Insomnia Insomnia

Insomnia in Psychiatric Disorders 135
Treatment
SSRI antidepressants like paroxetine, fluoxetine, sertraline, fluvoxamine, or
citalopram are the current consensus to start treating a patient with uncomplicated
panic. Many patients with panic disorder have what is described as supersensitivity
syndrome, which is an initial agitation and more frequent panic in the first 1 to 2
weeks of starting an SSRI medication. Further reduction of the dosage adding benzodiazepine,
or switching to a different compound from the same family usually
gets the patient through this relatively short period (10).
Benzodiazepines are powerful anti-panic drugs. The major advantage of benzodiazepines
is their quick onset of action. Follow-up studies suggest that benzodiazepine-responsive
patients maintain their gain for several years and do not develop
tolerance. Maintenance doses are usually lower than the dosages used for acute
treatment (10).
MAOIs are potent anti-panic drugs, yet their use is limited by the necessity to
regulate the diet and continuously evaluate the concomitant medications.
Tricyclic antidepressants, particularly Imipramine and Clomipramine, are very
effective anti-panic medications.
Case 2
A 30-year-old single female was seen in the sleep center for symptoms of
difficulty initiating and maintaining sleep. She complained that her insomnia
symptoms started 1 year ago, yet it worsened in the previous 3 months. She
worked as a school teacher. The new school year started 2 months prior to her
visit. She admitted to lying in bed at night awake worrying about what might
go wrong at school. She went to bed at 10 PM. She stayed awake for a couple
of hours tossing, turning, and worrying. She woke up two to three times at
night and at least once she was up for about an hour. She glanced at the clock
and worried about not being able to fall asleep. She got up at 6 AM and usually
did not need an alarm.
She felt tired during the day, yet denied sleepiness behind the wheel or at
any time when physically inactive. She denied being able to take naps. The
patient did not smoke and seldom drank alcoholic beverages.
She denied any history of a psychiatric disorder. She reported a history of
a knee injury while jogging and denied any other medical problems. Physical
exam was essentially normal.
During the evaluation, the patient appeared tense and her voice was shaky.
In the latter part of the visit and while discussing the treatment plan, the patient
appeared more anxious and was tremulous. She had increasing difficulty
focusing on the conversation.
When the patient’s anxiety signs were addressed, she reported that her
anxiety symptoms date back to at least 5 to 6 years ago if not longer. She