CASE: Worsening insomnia
Mr. Q, age 44, presents for evaluation of altered mental status characterized by disorientation, impaired attention and concentration, paranoid delusions, and prominent auditory and visual hallucinations. His initial Folstein Mini-Mental State Examination (MMSE) score is 7 of 30, indicating severe impairment. He further describes a recent history of nausea, intermittent vomiting, and anorexia. He takes hydrocodone/acetaminophen, 5/500 mg, 4 times daily for lower back and joint pain. Additionally, he has a pacemaker, which was placed when Mr. Q was in his late 30s to treat sinus bradycardia.
Mr. Q’s fiancée describes his 6-month history of worsening sleep disturbance, noting insomnia, fractured sleep, dream enactment, and daytime fatigue. During this time, Mr. Q averaged 3 to 4 hours of sleep nightly without day-time naps. Ten days ago, he stopped sleeping completely and his cognitive function decompensated rapidly. He became increasingly paranoid, believing government agents had been dispatched to kill him. Several days before admission, Mr. Q developed auditory and visual hallucinations. He reports that he hears voices warning him of Armageddon and sees reincarnated spirits of deceased relatives. He describes his mood as “fine” and “okay” and lacks insight into his psychiatric symptoms other than his sleeplessness.
Mr. Q’s family says he has a history of transient mild depression after his older brother died from an unknown neurologic disease 3 years ago. Mr. Q did not receive pharmacotherapy or psychotherapy but his symptoms resolved. His family says that Mr. Q has been using marijuana daily for several years, but they are unaware of other substance use. They deny a family history of psychiatric illness.
On physical examination, Mr. Q appears thin, agitated, and in mild distress. He has a fever of 99.2°F. His blood pressure drops intermittently from a baseline of 120/70 mm Hg to 100/60 mm Hg, at which point he experiences transient normal sinus tachycardia. Neurologic examination reveals psychomotor agitation and diffuse myoclonic tremor.
The authors’ observations
Table 1
Differential diagnosis of insomnia
| Type of disorder | Examples |
|---|---|
| Sleep disorders | Narcolepsy, REM sleep disorder, periodic limb movement disorder, restless leg syndrome, parasomniac conditions |
| Psychiatric disorders | Mania or hypomania, psychosis, substance intoxication or withdrawal, dementia, delirium |
| Neurologic disorders | Stroke, malignancy, infection or abscess, metabolic or viral encephalopathy, seizure disorder, prion disease |
| Somatic conditions | Cardiorespiratory disease, central or obstructive sleep apnea, congestive heart failure (Cheyne-Stokes respiration), pain, nocturnal movement disorder, gastroesophageal reflux disease, nocturia |
| Other causes | Jet lag, shift work, environment, lifestyle, medication |
| REM: rapid eye movement Source: Reference 1 | |
Medications that can cause or exacerbate insomnia
| Class/category | Medication(s) |
|---|---|
| Stimulants | Bupropion, dextroamphetamine, methylphenidate |
| Decongestants | Pseudoephedrine, phenylephrine |
| Antihypertensives or antiarrythmics | α- and β-antagonists |
| Respiratory medications | Albuterol, theophylline |
| Hormones | Corticosteroids, thyroid medications |
| Anticonvulsants | Lamotrigine |
| Medications that induce rebound insomnia | Benzodiazepines, sedative-hypnotics, opioids |
| Nonprescription medications | Caffeine, alcohol, nicotine, illicit psychostimulants |
EVALUATION: Inconclusive results
Routine laboratory studies reveal mild normocytic anemia and mild hypokalemia. Liver panel, renal function, cardiac profile, brain natriuretic peptide level, folate and vitamin B12 levels, thyroid studies, and human immunodeficiency virus serology are negative or within normal limits. Urinalysis reveals the presence of ketones, indicative of Mr. Q’s recent anorexia. Chest radiography and CT imaging of the head, abdomen, and pelvis also are unremarkable. MRI is contraindicated because of Mr. Q’s implanted pacemaker. Pulse oximetry does not suggest apneic events. Mr. Q and his family refuse a lumbar puncture, which precludes cerebrospinal fluid (CSF) analysis. Electroencephalography (EEG) records normal patterns of wakefulness oscillating with transient periods of stage 1 sleep. A detailed family interview reveals that Mr. Q’s older brother had a history of epilepsy and died at age 49 following a prolonged hospitalization for recurrent seizures and similar insomnia symptoms. History from the patient’s paternal lineage is not available.