Insomnia, anxiety and panic attack

John is a 32 year old rugby league player who presented with a complaint of fogginess and heaviness in his head when he wakes up, which persists during the day causing difficulty with his studies at the university. He complains of episodes of waking up in the first two hours after falling asleep with a sensation of not being able to breathe, palpitations and a sense of tightness in his chest. He also complains of a sensation of uneasiness/soreness and tightness in the back of his throat.

John had been seen in the past for difficulty initiating and maintaining sleep at the time when his sporting career was towards the end. He has been a player mostly at local level and he found himself with no other skill apart from playing. That had caused some degree of depressed mood and anxiety and he had to resort to living with the family. He engaged himself in a bridging course at university with the intent of enrolling in a teaching career.

In retrospect he had difficulty initiating and maintaining sleep going back to the age of 13-14 after the death of his grandmother. He was very close to her and the death was loaded with significant emotions. The event was important enough to be still present and vivid in his mind.

He described a sleep pattern suggestive of mild delayed phase going to bed between midnight-1am and falling asleep in a variable amount of time but usually less than an hour. Over the last month almost on a nightly basis he would find himself awake about an hour or so after sleep onset with shortness of breath, chest tightness, and palpitations. He has no history of heartburn and oesophageal reflux. He is a very fit young man with no features suggestive of sleep apnea. Both sleep apnea and oesophageal reflux can be associated with waking up with a choking sensation.

Because of the waking up with shortness of breath and palpitations he had gone through a cardiological examination including exercise stress testing, which was normal. An overnight oximetry, which measures oxygen through the night while the person is asleep, suggested no evidence of disturbed breathing (no sleep apnea).

However John admitted drinking 6 or more caffeinated beverages per day. This amount of caffeine can on its own cause difficulty with sleep, in particular “light” sleep and frequent waking up through the night.

John’s presentation is very much in keeping with anxiety disorder with panic attacks as well as a mild degree of delayed sleep phase syndrome. Because the problem has been present intermittently for a few years there was also an element of psycho physiological insomnia (see Chapter 2) with a strongly negative association between bedroom and bedtime.

Over the previous few months John has tried to exclude any potential somatic (“body”) reasons for his symptoms, which have led to extensive blood testing as well as cardiological investigations as mentioned above.

There was a good discussion with John regarding how anxiety causes a state of hyper-arousal, which is not conducive to sleep (see chapter 00 pg 00). We discussed the relevance of his daytime function to his sleep. Particularly John displayed an element of poor self-esteem and a recurrent pattern of failures both in his playing career as well as at school. It was suggested he maintains a regular bedtime and regular wake-up time. He was requested to undertake relaxation and meditation at least twice a day. He was also started on an anti-anxiety medication called alprazolam (Xanax®) 0.5mg half an hour before going to bed. He was warned of the possibility of mild sedation in the morning due to the medication, although rare. Given his level of anxiety the use of an anti-anxiety medication was felt to be an important part of the treatment.

He was also advised to reduced the caffeinated beverages to less than 3 a day and avoiding them altogether after 3 pm.

About 6 weeks after the first encounter he found that his sleep was more regular with no waking up with shortness of breath or choking sensation. He was still concerned about not feeling fully clear of the fogginess and heaviness that had been one of his concerns but his academic record was improving.

At further follow-up appointments he was still concerned about the possibility of something “significantly wrong” with his body but he admitted that there was an improvement.

Now with a more stable sleep and wake pattern and with the beneficial effect of the anti-anxiety medication he also started psychological counselling to try to reassess the origin and the perpetuating factors of his anxiety disorder.

Comment: This is an example of how sometimes difficultly initiating and maintaining sleep and the sensation of poor daytime function can be associated with significant anxiety disorder as well as panic attack. Contrary to what people often think, panic attacks can start while the person is asleep and are not just a feature of the awake person. In this case the use of an anti-anxiety medication was needed given the high level of hyper arousal. The medication can be continued while the person is going through a counselling treatment (such as cognitive behavioural treatment for anxiety) and then can be slowly tapered off. As is often the case there was also an element of mild delayed sleep phase and psycho-physiological insomnia that improved once the level of anxiety was reduced and the sleep and wake pattern was maintained regular.

The number of caffeinated drinks (coffee, tea, chocolate, coke and other soft drinks) should also be noted. The effect of caffeine varies from one person to another, but in someone like John with difficulty initiating and maintaining sleep, reduction in the amount of caffeine, or complete cessation, is an important part of treatment.