Management of Insomnia and Paranoia in Patients with Generalized Anxiety Disorder and Post-Traumatic Stress Disorder

Pharmacologic Management

• The American Academy of Sleep Medicine recommends increasing olanzapine dosage to address both paranoia and insomnia, with split dosing of 5mg in the morning and 5-10mg at bedtime 1
• Olanzapine has demonstrated efficacy for sleep disturbances in psychiatric patients, according to the American Academy of Sleep Medicine 2
• The American College of Physicians suggests avoiding adding benzodiazepines as first-line therapy due to risk of dependence and abuse potential, as well as potential for cognitive impairment 3
• The American Society of Clinical Oncology recommends considering hospitalization if paranoia significantly worsens or if patient develops beliefs that could lead to harmful behavior 4
• The American College of Physicians recommends considering adding low-dose doxepin (3-6mg) for insomnia if olanzapine adjustment is insufficient after 2-4 weeks 5

Non-Pharmacologic Interventions

• The American College of Physicians recommends initiating cognitive behavioral therapy for insomnia (CBT-I) as the primary treatment for insomnia, which includes cognitive therapy, stimulus control, sleep restriction therapy, sleep hygiene education, and relaxation techniques 6, 7
• The American Academy of Sleep Medicine suggests considering adding Exposure, Relaxation, and Rescripting Therapy (ERRT) for trauma-related nightmares, as well as Progressive Deep Muscle Relaxation training and systematic desensitization techniques 8

Treatment Algorithm

• The American College of Physicians recommends a treatment algorithm that includes increasing olanzapine to split dosing, initiating CBT-I, reassessing in 1-2 weeks, and considering adding low-dose doxepin or intensifying CBT-I if insufficient improvement is seen 4, 5, 7, 8