Insomnia and Sleep Disorders Case Study Essay

Insomnia and Sleep Disorders Case Study Essay

Use APA 6th Edition Format and support your work with at least 3 peer-reviewed references within 5 years of publication. Remember that you need a cover page and a reference page. All paragraphs need to be cited properly. Please use headers. All responses must be in a narrative format and each paragraph must have at least 4 sentences. Lastly, you must have at least 2 pages of content, no greater than 4 pages, excluding cover page and reference page. Insomnia and Sleep Disorders Case Study Essay


Case Study #3: Insomnia and Sleep Disorders

S.H., age 47, reports difficulty falling asleep and staying asleep. These problems have been ongoing for many years, but she has never mentioned them to her health care provider. She has generally “lived with it” and self treated the problem with OTC Tylenol PM. Currently, she is also experiencing perimenopausal symptoms of night sweats and mood swings. Current medical problems include hypertension controlled with medications. Past medical history includes childhood illnesses of measles, chickenpox, and mumps. Family history is positive for diabetes on the maternal side and hypertension on the paternal side. Her only medication is an angiotensin converting enzyme inhibitor and diuretic combination for hypertension control. She generally does not like taking medication and does not take any other OTC products. Insomnia and Sleep Disorders Case Study Essay

Diagnosis: InsomnIa

1. List specific goals of therapy for S.H.

2. What drug therapy would you prescribe? Why?

3. What are the parameters for monitoring the success of the therapy?

4. Discuss specific patient education based on the prescribed therapy

5. List one or two adverse reactions for the selected agent that would cause you to change therapy.

6. What would be the choice for second-line therapy?

7. What OTC and/or alternative medicines might be appropriate for this patient?

8. What dietary and lifestyle changes might you recommend?

9. Describe one or two drug–drug or drug–food interactions for the selected agent Insomnia and Sleep Disorders Case Study Essay

