Insomnia due to difficulty adjusting to a new situation

Mrs. Hanna is a 57 year old lady who presented with difficulty initiating and maintaining sleep over the last 8 months. She is a non-smoker with minimal alcohol intake and 4 cups of coffee per day. She describes some difficulty starting and maintaining sleep going back about 4 years at the time of a car accident, which caused some spinal injury. However the difficulty with sleep has been particularly problematic over the last 9 months. This corresponded to her resettlement back to Newcastle from South Australia. She had been living in Adelaide following her husband who was a senior executive for a manufacturing company. They had been in Adelaide for 10 years even though she would regularly come back to Newcastle every year to visit the family.

About 4 years ago when she was involved in a motor vehicle accident she had a few months of difficulty initiating and maintaining sleep mostly related to the accident and some back pain, which prevented her from sleeping. However, following rehabilitation her sleep had gone back to normal.

About 9 months prior to this presentation following her husband’s retirement the couple moved back to Newcastle. This has been a difficult period for both the patient and her husband. The husband had major difficulties adjusting to a new lifestyle after having been a very busy person. It created some difficulty within the marriage. Mrs. Hanna also had settled well in Adelaide having developed a network of friends and although keen in coming back to her country of origin she was ambivalent about moving back to Newcastle. Although she walks every morning, attends the local church and is involved with the local community, she does not feel fully satisfied at the end of the day. She is missing the friends and relationship that she had developed over many years in the other country.

She goes to bed between 10-11pm and falls asleep between 30 minutes – 2 hours. She has no history of snoring. She is not a restless sleeper, however, she tends to wake up a couple of times per night for up to 30 minutes and eventually she has a final awakening between 3-6am. She tends to feel unrefreshed. She does not nap through the day.

She is not an anxious person, she is not depressed and she has a good understanding of her condition.

Our discussion initially focused on the difficulty that the couple had encountered in readjusting to a new lifestyle. The husband, who had been spending most of the time away from home, was now spending most of his time at home and he had difficulty readjusting to a less busy lifestyle. This appears to reflect, to some degree, on Mrs Hanna who, although happy to have more time to spend with her husband, needed to adjust to a new set of situations.

Reassessing her decision to move back to Newcastle it became more obvious that the decision was somewhat difficult and she was not completely sure about moving back. There were lots of positives, particularly being back where she was born.  However, she had developed a fairly strong network of friends in Toronto and she could have easily decided to remain in South Australia. This kind of tension has not really been completely resolved and it would be one reason for her poor sense of well being during the day.

In this case it is essential that the person is aware of this tension and starts developing some strategies to get more involved locally.

As far as her sleep is concerned the daytime issues would certainly have affected it. We agreed in undertaking restriction of time in bed going to bed around midnight. Wake-up time is fairly fixed; being an early person she would get up at 6am and avoid any naps through the day. She was also started on Melatonin 3mg at 9pm to be continued for the following 4-8 weeks.

At follow-up about 4 weeks later Mrs. Hanna had made progress in becoming progressively more involved in the local community. She has also become progressively more aware of the uncertainty about moving back to Newcastle but she is now settled and determined to make the most of it. Her sleep quality has improved even though some nights she still has some difficulty remaining asleep. Overall her sleep quality and her daytime functioning were improved. Melatonin was stopped about 6 weeks after starting it and her overall sense of well-being was maintained.

This is an example of how difficulty initiating and maintaining sleep can be associated with a significant change in lifestyle such as moving home or state. Any situation where there is a significant change in lifestyle can potentially lead to some degree of tension and anxiety and this may reflect in the sleep quality which becomes poor. Not being able to sleep well, of course, would make daytime functioning progressively worse and the two issues would compound together to result in a poor sense of well being.

Other situations that can lead to similar presentation include a change in occupation, changing school, moving out of the family home, becoming a retiree, to mention a few examples.