Shirah Vollmer MD

The Musings of Dr. Vollmer

“I Can’t Sleep:” Saying No to Prescription Hypnotics

Posted by Dr. Vollmer on January 24, 2010

This blog is part of my series on sleep pathology.

Today I saw my nine year old girl who was featured in my previous blog entitled “I Can’t Sleep“. Her mom informs me that she has been diagnosed with Period Limb Movement Disorder. This is new information. I think to myself, Periodic Limb Movement Disorder, what is that? After she left I did some research. It turns out that PLMD used to be called nocturnal myoclonus. Sigh! I knew what that was, but I never got the memo that they changed the name. I suppose that since I am a psychiatrist and not a neurologist that this name change never hit Psychiatric Times. Thank goodness for the internet.  I think they, whoever they are who change the name of neurological diagnoses, wanted to confuse me, but I know that is silly, so I return to trying to understand what is going on. Here is what I learned.

Periodic Limb Movement Disorder (PLMD) is repetitive cramping or jerking of the legs during sleep. The movements often disrupt sleep and they can lead to daytime sleepiness. PLMD is often linked with Restless Legs Syndrome (RLS). RLS is a condition involving strange sensations in the legs while awake and an irresistible urge to move the limbs to relieve the sensation. At least 80% of people with restless legs syndrome have PLMD, but the reverse is not true.

If PLMD is not associated with another disease or medication it is called primary PLMD and it has no known cause. On the other hand, if PLMD is linked to another problem it is called secondary PLMD. Secondary PLMD has many different causes such as diabetes mellitus and medications such as Haldol or L-dopa. Most people with PLMD are unaware of their leg movements unless their bed partner tells them. Typically, the knee, ankle and big toe joints all bend as part of the movements. The movements vary from slight to strenuous and wild kicking and thrashing. The movements last about 2 seconds and thus are much slower than the leg jerks of myoclonus. The movements are rhythmic and repetitive and occur every 2-40 seconds. Sleep lab testing is necessary to confirm PLMD. Treatment does not cure it, but medications can help.

So, now I am up to speed about what my patient suffers from. I review her sleep study, I speak with her pediatric neurologist. Often times, when I consult with other physicians, I find them to be hard to reach, dismissive and hurried. In this case, I was pleasantly surprised. We spoke for fifteen minutes and we ended our conversation because I had to see another patient. He was warm, informative, interested in what I had to say, and most surprisingly, insightful about this young girl and her family dynamics. He also said that there may be a relationship between PLMD and ADHD, but he was not sure. I felt encouraged to have such a positive collegial interaction. He explained to me that there are no medications which are FDA approved to help children sleep. There are also no FDA approved medications to treat PLMD in children. Nevertheless, he has had great success giving children the same medications which are approved for adult PLMD.

Even though this young girl was treated for her PLMD, by her mother’s report, she was still not sleeping well. After the initial appointment, I was hesitant to treat her sleep problem with medication. Her mom decided to give her Benadryl, an over-the-counter medication which is used for allergies, but it can also be used as a sleep aid. It worked. The mom was very happy. The sleep problem has been solved. Now, I could focus on her other issue, anxiety. She complains of getting worried to the point where it is sometimes hard to breathe. We talk about this symptom at great length. I discover that she has half-siblings I did not know about, even though I inquired during the initial three hour consultation. As with learning about PLMD, I am once again reminded that time is important in an evaluation because there is an unfolding of information.

Unlike in our previous appointment, this time the mom was relaxed. To an outside observer, there would be no hint of previous tension. I did not understand what changed, but I was relieved. Clearly, she was sleeping better and this put the mom at ease, but I sensed there was more to it than that. I had a hunch that the mom had appreciated that I was not quick on the trigger to prescribe medication to help her daughter sleep and this helped to build her trust in me. Again, I am speculating.

There was a strong family history of anxiety. This little girl had frequent, indeed almost daily, episodes of feeling like she could not breathe. Consequently, I prescribed a medication that other family members had taken. We all agreed that we would see how things go. There was a good feeling in the room.  I felt like I could breathe better as well.

When I do not prescribe a medication, usually a hypnotic or an anti-anxiety medication, patients often get very angry. When the patient is the child and the parent has an idea of what I should prescribe, the disappointment is exponentially worse. After all these years, saying no to patients in distress is still quite challenging. The last visit with this mom and child was tough. Today, the tides turned. Although I have my theory that because I stood my ground, I earned some respect, it is just a theory, and once again, I am not sure why things are so much better. I know the Benadryl is a key factor, but I ask myself why the mom stayed with me. Why did she not seek care elsewhere? I return to my theory that although she was disappointed, she was also relieved that she could not push me into doing what she wanted. Like a parent with a child, sometimes saying no contains the person asking for something such that although they experience disappointment, they also experience comfort. This is the comfort in knowing that someone else is taking responsibility. I think this mom needed that. I think she ended up appreciating that. When dealing with children, I am not given permission to talk to the parent about the dynamics of my relationship with them. In other words, I cannot explicitly float the idea that I think things got better in our relationship because I said no to her. After all, she is not my patient. I am left back in my own head. Luckily, this time, that is not a bad place to be.

10 Responses to ““I Can’t Sleep:” Saying No to Prescription Hypnotics”

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    Thanks Garretot. I appreciate the feedback. Shirah

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