Insomnia may be something that doctors avoid bringing upI went to my family physician for a routine physical last week. I hadn’t had one in a while, so I decided to get the exam and requisitions for the usual blood work.

This doctor is one whose opinions I respect. But I never hesitate to speak up when information I have leads me to question those opinions. One topic we’ve had discussions about is insomnia and sleeping pills.

I use Ambien rarely now—sometimes only half a pill—and I’ve still got plenty left from the prescription she wrote last year. So I didn’t plan to mention sleeping pills or insomnia because I didn’t need to.

 

In the Consulting Room

The nurse sat down at the computer to update my medical record, asking about medications and supplements.

Yes, I was still using Ambien. No, I didn’t need a refill.

The nurse then walked out and the doctor walked in.

So what could she do for me today?

I explained the routine nature of my visit and that I wanted the usual blood tests.

She listened to my heart and lungs, placed her fingers under my jaw to feel for lumps, checked my ears and throat. She verified that my weight was stable and that I was getting regular exercise. She typed the lab requisitions into the computer and said I could pick them up on my way out. Then she left.

After the Consultation

Putting on my coat and boots, I happened to glance at the computer, where my medical record was still open. Three words jumped out, the only ones in bold red letters at the top right side of the screen: CHRONIC INSOMNIA. ANXIETY.

The sight was jarring. These words—diagnoses my doctor and I had talked about—felt like accusations. Why, at that moment, did everything I’d learned in my years of studying insomnia—its association with hyperarousal, the stigma attached to it and other disorders involving the brain, the work I’d done to learn to manage my sleep—fly out the window and leave me feeling bad about myself?

I scanned the record for other diagnoses and found one. It appeared in regular black type on the left.

A comment made by a friend of mine suddenly came to mind:

“Usually doctors are hesitant to prescribe sleeping pills for regular use,” she said, “and I’m hesitant to ask. Having worked in a medical office, I think that when you ask for pain pills a lot, or sleeping pills or muscle relaxants or anti-anxiety things, that’s a red flag for being a drug abuser.”

A red flag for being a drug abuser—was that why chronic insomnia and anxiety were at the top of my record in boldface and red? Because several medications used to treat sleep problems and anxiety are controlled substances and I use one? After decades of responsible use of sleeping pills—never using more than a few at a time, never developing tolerance or dependency—am I still seen as a potential drug abuser by my doctor?

The Question Not Asked

Later another thought came to mind. Chronic insomnia is the first thing anyone would see in my medical record, so why had the doctor not asked about my sleep?

I can’t exactly fault her for the omission. She may have assumed, since I didn’t raise the issue myself and didn’t need a sleeping pill prescription, that my sleep must be fine. She may have remembered other conversations we’ve had about my sleep problem—conversations involving some emotion—and decided to leave well enough alone.

All the same, it would have been nice if she’d asked about my sleep. In my imagination, that conversation would go something like this:

Dr: So how’s your sleep these days?

Me: Never better.

Dr: Really?

Me: Yes. With all the study and experimentation I’ve done, I think I’m managing my sleep about as well as a person prone to stress-related sleep disturbance can. There’s not much backsliding these days.

Dr: That’s wonderful. That’s an achievement.

Me: Yes. It is.

Does your doctor routinely ask about your sleep?

Posted by Lois Maharg, The Savvy Insomniac

Lois Maharg has worked with language for many years. She taught ESL, coauthored two textbooks, and then became a reporter, writing about health, education, government, Latino affairs, and food. Her lifelong struggle with insomnia and interest in investigative reporting motivated her to write a book, The Savvy Insomniac: A Personal Journey through Science to Better Sleep. She now freelances as an editor and copy writer at On the Mark Editing.

9 Comments

  1. It’s dismaying that you would be treated this way by a doctor, even if innocently. Why is it that medics don’t take our condition more seriously? Thank you for (once again) bringing this to everyone’s attention.

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  2. Hi Eric,

    I think a couple things are involved. One, most GPs I’ve had a relationship with haven’t really known how to treat chronic insomnia. Some are uncomfortable prescribing sleep medication because of concerns about adverse effects. They may also be part of family practices with policies specifying exactly how these medications are to be prescribed. The result is a one-size-fits-all approach to treatment. I guess that helps doctors with liability concerns. But it’s the opposite of the kind of personalized medicine I’d like to see.

    The other thing is that 10-minute appointments seem to be the rule rather than the exception these days. Family doctors may not feel they have time to do a check of all bodily systems—even those a patient has had trouble with in the past. So they stick to addressing the issues the patient brings up on the day of the appointment.

    Thanks for writing in.

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  3. My doctor never asks me about my sleep even though I’ve been taking zopiclone for years. She really doesn’t want to know. I’m trying to get off them but with little success. I don’t raise the issue any more because I know that she is uncomfortable with it. I still feel it is my fault.

