Inpatient multidimensional management of treatment-resistant in somnia

Twenty patients with severe chronic refractory insomnia underwent inpatient psychiatric treatment. All patients had Axis I and/or Axis II diagnoses. in most cases affective and substance use disorders as well as various personality disorders. An individualized combination of psychotherapeutic and behavioral techniques was directed primarily toward treating the underlying mental disorders. Fourteen patients received medication. In spite of the wellknown resistance of chronic insomniacs to conventional treatment efforts. 16 of the 20 patients achieved good nightly sleep while they improved in social interactions and overall quality of life and remained improved at six months' follow-up. Thus, the inpatient psychiatric unit appears to be an ideal setting for the multidimensional management of treatment-resistant insomnia. From the department ofpsychiatryand the Sleep Research and Treatment Center, Pennsylvania State University College of Medicine, Hershey, Pa. Reprint requests to Dr. Tan, Department of Psychiatry, Hershey Medical Center, Hershey, fJ<111033. I nsomnia, a relative deficiency in the amount or quality of sleep,' is the most prevalent sleep complaint encountered by physicians. About 20% of all adult general medical patients complain of it, while among psychiatric patients this percentage rises to 35. 2 Insomnia occurs more frequently among women and the elderly,3" in persons of lower socioeconomic status/ and in those with psychological disturbances."· Also, it has been demonstrated that situational factors, 1.7 medical conditions, '.7 and the administration or withdrawal of certain drugs'·7.• may adversely affect sleep. Further, stressful life events are closely related to the onset of insomnia; certain patterns of personal vulnerability lead to inadequate coping mechanisms for dealing with stress and to the development and persistence of chronic insomnia. 10 1\vo major sources of data have demonstrated the central role of psychopathology in the pathogenesis of chronic insomnia: studies of Minnesota Multiphasic Personality Inventory (MMPI) profiles of personality patterns"·t2 and of DSM-III multiaxial diagnoses. Il The MMPI profiles not only show consistently high levels of psychopathology, but they also indicate specific personality patterns characterized by anxiety, rumination, neurotic depression, inhibition of emoPSYCHOSOMATICS tions, and inability to express anger. 11.12 Patients with chronic insomnia also have an extremely high prevalence of psychiatric diagnoses, with dysthymic, anxiety, somatoform, and substance use disorders being the most common Axis I diagnoses and with compulsive personality disorder or trait being the most common Axis II diagnosis. Il From both MMPI and DSM-III studies of these patients, characteristic patterns of internalization of emotions emerge.,·II.1l Kales and associates" hypothesized that these internalizing patterns lead to sustained emotional arousal and heightened physiologic activation before bedtime and during the night, 14t7 resulting in sleeplessness.'·II.t2 These patterns, coupled with fear of habitually poor sleep, I. may produce a circular and escalating progression that establishes a conditioned pattern of chronic insomnia.I.··1I In spite of the central role of psychopathology in its pathogenesis, chronic insomnia is a complex problem with multidimensional causalities. '·7 Treatment should be directed not only to the underlying psychological conflicts, the impaired ability to cope with life stress, and any medical factors but also to the consequences of insomnia itself.' A multidimensional approach to treatment should include the use of general measures'· (eg, modifying lifestyle patterns such as by regularizing schedules and gradually increasing exercise levels), '.'0 supportive and insight-oriented psychotherapy (individual. group, and family),21.22 behavior therapy (progressive muscle relaxation or stimulus control), 121." and phannacotherapy (hypnotics or antidepressants). 1.7 When outpatient treatment has not been effective for patients with severe and chronic insomnia, a multidimensional approach to inpatient psychiatric treatment is often indicated. This article describes such a strategy. IPatients and assessment procedures The study group comprised 20 patients with a primary complaint of severe chronic insomnia who were among a group of 122 persons with insomnia consecutively evaluated in our Sleep Disorders Clinic. The eight men and 12 women studied ranged in age from 18 to 71 years, with a mean of 55. I years. The duration of the insomnia ranged from one to 48 years, with the mean being 13.3 years. Owing to the severity and complexity of their symptomatology. the resulting impainnent. and the prior failure of outpatient therapies. these patients were admitted to the inpatient psychiatric unit. The severity of the insomnia. the generalized level of functioning. and the subsequent effects of inpatient therapy were assessed on the basis of the patients' clinical complaints and history. Given that previous outpatient therapeutic measures had failed. the patients served as their own con-