Insomnia Insomnia

86 Attarian
insomnia or for other sleep disorders (19–21). Another problem with the use of benzodiazepines
in patients with idiopathic insomnia is the tendency among such patients
to have atypical reactions to medications (7); for example, little sedation from
large doses of sedative/hypnotics (7). According to sporadic case reports, some patients
with idiopathic insomnia have responded to low-dose tricyclics, antipsychotic
medications, or opiates (7,22). More recently, 5 mg of melatonin has been
shown to be helpful in treating chronic insomnia in school-age children (23).
Case 2
A 36-year-old man presented to the sleep center clinic for a first-time
evaluation concerning his long-standing inability to fall or stay asleep. He
stated that as far back as he could remember, even as a child in grade school,
he had trouble falling asleep. His mother told him that even as a newborn he
slept much less than his siblings had. He went to bed around 10 PM and tossed
and turned for an hour or so before falling asleep. He stated that his sleep was
very light, and he tended to wake up once or twice in the middle of the night
and stayed awake an undetermined amount of time, tossing and turning in
bed. Whenever he was unable to fall asleep, he became restless, constantly
watching the digital clock on his bedside table and only rarely getting out of
bed to watch TV. He went to bed every night anticipating not falling asleep.
As a result, he got about 4–5 hours of sleep a night, and did not feel refreshed.
Sometimes, after a few bad nights during which he would hardly get any
sleep, he would sleep 1 night for about 7 hours, and then would feel significantly
better and refreshed in the morning. He denied excessive daytime
sleepiness, and denied falling asleep in inappropriate situations. He denied
being able to take naps. He stated that whether he slept at home or somewhere
else, he was still unable to fall asleep and had the same trouble falling and
staying asleep. He denied symptoms of restless legs or of periodic limb movements.
He denied snoring, heartburn, cataplexy, sleep paralysis, hypnagogic
hallucinations, or symptoms of apnea. In the past, he had tried zaleplon and
trazodone. Zaleplon had not helped, and although trazodone helped him to
sleep, it produced excessive daytime tiredness, grogginess, and fatigue. He
also tried over-the-counter sleeping aids that did not make his sleep satisfactory
in length or quality. He did not drink caffeinated beverages after the
early afternoon, nor alcohol in the early afternoon, but he did chew tobacco
throughout the day, even into the late evening. He had no other complaints.
His family history was significant for a similar type of insomnia in his grandmother
and mother, but not in his father or siblings. Physical exam was normal.
All-night PSG revealed increased sleep latency and poor sleep efficiency at
48% due to prolonged unexplained awakenings. An actigraph, worn for 1 week,
confirmed his subjective reports of 4–5 hours of fragmented sleep at night.
With strict compliance of sleep hygiene regulations and 1 mg of estazolam
at bedtime, he was able to improve his sleep efficiency to a considerable
degree, but not resolve his insomnia entirely (24).