaints of insomnia (2, X3), or diagnose insomnia complaints (5). This had led some clinicians away from use of laboratory 116
records in diagnosing insomnia in sleep clinic patients (19). Struggling within the morass of conceptual ambiguities about insomnia, and guided by few objective tests or research studies on specific subtypes of insomnia, the clinician must, at present, proceed intuitively, sort out major from minor causes of insomnia in complex cases, and therapeutically attack the probable causes of insomnia in each case according to a preset plan. Such methods are facilitated by rapport fostered in psychiatric interviews and supported by the resources of a general hospital. Forty-four of our patients had previously seen psychiatrists. Of these, 23 had been treated in regular, long-term psychotherapy-all but two by psychiatrists. Six patients whose insomnia was alleviated by clinic treatment continued to see their psychotherapists. Some patients, e.g., Patient 2, continued to suffer anxiety after insomnia was relieved. Psychotherapy and the sleep clinic program seemed to focus on different aspects of distress. Despite diagnostic imprecision, our experience suggests that patients with severe chronic insomnia may be managed within the format of office interviews, without the routine use of costly laboratory investigations. This experience, plus that of others in treating hypersomnia (20), suggests that the majority of sleep disorders may be handled reasonably well by simple methods. Further clinical experience and comparisons among similar insomniac populations managed differently will be needed to resolve current disparities in diagnostic approach and therapeutic practices. In conclusion, we suggest that the diversity of medical and psychiatric causes for insomnia, the presence of hospital diagnostic facilities and wellformed consultative arrangements, the high proportion of psychopathology among insomnia patients, and the favorable outcome from a short-term practical psychiatric approach to insomnia as well as to other sleep problems, render the psychiatric service of a general hospital a favorable setting in which to base a sleep clinic.
References 1. Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Ed.2. Washington, D.C., American Psychiatric Association, 1968 2. Carskadon MA, Dement WC, Mitler MM, et al: Self-reports versus sleep laboratory findings in 122 drug-free subjects with complaints of chronic insomnia. Am J Psychiatry 28:769-783, 1973
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3. Frankel BL, Coursey RD, Buchbinder R, et al: Recorded and reported sleep in chronic primary insomnia. Arch Gen Psychiatry 331615-623, 1976 4. Williams RL, Karacan I, Hursch CJ: Electroencephalography (EEG) of Human Sleep: Clinical Applications. New York, Wiley, 1974, pp 120-122 5. Regestein QR, Reich P: Current problems in the diagnosis and treatment of chronic insomnia. Perspect Biol Med 21:232-239, 1978 6. Bielski RJ, Friedel RO: Prediction of tricyclic antidepressant response. Arch Gen Psychiatry 33:1479-1489, 1976 7. Regestein QR: Treating insomnia: A practical guide for managing chronic sleeplessness, circa 1975. Compr Psychiatry 17:517-525, 1976 8. Brezinova V, Oswald I: Sleep after a bedtime beverage. Br Med J 2:431433, 1972 9. Jacobson E: Progressive Relaxation. Chicago, University of Chicago Press, 1931 10. Kripke DF, Cook B, Lewis OF: Sleep of night workers: EEG recordings. Psychophysiology 7~377384, 1971 11. Goldstein A, Warren R, Kaizer S: Psychotropic effects of caffeine in man. I. Individual differences in sensitivity to caffeine-induced wakefulness. J Pharmacol Exp Ther 149:156-159, 1965 12. Benson H, Rosner BA, Marzetta BR, et al: Decreased blood pressure in pharmacologically treated hypertensive patients who regularly elicited the relaxation response. Lancet 1:289-291, 1974
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13. Regestein QR, Hartmann E, Reich I’: A head movement disorder occurring in dreaming sleep. J Nerv Ment Dis X4:432436, 1977 14. Eisenberg L: The social imperatives of medical research. Science 198:1105-1110, 1977 15. Association of Sleep Disorders Centers. Diagnostic classification of sleep and arousal disorders. Sleep 2117-137, 1979 16. Weitzman FD, Pollak Cl’: Disorders of the circadian sleep-wake cycle. Med Times 107:83-94, 1979 17. Karacan I, Williams RL, Salis PJ, Hursch CJ: New approaches to the evaluation and treatment of insomnia. Psychosomatics 12:81-88, 1971 18. Schwarz BA, Guilband G, Fischgold H: Electroencephalographic studies of night sleep. I. Chronic “insomnia.” Presse Med 71:1474-1476, 1963 19. Soldatos CR, Kales A, Kales JD: Management of insomnia. Ann Rev Med 30:301-312, 1979 20. Guilleminault C, Dement WC: 235 cases of excessive daytime sleepiness. J Neurol Sci 31:13-27, 1977
Uzrect reprint requests to: Quentin R. Regestein, M.D. Division of Psychiatry Peter Bent Brigham Hospital 721 Huntington Avenue Boston, MA 02115
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