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    1. Hi Liz,

      All the things you’re saying here are so familiar to me and I’m sure I’m not the only one who feels this way. The blame part is really unfortunate, but perfectly understandable. Sleep is considered by some people (including doctors) to be a function subject to voluntary control. Anyone who has trouble sleeping must be doing something wrong: taking naps, going to bed too early, sleeping in late, drinking too much coffee, too much alcohol, and so forth.

      Having to resort to sleeping pills is, from this perspective, a sign of failure. And, at least here in the United States, the prescribing of sleeping pills is monitored. Doctors aren’t eager to prescribe drugs like zopiclone long term.

      This view of sleep as under voluntary control discounts the constitutional factors that make sleep harder for some people than others. More and more of these genetic factors are coming to light now and for some time I’ve had it in mind to blog about these recent discoveries. But that post will have to wait until I’ve got enough spare time to do all the reading it will require.

      Thanks for writing in!

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  4. Rather than stay on sleeping or anxiety drugs, ask your doctor for a sleep study. Breathing disorders such as sleep apnea can cause chronic insomnia.
    I know because I had chronic insomnia for 3 yrs before a new NP at a neurology clinic mentioned sleep clinic. This was after I described my sleep as fragmented with vivid dreams. Before that I was waking up after only 4 hrs sleep, wide awake. Other times, I couldn’t get to sleep until 2am and slept only 3-4 hrs. She said that sounded like a breathing disorder. Turns out I have sleep apnea from tongue obstruction. I had been on clonazepam for over a year for the restless legs and nocturnal myoclonic jerks (caused by sleep apnea). It can also cause random pain. Couldn’t believe all the doctors I went through over the years who were clueless. Don’t keep suffering with sleep deprivation and unrefreshing sleep. Ask for a sleep study!

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  5. My file currently says “generalized anxiety disorder,” although this was never discussed with me. My doctor is of the mindset that since I have chronic insomnia, I must be depressed.

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    1. Hello,

      I find it strange—but all too believable—that your doctor never discussed the GAD with you. There’s a stigma attached to disorders involving the brain and some doctors seem to share it.

      Yes, some people who have chronic insomnia also have depression, but others do not. If you’re not satisfied with the treatment you’re getting for the insomnia, maybe it’s time to consult with a sleep specialist or someone who has more of an interest in treating sleep problems.

      Good luck!

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  6. Interesting conversation. I’ve had insomnia for years. My PCP has prescribed Restoril and Ambien and switching every couple of months seems to be doing the trick. We’ve tried others that either leave me too groggy or do little at all. It was suggested I see a psychiatrist to address the issue. Cognitive Behavior Therapy wasn’t working so the Restoril/Ambien was continued. My issue is that my head doesn’t shut down at night and these two meds seem to do the best at that sort of thing. Others just make me sleepy while thoughts still race across my mind for hours. So this may be more of an attention disorder (never diagnosed but it’s just my opinion based on what seems to work and what clearly does not). So here’s the issue. The psychiatrist I was seeing is no longer working outpatient care. They switched me to another who wants me off the Restoril and Ambien. I’ve been taking Trazadone (sleepy, vivid dreams, awakening a lot during the night). Now Rozerem (I don’t even get a yawn from this and am awake two to three nights in a row trying to maintain a normal work life in the day). I feel like hell. Ambien worked but she just won’t prescribe it. Now that I am insistent that Ambien is the only thing that works, I’m afraid I’m being labeled a potential abuser. I’ve mentioned the Rozerem is not working (for weeks) and I’m just supposed to stick with it. trust me, I wish I was not so dependent on sleep meds, but the fact is I am. Relaxing my toes and thinking of sunny beaches doesn’t work. lack of sleep is no way to live. Maybe depression leads to sleep disorders, but isn’t it just as likely that lack of quality sleep leads to anxiety/depression as well? Just frustrated.

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    1. Hello David,

      Your story sounds familiar—I’ve heard similar accounts from several friends and acquaintances. Finding a treatment strategy that works—and then having to give it up because it’s not on a new doctor’s prescribing list—must make you feel frustrated (if not angry).

      I think you’ll do better, rather than consulting a psychiatrist about your insomnia, if you talk to a sleep specialist about the problem. Sleep medicine is a field unto itself these days. Psychiatrists may be somewhat familiar with the current prescribing trends and have the clinical background to know what usually works and what doesn’t; others may not. Based on what you’re telling me about your current psychiatrist, it doesn’t sound as if she’s making the best recommendations given the problem you’ve described.

      Another important reason to see a sleep specialist is to get a proper diagnosis. Once that’s settled, better treatment will hopefully follow.

      Best of luck getting the right kind of help soon.

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