Insomnia is defined as a state in which an individual has difficulty initiating or maintaining
sleep, or experiencing unrefreshed sleep despite ample opportunity and situation to sleep.1
third of the total population experiences at least intermittent insomnia, and approximately 10
to 15% experience chronic sleep problems. Nevertheless, general awareness and interest in insomnia are insufficient, and accurate diagnosis and adequate treatment of insomnia are often
not addressed in clinical settings.2-5
Pharmacotherapy is currently widely used in the treatment of insomnia and can be helpful
for transient insomnia, but research regarding its effectiveness and safety of long-term use is
not sufficient. Therefore, to overcome the limitations of pharmacotherapy in the treatment of
patients with insomnia, non-pharmacological treatment options (cognitive behavioral therapy
for insomnia, CBTi) are used. CBT is a psychotherapeutic approach which addresses maladaptive cognitive processes and behaviors through goal directed, explicit systematic procedures. Insomnia and Sleep Disorders Case Study Essay
The main purpose of CBTi is to eliminate maintaining factors that are presumed to perpetuate
chronic insomnia.6
There have been studies reporting that CBTi is effective in primary insomnia as well as in secondary insomnia associated with the use of drugs and substances, medical
problems or psychiatric disorders.7
However, studies have shown that CBT appears to be costly
and time-consuming compared to pharmacotherapy, and have addressed difficulties in impleReceived: March 29, 2013
Revised: July 2, 2013
Accepted: August 13, 2013
Seung Chul Hong, MD, PhD
Department of Psychiatry,
St. Vincent’s Hospital,
The Catholic University of Korea
College of Medicine,
93-1 Jungbu-daero, Paldal-gu,
Suwon 442-723, Korea
Tel +82-31-249-7150
Fax +82-31-248-6758
Case Studies of Chronic Insomnia Patients Participating
in Group Cognitive Behavioral Therapy for Insomnia
Mi Jin Yi, MD1
, Tae Won Kim, MD1
, Jong Hyeon Jeong, MD, PhD1
, Soo Hyun Joo, MD1
Seung Chul Hong, MD, PhD1
, Soo Yeon Suh, PhD, CBSM2
Department of Psychiatry, St. Vincent’s Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea Insomnia and Sleep Disorders Case Study Essay
Human Genome Institute, Korea University Ansan Hospital, Ansan, Korea
Background and ObjectiveaaPharmacotherapy currently widely used in the treatment of insomnia can be helpful in transient insomnia, but research regarding its effectiveness and safety of long-term use is not enough. Therefore, to complement the limitations of
pharmacotherapy in the treatment of patients with insomnia, non-pharmacologic treatment methods (cognitive behavioral therapy,
CBT) are used. But CBT for insomnia appear to be costly and time-consuming compared to pharmacotherapy, clinical practice in the
field can be difficult to be applied. We took the format of group therapy rather than individual therapy to complement the disadvantages
of CBT and now we would like to have a thought into its meaning by reporting the effectiveness of group CBT for insomnia.
MethodsaaPatients were recruited at Sleep Center of St. Vincent’s Hospital, 2 men and 3 women led to a group of five patients. CBT is a
treatment for correction factors that cause and maintain insomnia, it includes a variety of techniques such as sleep hygiene education,
stimulus control, sleep restriction, relaxation and cognitive therapy. A series of treatment were performed five sessions once a week with
a frequency from February to March 2012 and were proceeded for about 1 hour and 30 minutes per session.
ResultsaaResults indicated that the subjective quality of sleep and sleep efficiency of all patients improved and Pittsburgh Sleep Quality
Index and Beck Depression Inventory were decreased in spite of reducing dose of medication.
ConclusionsaaLike these cases, we can contribute to reduce the time and economic burden by performing group CBT for insomnia
rather than individual therapy. Sleep Med Res 2012;3:45-49
Key WordsaaInsomnia, Cognitive behavioral therapy, Group therapy, Pharmacotherapy. Insomnia and Sleep Disorders Case Study Essay
Sleep Med Res 2012;3:45-49
online © ML Comm
46 Sleep Med Res 2012;3:45-49
Group CBT for Insomnia
menting CBTi within clinical practice due to the lack of practitioners.8-16 The authors implemented group CBTi rather than
individual therapy to enhance cost effectiveness. In this paper,
we report several cases of patients who participated in group
CBTi and were successful in reducing or discontinuing their
sleep medication.
Five patients (two men and three women, mean age = 55 ±
6.85) were recruited from the Sleep Center of St. Vincent’s Hospital. All patients reported sleep disturbance and voluntarily
participated in group CBTi. This report refers to five patients
who were randomly assigned as Patient A, B, C, D and E.
Patient A was a 54-year-old nun who described herself as
‘detail-oriented and perfectionistic.’ She was diagnosed with
breast cancer 5 years ago when she visited the hospital for a
routine examination. Along with breast cancer, she was also
diagnosed with depressed mood and insomnia. When she visited about 6 months ago, her back pain became worse,  Insomnia and Sleep Disorders Case Study Essay which
subsequently made it more difficult for her to sleep. She initiated treatment in pain control and physical therapy in the Department of Rehabilitation medicine as an outpatient. She was
prescribed 10 mg of Zolpidem. Her pain and insomnia improved, but she continued to take sleep medication on an as
needed basis. Her main goal for participating in this treatment
was discontinuation of her sleep medication.
Patient B was a 52-year-old public official who had timid and
sensitive personality. He started to experience anxiety and heart
palpitations, physical symptoms of dizziness and sleep disorders
about two years ago when his mother passed away. He reported
taking sleep medication, and claimed he had no improvement.
He reported participating in cognitive-behavioral therapy for
insomnia previously, which he reported was not very effective.
Patient C was a 64-year-old woman who experienced anxiety
symptoms. She reported visiting the hospital with main complaints of insomnia which started six years ago when her son Insomnia and Sleep Disorders Case Study Essay
got married with the start of frequent and repetitive conflicts
with her daughter-in-law. Approximately 2 months ago, she returned to the hospital after arguing with her daughter-in-law,
which in turn exacerbated her insomnia. Since then, she has
made efforts to reconcile with her daughter-in-law and has also
started taking sleep medication, which has somewhat improved
her sleep.
Patient D was a 46-year-old construction company worker
who became nervous and experienced worsening physical
symptoms such as headaches under stress. His main sources of
stress were conflicts with his wife and work. He was diagnosed
with anxiety disorder at a private psychiatry clinic, and he had
been consistently taking medication for 7 years prior to visiting Insomnia and Sleep Disorders Case Study Essay
the hospital. About 1.5 years ago, he was involved in an automobile accident, which amplified his anxiety and hyperarousal
symptoms. He reported that since the accident, he has been experiencing symptoms consistent with posttraumatic stress disorder, including severe nightmares.
Patient E was a 59-year-old woman who first visited the hospital about two years ago after her brother-in-law failed to return money that she had lent him, leaving her with depression
and insomnia. About one year ago, she began to care for her
mother-in-law, who had dementia, and the additional stress exacerbated her insomnia. She reported suffering from insomnia
almost every night despite taking sleep medication.
Based on Spielman and Glovinsky’s model (1991), CBTi is a
treatment that targets perpetuating factors that cause and maintain insomnia, including a variety of techniques such as sleep
hygiene education, stimulus control, sleep restriction, relaxation
and cognitive therapy. Treatment sessions consisted of five
weekly sessions between February and March 2012, and each
session lasted for about 1hour and 30 minutes.
In the first session, members of the group introduced themselves and received sleep education and orientation about CBTi.


