The Management of Chronic Insomnia Disorder Discussion Paper

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The Management of Chronic Insomnia Disorder Discussion Paper

Narrative Note

DATE SEEN: 7/12/2022

SUBJECTIVE:

Chief Complaint: The patient complains restlessness and felling “on edge”

History of present illness:

PMH:

The patient, Pt, states that she is a recovering alcoholic for nine years. She records having been visiting a private psychiatrist for 10 years. She also reports that the doctor has her on Restaril 15mg at bedtime for insomnia which he has had for ten years and klonopin 0.5mg four times a day for her anxiety.

Accidents/Injuries:

The reports no injuries.

Hospitalizations:

TJ did not provide any account of recent hospitalizations. The Management of Chronic Insomnia Disorder Discussion Paper

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Social History:

The patient is retired and lives with her husband. She states that she has little interaction with her children but they call her husband to check on her. Her husband is very supportive and ensures she takes her medication as prescribed and drives her to all her appointments.

Family History:

The patient’s mother is deceased and was diagnosed with generalized anxiety disorder at 25. Her father suffered from alcoholism all his life and died of cirrhosis at 55.

Allergies:

Pt denies any allergies to medications, latex and foods.

Current Medications:

The patient takes Restaril 15mg at bedtime for insomnia and klonopin 0.5mg four times a day for her anxiety.

MSE:

Appearance and Behavior: The patient appeared tense and restless. She could not maintain eye contact during the examination.

Speech: The patient’s speech was normal with no stammering or vocal tremors detected.

Mood: As stated, Pt stated feeling “on edge.” She was seen to be irritable during the assessment as she would get agitated if an intrusive question was asked.

Thought Process: She stated experiencing periods of unexplained extreme fear and when they subsided, she experienced anticipatory anxiety that the episode may recur.

Cognition: Pt had difficulty concentrating as some questions needed to be asked twice or thrice. Insight/Judgment: While the patient is aware that her anxiety is pathological and has no material cause, she avoids situations where she experiences anxiety as she finds the feeling intolerable.

Differential Diagnoses:

1 – Generalized Anxiety Disorder
01 – Insomnia Disorder

Signs and Symptoms:

Generalized Anxiety Disorder: Feelings of restlessness and being on the edge, irritability, difficulty concentrating,
Insomnia Disorder: Difficulty falling and staying asleep, and difficulty paying attention, and irritability.

Client’ Progress: N/A

Patient’s Stated Goals:

The patient seeks to learn how to address her feelings of anxiety outside of her medication.
She also seeks to find healthy ways of falling and staying asleep

Treatment Plan

Generalized Anxiety Disorder The Management of Chronic Insomnia Disorder Discussion Paper

LONG-TERM GOAL: Pt continue with Restoril 15mg tag po qhs. Pt’s therapist and husband will continue to provide emotional support as well as encouragement
TEACHING PLAN: She will also learn how to recognize, accept and cope with the feelings of anxiety (Michaelides and Zis, 2019).

Insomnia Disorder

LONG-TERM GOAL: Pt continue with Klonopin 0.5mg tab po TID.
TEACHING PLAN: Pt will learn sleep hygiene, stimulus control and temporal control. She will also learn sleep restriction, paradoxical intention and relaxation training (Mysliwiec, et al. 2020).

References

Michaelides, A., & Zis, P. (2019). Depression, anxiety and acute pain: links and management challenges. Postgraduate medicine, 131(7), 438-444.

Mysliwiec, V., Martin, J. L., Ulmer, C. S., Chowdhuri, S., Brock, M. S., Spevak, C., & Sall, J. (2020). The management of chronic insomnia disorder and obstructive sleep apnea: synopsis of the 2019 US Department of Veterans Affairs and US Department of Defense clinical practice guidelines. Annals of internal medicine, 172(5), 325-336.