Insomnia Treatment: A Case Study Combining Medication and CBT-I

Insomnia can be a debilitating condition, especially when it is accompanied by anxiety and heightened sensitivity to stress. This case study explores the journey of a 30-year-old male who struggled with chronic insomnia and anxiety for over a decade. His story highlights the importance of combining pharmacological treatment with cognitive behavioral therapy for insomnia (CBT-I) to achieve long-term relief and emotional stability.

Patient Background

The individual is a 30-year-old male with a bachelor's degree from a prestigious university. He has suffered from persistent insomnia for 10 years and has continuously attempted various methods to alleviate his symptoms, only to face recurring episodes. Despite his struggles, he remains optimistic and resilient. He experiences no depressive symptoms but often feels mentally and physically drained, pushing through daily life with sheer willpower. Outside of his sleep issues, he demonstrates strong problem-solving skills in both personal and professional settings, maintaining a disciplined and responsible lifestyle with no bad habits.

His condition was further complicated by a prior history of health anxiety and panic attacks. Recently, he experienced a resurgence of these symptoms due to intense work-related stress. This led to physical manifestations such as tachycardia, elevated blood pressure, and head pressure. His emotional sensitivity was heightened, making him prone to panic from even minor triggers. Although he logically understood these fears were unfounded, his nervous system remained highly reactive.

Medical History and Initial Treatments

His journey began with a visit to a traditional Chinese medicine (TCM) clinic, where he was advised to exercise more. This suggestion, however, triggered a panic response, resulting in a heart rate spike and elevated blood pressure. He was subsequently referred to a cardiology department at a tertiary hospital, where his heart rate was recorded between 130–150 beats per minute, and his blood pressure reached 190/130 mmHg. The physician prescribed bisoprolol fumarate to manage the tachycardia and hypertension.

Recognizing his symptoms as anxiety-related, he consulted a neurology department at the same hospital. The neurologist provided emotional reassurance and diagnosed his condition as stemming from anxiety and nervous exhaustion. He was prescribed Shendan Oral Liquid, Oryzanol, and Vitamin B, along with lifestyle recommendations such as increased social interaction and physical activity.

Although bisoprolol effectively lowered his heart rate to around 55 beats per minute and reduced his blood pressure, it came with side effects—most notably, worsened insomnia and the emergence of depressive symptoms, which further destabilized his emotional state.

Complications with Medication

In search of relief, he visited a local hospital and was prescribed alprazolam for insomnia. However, this medication interacted negatively with the existing cardiovascular drugs, causing bradycardia and intensifying his depression. Meanwhile, the neurologist's treatment plan, while well-intentioned, lacked immediate efficacy, leaving the patient in a state of despair and frustration.

Case Analysis

Several key factors contributed to the complexity of his condition:

• Psychological Barriers to Sleep: Long-term insomnia had created a mental block, making it difficult to fall asleep even under minimal stress.
• Reduced Stress Tolerance: Chronic fatigue and nervous exhaustion diminished his ability to cope with unexpected stressors.
• Amplified Fear Response: Anxiety and fear were easily triggered by mild stress, leading to physiological symptoms like palpitations and high blood pressure.
• Emotional Sensitivity: His youth and healthy lifestyle ruled out organic causes of hypertension, pointing to emotional and neurological origins.
• Limitations in Medical Care: While traditional Chinese medicine showed little efficacy, Western cardiology often overlooked the psychological roots of his symptoms.
• Need for Integrated Treatment: Neurological interventions were too slow and lacked actionable behavioral guidance, leaving him trapped in a cycle of anxiety and insomnia.

Turning Point in Recovery

Despite setbacks, the patient began to regain control through a combination of medication adjustments and psychological strategies:

1. Discontinuation of Bisoprolol: After realizing the drug exacerbated his insomnia and mood, he stopped taking it, noting that his resting heart rate was normally below 90.
2. Active Coping with Depression: When depressive episodes occurred, he used physical activity and social interaction to manage his mood effectively.
3. Managing Blood Pressure Anxiety: Due to his fear of high blood pressure, he avoided obsessively checking it and instead focused on stabilizing his mental state.
4. Controlled Use of Alprazolam: He used the lowest effective dose of alprazolam to manage anxiety and insomnia, gradually tapering off without experiencing withdrawal symptoms.
5. Improved Physical and Emotional State: Within two weeks, his heart rate normalized to around 70 bpm, and symptoms like dizziness and head pressure disappeared.
6. Addressing Long-Term Sleep Issues: Although his overall sleep improved, he still struggled with sleep onset anxiety due to years of conditioned insomnia.
7. CBT-I Implementation: With a tailored cognitive behavioral therapy plan, he learned to let go of the pressure to fall asleep immediately, resulting in stable, restful sleep for over a month without medication.

Key Takeaways and Recommendations

This case underscores the importance of a multidisciplinary approach to treating insomnia and anxiety disorders:

Accurate Diagnosis is Crucial

Physical symptoms like high blood pressure, rapid heartbeat, and dizziness must be carefully evaluated to determine whether they stem from neurological or organic causes. Misdiagnosis can lead to inappropriate treatments and worsen the patient's condition.

Medication Can Be Beneficial When Used Wisely

In cases of severe anxiety, short-term medication use is not only acceptable but often necessary. Low-dose, as-needed prescriptions can prevent dependency and reduce the risk of relapse when combined with psychological interventions.

Psychological Support is Essential

Medication alone cannot address the root causes of anxiety and insomnia. Integrating therapy—especially CBT-I—into treatment plans allows patients to build long-term coping mechanisms and reduce reliance on drugs.

Cognitive Behavioral Therapy as a First-Line Treatment

For insomnia without severe psychiatric comorbidity, CBT-I should be the first-line treatment. Our structured self-help program has shown consistent success in helping individuals overcome chronic sleep issues by addressing maladaptive thoughts and behaviors related to sleep.

Combining medication with behavioral therapy is a proven strategy in sleep medicine. While medication can provide short-term relief, CBT-I offers lasting results without the risk of dependency or side effects.

If you are experiencing similar challenges, consider exploring evidence-based treatment strategies that combine both pharmacological and psychological approaches. While I cannot offer direct medical treatment, sharing these insights can help guide you toward a more effective and sustainable recovery path.