All patients stayed long in bed at a wake state or napped too
much to compensate for the lack of overnight sleep, which
eventually leaded to the chronic insomnia, interventions to correct the inadequate sleep condition were performed. Pittsburgh Insomnia and Sleep Disorders Case Study Essay
Sleep Quality Index (PSQI) and the Beck Depression Inventory
(BDI) were used to evaluate the state of sleep quality and patients’ mood in a subjective manner. In addition, in order to
check the patients’ sleep patterns more specifically, the patients
were asked to keep a weekly sleep diary. Sleep diaries were
checked every session by reviewing the diaries to see changes in
sleep patterns during the treatment period, and were also used
to make recommendations to prescribe sleep and wake times.
In the second session, we performed behavioral therapy, including sleep restriction and stimulus control to modify maladaptive sleep habits that served to maintain insomnia. For example, Patient A was told to correct the irregular bedtime
schedule, and to try to correct maladaptive habits, such as
watching TV lying on the bed before falling asleep. For patient
B, his sleep diaries revealed that he had prolonged his sleep onset latency. He reported lying in bed for more than two hours
due to sleep worry. Patient B was told not to stay in bed unless
he was able to fall asleep within 30 minutes. During these sessions, we prescribed a time in bed which was tailored to each
individual patient to increase sleep efficiency. Additionally, the
patients fixed their wake time and considered their desired
sleep hours based on their average number of hours of sleep.
For example, patient A usually slept about 6.2 hours per night.
She desired to wake up at 7:30 AM and sleep for 7 hours per
night, so her bed time was set at 00:30 AM. She adhered strictly
to her ‘time in bed’, and after a week, her sleep efficiency was increased from 72.7% to 84.7%. Prescription for sleep and wake
times can be found in Table 1.  Insomnia and Sleep Disorders Case Study Essay
Yi MJ, et al. 47
In the third session, all patients were introduced to and practiced progressive muscle relaxation to decrease the levels of hyperarousal. It is well-known that chronic insomnia patients experience heightened hyperarousal characterized by excessive
worrying. Relaxation techniques can help decrease hyperarousal states and promote sleep.17 Patients were generally satisfied,
and were instructed to practice relaxation techniques at home 2-3
times per day with other family members, who read the script
for them, or through the CD that was distributed to them.
During the fourth session, cognitive restructuring was implemented to target maladaptive and dysfunctional beliefs about
sleep. We checked the patients’ distorted cognitions about insomnia and replaced these automatic thoughts with rational
and adaptive thoughts.18 For example, patient C thought that
she always had to sleep for at least 8 hours. If she could not sleep
for 8 hours, she interpreted it as abnormal and worried excessively. However, after receiving sleep education that taught her
that sleep time differs depending on the individual and that
other extraneous factors had little to do with sleep, she was able
to realize that her belief about sleep was not reasonable and was
able to let go of her strong belief that she needed 8 hours of
sleep. In the last session, we summarized the course of treatment and discussed maintaining treatment effects and relapse
prevention. Insomnia and Sleep Disorders Case Study Essay
Pittsburgh Sleep Quality Index is a self-rated questionnaire
which assesses sleep quality and disturbances over a 1-month
time interval. Nineteen individual items generate seven “component” scores; subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep
medication, and daytime dysfunction.19
Beck Depression Inventory created by Dr. Aaron T. Beck is a
21-question multiple-choice self-report inventory, which is one
of the most widely used instruments for measuring the severity
of depression.20
Sleep diaries are a record of an individual’s sleeping and waking times with related information, usually over a period of several weeks. It is self-reported or can be reported by a care-giver.
Information contained in a sleep diary includes the following;
Bed time, wake time, lights out, sleep onset latency, wake after
sleep onset, number of awakenings, sleep quality, the name, dosage and timing of sleep medications, and daytime functioning.21
Statistical analysis was performed using the Wilcoxon signed
ranks test. Insomnia and Sleep Disorders Case Study Essay